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Alex G, Shanoj KC, Varghese DR, Sageer Babu AS, Reji R, Shenoy PD. Co prescription of anti-acid therapy reduces the bioavailability of mycophenolate mofetil in systemic sclerosis patients: A crossover trial. Semin Arthritis Rheum 2023; 63:152270. [PMID: 37820508 DOI: 10.1016/j.semarthrit.2023.152270] [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: 06/01/2023] [Revised: 08/13/2023] [Accepted: 08/27/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE Mycophenolate mofetil (MMF) is an effective treatment option for interstitial lung disease (ILD) in systemic sclerosis (SSc). Many patients require co-administration of proton pump inhibitors (PPI) or H2 receptor blockers (HRB) because of various gastrointestinal (GI) manifestations in SSc. Co-treatment with PPI or HRB have shown to reduce serum drug levels in post-transplant patients. We wanted to see if there is a similar phenomenon for Mycophenolate in SSc. METHODS Twenty SSc patients, who were on a stable dose of MMF (1.5-3 g) underwent a sequential cross over study with MMF alone in the first month, followed by co-treatment with Ranitidine and then Esomeprazole in the second and third month respectively. Estimation of 12-hour area under curve (AUC) of Mycophenolic Acid (MPA) levels and total GI score were calculated at the end of each month and compared between the treatment arms. [Trial registration: CTRI/2020/06/025,939] RESULTS: Co-administration of esomeprazole was associated with 32.7% (mean difference = 22.28 μg h ml-1) reduction in mean AUC MPA, whereas ranitidine caused a reduction of 21.97% (mean difference = 14.93 μg h ml-1) in MPA AUC when compared to MMF without anti-acid therapies. The addition of ranitidine or esomeprazole resulted in significant reduction in the total GI score. CONCLUSION Co-administration of PPI or HRB can significantly reduce the bioavailability of MMF in patients with SSc. To avoid therapeutic failure of MMF drug level monitoring is essential when these agents are co-prescribed with MMF.
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Affiliation(s)
- Glaxon Alex
- Centre for Arthritis and Rheumatism Excellence (CARE), Kochi, India
| | - K C Shanoj
- Centre for Arthritis and Rheumatism Excellence (CARE), Kochi, India
| | | | - A S Sageer Babu
- Centre for Arthritis and Rheumatism Excellence (CARE), Kochi, India
| | - Reshma Reji
- Centre for Arthritis and Rheumatism Excellence (CARE), Kochi, India
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Mathew JS, Philips CA. Drug Interactions and Safe Prescription Writing for Liver Transplant Recipients. J Clin Exp Hepatol 2023; 13:869-877. [PMID: 37693257 PMCID: PMC10483006 DOI: 10.1016/j.jceh.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/28/2023] [Indexed: 09/12/2023] Open
Abstract
Immunosuppression optimization is central to graft function in liver transplant recipients. Post-transplantation patients develop new onset or worsening metabolic syndrome, are prone to atypical infections, and are at higher risk of developing cardiac and brain-related clinical events. In this context, liver transplant recipients are at risk of using multiple comedications alongside immunosuppressants. It is imperative for the transplant physician to understand the various drug-drug interactions that potentially reduce or promote toxicity of immunosuppression, as well as associated synergistic or antagonistic effects on extrahepatic organ systems. This comprehensive review discusses drug-drug interactions in liver transplant recipients and the impact and role of complementary and alternative medicines among individuals on immunosuppression.
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Affiliation(s)
- Johns S. Mathew
- Gastrointestinal, Hepatobiliary and Multi-organ Transplant Surgery, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala 683112, India
| | - Cyriac A. Philips
- Clinical and Translational Hepatology & Monarch Liver Laboratory, The Liver Institute, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala 683112, India
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Impact of Fasting Status and Circadian Variation on the Pharmacokinetics of Mycophenolate Mofetil and the Glucuronide Metabolite in Renal Transplant Recipients. Transplant Direct 2023; 9:e1448. [PMID: 36875939 PMCID: PMC9977486 DOI: 10.1097/txd.0000000000001448] [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: 12/22/2022] [Accepted: 12/28/2022] [Indexed: 02/11/2023] Open
Abstract
Mycophenolate mofetil (MMF) is an immunosuppressive prodrug often used to prevent allograft rejection following solid organ transplantation. After oral administration, MMF is rapidly hydrolyzed to the active metabolite mycophenolate acid (MPA), which is inactivated by glucuronosyltransferase to the mycophenolic acid glucuronide metabolite (MPAG). The aim was 2-fold: to investigate the impact of circadian variation and fasting versus nonfasting status on MPA and MPAG pharmacokinetics in renal transplant recipients (RTRs). Methods RTRs with stable graft function treated with tacrolimus, prednisolone, and MMF (750 mg BID) were included in this open, nonrandomized study. Two 12-h pharmacokinetic investigations were conducted in succession following morning and evening doses, both in a fasting and in a real-life nonfasting condition. Results A total of 30 (22 men) RTRs performed one 24-h investigation, and 16 repeated the investigation within 1 mo. In a real-life nonfasting state, MPA area under the curve (AUC)0-12 and C 0 failed to meet the bioequivalence criteria. Following the evening dose, mean MPA AUC12-24 was 16% lower (P < 0.001) compared with AUC0-12, and a shorter T max was observed (P = 0.09). Under fasting conditions, MPA AUC12-24 was 13% lower than AUC0-12, and the absorption rate was slower after the evening dose (P < 0.05). MPAG displayed circadian variation only under real-life conditions with lower AUC0-12 following the evening dose (P < 0.001). Conclusions Both MPA and MPAG showed circadian variation with somewhat lower systemic exposures following the evening dose with limited clinical relevance in the dosing of MMF in RTRs. Fasting status affects MMF absorption rate differently, but with similar results in systemic exposure.
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Mizaki T, Nobata H, Banno S, Yamaguchi M, Kinashi H, Iwagaitsu S, Ishimoto T, Kuru Y, Ohnishi M, Sako KI, Ito Y. Population pharmacokinetics and limited sampling strategy for therapeutic drug monitoring of mycophenolate mofetil in Japanese patients with lupus nephritis. J Pharm Health Care Sci 2023; 9:1. [PMID: 36624529 PMCID: PMC9830922 DOI: 10.1186/s40780-022-00271-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/25/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Mycophenolate mofetil (MMF), a prodrug of the immunosuppressive agent mycophenolic acid (MPA), is difficult to administer because of the pharmacokinetic complexity of MPA. Although dosage adjustment according to the 12-h area under the concentration-time curve (AUC0-12) is thought to be desirable, multiple blood samplings for AUC calculation may pose a clinical challenge. A limited sampling strategy (LSS) would provide a solution; however, little is known about MPA pharmacokinetics in lupus nephritis patients, especially in those with Asian backgrounds, or few, if any, LSSs are reported for them. METHODS Thirty-four adult Japanese patients receiving MMF for lupus nephritis were examined retrospectively. MPA pharmacokinetics were investigated, and a PPK model was developed using Phoenix® NLME™ software. Single and double blood sampling strategies from Bayesian estimation using the PPK model and from multiple linear regression were compared. Tolerability was also evaluated. RESULTS In the pharmacokinetic analysis, renal function and serum albumin had significant effects on dose-normalized AUC0-12; and serum albumin, concomitant proton pump inhibitor (PPI) and iron/magnesium oxide did on dose-normalized maximum concentration. As a PPK model, a two-compartment model was developed with a transit absorption model and first-order elimination, in which creatinine clearance and serum albumin were covariates for MPA clearance. The double sampling strategy at 1 and 4 h by multiple linear regression showed the best agreement with the observed AUC0-12 (r2 = 0.885). Of the single sampling strategies, the one at 6 h by Bayesian estimation performed best (r2 = 0.769). The tolerability evaluation showed that correlations were suggested for gastrointestinal involvement. CONCLUSIONS The present study developed the first PPK model of MPA for Japanese lupus nephritis patients. As for LSSs, a double sampling strategy at 1 and 4 h by multiple linear regression would work best; when only a single blood sampling is allowed, a strategy at 6 h by Bayesian estimation using the PPK model developed in this study would be best. The LSSs good enough for clinical use may facilitate safer, more effective, and individualized therapy.
