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Coggins SA, Greenberg RG. Pharmacokinetic and Pharmacodynamic Approaches to Optimize Antibiotic Use in Neonates. Clin Perinatol 2025; 52:67-86. [PMID: 39892955 DOI: 10.1016/j.clp.2024.10.005] [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] [Indexed: 02/04/2025]
Abstract
Newborn infants (particularly those born preterm) are frequently exposed to empiric antibiotics at birth, and antibiotics are among the most commonly prescribed medications in neonatal intensive care units. Challenges in optimizing neonatal antibiotic dosing include: technical and ethical barriers to neonatal pharmacoanalytic study design and sampling, difficulty in extrapolating adult and pediatric data due to unique neonatal physiology, and a lack of validated pharmacodynamic targets specific to neonatal populations. In this review, we summarize basic concepts in pharmacokinetics (PK) and pharmacodynamics (PD), describe pharmacometric strategies utilized in contemporary PK/PD analyses, and review the evolution of PK/PD data guiding neonatal dosing among 3 commonly used antibiotics.
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Affiliation(s)
- Sarah A Coggins
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Neonatology (2 Main NW), Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, 300 West Morgan Street Suite 800, Durham, NC 27701, USA
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2
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Yuan Y, Hu W, Chen C, Yao R, Zhang S, Zhu X, Xu B, Huang Z, Zhang S, Wang X, Zheng M, Huang X, Standing JF. Pharmacokinetic, Pharmacodynamic and Pharmacogenetic Studies Related to Vincristine-Induced Peripheral Neuropathy in Chinese Pediatric ALL Patients. Clin Pharmacol Ther 2025; 117:454-464. [PMID: 39367622 DOI: 10.1002/cpt.3462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Accepted: 09/23/2024] [Indexed: 10/06/2024]
Abstract
Vincristine (VCR) can cause vincristine-induced peripheral neuropathy (VIPN) during the treatment of acute lymphoblastic leukemia (ALL) and the mechanisms are complicated. The aim of this study was to investigate the influencing factors on the population pharmacokinetics (PopPK) and pharmacodynamics (PD) related to VIPN, including clearance routes, drug-drug interactions (DDI), and genetic characteristics. Pediatric patients being treated for ALL were recruited to PK study where VCR and its metabolite (M1) were measured using a novel assay. The incidence of VIPN was also recorded. DNA sequencing of relevant PK and PD genes was performed. PopPK and PK/PD models were developed, pharmacogenetic and DDI analyses were conducted. In total, 79 children were recruited. The results showed that allometric scaling, ABCB1-rs1128503 genotype, and posaconazole (POS) significantly improved the PopPK model fit. VIPN was significantly correlated with the exposure of VCR. Co-administration with POS shifted the effect curve for VIPN to the left, indicating increased VIPN risk at the same exposure levels. No significant effects on VIPN were observed for CYP3A5 (rs776746), CYP3A4 (rs2242480), CEP72 (rs924607), or various ABCB1 variants (rs1128503, rs2032582, rs1045642, rs4728709, rs4148737, and rs10276036), nor with the co-administration of fluconazole or dasatinib. In summary, co-administration of POS increased VCR exposure by 0.4-fold and raised the risk of VIPN, with an occurrence probability generally exceeding 0.7. Therapeutic drug monitoring of VCR in clinical practice may be necessary to enable appropriate dose adjustments and individualized treatment.
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Affiliation(s)
- Yawen Yuan
- Department of Pharmacy, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Infection, Immunity, Inflammation Section, UCL Institute of Child Health, London, UK
| | - Wenting Hu
- Department of Hematology/Oncology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Changcheng Chen
- Department of Hematology/Oncology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ruen Yao
- Department of Medical Genetics, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shunguo Zhang
- Department of Pharmacy, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao Zhu
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai, China
| | - Bulong Xu
- Department of Pharmacy, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhonghui Huang
- Infection, Immunity, Inflammation Section, UCL Institute of Child Health, London, UK
| | - Shengyuan Zhang
- Infection, Immunity, Inflammation Section, UCL Institute of Child Health, London, UK
| | - Xuexian Wang
- Department of Pharmacy, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mei Zheng
- Department of Pharmacy, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaohui Huang
- Department of Clinical Pharmacy, School of Medicine, Xinhua Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Joseph F Standing
- Infection, Immunity, Inflammation Section, UCL Institute of Child Health, London, UK
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Ahmadi Daryakenari N, Wang S, Karniadakis G. CMINNs: Compartment model informed neural networks - Unlocking drug dynamics. Comput Biol Med 2025; 184:109392. [PMID: 39608036 DOI: 10.1016/j.compbiomed.2024.109392] [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: 09/10/2024] [Revised: 10/21/2024] [Accepted: 11/07/2024] [Indexed: 11/30/2024]
Abstract
In the field of pharmacokinetics and pharmacodynamics (PKPD) modeling, which plays a pivotal role in the drug development process, traditional models frequently encounter difficulties in fully encapsulating the complexities of drug absorption, distribution, and their impact on targets. Although multi-compartment models are frequently utilized to elucidate intricate drug dynamics, they can also be overly complex. To generalize modeling while maintaining simplicity, we propose an innovative approach that enhances PK and integrated PK-PD modeling by incorporating fractional calculus or time-varying parameter(s), combined with constant or piecewise constant parameters. These approaches effectively model anomalous diffusion, thereby capturing drug trapping and escape rates in heterogeneous tissues, which is a prevalent phenomenon in drug dynamics. Furthermore, this method provides insight into the dynamics of drug in cancer in multi-dose administrations. Our methodology employs a Physics-Informed Neural Network (PINN) and fractional Physics-Informed Neural Networks (fPINNs), integrating ordinary differential equations (ODEs) with integer/fractional derivative order from compartmental modeling with neural networks. This integration optimizes parameter estimation for variables that are time-variant, constant, piecewise constant, or related to the fractional derivative order. The results demonstrate that this methodology offers a robust framework that not only markedly enhances the model's depiction of drug absorption rates and distributed delayed responses but also unlocks different drug-effect dynamics, providing new insights into absorption rates, anomalous diffusion, drug resistance, persistence, and pharmacokinetic tolerance, all within a system of just two (fractional) ODEs with explainable results. These findings have the potential to streamline drug development by improving the prediction of drug behavior in complex biological systems and shedding light on cancer cell death mechanisms, ultimately aiding in the design of more effective therapeutic strategies.
