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Foote HP, Thomassy H, Baquero L, Cayli M, Jacobs E, Paladugu A, Roy A, Heyward E, Clark RH, Hornik CP, Benjamin DK, Benjamin DK, Greenberg RG. Acyclovir Dosing Practices Across a Multicenter Cohort of Neonatal Intensive Care Units. Pediatr Infect Dis J 2024:00006454-990000000-00925. [PMID: 38920385 DOI: 10.1097/inf.0000000000004459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
BACKGROUND Acyclovir is the first-line therapy for neonatal herpes simplex virus infections. Therapy can mitigate morbidity and mortality but carries a risk for toxicity. We aimed to compare acyclovir dosing in neonatal intensive care units to published recommendations based on population pharmacokinetic (PopPK) analysis. METHODS We performed a multicenter cohort study of infants in neonatal intensive care units managed by the Pediatrix Medical Group from 1997 to 2020. We included all infants who received acyclovir with complete dosing information. Our primary outcome was the proportion of courses with dosing within 80%-120% of the PopPK recommended daily dose and at the recommended dosing frequency. We compared dosing before and after the publication of the 2014 PopPK recommendations using linear probability modeling. RESULTS We identified 6862 infants with complete dosing information across 308 centers. Dosing met PopPK recommendations for 41% of treatment courses for infants <30 weeks postmenstrual age (PMA), 71% for infants 30 to <36 weeks PMA and <1% for infants ≥ 36 weeks PMA. Comparison of dosing from 1997 to 2013 with that from 2015 to 2020 showed a significant increase in dosing meeting PopPK recommendations for infants <30 weeks PMA (P = 0.008) and infants 30 to <36 weeks PMA (P = 0.02) but not infants ≥ 36 weeks PMA (P = 0.29). No significant increase in dosing meeting PopPK recommendations was seen for any PMA group when comparison was limited to more recent years (2008-2013 vs. 2015-2020). CONCLUSIONS Dosing meeting PopPK recommendations increased over time for some PMA groups, but dosing different than PopPK recommendations remains common. More research is needed to clarify optimal dosing strategies in these infants.
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Affiliation(s)
- Henry P Foote
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Haley Thomassy
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- High School or College Student Affiliated With the Duke Clinical Research Institute's R25 Summer Training in Academic Research Program
| | - Leonardo Baquero
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- High School or College Student Affiliated With the Duke Clinical Research Institute's R25 Summer Training in Academic Research Program
| | - Mina Cayli
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- High School or College Student Affiliated With the Duke Clinical Research Institute's R25 Summer Training in Academic Research Program
| | - Elijah Jacobs
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- High School or College Student Affiliated With the Duke Clinical Research Institute's R25 Summer Training in Academic Research Program
| | - Anish Paladugu
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- High School or College Student Affiliated With the Duke Clinical Research Institute's R25 Summer Training in Academic Research Program
| | - Anisha Roy
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- High School or College Student Affiliated With the Duke Clinical Research Institute's R25 Summer Training in Academic Research Program
| | - Elizabeth Heyward
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | | | - Christoph P Hornik
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | | | - Daniel K Benjamin
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Rachel G Greenberg
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
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D'Agate S, Ruiz Gabarre D, Della Pasqua O. Population pharmacokinetics and dose rationale for aciclovir in term and pre-term neonates with herpes. Pharmacol Res Perspect 2024; 12:e1193. [PMID: 38775304 PMCID: PMC11110484 DOI: 10.1002/prp2.1193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/23/2024] [Indexed: 05/25/2024] Open
Abstract
Aciclovir is considered the first-line treatment against Herpes simplex virus (HSV) infections in new-borns and infants. As renal excretion is the major route of elimination, in renally-impaired patients, aciclovir doses are adjusted according to the degree of impairment. However, limited attention has been given to the implications of immature renal function or dysfunction due to the viral disease itself. The aim of this investigation was to characterize the pharmacokinetics of aciclovir taking into account maturation and disease processes in the neonatal population. Pharmacokinetic data obtained from 2 previously published clinical trials (n = 28) were analyzed using a nonlinear mixed effects modeling approach. Post-menstrual age (PMA) and creatinine clearance (CLCR) were assessed as descriptors of maturation and renal function. Simulation scenarios were also implemented to illustrate the use of pharmacokinetic data to extrapolate efficacy from adults. Aciclovir pharmacokinetics was described by a one-compartment model with first-order elimination. Body weight and diagnosis (systemic infection) were statistically significant covariates on the volume of distribution, whereas body weight, CLCR and PMA had a significant effect on clearance. Median clearance varied from 0.2 to 1.0 L/h in subjects with PMA <34 or ≥34 weeks, respectively. Population estimate for volume of distribution was 1.93 L with systemic infection increasing this value by almost 3-fold (2.67 times higher). A suitable model parameterization was identified, which discriminates the effects of developmental growth, maturation, and organ function. Exposure to aciclovir was found to increase with decreasing PMA and renal function (CLCR), suggesting different dosing requirement for pre-term neonates.
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Affiliation(s)
- S. D'Agate
- Clinical Pharmacology & Therapeutics GroupUniversity College LondonLondonUK
| | - D. Ruiz Gabarre
- Clinical Pharmacology & Therapeutics GroupUniversity College LondonLondonUK
- Present address:
Institute for Regeneration and RepairUniversity of EdinburghEdinburghUK
| | - O. Della Pasqua
- Clinical Pharmacology & Therapeutics GroupUniversity College LondonLondonUK
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3
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Thomas SJ, Ouellette CP. Viral meningoencephalitis in pediatric solid organ or hematopoietic cell transplant recipients: a diagnostic and therapeutic approach. Front Pediatr 2024; 12:1259088. [PMID: 38410764 PMCID: PMC10895047 DOI: 10.3389/fped.2024.1259088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 01/26/2024] [Indexed: 02/28/2024] Open
Abstract
Neurologic complications, both infectious and non-infectious, are frequent among hematopoietic cell transplant (HCT) and solid organ transplant (SOT) recipients. Up to 46% of HCT and 50% of SOT recipients experience a neurological complication, including cerebrovascular accidents, drug toxicities, as well as infections. Defects in innate, adaptive, and humoral immune function among transplant recipients predispose to opportunistic infections, including central nervous system (CNS) disease. CNS infections remain uncommon overall amongst HCT and SOT recipients, compromising approximately 1% of total cases among adult patients. Given the relatively lower number of pediatric transplant recipients, the incidence of CNS disease amongst in this population remains unknown. Although infections comprise a small percentage of the neurological complications that occur post-transplant, the associated morbidity and mortality in an immunosuppressed state makes it imperative to promptly evaluate and aggressively treat a pediatric transplant patient with suspicion for viral meningoencephalitis. This manuscript guides the reader through a broad infectious and non-infectious diagnostic differential in a transplant recipient presenting with altered mentation and fever and thereafter, elaborates on diagnostics and management of viral meningoencephalitis. Hypothetical SOT and HCT patient cases have also been constructed to illustrate the diagnostic and management process in select viral etiologies. Given the unique risk for various opportunistic viral infections resulting in CNS disease among transplant recipients, the manuscript will provide a contemporary review of the epidemiology, risk factors, diagnosis, and management of viral meningoencephalitis in these patients.