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Affiliation(s)
- Tomoko Mizaki
- grid.411234.10000 0001 0727 1557Department of Pharmacy, Aichi Medical University Medical Center, 17-33 Nikkicho, Okazaki, Aichi 444-2148 Japan ,grid.411234.10000 0001 0727 1557Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Hironobu Nobata
- grid.411234.10000 0001 0727 1557Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Shogo Banno
- grid.411234.10000 0001 0727 1557Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Makoto Yamaguchi
- grid.411234.10000 0001 0727 1557Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Hiroshi Kinashi
- grid.411234.10000 0001 0727 1557Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Shiho Iwagaitsu
- grid.411234.10000 0001 0727 1557Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Takuji Ishimoto
- grid.411234.10000 0001 0727 1557Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Yukiko Kuru
- grid.411234.10000 0001 0727 1557Medical Education Center, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Masafumi Ohnishi
- grid.411234.10000 0001 0727 1557Department of Pharmacy, Aichi Medical University Medical Center, 17-33 Nikkicho, Okazaki, Aichi 444-2148 Japan ,grid.411234.10000 0001 0727 1557Department of Pharmacy, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Ken-ichi Sako
- grid.444657.00000 0004 0606 9754Department of Clinical Pharmacy, Nihon Pharmaceutical University, 10281 Komuro, Kitaadachigun Inamachi, Saitama, 362-0806 Japan
| | - Yasuhiko Ito
- grid.411234.10000 0001 0727 1557Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
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Farrell J, Ho L. Management of Patients with Systemic Sclerosis-Associated Interstitial Lung Disease: A Focus on the Role of the Pharmacist. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2023; 12:101-112. [PMID: 37163188 PMCID: PMC10164394 DOI: 10.2147/iprp.s399518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/23/2023] [Indexed: 05/11/2023] Open
Abstract
Interstitial lung disease (ILD) is a common manifestation of systemic sclerosis (SSc), which becomes fibrosing and progressive in some patients. Regular monitoring of patients with SSc-ILD is important to assess progression and inform treatment decisions. Therapy for SSc-ILD may include immunomodulatory and antifibrotic therapies. Therapeutic decisions should be made on a case-by-case basis, ideally following multidisciplinary discussion. Most patients with SSc-ILD have several organ manifestations of SSc or comorbidities and are taking a complex medication regimen. Patients with SSc are particularly susceptible to gastrointestinal side-effects of medications due to the gastrointestinal manifestations of the disease. Pharmacists play an important role in the management of patients with SSc-ILD by assisting patients with access to medications, optimizing medication regimens, and advising on alternative dosage forms. Pharmacists can also contribute to patient education to help patients better understand their treatment and how to prevent and manage potential side effects.
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Affiliation(s)
- Jessica Farrell
- Albany College of Pharmacy and Health Sciences and Albany Medical Center Division of Rheumatology, Albany, NY, USA
- Correspondence: Jessica Farrell, Albany College of Pharmacy and Health Sciences and Albany Medical Center Division of Rheumatology, Albany, NY, USA, Email
| | - Lawrence Ho
- Center for Interstitial Lung Disease, University of Washington, Seattle, WA, USA
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Drug-Drug Interactions Between Mycophenolic Acid and Proton Pump Inhibitors. Ther Drug Monit 2021; 44:384-390. [DOI: 10.1097/ftd.0000000000000947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/20/2021] [Indexed: 10/19/2022]
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Saketkoo LA, Frech T, Varjú C, Domsic R, Farrell J, Gordon JK, Mihai C, Sandorfi N, Shapiro L, Poole J, Volkmann ER, Lammi M, McAnally K, Alexanderson H, Pettersson H, Hant F, Kuwana M, Shah AA, Smith V, Hsu V, Kowal-Bielecka O, Assassi S, Cutolo M, Kayser C, Shanmugam VK, Vonk MC, Fligelstone K, Baldwin N, Connolly K, Ronnow A, Toth B, Suave M, Farrington S, Bernstein EJ, Crofford LJ, Czirják L, Jensen K, Hinchclif M, Hudson M, Lammi MR, Mansour J, Morgan ND, Mendoza F, Nikpour M, Pauling J, Riemekasten G, Russell AM, Scholand MB, Seigart E, Rodriguez-Reyna TS, Hummers L, Walker U, Steen V. A comprehensive framework for navigating patient care in systemic sclerosis: A global response to the need for improving the practice of diagnostic and preventive strategies in SSc. Best Pract Res Clin Rheumatol 2021; 35:101707. [PMID: 34538573 PMCID: PMC8670736 DOI: 10.1016/j.berh.2021.101707] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Systemic sclerosis (SSc), the most lethal of rheumatologic conditions, is the cause of death in >50% of SSc cases, led by pulmonary fibrosis followed by pulmonary hypertension and then scleroderma renal crisis (SRC). Multiple other preventable and treatable SSc-related vascular, cardiac, gastrointestinal, nutritional and musculoskeletal complications can lead to disability and death. Vascular injury with subsequent inflammation transforming to irreversible fibrosis and permanent damage characterizes SSc. Organ involvement is often present early in the disease course of SSc, but requires careful history-taking and vigilance in screening to detect. Inflammation is potentially reversible provided that treatment intensity quells inflammation and other immune mechanisms. In any SSc phenotype, opportunities for early treatment are prone to be under-utilized, especially in slowly progressive phenotypes that, in contrast to severe progressive ILD, indolently accrue irreversible organ damage resulting in later-stage life-limiting complications such as pulmonary hypertension, cardiac involvement, and malnutrition. A single SSc patient visit often requires much more physician and staff time, organization, vigilance, and direct management for multiple organ systems compared to other rheumatic or pulmonary diseases. Efficiency and efficacy of comprehensive SSc care enlists trending of symptoms and bio-data. Financial sustainability of SSc care benefits from understanding insurance reimbursement and health system allocation policies for complex patients. Sharing care between recognised SSc centers and local cardiology/pulmonary/rheumatology/gastroenterology colleagues may prevent complications and poor outcomes, while providing support to local specialists. As scleroderma specialists, we offer a practical framework with tools to facilitate an optimal, comprehensive and sustainable approach to SSc care. Improved health outcomes in SSc relies upon recogntion, management and, to the extent possible, prevention of SSc and treatment-related complications.
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Affiliation(s)
- Lesley Ann Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, USA; Tulane University School of Medicine, New Orleans, USA; Louisiana State University School of Medicine, Section of Pulmonary Medicine, New Orleans, USA; University Medical Center - Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, New Orleans, USA.