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Affiliation(s)
| | - Shupeng Wang
- Division of Applied Mathematics, Brown University, Providence, RI, USA
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Heida A, Jager NGL, Aarnoutse RE, de Winter BCM, de Jong H, Keizer RJ, Cornelissen EAM, Ter Heine R. Model-informed dose optimization of mycophenolic acid in pediatric kidney transplant patients. Eur J Clin Pharmacol 2024; 80:1761-1771. [PMID: 39153087 PMCID: PMC11458656 DOI: 10.1007/s00228-024-03743-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 08/09/2024] [Indexed: 08/19/2024]
Abstract
PURPOSE We aimed to develop and evaluate a population PK model of mycophenolic acid (MPA) in pediatric kidney transplant patients to aid MPA dose optimization. METHODS Data were collected from pediatric kidney transplant recipients from a Dutch academic hospital (Radboudumc, the Netherlands). Pharmacokinetic model-building and model-validation analyses were performed using NONMEM. Subsequently, we externally evaluated the final model using data from another academic hospital. The final model was used to develop an optimized dosing regimen. RESULTS Thirty pediatric patients were included of whom 266 measured MPA plasma concentrations, including 20 full pharmacokinetic (PK) curves and 24 limited sampling curves, were available. A two-compartment model with a transition compartment for Erlang-type absorption best described the data. The final population PK parameter estimates were Ktr (1.48 h-1; 95% CI, 1.15-1.84), CL/F (16.0 L h-1; 95% CI, 10.3-20.4), Vc/F (24.9 L; 95% CI, 93.0-6.71E25), Vp/F (1590 L; 95% CI, 651-2994), and Q/F (36.2 L h-1; 95% CI, 9.63-74.7). The performance of the PK model in the external population was adequate. An optimized initial dose scheme based on bodyweight was developed. With the licensed initial dose, 35% of patients were predicted to achieve the target AUC, compared to 42% using the optimized scheme. CONCLUSION We have successfully developed a pharmacokinetic model for MPA in pediatric renal transplant patients. The optimized dosing regimen is expected to result in better target attainment early in treatment. It can be used in combination with model-informed follow-up dosing to further individualize the dose when PK samples become available.
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Affiliation(s)
- Astrid Heida
- Department of Pharmacy, Radboud Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Nynke G L Jager
- Department of Pharmacy, Radboud Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Huib de Jong
- The Erasmus MC Transplant Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Elisabeth A M Cornelissen
- Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
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Centanni M, Reijnhout N, Thijs A, Karlsson MO, Friberg LE. Pharmacogenetic Testing or Therapeutic Drug Monitoring: A Quantitative Framework. Clin Pharmacokinet 2024; 63:871-884. [PMID: 38842789 PMCID: PMC11222190 DOI: 10.1007/s40262-024-01382-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Pharmacogenetic profiling and therapeutic drug monitoring (TDM) have both been proposed to manage inter-individual variability (IIV) in drug exposure. However, determining the most effective approach for estimating exposure for a particular drug remains a challenge. This study aimed to quantitatively assess the circumstances in which pharmacogenetic profiling may outperform TDM in estimating drug exposure, under three sources of variability (IIV, inter-occasion variability [IOV], and residual unexplained variability [RUV]). METHODS Pharmacokinetic models were selected from the literature corresponding to drugs for which pharmacogenetic profiling and TDM are both clinically considered approaches for dose individualization. The models were used to simulate relevant drug exposures (trough concentration or area under the curve [AUC]) under varying degrees of IIV, IOV, and RUV. RESULTS Six drug cases were selected from the literature. Model-based simulations demonstrated that the percentage of patients for whom pharmacogenetic exposure prediction is superior to TDM differs for each drug case: tacrolimus (11.0%), tamoxifen (12.7%), efavirenz (49.2%), vincristine (49.6%), risperidone (48.1%), and 5-fluorouracil (5-FU) (100%). Generally, in the presence of higher unexplained IIV in combination with lower RUV and IOV, exposure was best estimated by TDM, whereas, under lower unexplained IIV in combination with higher IOV or RUV, pharmacogenetic profiling was preferred. CONCLUSIONS For the drugs with relatively low RUV and IOV (e.g., tamoxifen and tacrolimus), TDM estimated true exposure the best. Conversely, for drugs with similar or lower unexplained IIV (e.g., efavirenz or 5-FU, respectively) combined with relatively high RUV, pharmacogenetic profiling provided the most accurate estimate for most patients. However, genotype prevalence and the relative influence of genotypes on the PK, as well as the ability of TDM to accurately estimate AUC with a limited number of samples, had an impact. The results could be used to support clinical decision making when considering other factors, such as the probability for severe side effects.