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Affiliation(s)
- Sanya J. Thomas
- Host Defense Program, Section of Infectious Diseases, Nationwide Children’s Hospital, Columbus, OH, United States
- Division of Infectious Diseases, Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, United States
| | - Christopher P. Ouellette
- Host Defense Program, Section of Infectious Diseases, Nationwide Children’s Hospital, Columbus, OH, United States
- Division of Infectious Diseases, Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, United States
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4
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Abeywickrema M, Kelly D, Kadambari S. Management of neonatal central nervous system viral infections: Knowledge gaps and research priorities. Rev Med Virol 2023; 33:e2421. [PMID: 36639694 DOI: 10.1002/rmv.2421] [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: 07/06/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 01/15/2023]
Abstract
Congenital CMV, enteroviruses, human parechovirus and herpes simplex virus are all common causes of severe central nervous system (CNS) infection in neonates. The introduction of screening (i.e. newborn hearing screening programme), integration of molecular syndromic testing (i.e. multiplex polymerase chain reaction assays) and increase in sexually transmitted infections (i.e. anogenital herpes) have contributed to increases in each of these infections over the last decade. However, therapeutic options are highly limited in part due to the lack of epidemiological data informing trials. This review will describe our current understanding of the clinical burden and epidemiology of these severe neonatal CNS infections, outline the novel antiviral and vaccines in the pipeline and suggest future research studies which could help develop new therapeutics.
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Affiliation(s)
- Movin Abeywickrema
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Dominic Kelly
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Seilesh Kadambari
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,University College London, Great Ormond Street Institute of Child Health, London, UK
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5
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Ericson JE, Benjamin DK, Boakye-Agyeman F, Cotten CM, Adler-Shohet F, Laughon M, Poindexter B, Harper B, Payne EH, Kaneshige K, Smith PB, Smith PB. Exposure-safety relationship for acyclovir in the treatment of neonatal herpes simplex virus disease. Early Hum Dev 2022; 170:105616. [PMID: 35763957 PMCID: PMC9645023 DOI: 10.1016/j.earlhumdev.2022.105616] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 06/16/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Neonatal herpes simplex virus (HSV) disease has been treated with high-dose (20 mg/kg/dose) acyclovir since 1991. AIMS Determine the safety of acyclovir in infants with neonatal HSV treated with high-dose acyclovir; examine the association between acyclovir dose and exposure with adverse events (AEs). STUDY DESIGN We obtained demographic information and acyclovir dosing via medical records. Acyclovir exposure was calculated using an established pharmacokinetic model. SUBJECTS Infants <120 days of age with neonatal HSV discharged from four academic children's hospitals. OUTCOME MEASURES We identified clinical and laboratory adverse events (AEs). RESULTS AND CONCLUSIONS We identified 49 infants with neonatal HSV treated with acyclovir; 42 infants had complete 21-day dosing information. Median mean daily dose was 59 mg/kg/day. Clinical AEs were common among all gestational and postnatal age groups. Rash was the most common clinical AE (37 %). Mild laboratory AEs occurred in 2-37 % of infants. The median maximum doses (mg/kg/day) were higher among infants with hypokalemia, elevated blood urea nitrogen, and thrombocytosis. For all other laboratory AEs, the median maximum doses for infants without events were higher or equal to the median maximum dose of infants with the AE. The odds of experiencing any clinical or laboratory AE did not differ by predicted acyclovir exposure for either area under the curve (AUC) or maximum concentration (Cmax) (odds ratio [OR] = 1.00 [0.98, 1.03] and OR = 1.01 [0.93, 1.12], respectively). Although AEs were common with high-dose acyclovir exposure, severe AEs were rare. Acyclovir exposure was not associated with AEs.
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Affiliation(s)
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC,Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Felix Boakye-Agyeman
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - C. Michael Cotten
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC,Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | | | - Matthew Laughon
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Barrie Harper
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | - P. Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States of America.
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6
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Minotti C, Barbieri E, Doni D, Impieri C, Giaquinto C, Donà D. Anti-infective Medicines Use in Children and Neonates With Pre-existing Kidney Dysfunction: A Systematic Review. Front Pediatr 2022; 10:868513. [PMID: 35558367 PMCID: PMC9087830 DOI: 10.3389/fped.2022.868513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background Dosing recommendations for anti-infective medicines in children with pre-existing kidney dysfunction are derived from adult pharmacokinetics studies and adjusted to kidney function. Due to neonatal/pediatric age and kidney impairment, modifications in renal clearance and drug metabolism make standard anti-infective dosing for children and neonates inappropriate, with a risk of drug toxicity or significant underdosing. The aim of this study was the systematic description of the use of anti-infective medicines in pediatric patients with pre-existing kidney impairment. Methods A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The EMBASE, Medline and Cochrane databases were searched on September 21st, 2021. Studies in all languages reporting data on pre-defined outcomes (pharmacokinetics-PK, kidney function, safety and efficacy) regarding the administration of anti-infective drugs in children up to 18 years with pre-existing kidney dysfunction were included. Results 29 of 1,792 articles were eligible for inclusion. There were 13 case reports, six retrospective studies, nine prospective studies and one randomized controlled trial (RCT), reporting data on 2,168 pediatric patients. The most represented anti-infective class was glycopeptides, with seven studies on vancomycin, followed by carbapenems, with five studies, mostly on meropenem. Antivirals, aminoglycosides and antifungals counted three articles, followed by combined antibiotic therapy, cephalosporins, lipopeptides with two studies, respectively. Penicillins and polymixins counted one study each. Nine studies reported data on patients with a decreased kidney function, while 20 studies included data on kidney replacement therapy (KRT). Twenty-one studies reported data on PK. In 23 studies, clinical outcomes were reported. Clinical cure was achieved in 229/242 patients. There were four cases of underdosing, one case of overdosing and 13 reported deaths. Conclusion This is the first systematic review providing evidence of the use of anti-infective medicines in pediatric patients with impaired kidney function or requiring KRT. Dosing size or interval adjustments in pediatric patients with kidney impairment vary according to age, critical illness status, decreased kidney function and dialysis type. Our findings underline the relevance of population PK in clinical practice and the need of developing predictive specific models for critical pediatric patients.