| | - Tracy Frech
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cecília Varjú
- Department of Rheumatology and Immunology, Medical School, University of Pécs, Pécs, Hungary
| | | | - Jessica Farrell
- Albany College of Pharmacy and Health Sciences, Albany, NY, USA; Steffens Scleroderma Foundation, Albany, NY, USA
| | - Jessica K Gordon
- Department of Rheumatology at Hospital for Special Surgery, New York, NY, USA
| | - Carina Mihai
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Lee Shapiro
- Steffens Scleroderma Foundation, Albany, NY, USA; Division of Rheumatology, Albany Medical Center, Albany, NY, USA
| | - Janet Poole
- Occupational Therapy Graduate Program, University of New Mexico, Albuquerque, NM, USA
| | - Elizabeth R Volkmann
- University of California, David Geffen School of Medicine, UCLA Scleroderma Program and UCLA CTD-ILD Program, Division of Rheumatology, Department of Medicine, Los Angeles, CA, USA
| | | | - Kendra McAnally
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Centre, Phoenix, AZ, USA
| | - Helene Alexanderson
- Function Allied Health Professionals, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden; Department of Medicin, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Pettersson
- Function Allied Health Professionals, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden; Department of Medicin, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Faye Hant
- Division of Rheumatology, Medical University of South Caroline, SC, USA
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Ami A Shah
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Vanessa Smith
- Department of Internal Medicine, Ghent University, and Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Vivien Hsu
- Rutgers- RWJ Scleroderma Program, New Brunswick, NJ, USA
| | - Otylia Kowal-Bielecka
- Department of Rheumatology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Shervin Assassi
- Rheumatology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS Polyclinic San Martino Hospital, Genova, Italy
| | - Cristiane Kayser
- Escola Paulista de Medicina, Federal University of São Paulo (UNIFESP) São Paulo, SP, Brazil
| | - Victoria K Shanmugam
- Department of Rheumatology, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
| | - Madelon C Vonk
- Department of the rheumatic diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kim Fligelstone
- Patient Research Partner, Scleroderma & Raynaud Society UK (SRUK), London, UK; Royal Free Hospital, London, UK
| | - Nancy Baldwin
- Patient Research Partner, Scleroderma Foundation, Chicago, IL, USA
| | | | - Anneliese Ronnow
- Federation of European Scleroderma Associations, Copenhagen, Denmark; Federation of European Scleroderma Associations, Budapest, Hungary; Federation of European Scleroderma Associations, London, UK
| | - Beata Toth
- Federation of European Scleroderma Associations, Copenhagen, Denmark; Federation of European Scleroderma Associations, Budapest, Hungary; Federation of European Scleroderma Associations, London, UK
| | | | - Sue Farrington
- Patient Research Partner, Scleroderma & Raynaud Society UK (SRUK), London, UK; Federation of European Scleroderma Associations, Copenhagen, Denmark; Federation of European Scleroderma Associations, Budapest, Hungary; Federation of European Scleroderma Associations, London, UK
| | - Elana J Bernstein
- Columbia University/New York-Presbyterian Scleroderma Program, Division of Rheumatology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | | | - László Czirják
- Department of Rheumatology and Immunology, Medical School, University of Pécs, Pécs, Hungary
| | - Kelly Jensen
- Tulane University School of Medicine, New Orleans, USA; Oregon Health and Science University, Portland, OR, USA
| | - Monique Hinchclif
- Yale School of Medicine, Department of Internal Medicine, Section of Rheumatology, Allergy & Immunology, USA
| | - Marie Hudson
- Division of heumatology and Department of Medicine, Jewish General Hospital and McGill University, Montreal, QC, Canada
| | - Matthew R Lammi
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, USA; Louisiana State University School of Medicine, Section of Pulmonary Medicine, New Orleans, USA; University Medical Center - Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, New Orleans, USA
| | | | - Nadia D Morgan
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Fabian Mendoza
- Rheumatology Division, Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mandana Nikpour
- Jefferson Institute of Molecular Medicine and Scleroderma Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - John Pauling
- University of Melbourne, Melbourne at St. Vincent's Hospital Melbourne, Victoria, Australia
| | - Gabriela Riemekasten
- Royal National Hospital for Rheumatic Diseases, Bath, UK; University of Lübeck, University Clinic of Schleswig-Holstein, Dept Rheumatology and Clinical Immunology, Lübeck, Germany
| | | | - Mary Beth Scholand
- University of Utah, Division of Pulmonary Medicine, Pulmonary Fibrosis Center, Salt Lake City, UT, USA
| | - Elise Seigart
- Department of Rheumatology and Clinical Immunology Charité - Universitätsmedizin Berlin and Berlin Institute of Health, Berlin, Germany
| | | | - Laura Hummers
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ulrich Walker
- Dept. of Rheumatology, Basel University Hospital, Basel, Switzerland
| | - Virginia Steen
- Division of Rheumatology, Department of Medicine, Georgetown University, Washington, DC, USA
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Andréasson K, Neringer K, Wuttge DM, Henrohn D, Marsal J, Hesselstrand R. Mycophenolate mofetil for systemic sclerosis: drug exposure exhibits considerable inter-individual variation-a prospective, observational study. Arthritis Res Ther 2020; 22:230. [PMID: 33023643 PMCID: PMC7539387 DOI: 10.1186/s13075-020-02323-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 09/22/2020] [Indexed: 12/14/2022] Open
Abstract
Objective Mycophenolate mofetil (MMF) is an established therapy for systemic sclerosis (SSc), but its pharmacokinetics in this disease remains unexplored. We have investigated drug exposure in MMF-treated patients with SSc in relation to clinical features of the disease and common concomitant drugs. Methods This study was predefined to include 35 MMF-treated SSc patients who were using MMF at a fixed dose of 0.5, 1.0 or 1.5 g twice daily since at least 3 months. The 12-h drug exposure of the active MMF metabolite mycophenolic acid (MPA) was estimated by repeated analysis of plasma MPA over a 6-h period. This 12-h drug exposure was dose normalised to a daily intake of 3 g MMF (MPA_AUC3g) in order to compare subjects using MMF at different doses. Drug exposure was analysed in reference to the clinical characteristics including body weight, renal function, autoantibodies, intestinal dysbiosis, intestinal inflammation assessed by faecal (F)-calprotectin, intestinal symptoms assessed by the University of California Los Angeles Scleroderma Trial Consortium Gastrointestinal Tract Instrument 2.0 and concomitant drug usage including proton-pump inhibitors (PPI). Results Thirty-four out of 35 study participants completed the study. The mean daily MMF dose was 2.1 g. Drug exposure expressed as MPA_AUC3g varied up to 8-fold between patients (median 115, range 27–226 mg h/L). MPA_AUC3g was inversely related to body weight (rs = − 0.58, p < 0.001) and renal function (rs = − 0.34, p = 0.054). Anti-topoisomerase-1 antibodies and male sex were associated with lower MPA_AUC3g (87 vs 123 and 71 vs 141; p = 0.008 and p = 0.015, respectively). MPA_AUC3g was inversely related to the intestinal abundance of lactobacilli and to F-calprotectin (rs = − 0.54, p = 0.004; rs = − 0.36, p = 0.034), but not to gastrointestinal symptoms. MPA_AUC3g was inversely related to PPI usage (rs = − 0.45, p = 0.007). We found no association between MPA_AUC3g and disease subtype, disease duration or disease activity. Conclusion MMF-treated SSc patients exhibit considerable inter-individual variation in drug exposure, and lower MPA levels were primarily found in PPI users with poor prognostic factors. Body weight, renal function, sex, serology, gastrointestinal manifestations and/or measuring individual MPA exposure should be considered when using MMF for SSc.
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Affiliation(s)
- Kristofer Andréasson
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden.
| | - Karl Neringer
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden
| | - Dirk M Wuttge
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden
| | - Dan Henrohn
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Jan Marsal
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Gastroenterology, Lund, Sweden
| | - Roger Hesselstrand
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden
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Report from the 2018 consensus conference on immunomodulating agents in thoracic transplantation: Access, formulations, generics, therapeutic drug monitoring, and special populations. J Heart Lung Transplant 2020; 39:1050-1069. [DOI: 10.1016/j.healun.2020.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 06/29/2020] [Indexed: 01/06/2023] Open
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10
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Neuberger M, Sommerer C, Böhnisch S, Metzendorf N, Mehrabi A, Stremmel W, Gotthardt D, Zeier M, Weiss KH, Rupp C. Effect of mycophenolic acid on inosine monophosphate dehydrogenase (IMPDH) activity in liver transplant patients. Clin Res Hepatol Gastroenterol 2020; 44:543-550. [PMID: 31924555 DOI: 10.1016/j.clinre.2019.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Due to the development of immunosuppressants, the focus in transplanted patients has shifted from short-term to long-term survival as well as a better adjustment of these drugs in order to prevent over- and under-immunosuppression. Mycophenolic acid (MPA) is a noncompetitive inhibitor of inosine monophosphate dehydrogenase (IMPDH) and approved for prophylaxis of acute rejection after kidney, heart, and liver transplantation, where it has become a part of the standard therapy. Targeting inosine monophosphate IMPDH activity as a surrogate pharmacodynamic marker of MPA-induced immunosuppression may allow a more accurate assessment of efficacy and aid in limiting toxicity in liver transplanted patients. AIM Assess IMPDH-inhibition in liver transplant recipients and its impact on biliary/infectious complications, acute cellular rejection (ACR) and liver dependent survival. METHODS This observational cohort study comprises 117 liver transplanted patients that were treated with mycophenolate mofetil (MMF) for at least 3 months. Blood samples (BS) were collected and MPA serum level and IMPDH activity were measured before (t(0)), 30minutes (t(30)) and 2h after (t(120)) MMF morning dose administration. Regarding MPA, we assessed the area under the curve (AUC). Patients were prospectively followed up for one year and assessed for infectious and biliary complications, episodes of ACR and liver dependent survival. RESULTS The MPA levels showed a broad interindividual variability at t(0) (2.0±1.8ng/ml), t(30) (12.7±9.0ng/ml) and t(120) (7.5±4.3ng/ml). Corresponding IMPDH activity was at t(o) (23.2±9.5 nmol/h/mg), at t(30) (16.3±8.8 nmol/h/mg) and t(120) (18.2±8.7 nmol/h/mg). With regard to MPA level we found no correlation with infectious or biliary complications within the follow-up period. Patients with baseline IMPDH(a) below the median had significant more viral infections (6 (10.2%) vs. 17 (29.3%); P=0.009) with especially more cytomegalovirus (CMV) infections (1 (3.4%) vs. 6 (21.4%); P=0.03)). Furthermore, patients with baseline IMPDH(a) above the median developed more often non-anastomotic biliary strictures (8 (13.6%) vs. 1 (1.7%), P=0.03). We found the group reaching the combined clinical endpoint of death and re-transplantation showing significantly lower MPA baseline values (t(0) 0.9±0.7 vs. 2.1±1.8μg/ml Mann-Whitney-U: P=0.02). We calculated a simplified MPA(AUC) with the MPA level at baseline, 30 and 120minutes after MPA administration. Whereas we found no differences with regard to baseline characteristics at entry into the study patients with MPA (AUC) below the median experienced significantly more often the combined clinical endpoint (12.1% (7/58) vs. 0.0% (0/57); P=0.002) and had a reduced actuarial re-transplantation-free survival (1.0 year vs. 0.58 years; Log-rank: P=0.007) during the prospective one-year follow-up period. In univariate and multivariate analysis including gender, age, BMI, ACR, MPA (AUC) and IMPDH(a) only BMI, MPA (AUC) and IMPDH(a) were independently associated with reduced actuarial re-transplantation-free survival. CONCLUSION MPA-levels and IMPDH-activity in liver transplanted patients allows individual risk assessment. Patients with higher IMPDH inhibition acquire more often viral infections. Insufficient IMPDH inhibition is associated with development of non-anastomotic bile duct strictures and reduced re-transplantation-free survival.