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Affiliation(s)
- Maddalena Centanni
- Department of Pharmacy, Uppsala University, Box 580, 751 23, Uppsala, Sweden
| | - Niels Reijnhout
- Department of Pharmacy, Uppsala University, Box 580, 751 23, Uppsala, Sweden
| | - Abel Thijs
- Department of Internal Medicine, Amsterdam UMC, Location VU University, Amsterdam, The Netherlands
| | - Mats O Karlsson
- Department of Pharmacy, Uppsala University, Box 580, 751 23, Uppsala, Sweden
| | - Lena E Friberg
- Department of Pharmacy, Uppsala University, Box 580, 751 23, Uppsala, Sweden.
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Bonate PL, Barrett JS, Ait-Oudhia S, Brundage R, Corrigan B, Duffull S, Gastonguay M, Karlsson MO, Kijima S, Krause A, Lovern M, Riggs MM, Neely M, Ouellet D, Plan EL, Rao GG, Standing J, Wilkins J, Zhu H. Training the next generation of pharmacometric modelers: a multisector perspective. J Pharmacokinet Pharmacodyn 2024; 51:5-31. [PMID: 37573528 DOI: 10.1007/s10928-023-09878-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 07/17/2023] [Indexed: 08/15/2023]
Abstract
The current demand for pharmacometricians outmatches the supply provided by academic institutions and considerable investments are made to develop the competencies of these scientists on-the-job. Even with the observed increase in academic programs related to pharmacometrics, this need is unlikely to change in the foreseeable future, as the demand and scope of pharmacometrics applications keep expanding. Further, the field of pharmacometrics is changing. The field largely started when Lewis Sheiner and Stuart Beal published their seminal papers on population pharmacokinetics in the late 1970's and early 1980's and has continued to grow in impact and use since its inception. Physiological-based pharmacokinetics and systems pharmacology have grown rapidly in scope and impact in the last decade and machine learning is just on the horizon. While all these methodologies are categorized as pharmacometrics, no one person can be an expert in everything. So how do you train future pharmacometricians? Leading experts in academia, industry, contract research organizations, clinical medicine, and regulatory gave their opinions on how to best train future pharmacometricians. Their opinions were collected and synthesized to create some general recommendations.
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Affiliation(s)
| | | | | | - Richard Brundage
- Metrum Research Group, University of Minnesota, Minneapolis, MN, USA
| | | | - Stephen Duffull
- Certara, Princeton, NJ, USA
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | | | | | - Shinichi Kijima
- Office of New Drug V, Pharmaceuticals and Medical Devices Agency (PMDA), Tokyo, Japan
| | | | - Mark Lovern
- Certara, Princeton, NJ, USA
- Certara, Raleigh, NC, USA
| | | | - Michael Neely
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | | | | | - Gauri G Rao
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Joseph Standing
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Department of Pharmacy, Great Ormond Street Hospital for Children, London, UK
| | | | - Hao Zhu
- Food and Drug Administration, Silver Springs, MD, USA
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Yeung CHT, Verstegen RHJ, Greenberg R, Lewis TR. Pharmacokinetic and pharmacodynamic principles: unique considerations for optimal design of neonatal clinical trials. Front Pediatr 2024; 11:1345969. [PMID: 38283405 PMCID: PMC10811156 DOI: 10.3389/fped.2023.1345969] [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: 11/28/2023] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
Core clinical pharmacology principles must be considered when designing and executing neonatal clinical trials. In this review, the authors discuss important aspects of drug dose selection, pharmacokinetics, pharmacogenetics and pharmacodynamics that stakeholders may consider when undertaking a neonatal or infant clinical trial.
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Affiliation(s)
- Cindy Hoi Ting Yeung
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ruud H. J. Verstegen
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Rachel Greenberg
- Duke Clinical Research Institute, Durham, NC, United States
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Tamorah Rae Lewis
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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Arsène S, Parès Y, Tixier E, Granjeon-Noriot S, Martin B, Bruezière L, Couty C, Courcelles E, Kahoul R, Pitrat J, Go N, Monteiro C, Kleine-Schultjann J, Jemai S, Pham E, Boissel JP, Kulesza A. In Silico Clinical Trials: Is It Possible? Methods Mol Biol 2024; 2716:51-99. [PMID: 37702936 DOI: 10.1007/978-1-0716-3449-3_4] [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] [Indexed: 09/14/2023]
Abstract
Modeling and simulation (M&S), including in silico (clinical) trials, helps accelerate drug research and development and reduce costs and have coined the term "model-informed drug development (MIDD)." Data-driven, inferential approaches are now becoming increasingly complemented by emerging complex physiologically and knowledge-based disease (and drug) models, but differ in setup, bottlenecks, data requirements, and applications (also reminiscent of the different scientific communities they arose from). At the same time, and within the MIDD landscape, regulators and drug developers start to embrace in silico trials as a potential tool to refine, reduce, and ultimately replace clinical trials. Effectively, silos between the historically distinct modeling approaches start to break down. Widespread adoption of in silico trials still needs more collaboration between different stakeholders and established precedence use cases in key applications, which is currently impeded by a shattered collection of tools and practices. In order to address these key challenges, efforts to establish best practice workflows need to be undertaken and new collaborative M&S tools devised, and an attempt to provide a coherent set of solutions is provided in this chapter. First, a dedicated workflow for in silico clinical trial (development) life cycle is provided, which takes up general ideas from the systems biology and quantitative systems pharmacology space and which implements specific steps toward regulatory qualification. Then, key characteristics of an in silico trial software platform implementation are given on the example of jinkō.ai (nova's end-to-end in silico clinical trial platform). Considering these enabling scientific and technological advances, future applications of in silico trials to refine, reduce, and replace clinical research are indicated, ranging from synthetic control strategies and digital twins, which overall shows promise to begin a new era of more efficient drug development.