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Affiliation(s)
- Chiara Minotti
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Elisa Barbieri
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Denis Doni
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Cristina Impieri
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Carlo Giaquinto
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Daniele Donà
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
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7
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Shoji K, Saito J, Nagai Y, Hayakawa I, Oho Y, Kato H, Tao C, Funaki T, Yamada M, Ogimi C. Serum and cerebrospinal fluid acyclovir pharmacokinetics in a neonate with HSV-2 meningoencephalitis. J Infect Chemother 2022; 28:1168-1171. [PMID: 35370079 DOI: 10.1016/j.jiac.2022.03.022] [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: 01/05/2022] [Revised: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
Abstract
A neonatal patient with Herpes simplex virus type-2 meningoencephalitis was treated by high-dose intravenous acyclovir therapy. Serum and cerebrospinal fluid (CSF) concentrations were measured retrospectively, showing that the CSF-to-serum concentration ratio was 0.67-0.71, which was higher than the previously reported values in other age groups.
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Affiliation(s)
- Kensuke Shoji
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan.
| | - Jumpei Saito
- Department of Pharmacy, National Center for Child Health and Development, Tokyo, Japan
| | - Yusa Nagai
- Division of Neurology, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
| | - Itaru Hayakawa
- Division of Neurology, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
| | - Yusuke Oho
- Department of Pharmacy, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroki Kato
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Chaki Tao
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
| | - Takanori Funaki
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
| | - Masaki Yamada
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan; Department for Advanced Medicine for Viral Infections, National Center for Child Health and Development, Tokyo, Japan
| | - Chikara Ogimi
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
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8
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Motisi MA, Tamborino A, Parigi S, Galli L, de Martino M, Chiappini E. The use of antiviral drugs in children. J Chemother 2021; 34:73-86. [PMID: 34633268 DOI: 10.1080/1120009x.2021.1979746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Viral infections are particularly common among children. They often have a mild course, are self-limiting and do not need any specific treatment. However, in some cases, the disease can be severe and lead to permanent disabilities. A variety of antiviral drugs are available for the treatments of certain infectious agents: for instance, acyclovir is used to treat herpes simplex virus encephalitis. Recommendations for flu treatment may change according to the current epidemiological surveillance data, on the basis of which antiviral sensibility can be forecast: recommended drugs for the 2020-21 flu season are oseltamivir, zanamivir, peramivir and baloxavir. Some drugs are used to treat congenital infections, such as valganciclovir and ganciclovir in congenital cytomegalovirus infection. Antiretroviral prophylaxis in newborns from HIV-1 infected mothers must be initiated as soon as possible, with one or more drugs according to therapeutic regimens based on the baby's risk category. According to the most recent guidelines, antiretroviral therapy must be started at diagnosis. Several antiretroviral drugs are available today and approved for use in children, so several combinations can be made. However, out of the 29 antiretroviral drugs approved for adults, only 38% (11/29) are approved for children under the age of two and about 60% (18/29) for children under the age of twelve. Treatment with direct antiviral agents against hepatitis C virus is approved for children over the age of three; it consists in different therapeutic regimens chosen on the basis of the viral genotype (ledipasvir/sofosbuvir for genotypes 1, 4, 5 and 6, sofosbuvir/ribavirin for genotypes 2 and 3, sofosbuvir/velpatasvir and glecaprevir/pibrentasvir for all genotypes) and it has dramatically changed the course of the illness. Many molecules have been studied in order to treat SARS-CoV-2 infection, but only remdesivir seems to play a role in shortening recovery time, although inclusion criteria are very specific and data on the use in children is limited.
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Affiliation(s)
- Marco Antonio Motisi
- Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Agnese Tamborino
- Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Sara Parigi
- Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Luisa Galli
- Infectious Diseases Unit, Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Maurizio de Martino
- Infectious Diseases Unit, Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Elena Chiappini
- Infectious Diseases Unit, Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
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9
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Miller LE, DeRienzo C, Smith PB, Bose C, Clark RH, Cotten CM, Benjamin DK, Hornik CD, Greenberg RG. Association between neonatal intensive care unit medication safety practices, adverse events, and death. J Perinatol 2021; 41:1739-1744. [PMID: 33033390 DOI: 10.1038/s41372-020-00857-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/15/2020] [Accepted: 09/26/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Determine the associations between neonatal intensive care unit (NICU) medication safety practices, laboratory-based adverse events (lab-AEs), and death. STUDY DESIGN We combined data from a 2016 survey of Pediatrix NICUs on use of medication safety practices with 2014-2016 infant data. We grouped NICUs based on the number of safety practices used (≤5, 6-7, and 8-10) and evaluated the association between the number of safety practices used and lab-AEs and deaths using logistic regressions. RESULTS Of the 94 NICUs included, 17% used ≤5 medication safety practices, 51% used 6-7, and 32% used 8-10. NICUs with more safety practices did not have a difference in lab-AEs or death. CONCLUSION In this cohort, the use of more medication safety practices was not associated with fewer lab-AEs or decreased death.
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Affiliation(s)
- Laura E Miller
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Chris DeRienzo
- Department of Medicine, Division of Population Health, Stanford University, Stanford, CA, USA
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Carl Bose
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | | | - Chi D Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
- Duke Clinical Research Institute, Durham, NC, USA.