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Affiliation(s)
- M Neuberger
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany
| | - C Sommerer
- University Hospital Heidelberg, Division of Nephrology, 69120 Heidelberg, Germany
| | - S Böhnisch
- University Hospital Heidelberg, Division of Nephrology, 69120 Heidelberg, Germany
| | - N Metzendorf
- University Hospital Heidelberg, Division of Nephrology, 69120 Heidelberg, Germany
| | - A Mehrabi
- University of Heidelberg, Department of General, Visceral, and Transplantation Surgery, 69120 Heidelberg, Germany
| | - W Stremmel
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany
| | - D Gotthardt
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany
| | - M Zeier
- University Hospital Heidelberg, Division of Nephrology, 69120 Heidelberg, Germany
| | - K H Weiss
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany
| | - C Rupp
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany.
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11
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The Effect of Proton Pump Inhibitor Use on Renal Function in Kidney Transplanted Patients. J Clin Med 2020; 9:jcm9010258. [PMID: 31963650 PMCID: PMC7019820 DOI: 10.3390/jcm9010258] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 01/15/2020] [Accepted: 01/15/2020] [Indexed: 12/20/2022] Open
Abstract
Recently, proton pump inhibitor (PPI) intake has been linked to acute kidney injury and chronic kidney disease. The objective of this study was to assess the effect of PPIs on renal function and rejection rate in kidney transplant patients. We performed a single center, retrospective analysis of 455 patients who received a kidney transplant between May 2010 and July 2015. Median follow-up time was 3.3 years. PPI prescription was assessed in half-year intervals. Primary outcome parameters were the estimated glomerular filtration rate (eGFR), change in the eGFR, and >30% and >50% eGFR decline for different time periods (up to four years post-transplantation). Our secondary outcome parameter was occurrence of biopsy proven acute rejection (BPAR) in the first two years after transplantation. Except for >30% eGFR decline from half a year to two years post-transplantation (p = 0.044) and change in the eGFR, >30% and >50% eGFR decline showed no association with PPI intake in our patient cohort (p > 0.05). Similarly, by analyzing 158 rejection episodes, BPAR showed no correspondence with mean daily PPI intake. We conclude that prolonged PPI intake has no relevant adverse effect on kidney transplant function or rejection rates. Polypharmacy, however, remains a problem in renal transplant recipients and it is thus advisable to question the necessity of PPI prescriptions when clear indications are missing.
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12
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Benjanuwattra J, Pruksakorn D, Koonrungsesomboon N. Mycophenolic Acid and Its Pharmacokinetic Drug‐Drug Interactions in Humans: Review of the Evidence and Clinical Implications. J Clin Pharmacol 2019; 60:295-311. [DOI: 10.1002/jcph.1565] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 11/08/2019] [Indexed: 12/14/2022]
Affiliation(s)
| | - Dumnoensun Pruksakorn
- Musculoskeletal Science and Translational Research Center Chiang Mai University Chiang Mai Thailand
- Department of Orthopedics, Faculty of Medicine Chiang Mai University Chiang Mai Thailand
| | - Nut Koonrungsesomboon
- Department of Pharmacology, Faculty of Medicine Chiang Mai University Chiang Mai Thailand
- Musculoskeletal Science and Translational Research Center Chiang Mai University Chiang Mai Thailand
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13
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Boonpheng B, Thongprayoon C, Bathini T, Sharma K, Mao MA, Cheungpasitporn W. Proton pump inhibitors and adverse effects in kidney transplant recipients: A meta-analysis. World J Transplant 2019; 9:35-47. [PMID: 31363460 PMCID: PMC6656659 DOI: 10.5500/wjt.v9.i2.35] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/26/2019] [Accepted: 05/14/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The adverse renal effects of proton pump inhibitors (PPIs) are increasingly recognized in both the general population and patients with chronic kidney disease. Several pharmacokinetic studies have also raised concerns regarding the interaction between PPIs and immunosuppressive drugs in transplant patients. Whether the adverse effects of PPIs have a clinical significance in kidney transplant recipients remains unclear. We performed this meta-analysis to assess the risk of adverse effects in kidney transplant recipients on PPI compared with those without PPI exposure.
AIM To investigate the risk of acute rejection, graft loss, hypomagnesemia, renal dysfunction, and overall mortality in kidney transplant recipients on PPI compared with those without PPI exposure.
METHODS A systematic review was conducted in MEDLINE, EMBASE, and Cochrane databases from inception through October 2018 to identify studies that evaluated the adverse effects of PPIs in kidney transplant recipients, including biopsy-proven acute rejection, graft loss, hypomagnesemia, renal function, and overall mortality. Effect estimates from the individual studies were extracted and combined using random-effect, generic inverse variance method of DerSimonian and Laird. The protocol for this meta-analysis is registered with PROSPERO, No. CRD42018115676.
RESULTS Fourteen observational studies with 6786 kidney transplant recipients were enrolled. No significant association was found between PPI exposure and the risk of biopsy-proven acute rejection at ≥ 1 year [pooled odds ratio (OR), 1.25; 95% confidence interval (CI), 0.82-1.91, I2 = 55%], graft loss at 1 year (pooled OR = 1.30, 95%CI: 0.75-2.24, I2 = 0%) or 1-year mortality (pooled OR = 1.53, 95%CI: 0.90-2.58, I2 = 34%). However, PPI exposure was significantly associated with hypomagnesemia (pooled OR = 1.56, 95%CI: 1.19-2.05, I2 = 27%). Funnel plots and Egger regression asymmetry test were performed and showed no publication bias.
CONCLUSION PPI use was not associated with significant risks of higher acute rejection, graft loss, or 1-year mortality. However, the risk of hypomagnesemia was significantly increased with PPI use. Thus, future studies are needed to assess the impact of PPIs on long-term outcomes.