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Maruyama T, Kimura T, Ebihara F, Kasai H, Matsunaga N, Hamada Y. Comparison of the predictive accuracy of the physiologically based pharmacokinetic (PBPK) model and population pharmacokinetic (PPK) model of vancomycin in Japanese patients with MRSA infection. J Infect Chemother 2023; 29:1152-1159. [PMID: 37673298 DOI: 10.1016/j.jiac.2023.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/26/2023] [Accepted: 08/29/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION The latest therapeutic drug monitoring guidelines for vancomycin (VCM) recommend that area under the concentration-time curve is estimated based on model-informed precision dosing and used to evaluate efficacy and safety. Therefore, we predicted VCM concentrations in individual methicillin-resistant Staphylococcus aureus-infected patients using existing a physiologically based pharmacokinetic (PBPK) model and 1- and 2-compartment population pharmacokinetic (PPK) models and confirmed and verified the accuracy of the PBPK model in estimating VCM concentrations with the PPK model. METHODS The subjects of the study are 20 patients, and the predicted concentrations were evaluated by comparing the observed and predicted trough and peak values of VCM concentrations for individual patients. RESULTS The results showed good correlation between the observed and predicted trough and peak concentrations of VCM was observed generally in the PBPK model, R2 values of 0.72, 0.62, and 0.40 with trough values of 0.49, 0.40, and 0.34 with peak values for PBPK model, 1-compartment, and 2-compartment model, respectively. CONCLUSIONS Although the performance of the PBPK model is not as predictive as the PPK model, generally similar predictive trends were obtained, suggesting that it may be a valuable tool for rapid and accurate prediction of AUC for VCM.
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Affiliation(s)
- Takumi Maruyama
- Department of Pharmacy, Tokyo Women's Medical University Hospital, 8-1, Kawadacho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Toshimi Kimura
- Department of Pharmacy, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Fumiya Ebihara
- Department of Pharmacy, Tokyo Women's Medical University Hospital, 8-1, Kawadacho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Hidefumi Kasai
- Laboratory of Pharmacometrics and Systems Pharmacology Keio Frontier Research and Education Collaboration Square (K-FRECS) at Tonomachi, Keio University Kawasaki, Kanagawa, 210-0821, Japan
| | - Nobuaki Matsunaga
- AMR Clinical Reference Center, National Center for Global Health and Medicine Hospital, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Yukihiro Hamada
- Department of Pharmacy, Tokyo Women's Medical University Hospital, 8-1, Kawadacho, Shinjuku-ku, Tokyo, 162-8666, Japan.
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Bardol M, Pan S, Walker SM, Standing JF, Dawes JM. Pharmacokinetic pharmacodynamic modeling of analgesics and sedatives in children. Paediatr Anaesth 2023; 33:781-792. [PMID: 37341161 PMCID: PMC10947261 DOI: 10.1111/pan.14712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/18/2023] [Accepted: 05/21/2023] [Indexed: 06/22/2023]
Abstract
Pharmacokinetic pharmacodynamic modeling is an important tool which uses statistical methodology to provide a better understanding of the relationship between concentration and effect of drugs such as analgesics and sedatives. Pharmacokinetic pharmacodynamic models also describe between-subject variability that allows identification of subgroups and dose adjustment for optimal pain management in individual patients. This approach is particularly useful in the pediatric population, where most drugs have received limited evaluation and dosing is extrapolated from adult practice. In children, the covariates of weight and age are used to describe size- and maturation-related changes in pharmacokinetics. It is important to consider both size and maturation in order to develop an accurate model and determine the optimal dose for different age groups. An adequate assessment of analgesic and sedative effect using pain scales or brain activity measures is essential to build reliable pharmacokinetic pharmacodynamic models. This is often challenging in children due to the multidimensional nature of pain and the limited sensitivity and specificity of some measurement tools. This review provides a summary of the pharmacokinetic and pharmacodynamic methodology used to describe the dose-concentration-effect relationship of analgesics and sedation in children, with a focus on the different pharmacodynamic endpoints and the challenges of pharmacodynamic modeling.