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10
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Barrett JS, Barrett RF, Vinks AA. Status Toward the Implementation of Precision Dosing in Children. J Clin Pharmacol 2021; 61 Suppl 1:S36-S51. [PMID: 34185896 DOI: 10.1002/jcph.1830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/04/2021] [Indexed: 01/19/2023]
Abstract
Precision dosing is progressing beyond the conceptual and proof-of-concept stages toward implementation. As the availability of dosing algorithms, tools, and platforms increases, so do the investment in technology services and actual implementation of clinical services offering these solutions to patients. Nowhere is this needed more than in pediatric populations, which are still reliant on adult drug development and bridging strategies to support dosing, often in the absence of actual dose-finding studies in the target pediatric population. Still, there is more work to be done to ensure that proper governance of these services is maintained, and that sustainability of these early implementations is guided by new science as it evolves and meaningful outcome data to confirm that such services deliver on both clinical and economic return on investment. In addition, the field should ensure that all approaches beyond a therapeutic drug monitoring-driven, pharmacokinetic-centric approach should be considered as the tools and services evolve, especially when pediatric-specific pharmacokinetic/pharmacodyamic and pharmacogenetic data are available and shown to be useful to guide dosing. This review evaluates current pediatric precision dosing efforts, highlighting their utility, longevity, and sustainability and assesses the current process for implementing such approaches examining current barriers that stand in the way of broader implementation and the stakeholders that must engage to ensure its ultimate success.
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Affiliation(s)
- Jeffrey S Barrett
- Quantitative Medicine, Critical Path Institute, Tucson, Arizona, USA
| | - Ryan F Barrett
- College of Chemical and Biological Engineering, Drexel University, Philadelphia, Pennsylvania, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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11
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Population Pharmacokinetics of Intravenous and Oral Acyclovir and Oral Valacyclovir in Pediatric Population To Optimize Dosing Regimens. Antimicrob Agents Chemother 2020; 64:AAC.01426-20. [PMID: 32988829 DOI: 10.1128/aac.01426-20] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/19/2020] [Indexed: 02/04/2023] Open
Abstract
Acyclovir is an antiviral currently used for the prevention and treatment of herpes simplex virus (HSV) and varicella-zoster virus (VZV) infections. This study aimed to characterize the pharmacokinetics (PK) of acyclovir and its oral prodrug valacyclovir to optimize dosing in children. Children receiving acyclovir or valacyclovir were included in this study. PK were described using nonlinear mixed-effect modeling. Dosing simulations were used to obtain trough concentrations above a 50% inhibitory concentration for HSV or VZV (0.56 mg/liter and 1.125 mg/liter, respectively) and maximal peak concentrations below 25 mg/liter. A total of 79 children (212 concentration-time observations) were included: 50 were taking intravenous (i.v.) acyclovir, 22 were taking oral acyclovir, and 7 were taking both i.v. and oral acyclovir, 57 for preventive and 22 for curative purposes. A one-compartment model with first-order elimination best described the data. An allometric model was used to describe body weight effect, and the estimated glomerular filtration rate (eGFR) was significantly associated with acyclovir elimination. To obtain target maximal and trough concentrations, the more suitable initial acyclovir i.v. dose was 10 mg/kg of body weight/6 h for children with normal renal function (eGFR ≤ 250 ml/min/1.73 m2) and 15 to 20 mg/kg/6 h for children with augmented renal clearance (ARC) (eGFR > 250 ml/min/1.73 m2). The 20-mg/kg/8 h dose for oral acyclovir and valacyclovir produced effective concentrations in more than 75% of children; however, a 15-mg/kg/6 h dose, if possible, is preferred. These doses should be prospectively confirmed, and therapeutic drug monitoring could be used to refine them individually. (This study has been registered at ClinicalTrials.gov under identifier NCT02539407.).
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12
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Sutiman N, Koh JC, Watt K, Hornik C, Murphy B, Chan YH, Lee JH. Pharmacokinetics Alterations in Critically Ill Pediatric Patients on Extracorporeal Membrane Oxygenation: A Systematic Review. Front Pediatr 2020; 8:260. [PMID: 32670992 PMCID: PMC7332755 DOI: 10.3389/fped.2020.00260] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/27/2020] [Indexed: 12/13/2022] Open
Abstract
Objectives: This study aimed to identify alterations in pharmacokinetics in children on extracorporeal membrane oxygenation (ECMO), identify knowledge gaps, and inform future pharmacology studies. Data Sources: We systematically searched the databases MEDLINE, CINAHL, and Embase from earliest publication until November 2018 using a controlled vocabulary and keywords related to "ECMO" and "pharmacokinetics," "pharmacology," "drug disposition," "dosing," and "pediatrics." Study Selection: Inclusion criteria were as follows: study population aged <18 years, supported on ECMO for any indications, received any medications while on ECMO, and reported pharmacokinetic data. Data Extraction: Clearance and/or volume of distribution values were extracted from included studies. Data Synthesis: Forty-one studies (total patients = 574) evaluating 23 drugs met the inclusion criteria. The most common drugs studied were antimicrobials (n = 13) and anticonvulsants (n = 3). Twenty-eight studies (68%) were conducted in children <1 year of age. Thirty-three studies (80%) were conducted without intra-study comparisons to non-ECMO controls. Increase in volume of distribution attributable to ECMO was demonstrated for nine (56%) drugs: cefotaxime, gentamicin, piperacillin/tazobactam, fluconazole, micafungin, levetiracetam, clonidine, midazolam, and sildenafil (range: 23-345% increase relative to non-ECMO controls), which may suggest the need for higher initial dosing. Decreased volume of distribution was reported for two drugs: acyclovir and ribavirin (50 and 69%, respectively). Decreased clearance was reported for gentamicin, ticarcillin/clavulanate, bumetanide, and ranitidine (range: 26-95% decrease relative to non-ECMO controls). Increased clearance was reported for caspofungin, micafungin, clonidine, midazolam, morphine, and sildenafil (range: 25-455% increase relative to non-ECMO controls). Conclusions: There were substantial pharmacokinetic alterations in 70% of drugs studied in children on ECMO. However, studies evaluating pharmacokinetic changes of many drug classes and those that allow direct comparisons between ECMO and non-ECMO patients are still lacking. Systematic evaluations of pharmacokinetic alterations of drugs on ECMO that incorporate multidrug opportunistic trials, physiologically based pharmacokinetic modeling, and other methods are necessary for definitive dose recommendations. Trial Registration Prospero Identifier: CRD42019114881.