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Affiliation(s)
- Boonphiphop Boonpheng
- Department of Internal Medicine, East Tennessee State University, Johnson City, TN37614, United States
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN55905, United States
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ85721, United States
| | - Konika Sharma
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY13326, United States
| | - Michael A Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN55905, United States
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS39216, United States
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14
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Nosadini M, Gadian J, Lim M, Sartori S, Thomas T, Dale RC. Mycophenolate mofetil in paediatric autoimmune or immune-mediated diseases of the central nervous system: clinical experience and recommendations. Dev Med Child Neurol 2019; 61:458-468. [PMID: 30221751 DOI: 10.1111/dmcn.14020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2018] [Indexed: 12/14/2022]
Abstract
AIM To gather data on mycophenolate mofetil (MMF) in paediatric autoimmune/immune-mediated central nervous system (CNS) conditions, focusing on safety and factors that may affect MMF efficacy. METHOD Retrospective, multicentre study based on four paediatric neurology centres. RESULTS Forty-four children were included (30 females, 14 males): 19 had proven/suspected autoimmune encephalitis, 14 had inflammatory demyelinating CNS diseases, and 11 had other autoimmune/immune-mediated CNS conditions. Before MMF, all received first-line immune therapies, and 17 had second-line rituximab and/or cyclophosphamide. MMF was started at a median of 9.5 months from disease onset (range 1-127mo) (median age 9y 4mo, range 1y 5mo-16y 5mo), and was used for median 18 months (range 0.3-73mo). On MMF, 31 patients were relapse-free, whereas eight relapsed (excluding patients with chronic-progressive course). Relapses on MMF were associated with medication weaning/cessation, or with suboptimal MMF dosage/duration. Adverse events of MMF occurred in eight patients: six moderate (gastrointestinal, movement disorder, dermatological) and two severe (infectious). INTERPRETATION MMF use in paediatric neuroimmunology is heterogeneous, although relatively safe. We have identified factors that may affect MMF efficacy and provide recommendations on MMF usage. WHAT THIS PAPER ADDS Mycophenolate mofetil (MMF) use was heterogeneous with relatively common adverse events, although mostly not severe. MMF treatment reduced median annualized relapse rate, although 20% of patients relapsed on MMF. A high relapse rate pre-MMF and late MMF start were associated with higher probability of relapsing on MMF. Most relapses were associated with suboptimal MMF dosage, short MMF duration, or concurrent medication weaning/discontinuation.
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Affiliation(s)
- Margherita Nosadini
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Kids Research at the Children's Hospital at Westmead, University of Sydney, Westmead, Australia.,Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Jonathan Gadian
- Children's Neurosciences Centre, Guy's & St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, Evelina London Children's Hospital, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Ming Lim
- Children's Neurosciences Centre, Guy's & St Thomas' NHS Foundation Trust, Kings Health Partners Academic Health Science Centre, Evelina London Children's Hospital, London, UK
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | | | - Russell C Dale
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Kids Research at the Children's Hospital at Westmead, University of Sydney, Westmead, Australia
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15
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Immunosuppressive drugs and the gastrointestinal tract in renal transplant patients. Transplant Rev (Orlando) 2018; 33:55-63. [PMID: 30473173 DOI: 10.1016/j.trre.2018.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 11/07/2018] [Accepted: 11/10/2018] [Indexed: 12/26/2022]
Abstract
Gastrointestinal (GI) discomfort is common after renal transplantation and can be caused by the use of various immunosuppressive drugs. GI symptoms affect the quality of life, lead to an impaired graft survival and an increased mortality. Moreover, diseases and disturbances of the GI tract also affect the pharmacokinetics of immunosuppressive drugs. This review addresses the interaction between immunosuppressive agents and GI disorders. The GI tract is involved in the metabolism of several immunosuppressive drugs. Calcineurin inhibitors, mTor inhibitors, and corticosteroids are subjected to metabolism by the intestinal cytochrome P450 (CYP3A) and by the drug efflux pump ABCB1. Mycophenolate is partly metabolized in the stomach and intestine and undergoes enterohepatic recirculation. Gastrointestinal disturbances can lead to a modified exposure to immunosuppressive drugs. In the first and second part of this review, we focus on the role of the GI tract in the pharmacokinetics of the immunosuppressive drugs and how to adjust immunosuppressive therapy in patients with vomiting, need for tube feeding, delayed gastric emptying, intestinal resection, and diarrhea. In the third part, we review the GI adverse effects of the various immunosuppressive drugs, with special attention for diarrhea and dyspepsia. Finally, we discuss the effects of drugs used for relief of GI complaints on the exposure to immunosuppressive agents.
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16
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McCune JS, Storer B, Thomas S, McKiernan J, Gupta R, Sandmaier BM. Inosine Monophosphate Dehydrogenase Pharmacogenetics in Hematopoietic Cell Transplantation Patients. Biol Blood Marrow Transplant 2018; 24:1802-1807. [PMID: 29656138 DOI: 10.1016/j.bbmt.2018.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 04/03/2018] [Indexed: 01/18/2023]
Abstract
We evaluated inosine monophosphate dehydrogenase (IMPDH) 1 and IMPDH2 pharmacogenetics in 247 recipient-donor pairs after nonmyeloablative hematopoietic cell transplant (HCT). Patients were conditioned with total body irradiation + fludarabine and received grafts from related or unrelated donors (10% HLA mismatch), with postgraft immunosuppression of mycophenolate mofetil (MMF) with a calcineurin inhibitor. Recipient and donor IMPDH genotypes (rs11706052, rs2278294, rs2278293) were not associated with day 28 T cell chimerism, acute graft-versus-host disease (GVHD), disease relapse, cytomegalovirus reactivation, nonrelapse mortality, or overall survival. Recipient IMPDH1 rs2278293 genotype was associated with a lower incidence of chronic GVHD (hazard ratio, .72; P = .008) in nonmyeloablative HCT recipients. Additional studies are needed to confirm these results with the goal of identifying predictive biomarkers to MMF that lower GVHD.
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Affiliation(s)
- Jeannine S McCune
- School of Pharmacy, University of Washington, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Population Sciences, City of Hope, Duarte, California; Department of Hematology and HCT, City of Hope, Duarte, California.
| | - Barry Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Sushma Thomas
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jožefa McKiernan
- Department of Population Sciences, City of Hope, Duarte, California
| | - Rohan Gupta
- Department of Hematology and HCT, City of Hope, Duarte, California
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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17
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Patel KS, Stephany BR, Barnes JF, Bauer SR, Spinner ML. Renal Transplant Acute Rejection with Lower Mycophenolate Mofetil Dosing and Proton Pump Inhibitors or Histamine-2 Receptor Antagonists. Pharmacotherapy 2017; 37:1507-1515. [PMID: 28976570 DOI: 10.1002/phar.2037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Pharmacokinetic data show reduced mycophenolic acid levels in renal transplant recipients taking mycophenolate mofetil (MMF) and proton pump inhibitors (PPIs) concomitantly. This reduced exposure could increase rejection risk. The typical initial MMF dose post renal transplantation is 2 g/day, which often requires dose reduction secondary to side effects. Existing studies have not shown significant acute rejection differences for patients taking MMF-PPI versus patients taking MMF-ranitidine. OBJECTIVE The purpose of this study was to evaluate clinical outcomes in renal transplant recipients receiving a lower MMF dose than previously studied (1.5 g/day) and either a PPI or histamine-2 receptor antagonist (H2RA). METHODS This retrospective cohort study included adult subjects receiving a renal transplant between January 1, 2009, and June 30, 2013. Comparison groups were defined based on acid-suppressing therapy class prescribed at discharge from transplantation. The primary outcome was acute rejection incidence within 1 year posttransplantation. RESULTS Of 728 renal transplant recipients screened, 522 were included: 183 taking a PPI and 339 taking an H2RA. There was no significant difference in acute rejection within 1 year (H2RA 19% versus PPI 14%, p=0.12) or 3 months (4% vs 5%, p=0.44, respectively) posttransplantation. Maintenance immunosuppression (MMF dose and tacrolimus troughs) was similar between groups at 3 months and 1 year. Graft and patient survivals were favorable (> 95%), and graft function at 1 year was stable and similar between groups. CONCLUSION Despite taking lower MMF doses than previously studied, subjects on a PPI compared to an H2RA were not at increased risk of acute rejection within 1 year posttransplantation.
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Affiliation(s)
- Kajal S Patel
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
| | - Brian R Stephany
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio
| | - Julie F Barnes
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
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18
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Johnson DA, Katz PO, Armstrong D, Cohen H, Delaney BC, Howden CW, Katelaris P, Tutuian RI, Castell DO. The Safety of Appropriate Use of Over-the-Counter Proton Pump Inhibitors: An Evidence-Based Review and Delphi Consensus. Drugs 2017; 77:547-561. [PMID: 28233274 PMCID: PMC5357248 DOI: 10.1007/s40265-017-0712-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The availability of over-the-counter (OTC) proton pump inhibitors (PPIs) for the short-term (2 weeks) management of frequent heartburn (≥2 days/week) has increased markedly, yet evidence-based recommendations have not been developed. A panel of nine international experts in gastroesophageal reflux disease developed consensus statements regarding the risks and benefits of OTC PPIs using a modified Delphi process. Consensus (based on ≥80% approval) was reached through multiple rounds of remote voting and a final round of live voting. To identify relevant data, the available literature was searched and summarized. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system terminology was used to rate the quality of evidence and strength of recommendations; consensus was based on ≥2/3 agreement. After 4 rounds of review, consensus was achieved for 18 statements. Notably, the available data did not directly reflect OTC use, but instead, prescription use; therefore, extrapolations to the OTC setting were often necessary. This limitation is regrettable, but it justifies performing this exercise to provide evidence-based expert opinion on a widely used class of drugs. The panel determined that using OTC PPIs according to label instructions is unlikely to mask the symptoms of esophageal or gastric cancer or adversely impact the natural history of related precursor conditions. OTC PPIs are not expected to substantially affect micronutrient absorption or bone mineral density or cause community-acquired pneumonia, Clostridium difficile infection, or cardiovascular adverse events. However, OTC PPI use may be associated with slightly increased risks for infectious diarrhea, certain idiosyncratic reactions, and cirrhosis-related spontaneous bacterial peritonitis. The available evidence does not suggest that OTC PPI use consistent with label instructions is associated with substantial health risks. To minimize potential risks, healthcare professionals and consumers must actively participate in decision making when managing reflux-related symptoms in the self-care setting.