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Affiliation(s)
- Maddlie Bardol
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - Shan Pan
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - Suellen M. Walker
- Department of Anaesthesia and Pain MedicineGreat Ormond St Hospital NHS Foundation TrustLondonUK
- Developmental Neurosciences Program, UCL Great Ormond St Institute of Child HealthUniversity College LondonLondonUK
| | - Joseph F. Standing
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- Department of PharmacyGreat Ormond St Hospital NHS Foundation TrustLondonUK
| | - Joy M. Dawes
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- Department of Anaesthesia and Pain MedicineGreat Ormond St Hospital NHS Foundation TrustLondonUK
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Ibrahim EIK, Karlsson MO, Friberg LE. Assessment of ibrutinib scheduling on leukocyte, lymph node size and blood pressure dynamics in chronic lymphocytic leukemia through pharmacokinetic-pharmacodynamic models. CPT Pharmacometrics Syst Pharmacol 2023; 12:1305-1318. [PMID: 37452622 PMCID: PMC10508536 DOI: 10.1002/psp4.13010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/13/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023] Open
Abstract
Ibrutinib is a Bruton tyrosine kinase (Btk) inhibitor for treating chronic lymphocytic leukemia (CLL). It has also been associated with hypertension. The optimal dosing schedule for mitigating this adverse effect is currently under discussion. A quantification of relationships between systemic ibrutinib exposure and efficacy (i.e., leukocyte count and sum of the product of perpendicular diameters [SPD] of lymph nodes) and hypertension toxicity (i.e., blood pressure), and their association with overall survival is needed. Here, we present a semi-mechanistic pharmacokinetic-pharmacodynamic modeling framework to characterize such relationships and facilitate dose optimization. Data from a phase Ib/II study were used, including ibrutinib plasma concentrations to derive daily 0-24-h area under the concentration-time curve, leukocyte count, SPD, survival, and blood pressure measurements. A nonlinear mixed effects modeling approach was applied, considering ibrutinib's pharmacological action and CLL cell dynamics. The final framework included (i) an integrated model for SPD and leukocytes consisting of four CLL cell subpopulations with ibrutinib inhibiting phosphorylated Btk production, (ii) a turnover model in which ibrutinib stimulates an increase in blood pressure, and (iii) a competing risk model for dropout and death. Simulations predicted that the approved dosing schedule had a slightly higher efficacy (24-month, progression-free survival [PFS] 98%) than de-escalation schedules (24-month, average PFS ≈ 97%); the latter had, on average, ≈20% lower proportions of patients with hypertension. The developed modeling framework offers an improved understanding of the relationships among ibrutinib exposure, efficacy and toxicity biomarkers. This framework can serve as a platform to assess dosing schedules in a biologically plausible manner.
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Miranda S, Harahap A, Mu'minin A, Putri AF, Pitaloka NI. Escherichia coli extended spectrum beta-lactamase meningitis in 3 months infant with subdural abscess and communicating hydrocephalus: A case report. Int J Surg Case Rep 2023; 106:108128. [PMID: 37054544 PMCID: PMC10123248 DOI: 10.1016/j.ijscr.2023.108128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 04/08/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Escherichia coli ESBL as the etiology of meningitis is rarely found and frequently missed in infants. Escherichia coli found in the environment is an indication of fecal contamination. CASE PRESENTATION A 3-month-old infant presented with focal seizures without fever, accompanied by positive meningeal sign and bulging large fontanelle. Laboratory examination found an increase in inflammation marker. A head CT scan showed hydrocephalus and subdural cysts. CLINICAL DISCUSSION The patient underwent a burr hole drainage. Subdural abscesses with yellowish pus and hydrocephalus were found during the operation. Escherichia coli ESBL growth from the pus culture. This patient diagnosed as meningitis, subdural abscess and communicating hydrocephalus. Evacuation of the subdural abscess by burr hole drainage, meropenem treatment, and shunt was placed in this case. CONCLUSION We suggest the source of infection in this patient related to poor hygiene practices prior to formula preparation. Early diagnosis and treatment are essential to prevent morbidity and mortality.
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Li J, Cai X, Chen Y, Wang C, Jiao Z. Parametric population pharmacokinetics of isoniazid: a systematic review. Expert Rev Clin Pharmacol 2023; 16:467-489. [PMID: 36971782 DOI: 10.1080/17512433.2023.2196401] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Isoniazid (INH) plays an important role in prevention and treatment of tuberculosis (TB). However, large pharmacokinetic (PK) variations are observed in patients receiving standard INH dosages. Considering the influence of PK variations on INH efficacy or adverse reactions, we reviewed the population PK studies of INH and explored significant covariates that influence INH PK. METHODS The PubMed and Embase databases were systematically searched from their inception to 30 January 2023. PPK studies on INH using a parametric nonlinear mixed-effect approach were included in this review. The characteristics and identified significant covariates of the included studies were summarized. RESULTS Twenty-one studies conducted in adults, and seven in pediatrics were included. A two-compartment model with first-order absorption and elimination was the frequently used structural model for INH. NAT2 genotype, body size, and age were identified as significant covariates affecting INH PK variation. The median clearance (CL) value in the fast metabolizers was 2.55-fold higher than that in the slow metabolizers. Infants and children had higher CL per weight values than adults with the same metabolic phenotype. In pediatric patients, CL value increased with postnatal age. CONCLUSIONS Compared with slow metabolizers, the daily dose of INH should be increased by 200-600 mg in fast metabolizers. To achieve effective treatment, pediatric patients need a higher dose per kilogram than adults. Further PPK studies of anti-tuberculosis drugs are needed to comprehensively understand the covariates that affect their PK characteristics and to achieve accurate dose adjustments.
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14
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Spanakis M. In Silico Pharmacology for Evidence-Based and Precision Medicine. Pharmaceutics 2023; 15:pharmaceutics15031014. [PMID: 36986874 PMCID: PMC10054111 DOI: 10.3390/pharmaceutics15031014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/07/2023] [Indexed: 03/30/2023] Open
Abstract
Personalized/precision medicine (PM) originates from the application of molecular pharmacology in clinical practice, representing a new era in healthcare that aims to identify and predict optimum treatment outcomes for a patient or a cohort with similar genotype/phenotype characteristics [...].