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Affiliation(s)
| | - Janine Cynthia Koh
- Children's Intensive Care Unit, Department of Pediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Kevin Watt
- Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
- Duke Clinical Research Institute, Durham, NC, United States
| | - Christoph Hornik
- Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
- Duke Clinical Research Institute, Durham, NC, United States
| | - Beverly Murphy
- Duke University Medical Center Library and Archives, Durham, NC, United States
| | - Yoke Hwee Chan
- Duke-NUS Medical School, Singapore, Singapore
- Children's Intensive Care Unit, Department of Pediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore, Singapore
- Children's Intensive Care Unit, Department of Pediatrics, KK Women's and Children's Hospital, Singapore, Singapore
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Abstract
Neonatal herpes simplex virus infection (HSV) is rare in neonates, with an estimated global incidence of 10 per 100,000 live births. Neonatal HSV is challenging to diagnose due to often vague signs and symptoms. Untreated, the mortality of some HSV subtypes exceeds 80%. Overtesting and overtreatment can result in prolonged hospitalizations and expose neonates to medication toxicity. In contrast, prompt evaluation and use of empiric antiviral therapy before the results of definitive testing can improve outcomes for infants with HSV. A wide degree of practice variation exists with respect to testing and treatment for neonatal HSV, and more research is required to safely risk-stratify this population. This review presents the epidemiology, risk factors, presenting features, and emergency department management of neonatal HSV infection.
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Abstract
Herpes simplex virus (HSV) acquired during delivery places the neonate at risk for mortality or long-term neurodevelopmental disability. Exposure generally occurs from recurrent genital herpes infection, although primary infections result in the highest risk of neonatal disease. Neonates generally present in the second or third week of life with lesions. Encephalitis with seizures indicates the presence of central nervous system involvement, and other end organs may also be impacted. Clinical suspicion for neonatal HSV infection warrants immediate initiation of appropriate antiviral therapy. In the last 50 years, antiviral therapy has progressed from agents with prohibitive toxicity or cumbersome administration to herpes virus-specific agents that dramatically improve clinical outcomes with manageable toxicity. Multicenter clinical trials have demonstrated the superiority of high-dose intravenous acyclovir for acute therapy, followed by long-term oral suppressive therapy. This work has dramatically reduced morbidity and mortality from neonatal HSV, representing the benchmark for future clinical trials in neonatal pharmacotherapy.
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Abstract
Neonates are a uniquely vulnerable population, compromised by immature physiology and critical illness if born premature. Furthermore, neonates have frequent exposures to drugs that lack adequate data on safety, efficacy, and appropriate dosing in this population. Key physiologic differences between neonates and older children and adults affect drug absorption, distribution, metabolism, and elimination. Adequate understanding and consideration of these differences is essential to ensure optimal dosing of therapeutic agents in this vulnerable population. Moreover, direct study of neonates through appropriately designed pharmacokinetic and pharmacodynamic studies can ensure the development of safe and effective therapeutics in our youngest populations of patients.
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Affiliation(s)
- Kanecia O. Zimmerman
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Mara L. Becker
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
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16
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Turner MA, Attar S, de Wildt SN, Vassal G, Mangiarini L, Giaquinto C. Roles of Clinical Research Networks in Pediatric Drug Development. Clin Ther 2017; 39:1939-1948. [PMID: 28943118 DOI: 10.1016/j.clinthera.2017.09.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/05/2017] [Accepted: 09/06/2017] [Indexed: 01/09/2023]
Abstract
The evaluation of drugs that are used in children has been neglected historically but is now well established as an essential part of clinical drug development. The increase in pediatric activity among industry, and other sectors, has highlighted the importance of joint working. All participants in pediatric drug development need to be aware of the "big picture." An increasingly important part of this big picture in pediatrics, as in other populations, is the design and conduct of clinical trials in networks. This narrative review provides an overview of the roles of clinical research networks in pediatric drug development. Networks take many forms as specialty networks and geographic networks but work toward common principles, including sharing resources between trials, and using experience with trial conduct to improve trial design. Networks develop standardized processes for trial conduct (including performance management) that increase the speed and predictability of trial conduct while reducing burdens on sites, sponsors, and intermediaries. Networks can provide validated, real-world information about natural history, participant distribution, and standards of care to inform planning of development programs, including extrapolation and clinical trial simulation. Networks can work across geographic and jurisdictional barriers to promote global interoperability of drug development. Networks support participant centrality. Networks offer an opportunity to develop relationships with investigators, sites, and methodological experts that span pre-competitive foundations for drug development and specific products. Sustainable networks benefit all stakeholders by providing a multifunctional platform that promotes the quality and timeliness of clinical drug development.
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Affiliation(s)
- Mark A Turner
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom.
| | - Sabah Attar
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud University, Nijmegen, the Netherlands; Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Gilles Vassal
- Department of Clinical Research, Gustave Roussy, Paris-Sud University, Paris, France
| | | | - Carlo Giaquinto
- Department of Women's and Children's Health, University of Padova, Padua, Italy
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Ericson JE, Gostelow M, Autmizguine J, Hornik CP, Clark RH, Benjamin DK, Smith PB. Safety of High-dose Acyclovir in Infants With Suspected and Confirmed Neonatal Herpes Simplex Virus Infections. Pediatr Infect Dis J 2017; 36:369-373. [PMID: 27977557 PMCID: PMC5348260 DOI: 10.1097/inf.0000000000001451] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Acyclovir is used to treat herpes simplex virus disease in infants. Treatment with high-dose acyclovir, 60 mg/kg/d, is recommended; however, the safety of this dosage has not been assessed in the past 15 years, and this dosage is not currently approved for infants by the US Food and Drug Administration. METHODS We included infants with neonatal herpes simplex virus disease treated with ≥14 days of intravenous acyclovir starting in the first 120 days of life admitted to 1 of 42 neonatal intensive care units managed by the Pediatrix Medical Group between 2002 and 2012. We determined the frequency and proportion of infants with clinical and laboratory adverse events (AEs) as well as the number and proportion of infant days with laboratory AEs occurring during acyclovir exposure. RESULTS We identified 89 infants during the study period with 1658 days of acyclovir exposure. Almost all received high-dose acyclovir therapy (79/89, 89%). The most common clinical AEs were hypotension and seizure, both occurring in 9% of infants. Thrombocytopenia was the most common laboratory AE occurring in 25% of infants and on 9% of infant-days. Elevated creatinine occurred in 2% of infants and 0.2% of infant-days and no infants developed renal failure requiring dialysis. Overall, 45% of infants had ≥1 AE. CONCLUSIONS In this cohort of infants treated during the high-dose acyclovir era, AEs were common but usually not severe. Many of the AEs reported in this cohort may be related to the underlying infection rather than due to acyclovir exposure.