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Affiliation(s)
- David A Johnson
- Department of Gastroenterology, Eastern Virginia Medical School, 885 Kempsville Rd, Suite 114, Norfolk, VA, 23505, USA.
| | - Philip O Katz
- Division of Gastroenterology, Einstein Medical Center, 5401 Old York Rd, Suite 363 Klein Building, Philadelphia, PA, 19141, USA.
| | - David Armstrong
- Division of Gastroenterology, McMaster University, HSC-3V3, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Henry Cohen
- Department of Gastroenterology, National University of Uruguay, Av. Italia 2370, 11600, Montevideo, Uruguay
| | - Brendan C Delaney
- Department of Surgery and Cancer, Imperial College, Kensington, London, SW7 2AZ, UK
| | - Colin W Howden
- Division of Gastroenterology, University of Tennessee Health Science Center, 956 Court Avenue, Suite H210, Memphis, TN, 38163, USA
| | - Peter Katelaris
- Department of Gastroenterology, University of Sydney, Concord, Sydney, 2139, Australia
| | - Radu I Tutuian
- Department of Gastroenterology, University of Bern School of Medicine, Freiburgerstr 10, Bern, Switzerland
| | - Donald O Castell
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, 11 Harleston Place, Charleston, SC, 29401, USA
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19
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Courson AY, Lee JR, Aull MJ, Lee JH, Kapur S, McDermott JK. Routine prophylaxis with proton pump inhibitors and post-transplant complications in kidney transplant recipients undergoing early corticosteroid withdrawal. Clin Transplant 2016; 30:694-702. [PMID: 27004722 DOI: 10.1111/ctr.12736] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2016] [Indexed: 12/11/2022]
Abstract
Surgical stress, corticosteroids, and mycophenolate may contribute to gastrointestinal ulcers/bleeding after kidney transplantation. Prophylactic acid suppression with H2RAs or PPIs is often utilized after transplantation, although unclear if truly indicated after early corticosteroid withdrawal (CSWD). PPIs have been associated with increased risks of Clostridium difficile infection (CDI), pneumonia, and acute rejection. This retrospective cohort study investigated benefits and risks of prolonged PPI use following kidney transplantation and included 286 kidney recipients undergoing CSWD within five d of transplant who were maintained on tacrolimus and mycophenolate mofetil/sodium. Patients on PPI before transplant, H2RA before/after transplant, and/or those with pre-transplant GI complications were excluded. A total of 171 patients received PPI>30 d, mean duration 287 ± 120 d (PPI group); 115 patients were not maintained on acid suppression (No-PPI group). GI ulceration and bleeding events were rare in PPI group (1.2% and 2.3%, respectively) and not observed in No-PPI group (p = NS). The incidence of infectious or hematological complications was not significantly different between groups. The PPI group experienced more biopsy-proven acute rejection (9.4% vs. 2.6%, p = 0.03). No direct benefit was observed with PPI in reducing the incidence of GI ulcers and bleeding events in kidney transplant recipients undergoing early CSWD. Further studies are needed to investigate the association of PPI and acute rejection.
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Affiliation(s)
- Alesa Y Courson
- Department of Pharmacy, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA.,Department of Pharmacy, Montefiore Medical Center, Bronx, NY, USA
| | - John R Lee
- Division of Nephrology, Department of Medicine, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
| | - Meredith J Aull
- Division of Transplantation Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
| | - Jennifer H Lee
- Department of Pharmacy, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
| | - Sandip Kapur
- Division of Transplantation Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
| | - Jennifer K McDermott
- Department of Pharmacy, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA.,Department of Pharmacy, Spectrum Health, Grand Rapids, MI, USA
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21
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Schaier M, Scholl C, Scharpf D, Schmitt WH, Schwenger V, Zeier M, Sommerer C. High interpatient variability in response to mycophenolic acid maintenance therapy in patients with ANCA-associated vasculitis. Nephrol Dial Transplant 2015; 30 Suppl 1:i138-45. [PMID: 25805745 DOI: 10.1093/ndt/gfv065] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Mycophenolic acid (MPA) is used in the maintenance therapy of antineutrophil cytoplasm antibody-associated systemic vasculitis (AASV). MPA exerts its immunosuppression by inhibiting inosine 5'-monophosphate dehydrogenase (IMPDH), depleting activated lymphocytes of guanine nucleotides and retarding their proliferation. The purpose of our study was to examine the correlation between clinical outcome and pharmacokinetic-pharmacodynamic (PD) relationships of MPA in patients with AASV. METHODS We studied 358 Caucasian control patients without any MPA therapy to examine basal IMPDH activity. Thirty Caucasian patients with AASV under maintenance therapy with mycophenolate mofetil (MMF) underwent therapeutic drug monitoring. RESULTS We observed a high interindividual variability with regard to basal IMPDH activity in patients without any MPA treatment (0.8-35 nmol/mg protein/h). Patients were followed for a mean (±SD) period of 22 ± 8 months. During the observation period, seven patients had a relapse with an elevated Birmingham Vasculitis Activity Score of 9.2 ± 6. The basal IMPDH activity (Abasal) in patients who subsequently relapsed was raised at baseline, before receiving their first dose of MMF, and further increased at the time of relapse, when compared with stable patients. Patients with a relapse during the maintenance therapy had significantly higher levels of IMPDH activity [IMPDH enzyme activity curve (AEC) (0-12)] than stable patients (P = 0.001), indicating inadequate IMPDH suppression. MPA-AUC (0-12) was significantly decreased in relapse patients, in contrast to stable patients (P < 0.05). CONCLUSIONS Due to the highly variable response to maintenance therapy with MPA, PD drug monitoring is a new tool for detecting inadequate immunosuppression in AASV patients.