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Affiliation(s)
- Marios Spanakis
- Department of Forensic Sciences and Toxicology, Faculty of Medicine, University of Crete, GR-71003 Heraklion, Greece
- Computational BioMedicine Laboratory, Institute of Computer Science, Foundation for Research & Technology-Hellas, GR-71110 Heraklion, Greece
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15
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Challenges and Possible Solutions to Direct-Acting Oral Anticoagulants (DOACs) Dosing in Patients with Extreme Bodyweight and Renal Impairment. Am J Cardiovasc Drugs 2023; 23:9-17. [PMID: 36515822 DOI: 10.1007/s40256-022-00560-7] [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] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
This article aims to highlight the dosing issues of direct oral anticoagulants (DOACs) in patients with renal impairment and/or obesity in an attempt to develop solutions employing advanced data-driven techniques. DOACs have become widely accepted by clinicians worldwide because of their superior clinical profiles, more predictable pharmacokinetics, and hence more convenient dosing relative to other anticoagulants. However, the optimal dosing of DOACs in extreme bodyweight patients and patients with renal impairment is difficult to achieve using the conventional dosing approach. The standard dosing approach (fixed-dose) is based on limited data from clinical studies. The existing formulae (models) for determining the appropriate doses for these patient groups leads to suboptimal dosing. This problem of mis-dosing is worsened by the lack of standardized laboratory parameters for monitoring the exposure to DOACs in renal failure and extreme bodyweight patients. Model-informed precision dosing (MIPD) encompasses a range of techniques like machine learning and pharmacometrics modelling, which could uncover key variables and relationships as well as shed more light on the pharmacokinetics and pharmacodynamics of DOACs in patients with extreme bodyweight or renal impairment. Ultimately, this individualized approach-if implemented in clinical practice-could optimise dosing for the DOACs for better safety and efficacy.
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16
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Bouazza N, Dokoumetzidis A, Knibbe CAJ, de Wildt SN, Ambery C, De Cock PA, Gasthuys E, Foissac F, Urien S, Hamberg AK, Poggesi I, Zhao W, Vermeulen A, Standing JF, Tréluyer JM. General clinical and methodological considerations on the extrapolation of pharmacokinetics and optimization of study protocols for small molecules and monoclonal antibodies in children. Br J Clin Pharmacol 2022; 88:4985-4996. [PMID: 36256514 DOI: 10.1111/bcp.15571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 09/05/2022] [Accepted: 09/20/2022] [Indexed: 12/01/2022] Open
Abstract
Pharmacometric modelling plays a key role in both the design and analysis of regulatory trials in paediatric drug development. Studies in adults provide a rich source of data to inform the paediatric investigation plans, including knowledge on drug pharmacokinetics (PK), safety and efficacy. In children, drug disposition differs widely from birth to adolescence but extrapolating adult to paediatric PK, safety and efficacy either with pharmacometric or physiologically based approaches can help design or in some cases reduce the need for clinical studies. Aspects to consider when extrapolating PK include the maturation of drug metabolizing enzyme expression, glomerular filtration, drug excretory systems, and the expression and activity of specific transporters in conjunction with other drug properties such as fraction unbound. Knowledge of these can be used to develop extrapolation tools such as allometric scaling plus maturation functions or physiologically based PK. PK/pharmacodynamic approaches and well-designed clinical trials in children are of key importance in paediatric drug development. In this white paper, state-of-the-art of current methods used for paediatric extrapolation will be discussed. This paper is part of a conect4children implementation of innovative methodologies including pharmacometric and physiologically based PK modelling in clinical trial design/paediatric drug development through dissemination of expertise and expert advice. The suggestions arising from this white paper should define a minimum set of standards in paediatric modelling and contribute to the regulatory science.