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Affiliation(s)
- Jessica E. Ericson
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA
| | | | - Julie Autmizguine
- Department of Pediatrics, CHU Sainte Justine, University of Montreal, Montreal, Quebec
- Department of Pharmacology, University of Montreal, Montreal, Quebec
| | - Christoph P. Hornik
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Reese H. Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - P. Brian Smith
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
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18
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Harris JB, Holmes AP. Neonatal Herpes Simplex Viral Infections and Acyclovir: An Update. J Pediatr Pharmacol Ther 2017; 22:88-93. [PMID: 28469532 DOI: 10.5863/1551-6776-22.2.88] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Neonatal herpes simplex virus (HSV) infections have high morbidity and mortality rates. Optimization of treatment and prevention strategies are imperative to improve the care and outcomes of neonates infected with HSV. Management of HSV includes reducing neonatal transmission, treating acute infections, and limiting adverse neurodevelopmental outcomes and future cutaneous outbreaks after acute infections. Transmission risk may be affected by route of delivery and maternal suppressive therapy. Neonatal HSV infections are divided into 3 categories: localized skin, eyes, or mouth; localized central nervous system; or disseminated infections. Parenteral acyclovir, the pharmacologic agent of choice, is used when treating each type of infection. However, dosage strategies and durations of therapy may vary based on disease state severity, presentation, and patient characteristics. Oral acyclovir may be used as suppressive therapy after acute treatment completion in specific neonatal populations, reducing long-term adverse neurodevelopmental outcomes and future skin eruptions. The mortality rate remains high even with treatment.
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Sohn JA, Kim HS, Oh J, Cho JY, Yu KS, Lee J, Shin SH, Lee JA, Choi CW, Kim EK, Kim BI, Park EA. Prediction of serum theophylline concentrations and cytochrome P450 1A2 activity by analyzing urinary metabolites in preterm infants. Br J Clin Pharmacol 2017; 83:1279-1286. [PMID: 27995649 DOI: 10.1111/bcp.13211] [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] [Received: 08/01/2016] [Revised: 11/08/2016] [Accepted: 12/12/2016] [Indexed: 01/17/2023] Open
Abstract
AIMS The purpose of this study was to explore clinical markers reflecting developmental changes in drug clearance by preterm infants. METHODS Preterm infants administered aminophylline or theophylline to treat apnoea of prematurity were enrolled in this study. Trough and one of 2 h, 4 h or 6 h post-dose blood samples and urine samples were collected during steady state, to determine the concentrations of theophylline and its targeted metabolites. CYP1A2*1C and CYP1A2*1F genotypes were analyzed. Total, renal and nonrenal clearances of theophylline were calculated, and cytochrome P450 1A2 (CYP1A2) activity was obtained from the ratio of 1-methyluric acid and 3-methylxanthine to theophylline in urine. Multiple linear regression analysis was performed to evaluate the relationships between theophylline clearance and the clinical characteristics of preterm infants. RESULTS A total of 152 samples from 104 preterm infants were analyzed. A strong association between the serum trough and urine theophylline concentrations was found (P < 0.001). Total, renal and nonrenal clearances of theophylline were 0.50 ± 0.29 ml kg-1 min-1 , 0.16 ± 0.06 ml kg-1 min-1 and 0.34 ± 0.28 ml kg-1 min-1 , respectively. CYP1A2 activity correlated positively with the postnatal age and postmenstrual age. However, CYP1A2 genotype was not associated with CYP1A2 activity, which was significantly associated with nonrenal clearance. CYP1A2 activity, postnatal age , weight and 24-h urine output were significantly associated with total theophylline clearance. CONCLUSIONS CYP1A2 activity can be monitored using noninvasive random urine samples, and it can be used to assess developmental changes in theophylline clearance by preterm infants.
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Affiliation(s)
- Jin A Sohn
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Jaeseong Oh
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, South Korea
| | - Joo-Youn Cho
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, South Korea
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, South Korea
| | - Juyoung Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Jin A Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Chang Won Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Beyong Il Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Eun Ae Park
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, South Korea
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20
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Mooij MG, Nies AT, Knibbe CAJ, Schaeffeler E, Tibboel D, Schwab M, de Wildt SN. Development of Human Membrane Transporters: Drug Disposition and Pharmacogenetics. Clin Pharmacokinet 2016; 55:507-24. [PMID: 26410689 PMCID: PMC4823323 DOI: 10.1007/s40262-015-0328-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Membrane transporters play an essential role in the transport of endogenous and exogenous compounds, and consequently they mediate the uptake, distribution, and excretion of many drugs. The clinical relevance of transporters in drug disposition and their effect in adults have been shown in drug–drug interaction and pharmacogenomic studies. Little is known, however, about the ontogeny of human membrane transporters and their roles in pediatric pharmacotherapy. As they are involved in the transport of endogenous substrates, growth and development may be important determinants of their expression and activity. This review presents an overview of our current knowledge on human membrane transporters in pediatric drug disposition and effect. Existing pharmacokinetic and pharmacogenetic data on membrane substrate drugs frequently used in children are presented and related, where possible, to existing ex vivo data, providing a basis for developmental patterns for individual human membrane transporters. As data for individual transporters are currently still scarce, there is a striking information gap regarding the role of human membrane transporters in drug therapy in children.
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Affiliation(s)
- Miriam G Mooij
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Room Sp-3458, Wytemaweg 80, PO-box 2060, 3000 CB, Rotterdam, The Netherlands
| | - Anne T Nies
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany.,University of Tuebingen, Tuebingen, Germany
| | - Catherijne A J Knibbe
- Faculty of Science, Leiden Academic Centre for Research, Pharmacology, Leiden, The Netherlands.,Hospital Pharmacy and Clinical Pharmacology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Elke Schaeffeler
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany.,University of Tuebingen, Tuebingen, Germany
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Room Sp-3458, Wytemaweg 80, PO-box 2060, 3000 CB, Rotterdam, The Netherlands
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany.,Department of Clinical Pharmacology, University Hospital Tuebingen, Tuebingen, Germany
| | - Saskia N de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Room Sp-3458, Wytemaweg 80, PO-box 2060, 3000 CB, Rotterdam, The Netherlands.