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Affiliation(s)
- Matthias Schaier
- Department of Nephrology, University of Heidelberg, University Hospital Heidelberg and Mannheim, Heidelberg, Germany
| | - Christian Scholl
- Department of Nephrology, University of Heidelberg, University Hospital Heidelberg and Mannheim, Heidelberg, Germany
| | - Dominik Scharpf
- Department of Nephrology, University of Heidelberg, University Hospital Heidelberg and Mannheim, Heidelberg, Germany
| | - Wilhelm H Schmitt
- Department of Nephrology, University of Heidelberg, University Hospital Heidelberg and Mannheim, Heidelberg, Germany
| | - Vedat Schwenger
- Department of Nephrology, University of Heidelberg, University Hospital Heidelberg and Mannheim, Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology, University of Heidelberg, University Hospital Heidelberg and Mannheim, Heidelberg, Germany
| | - Claudia Sommerer
- Department of Nephrology, University of Heidelberg, University Hospital Heidelberg and Mannheim, Heidelberg, Germany
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Rissling O, Glander P, Hambach P, Mai M, Brakemeier S, Klonower D, Halleck F, Singer E, Schrezenmeier EV, Dürr M, Neumayer HH, Budde K. No relevant pharmacokinetic interaction between pantoprazole and mycophenolate in renal transplant patients: a randomized crossover study. Br J Clin Pharmacol 2015; 80:1086-96. [PMID: 25913040 DOI: 10.1111/bcp.12664] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/04/2015] [Accepted: 04/20/2015] [Indexed: 02/03/2023] Open
Abstract
AIMS Mycophenolic acid (MPA) suppresses lymphocyte proliferation through inosine monophosphate dehydrogenase (IMPDH) inhibition. Two formulations have been approved: mycophenolate mofetil (MMF) and enteric-coated mycophenolate sodium (EC-MPS). Pantoprazole (PAN) inhibits gastric acid secretion, which may alter MPA exposure. Data from healthy volunteers suggest a significant drug-drug interaction (DDA) between pantoprazole and MPA. In transplant patients, a decreased MPA area under the concentration-time curve (AUC) may lead to higher IMPDH activity, which may lead to higher acute rejection risk. Therefore this DDA was evaluated in renal transplant patients under maintenance immunosuppressive therapy. METHODS In this single-centre, open, randomized, four-sequence, four-treatment crossover study, the influence of PAN 40 mg on MPA pharmacokinetics such as (dose-adjusted) AUC0-12 h (dAUC) was analysed in 20 renal transplant patients (>6 months post-transplantation) receiving MMF (1-2 g day(-1) ) and EC-MPS in combination with ciclosporin. The major metabolite MPA glucuronide (MPAG) and the IMPDH activity were also examined. RESULTS MMF + PAN intake led to a lowest mean dAUC for MPA of 41.46 ng h ml(-1) mg(-1) [95% confidence interval (CI) 32.38, 50.54], while MPA exposure was highest for EC-MPS + PAN [dAUC: 46.30 ng h ml(-1) mg(-1) (95% CI 37.11, 55.49)]. Differences in dAUC and dose-adjusted maximum concentration (dCmax) were not significant. Only for MMF [dAUC: 41.46 ng h ml(-1) mg(-1) (95% CI 32.38, 50.54)] and EC-MPS [dAUC: 43.39 ng h ml(-1) mg(-1) (95% CI 33.44, 53.34)] bioequivalence was established for dAUC [geometric mean ratio: 101.25% (90% CI 84.60, 121.17)]. Simultaneous EC-MPS + PAN intake led to an earlier time to Cmax (tmax) [median: 2.0 h (min-max: 0.5-10.0)] than EC-MPS intake alone [3 h (1.5-12.0); P = 0.037]. Tmax was not affected for MMF [1.0 h (0.5-5.0)] ± pantoprazole [1.0 h (0.5-6.0), P = 0.928). No impact on MPAG pharmacokinetics or IMPDH activity was found. CONCLUSION Pantoprazole influences EC-MPS and MMF pharmacokinetics but as it had no impact on MPA pharmacodynamics, the immunosuppressive effect of the drug was not impaired.
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Affiliation(s)
- Olesja Rissling
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany.,Institute of Pharmacy, Department of Biology, Chemistry, Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Petra Glander
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | - Pia Hambach
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | - Marco Mai
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | - Susanne Brakemeier
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | - Daniela Klonower
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | - Eugenia Singer
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | | | - Michael Dürr
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | | | - Klemens Budde
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
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Abstract
Proton pump inhibitors (PPIs) are used extensively for the treatment of gastric acid-related disorders, often over the long term, which raises the potential for clinically significant drug interactions in patients receiving concomitant medications. These drug–drug interactions have been previously reviewed. However, the current knowledge is likely to have advanced, so a thorough review of the literature published since 2006 was conducted. This identified new studies of drug interactions that are modulated by gastric pH. These studies showed the effect of a PPI-induced increase in intragastric pH on mycophenolate mofetil pharmacokinetics, which were characterised by a decrease in the maximum exposure and availability of mycophenolic acid, at least at early time points. Post-2006 data were also available outlining the altered pharmacokinetics of protease inhibitors with concomitant PPI exposure. New data for the more recently marketed dexlansoprazole suggest it has no impact on the pharmacokinetics of diazepam, phenytoin, theophylline and warfarin. The CYP2C19-mediated interaction that seems to exist between clopidogrel and omeprazole or esomeprazole has been shown to be clinically important in research published since the 2006 review; this effect is not seen as a class effect of PPIs. Finally, data suggest that coadministration of PPIs with methotrexate may affect methotrexate pharmacokinetics, although the mechanism of interaction is not well understood. As was shown in the previous review, individual PPIs differ in their propensities to interact with other drugs and the extent to which their interaction profiles have been defined. The interaction profiles of omeprazole and pantoprazole sodium (pantoprazole-Na) have been studied most extensively. Several studies have shown that omeprazole carries a considerable potential for drug interactions because of its high affinity for CYP2C19 and moderate affinity for CYP3A4. In contrast, pantoprazole-Na appears to have lower potential for interactions with other medications. Lansoprazole and rabeprazole also seem to have a weaker potential for interactions than omeprazole, although their interaction profiles, along with those of esomeprazole and dexlansoprazole, have been less extensively investigated. Only a few drug interactions involving PPIs are of clinical significance. Nonetheless, the potential for drug interactions should be considered when choosing a PPI to manage gastric acid-related disorders. This is particularly relevant for elderly patients taking multiple medications, or for those receiving a concomitant medication with a narrow therapeutic index.
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Concomitant proton pump inhibitors with mycophenolate mofetil and the risk of rejection in kidney transplant recipients. Transplantation 2014; 97:518-24. [PMID: 24162246 DOI: 10.1097/01.tp.0000436100.65983.10] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Recent pharmacokinetic studies have demonstrated that proton pump inhibitors (PPI) reduce exposure of mycophenolic acid. However, the clinical significance of this drug-drug interaction on transplantation outcomes has not been determined. METHODS This was a retrospective cohort study in kidney transplant recipients who were prescribed rabbit antithymocyte globulin, calcineurin inhibitor, mycophenolate mofetil, and steroids. We evaluated the impact of PPI use on the 1-year rates of biopsy-proven acute rejection (BPAR). RESULTS Two hundred thirteen patients who were prescribed PPI were compared with 384 patients who were on standard acid-suppressive therapy with ranitidine. BPAR occurred in similar rates in both groups (15% vs. 12%; P=0.31). In a multivariable analysis, black race was associated with a higher risk of rejection (risk ratio [RR], 2.38; 95% confidence interval [CI], 1.41-4.03). While controlling for rejection risk factors, PPI exposure was associated with an increased risk of rejection in black patients (RR, 1.93; 95% CI, 1.18-3.16) but not in non-black patients (RR, 0.54; 95% CI, 0.19-1.49). At 1 year, BPAR type, BPAR grade, patient and graft survival, graft function, and time to BPAR were not associated with PPI exposure. CONCLUSION In this retrospective study, PPI use in the first transplant year was associated with an increased risk for BPAR in black patients but not in non-black patients. It is possible that a reduction in mycophenolic acid exposure contributed to the increased risk.
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High prevalence of potential drug interactions affecting mycophenolic acid pharmacokinetics in nonmyeloablative hematopoietic stem cell transplant recipients. Int J Clin Pharmacol Ther 2013; 51:711-7. [PMID: 23782584 PMCID: PMC3758456 DOI: 10.5414/cp201884] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2013] [Indexed: 11/25/2022] Open
Abstract
Objective: Mycophenolic acid (MPA) exposure is associated with clinical outcomes in hematopoietic cell transplant (HCT) recipients. Various drug interaction studies, predominantly in healthy volunteers or solid organ transplant recipients, have identified medications which impact MPA pharmacokinetics. Recipients of nonmyeloablative HCT, however, have an increased burden of comorbidities, potentially increasing the number of concomitant medications and potential drug interactions (PDI) affecting MPA exposure. Thus, we sought to be the first to characterize these PDI in nonmyeloablative HCT recipients. Materials and methods: We compiled PDI affecting MPA pharmacokinetics and characterized the prevalence of PDI in nonmyeloablative HCT recipients. A comprehensive literature evaluation of four databases and PubMed was conducted to identify medications with PDI affecting MPA pharmacokinetics. Subsequently, a retrospective medication review was conducted to characterize the cumulative PDI burden, defined as the number of PDI for an individual patient over the first 21 days after allogeneic graft infusion, in 84 nonmyeloablative HCT recipients. Results: Of the 187 concomitant medications, 11 (5.9%) had a PDI affecting MPA pharmacokinetics. 87% of 84 patients had one PDI, with a median cumulative PDI burden of 2 (range 0 – 4). The most common PDI, in descending order, were cyclosporine, omeprazole and pantoprazole. Conclusion: Only a minority of medications (5.9%) have a PDI affecting MPA pharmacokinetics. However, the majority of nonmyeloablative HCT recipients had a PDI, with cyclosporine and the proton pump inhibitors being the most common. A better understanding of PDI and their management should lead to safer medication regimens for nonmyeloablative HCT recipients.