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Affiliation(s)
- Naïm Bouazza
- Pediatric and Perinatal Drug Evaluation and Pharmacology, Université Paris Cité, Paris, France.,Unité de Recherche Clinique Université Paris Cité Necker-Cochin, AP-HP, Paris, France.,CIC-1419 Inserm, Cochin-Necker, Paris, France
| | | | - Catherijne A J Knibbe
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.,Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Intensive Care and Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Claire Ambery
- Clinical Pharmacology Modelling and Simulation, GlaxoSmithKline plc, London, UK
| | - Pieter A De Cock
- Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium.,Department of Pharmacy, Ghent University Hospital, Ghent, Belgium.,Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Elke Gasthuys
- Department of Bioanalysis, Faculty of Pharmaceutical Sciences, University of Ghent, Ghent, Belgium
| | - Frantz Foissac
- Pediatric and Perinatal Drug Evaluation and Pharmacology, Université Paris Cité, Paris, France.,Unité de Recherche Clinique Université Paris Cité Necker-Cochin, AP-HP, Paris, France.,CIC-1419 Inserm, Cochin-Necker, Paris, France
| | - Saïk Urien
- Pediatric and Perinatal Drug Evaluation and Pharmacology, Université Paris Cité, Paris, France.,Unité de Recherche Clinique Université Paris Cité Necker-Cochin, AP-HP, Paris, France.,CIC-1419 Inserm, Cochin-Necker, Paris, France
| | - Anna-Karin Hamberg
- Department of Clinical Pharmacology, Uppsala University Hospital, Uppsala, Sweden
| | - Italo Poggesi
- Clinical Pharmacology and Pharmacometrics, Janssen Research & Development, Beerse, Belgium
| | - Wei Zhao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China.,Clinical Research Centre, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - An Vermeulen
- Department of Bioanalysis, Faculty of Pharmaceutical Sciences, University of Ghent, Ghent, Belgium
| | - Joseph F Standing
- Infection, Inflammation and Immunology, UCL Great Ormond Street Institute of Child Health, London, UK.,Department of Pharmacy, Great Ormond Street Hospital for Children, London, UK
| | - Jean-Marc Tréluyer
- Pediatric and Perinatal Drug Evaluation and Pharmacology, Université Paris Cité, Paris, France.,Unité de Recherche Clinique Université Paris Cité Necker-Cochin, AP-HP, Paris, France.,CIC-1419 Inserm, Cochin-Necker, Paris, France
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17
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Li R, Ma L, Li F, Li L, Bi Y, Yuan Y, Li Y, Xu Y, Zhang X, Liu J, Bhattaram VA, Wang J, Schuck R, Pacanowski M, Zhu H. Model‐Informed Approach Supporting Drug Development and Regulatory Evaluation for Rare Diseases. J Clin Pharmacol 2022; 62 Suppl 2:S27-S37. [DOI: 10.1002/jcph.2143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 08/15/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Ruo‐Jing Li
- Office of Clinical Pharmacology Center for Drug Evaluation and Research Food and Drug Administration Silver Spring Maryland USA
| | - Lian Ma
- Office of Clinical Pharmacology Center for Drug Evaluation and Research Food and Drug Administration Silver Spring Maryland USA
| | - Fang Li
- Office of Clinical Pharmacology Center for Drug Evaluation and Research Food and Drug Administration Silver Spring Maryland USA
| | - Liang Li
- Office of Clinical Pharmacology Center for Drug Evaluation and Research Food and Drug Administration Silver Spring Maryland USA
| | - Youwei Bi
- Office of Clinical Pharmacology Center for Drug Evaluation and Research Food and Drug Administration Silver Spring Maryland USA
| | - Ye Yuan
- Office of Clinical Pharmacology Center for Drug Evaluation and Research Food and Drug Administration Silver Spring Maryland USA
| | - Yangbing Li
- Office of Clinical Pharmacology Center for Drug Evaluation and Research Food and Drug Administration Silver Spring Maryland USA
| | - Yuan Xu
- Office of Clinical Pharmacology Center for Drug Evaluation and Research Food and Drug Administration Silver Spring Maryland USA
| | - Xinyuan Zhang
- Office of Clinical Pharmacology Center for Drug Evaluation and Research Food and Drug Administration Silver Spring Maryland USA
| | - Jiang Liu
- Office of Clinical Pharmacology Center for Drug Evaluation and Research Food and Drug Administration Silver Spring Maryland USA
| | - Venkatesh Atul Bhattaram
- Office of Clinical Pharmacology Center for Drug Evaluation and Research Food and Drug Administration Silver Spring Maryland USA
| | - Jie Wang
- Office of Clinical Pharmacology Center for Drug Evaluation and Research Food and Drug Administration Silver Spring Maryland USA
| | - Robert Schuck
- Office of Clinical Pharmacology Center for Drug Evaluation and Research Food and Drug Administration Silver Spring Maryland USA
| | - Michael Pacanowski
- Office of Clinical Pharmacology Center for Drug Evaluation and Research Food and Drug Administration Silver Spring Maryland USA
| | - Hao Zhu
- Office of Clinical Pharmacology Center for Drug Evaluation and Research Food and Drug Administration Silver Spring Maryland USA
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18
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Centanni M, Thijs A, Desar I, Karlsson MO, Friberg LE. Optimization of blood pressure measurement practices for pharmacodynamic analyses of tyrosine-kinase inhibitors. Clin Transl Sci 2022; 16:73-84. [PMID: 36152309 PMCID: PMC9841306 DOI: 10.1111/cts.13423] [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: 07/06/2022] [Revised: 08/23/2022] [Accepted: 09/14/2022] [Indexed: 02/06/2023] Open
Abstract
Blood pressure measurements form a critical component of adverse event monitoring for tyrosine kinase inhibitors, but might also serve as a biomarker for dose titrations. This study explored the impact of various sources of within-individual variation on blood pressure readings to improve measurement practices and evaluated the utility for individual- and population-level dose selection. A pharmacokinetic-pharmacodynamic modeling framework was created to describe circadian blood pressure changes, inter- and intra-day variability, changes from dipper to non-dipper profiles, and the relationship between drug exposure and blood pressure changes over time. The framework was used to quantitatively evaluate the influence of physiological and pharmacological aspects on blood pressure measurements, as well as to compare measurement techniques, including office-based, home-based, and ambulatory 24-h blood pressure readings. Circadian changes, as well as random intra-day and inter-day variability, were found to be the largest sources of within-individual variation in blood pressure. Office-based and ambulatory 24-h measurements gave rise to potential bias (>5 mmHg), which was mitigated by model-based estimations. Our findings suggest that 5-8 consecutive, home-based, measurements taken at a consistent time around noon, or alternatively within a limited time frame (e.g., 8.00 a.m. to 12.00 p.m. or 12.00 p.m. to 5.00 p.m.), will give rise to the most consistent blood pressure estimates. Blood pressure measurements likely do not represent a sufficiently accurate method for individual-level dose selection, but may be valuable for population-level dose identification. A user-friendly tool has been made available to allow for interactive blood pressure simulations and estimations for the investigated scenarios.