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21
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Antimicrobial Agent Dosing in Infants. Clin Ther 2016; 38:1948-60. [DOI: 10.1016/j.clinthera.2016.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/29/2016] [Accepted: 06/30/2016] [Indexed: 11/19/2022]
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Abstract
In the United States, the Best Pharmaceuticals for Children Act and the Pediatric Research Equity Act continue to promote clinical trials in pediatric populations across all age ranges. In 2014 and 2015, over 70 changes were made to drug labels with updates on information regarding pediatric populations. Additionally, multiple new therapies have received first-approvals for the treatment of pediatric indications ranging form rare genetic metabolic diseases to oncology. In the European Union, there have been more than 30 new authorizations for medicines used in children and 130 approved pediatric investigation plans. Despite the progress that has been made over the last two years, much work remains to further the development of safe and effective therapies for pediatric patients.
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Affiliation(s)
- Laura A Wang
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA; Department of Pediatrics, Children's Health Center, College of Medicine, Duke University, T901, Durham, NC 27705, USA.
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 301 Pharmacy Lane, CB #7569, Chapel Hill, NC 27599, USA
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23
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England A, Wade K, Smith PB, Berezny K, Laughon M. Optimizing operational efficiencies in early phase trials: The Pediatric Trials Network experience. Contemp Clin Trials 2016; 47:376-82. [PMID: 26968616 PMCID: PMC4997801 DOI: 10.1016/j.cct.2016.03.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 03/02/2016] [Accepted: 03/07/2016] [Indexed: 01/09/2023]
Abstract
Performing drug trials in pediatrics is challenging. In support of the Best Pharmaceuticals for Children Act, the Eunice Kennedy Shriver National Institute of Child Health and Human Development funded the formation of the Pediatric Trials Network (PTN) in 2010. Since its inception, the PTN has developed strategies to increase both efficiency and safety of pediatric drug trials. Through use of innovative techniques such as sparse and scavenged blood sampling as well as opportunistic study design, participation in trials has grown. The PTN has also strived to improve consistency of adverse event reporting in neonatal drug trials through the development of a standardized adverse event table. We review how the PTN is optimizing operational efficiencies in pediatric drug trials to increase the safety of drugs in children.
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Affiliation(s)
- Amanda England
- Division of Neonatal-Perinatal Medicine, The University of North Carolina at Chapel Hill, N.C. Memorial Hospital, 101 Manning Drive, CB#7596, Chapel Hill, NC 27599-7596, USA
| | - Kelly Wade
- Division of Neonatology, Children's Hospital of Pennsylvania, CHOP Newborn Care at the Hospital of the University of Pennsylvania, 800 Spruce St., Philadelphia, PA 19107, USA
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC 27710, USA; Duke Clinical Research Institute, Duke University School of Medicine, P.O. Box 17969, Durham, NC 27715, USA
| | - Katherine Berezny
- Duke Clinical Research Institute, Duke University School of Medicine, P.O. Box 17969, Durham, NC 27715, USA
| | - Matthew Laughon
- Division of Neonatal-Perinatal Medicine, The University of North Carolina at Chapel Hill, N.C. Memorial Hospital, 101 Manning Drive, CB#7596, Chapel Hill, NC 27599-7596, USA.
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Abstract
BACKGROUND Valacyclovir is a prodrug of acyclovir. Although acyclovir is approved for children in Europe, valacyclovir is not approved, despite being used off-label. The aim of the study was to extrapolate the approved dosages of acyclovir, to valacyclovir dosages, in children using Monte Carlo simulations based on the population pharmacokinetic (PopPK) models of valacyclovir and acyclovir. METHODS Assuming that the recommended dosages of acyclovir are efficacious, a PopPK model of acyclovir was used to perform simulations to determine a critical concentration (Ccrit) for which a target criterion is fulfilled, ie, 90% of the simulated patients have acyclovir levels above Ccrit for at least half the time. The same was done for a secondary target, drug exposure, determining a critical area under the curve in 24 hours at steady state. Then a PopPK model of valacyclovir was used to determine by simulations, dosage regimens that fulfill the criteria for both targets. This was repeated for various indications and age groups. RESULTS Indicatively, for the treatment of varicella zoster virus, in ages 2-12 years, Ccrit and critical area under the curve in 24 hours at steady state were found to be 0.39 mg/L and 9.6 mg/L × h, respectively, using the acyclovir approved doses 20 mg/kg 4 times daily. For these breakpoints, a 20 mg/kg, 3 times daily, valacyclovir dose achieves the targets in 97% and 100% of the patients, respectively. We found that some patients receive higher than the ideal doses of acyclovir. CONCLUSIONS Simulations were used to determine the appropriate doses of valacyclovir in children to support a pediatric investigation plan targeting a paediatric-use marketing authorization application in the European Medicines Agency.
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25
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Enioutina EY, Constance JE, Stockmann C, Linakis MW, Yu T, Rower JE, Balch AH, Sherwin CM. Pharmacokinetic considerations in the use of antivirals in neonates. Expert Opin Drug Metab Toxicol 2015; 11:1861-78. [PMID: 26535960 DOI: 10.1517/17425255.2015.1108963] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Neonatal patients, because of the inability of their immune system to properly respond to microbial challenge, are highly susceptible to viral infections. Immunoglobulins, monoclonal antibody and antiviral drugs are used for prophylaxis and treatment of viral diseases in neonates. Neonates and, especially, preterm infants differ in drug absorption, distribution, metabolism and excretion from adults and older children. AREAS COVERED This review will evaluate deficiencies of neonatal immune responses to microbial challenge that predispose newborns to viral infections, clinical manifestations and the treatment of viral diseases in neonates. We focus on published studies describing antiviral drug pharmacokinetics in neonates and make recommendations on the dosing of these drugs, allowing achievement of maximal clinical benefits in neonates. EXPERT OPINION While some efforts were undertaken to study pharmacokinetics and pharmacodynamics of antiviral drugs, much more needs to be done. Current data indicate that the pharmacokinetics of antiviral drugs may vary significantly depending on gestational age, maturation processes of drug-metabolizing enzymes and renal clearance. Specifics of pharmacokinetics of antiviral drugs need to be taken into consideration when they are prescribed to neonates and infants.