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Abd Rahman AN, Tett SE, Staatz CE. Clinical Pharmacokinetics and Pharmacodynamics of Mycophenolate in Patients with Autoimmune Disease. Clin Pharmacokinet 2013; 52:303-31. [DOI: 10.1007/s40262-013-0039-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
Clinically relevant drug-drug interactions contribute considerably to potentially dangerous drug side-effects and are frequently the reason for hospitalization. Nevertheless they are often overlooked in daily practice. For most antirheumatic drugs a vast number of interactions have been described but only a minority with clinical relevance. Several potentially important drug interactions exist for non-steroidal anti-inflammatory drugs (NSAIDs), methotrexate, azathioprine, mycophenolate-mofetil and especially for cyclosporin A. Most importantly co-medication with methotrexate and sulfmethoxazole trimethoprim as well as azathioprine and allopurinol carries the risk of severe, sometimes life-threatening consequences. Nevertheless, besides these well-known high-risk combinations in each case of polypharmacy with antirheumatic drugs it is necessary to bear in mind the possibility of drug interactions. As polypharmacy is a common therapeutic practice in older patients with rheumatic diseases, they are at special risk.
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Gabardi S, Olyaei A. Evaluation of potential interactions between mycophenolic acid derivatives and proton pump inhibitors. Ann Pharmacother 2012; 46:1054-64. [PMID: 22811345 DOI: 10.1345/aph.1r071] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To evaluate the incidence of gastrointestinal (GI) complications in solid organ transplant (SOT) recipients, impact of the complications on transplant outcomes, and the potential interactions between mycophenolic acid (MPA) derivatives and proton pump inhibitors (PPIs). DATA SOURCES An unrestricted literature search (1980-January 2012) was performed with MEDLINE and EMBASE using the following key words: drug-drug interaction, enteric-coated mycophenolic acid, GI complications, mycophenolate mofetil, solid organ transplant, and proton pump inhibitor, including individual agents within the class. Abstracts from scientific meetings were also evaluated. Additionally, reference citations from identified publications were reviewed. STUDY SELECTION AND DATA EXTRACTION Relevant English-language, original research articles and review articles were evaluated if they focused on any of the topics identified in the search or included substantial content addressing GI complications in SOT recipients or drug interactions. DATA SYNTHESIS GI complications are frequent among SOT recipients, with some studies showing prevalence rates as high as 70%. Transplant outcomes among renal transplant recipients are significantly impacted by GI complications, especially in patients requiring immunosuppressant dosage reductions or premature discontinuation. To this end, PPI use among patients receiving transplants is common. Recent data demonstrate that PPIs significantly reduce the overall exposure to MPA after oral administration of mycophenolate mofetil. Similar studies show this interaction does not exist between PPIs and enteric-coated mycophenolic acid (EC-MPA). Unfortunately, most of the available data evaluating this interaction are pharmacokinetic analyses that do not investigate the clinical impact of this interaction. CONCLUSIONS A significant interaction exists between PPIs and mycophenolate mofetil secondary to reduced dissolution of mycophenolate mofetil in higher pH environments. EC-MPA is not absorbed in the stomach; therefore, low intragastric acidity does not impact EC-MPA and bioavailability is maintained with this formulation during PPI coadministration. The clinical impact of this interaction is unknown, yet one can theorize that reduced exposure to MPA in SOT recipients can increase the risk of allograft rejection and/or failure.
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Affiliation(s)
- Steven Gabardi
- Department of Transplant Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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Lange U, Müller-Ladner U. [Potential interactions of rheumatologic medications in the elderly]. DER ORTHOPADE 2012; 41:539-545. [PMID: 22732770 DOI: 10.1007/s00132-012-1930-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Improving the safety of prescriptions for elderly patients is of substantial interest for physicians of all specialities as well as for general health policy and health services. Owing to the increase in drug prescriptions with age and various drug-drug interactions, the number of adverse drug event-related hospital admissions needs to be minimized as far as possible. Therefore, the present overview focuses on the most important potential drug-drug interactions with a specific focus on antirheumatic medications prescribed for elderly patients.
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Affiliation(s)
- U Lange
- Internistische Rheumatologie, Osteologie, Physikalische Medizin, Justus-Liebig-Universität Gießen, Gießen, Deutschland.
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Diminished Mycophenolic Acid Exposure Caused by Omeprazole May Be Clinically Relevant in the First Week Posttransplantation. Ther Drug Monit 2012; 34:331-6. [DOI: 10.1097/ftd.0b013e31824d6e8e] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kees MG, Steinke T, Moritz S, Rupprecht K, Paulus EM, Kees F, Bucher M, Faerber L. Omeprazole impairs the absorption of mycophenolate mofetil but not of enteric-coated mycophenolate sodium in healthy volunteers. J Clin Pharmacol 2011; 52:1265-72. [PMID: 21903891 DOI: 10.1177/0091270011412968] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 2 crossover studies, 12 healthy volunteers (6 male/6 female) received a single oral dose of mycophenolate mofetil (MMF) 1000 mg or an equimolar dose of enteric-coated mycophenolate sodium (EC-MPS) 720 mg fasting with and without coadministered omeprazole 20 mg bid. The plasma concentrations of mycophenolic acid (MPA) and of the inactive metabolite mycophenolic acid glucuronide (MPA-G) were measured by high-performance liquid chromatography (HPLC). In addition, dissolution of MMF 500 mg or EC-MPS 360 mg tablets was determined using an USP paddle apparatus in aqueous buffer of pH 1 to 7. The bioavailability of MPA following administration of MMF or EC-MPS was similar except for the time to peak concentration, which was longer in the EC-MPS group. Concomitant treatment with omeprazole lowered significantly C(max) and AUC(12h) of MPA following administration of MMF. The pharmacokinetics of EC-MPS was not affected. Dissolution of MMF in aqueous buffer decreased dramatically at pH above 4.5. The EC-MPS tablet was stable up to pH 5. Above, EC-MPS was quantitatively disintegrated and MPS quantitatively dissolved. There is strong evidence that impaired absorption of MMF with concomitant proton pump inhibitors is due to incomplete dissolution of MMF in the stomach at elevated pH.
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Affiliation(s)
- M G Kees
- Department of Anesthesiology and Intensive Care, Charité University Hospital Berlin-Campus Benjamin Franklin, Hindenburgdamm, Berlin, Germany.
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The role of proton pump inhibitors on early mycophenolic acid exposure in kidney transplantation: evidence from the CLEAR study. Ther Drug Monit 2011; 33:120-3. [PMID: 21192310 DOI: 10.1097/ftd.0b013e318206a1b1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Proton pump inhibitors (PPIs) are often prescribed posttransplantation to prevent gastrointestinal complications. A series of recent studies have reported a relationship between PPI comedication and decreased mycophenolic acid (MPA) exposure. The objective of this subanalysis of the CLEAR data set was to determine the impact of PPI therapy on full MPA area under the curve exposures at Day 5 post kidney transplant. MATERIAL AND METHODS Patients were randomized to receive either intensified dosing of mycophenolate mofetil (1.5 g twice daily on Days 1-5, then 1.0 g twice daily, n = 68) or standard dosing (1.0 g twice daily, n = 67). All recipients received tacrolimus and prednisone. RESULTS In the modified intention-to-treat population, 57.9% of patients (73 of 126) received PPI therapy. The most frequently administered therapies were pantoprazole and omeprazole. There was no significant difference in mean MPA area under the curve at Day 5 for patients receiving PPI therapy as compared with those not receiving PPI therapy (51.3 versus 55.8 mg.h/L, P = 0.265). However, the MPA concentration-time curve analysis demonstrated a significant decrease in MPA concentrations at 2 hours and 12 hours postdose in patients receiving PPI therapy (P = 0.0009 and P = 0.034). No significant differences were identified in the 3-g arm specifically. In the multivariate model, only serum creatinine and albumin significantly predicted MPA area under the curve less than 30 mg.h/L at Day 5. DISCUSSION AND CONCLUSION PPI therapy in combination with mycophenolate mofetil does not appear to have a significant impact on full MPA exposure. Because MPA pharmacokinetics were not significantly impacted when a 3-g, 5-day loading dose of mycophenolate mofetil was used in combination with PPI therapy, this strategy may be required for adequate MPA exposure whether or not a patient receives PPI comedication.
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