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Affiliation(s)
- Elena Yu Enioutina
- a Division of Clinical Pharmacology, Department of Pediatrics , University of Utah School of Medicine , 295 Chipeta Way, Salt Lake City , UT 84108 , USA.,b Division of Microbiology and Immunology, Department of Pathology , University of Utah School of Medicine , 15 North Medical Drive East, Salt Lake City , UT 84112 , USA
| | - Jonathan E Constance
- a Division of Clinical Pharmacology, Department of Pediatrics , University of Utah School of Medicine , 295 Chipeta Way, Salt Lake City , UT 84108 , USA
| | - Chris Stockmann
- a Division of Clinical Pharmacology, Department of Pediatrics , University of Utah School of Medicine , 295 Chipeta Way, Salt Lake City , UT 84108 , USA
| | - Matthew W Linakis
- a Division of Clinical Pharmacology, Department of Pediatrics , University of Utah School of Medicine , 295 Chipeta Way, Salt Lake City , UT 84108 , USA
| | - Tian Yu
- a Division of Clinical Pharmacology, Department of Pediatrics , University of Utah School of Medicine , 295 Chipeta Way, Salt Lake City , UT 84108 , USA
| | - Joseph E Rower
- a Division of Clinical Pharmacology, Department of Pediatrics , University of Utah School of Medicine , 295 Chipeta Way, Salt Lake City , UT 84108 , USA
| | - Alfred H Balch
- a Division of Clinical Pharmacology, Department of Pediatrics , University of Utah School of Medicine , 295 Chipeta Way, Salt Lake City , UT 84108 , USA
| | - Catherine M Sherwin
- a Division of Clinical Pharmacology, Department of Pediatrics , University of Utah School of Medicine , 295 Chipeta Way, Salt Lake City , UT 84108 , USA
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26
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Steinberg I, Kimberlin DW. Acyclovir Dosing and Acute Kidney Injury: Deviations and Direction. J Pediatr 2015; 166:1341-4. [PMID: 25890674 DOI: 10.1016/j.jpeds.2015.03.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 03/30/2015] [Indexed: 12/25/2022]
Affiliation(s)
- Irving Steinberg
- Division of Pediatric Pharmacotherapy, Department of Pediatrics, LAC+USC Medical Center, University of Southern California, Keck School of Medicine and School of Pharmacy, Los Angeles, California
| | - David W Kimberlin
- Division of Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama.
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27
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Abstract
Neonatal fungal and viral infections are associated with mortality and neurologic impairment among survivors. Advances in pharmacokinetics (PK) and pharmacodynamics (PD) of antimicrobial medications have led to improved dosing guidance for neonates. This article discusses the basic PK/PD properties and dosing of the most common antifungal and antiviral medications used in neonates.
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28
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Cies JJ, Moore WS, Miller K, Small C, Carella D, Conley S, Parker J, Shea P, Chopra A. Therapeutic Drug Monitoring of Continuous-Infusion Acylovir for Disseminated Herpes Simplex Virus Infection in a Neonate Receiving Concurrent Extracorporeal Life Support and Continuous Renal Replacement Therapy. Pharmacotherapy 2014; 35:229-33. [DOI: 10.1002/phar.1526] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jeffrey J. Cies
- St. Christopher's Hospital for Children; Philadelphia Pennsylvania
- Drexel University College of Medicine; Philadelphia Pennsylvania
- Alfred I duPont Hospital for Children; Wilmington Delaware
| | - Wayne S. Moore
- Alfred I duPont Hospital for Children; Wilmington Delaware
| | - Kyle Miller
- St. Christopher's Hospital for Children; Philadelphia Pennsylvania
| | - Christine Small
- St. Christopher's Hospital for Children; Philadelphia Pennsylvania
- Drexel University College of Medicine; Philadelphia Pennsylvania
| | - Dominick Carella
- St. Christopher's Hospital for Children; Philadelphia Pennsylvania
- Drexel University College of Medicine; Philadelphia Pennsylvania
| | - Susan Conley
- St. Christopher's Hospital for Children; Philadelphia Pennsylvania
- Drexel University College of Medicine; Philadelphia Pennsylvania
| | - Jason Parker
- St. Christopher's Hospital for Children; Philadelphia Pennsylvania
- Drexel University College of Medicine; Philadelphia Pennsylvania
| | - Paul Shea
- St. Christopher's Hospital for Children; Philadelphia Pennsylvania
- Drexel University College of Medicine; Philadelphia Pennsylvania
| | - Arun Chopra
- NYU Langone Medical Center; New York New York
- NYU School of Medicine; New York New York
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29
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Gonzalez D, Paul IM, Benjamin DK, Cohen-Wolkowiez M. Advances in pediatric pharmacology, therapeutics, and toxicology. Adv Pediatr 2014; 61:7-31. [PMID: 25037123 PMCID: PMC4120955 DOI: 10.1016/j.yapd.2014.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
In the United States, passage of the FDASIA legislation made BPCA and PREA permanent, no longer requiring reauthorization every 5 years. This landmark legislation also stressed the importance of performing clinical trials in neonates when appropriate. In Europe the Pediatric Regulation, which went into effect in early 2007, also provides a framework for expanding pediatric clinical research. Although much work remains, as a result of greater regulatory guidance more pediatric data are reaching product labels.
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Affiliation(s)
- Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Chapel Hill, NC 27599, USA; Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA
| | - Ian M Paul
- Department of Pediatrics, College of Medicine, Penn State University, 500 University Drive, HS83, Hershey, PA 17033, USA; Department of Public Health Sciences, College of Medicine, Penn State University, 500 University Drive, HS83, Hershey, PA 17033, USA
| | - Daniel K Benjamin
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA; Department of Pediatrics, College of Medicine, Duke University, T901/Children's Health Center, Durham, NC 27705, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA; Department of Pediatrics, College of Medicine, Duke University, T901/Children's Health Center, Durham, NC 27705, USA.
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30
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Roberts JK, Stockmann C, Constance JE, Stiers J, Spigarelli MG, Ward RM, Sherwin CMT. Pharmacokinetics and Pharmacodynamics of Antibacterials, Antifungals, and Antivirals Used Most Frequently in Neonates and Infants. Clin Pharmacokinet 2014; 53:581-610. [DOI: 10.1007/s40262-014-0147-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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