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Affiliation(s)
| | - Abel Thijs
- Department of Internal Medicine, Amsterdam UMCLocation VU UniversityAmsterdamThe Netherlands
| | - Ingrid Desar
- Department of Medical OncologyRadboud University Medical CenterNijmegenThe Netherlands
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19
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Chia YL, Tummala R, Mai TH, Rouse T, Streicher K, White WI, Morand EF, Furie RA. Relationship Between Anifrolumab Pharmacokinetics, Pharmacodynamics, and Efficacy in Patients With Moderate to Severe Systemic Lupus Erythematosus. J Clin Pharmacol 2022; 62:1094-1105. [PMID: 35352835 PMCID: PMC9545691 DOI: 10.1002/jcph.2054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/13/2021] [Indexed: 11/25/2022]
Abstract
This study aimed to elucidate the pharmacokinetic/pharmacodynamic and pharmacodynamic/efficacy relationships of anifrolumab, a type I interferon receptor antibody, in patients with moderate to severe systemic lupus erythematosus. Data were pooled from the randomized, 52-week, placebo-controlled TULIP-1 and TULIP-2 trials of intravenous anifrolumab (150 mg/300 mg, every 4 weeks for 48 weeks). Pharmacodynamic neutralization was measured with a 21-gene type I interferon gene signature (21-IFNGS) in patients with high IFNGS. The pharmacokinetic/pharmacodynamic relationship was analyzed graphically and modeled with a nonlinear mixed-effects model. British Isles Lupus Assessment Group-based Composite Lupus Assessment (BICLA) response rates were compared across 21-IFNGS neutralization quartiles. Overall, 819 patients received ≥1 dose of anifrolumab or placebo, of whom 676 were IFNGS high. Over 52 weeks, higher average anifrolumab serum concentrations were associated with increased median 21-IFNGS neutralization, which was rapid and sustained with anifrolumab 300 mg (>80%, weeks 12-52), lower and delayed with anifrolumab 150 mg (>50%, week 52), and minimal with placebo. The proportion of patients with week 24 anifrolumab trough concentration exceeding the IC80 (3.88 μg/mL) was greater with anifrolumab 300 mg vs anifrolumab 150 mg (≈83% vs ≈27%), owing to the higher estimated median trough concentration (15.6 vs 0.2 μg/mL). BICLA response rates increased with 21-IFNGS neutralization; more patients had a BICLA response in the highest vs lowest neutralization quartiles at week 52 (58.1% vs 37.6%). In conclusion, anifrolumab 300 mg every 4 weeks rapidly, substantially, and sustainably neutralized the 21-IFNGS and was associated with clinical efficacy, supporting this dosing regimen in patients with systemic lupus erythematosus.
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Affiliation(s)
- Yen Lin Chia
- BioPharmaceuticals R&DAstraZeneca USSouth San FranciscoCaliforniaUSA
- SeagenSouth San FranciscoCaliforniaUSA
| | - Raj Tummala
- BioPharmaceuticals R&DAstraZeneca USGaithersburgMarylandUSA
| | - Tu H. Mai
- BioPharmaceuticals R&DAstraZeneca USSouth San FranciscoCaliforniaUSA
- GenentechSouth San FranciscoCaliforniaUSA
| | - Tomas Rouse
- BioPharmaceuticals R&DAstraZeneca R&DGothenburgSweden
| | | | - Wendy I. White
- BioPharmaceuticals R&DAstraZeneca USGaithersburgMarylandUSA
| | - Eric F. Morand
- Centre for Inflammatory Disease Monash HealthMonash UniversityMelbourneVictoriaAustralia
| | - Richard A. Furie
- Division of RheumatologyDonald and Barbara Zucker School of Medicine at Hofstra/Northwell HealthGreat NeckNew YorkUSA
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20
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Mohammadi Jouabadi S, Nekouei Shahraki M, Peymani P, Stricker BH, Ahmadizar F. Utilization of Pharmacokinetic/Pharmacodynamic Modeling in Pharmacoepidemiological Studies: A Systematic Review on Antiarrhythmic and Glucose-Lowering Medicines. Front Pharmacol 2022; 13:908538. [PMID: 35795566 PMCID: PMC9251370 DOI: 10.3389/fphar.2022.908538] [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: 03/30/2022] [Accepted: 05/04/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction: In human pharmacology, there are two important scientific branches: clinical pharmacology and pharmacoepidemiology. Pharmacokinetic/pharmacodynamic (PK/PD) modeling is important in preclinical studies and randomized control trials. However, it is rarely used in pharmacoepidemiological studies on the effectiveness and medication safety where the target population is heterogeneous and followed for longer periods. The objective of this literature review was to investigate how far PK/PD modeling is utilized in observational studies on glucose-lowering and antiarrhythmic drugs. Method: A systematic literature search of MEDLINE, Embase, and Web of Science was conducted from January 2010 to 21 February 2020. To calculate the utilization of PK/PD modeling in observational studies, we followed two search strategies. In the first strategy, we screened a 1% random set from 95,672 studies on glucose-lowering and antiarrhythmic drugs on inclusion criteria. In the second strategy, we evaluated the percentage of studies in which PK/PD modeling techniques were utilized. Subsequently, we divided the total number of included studies in the second search strategy by the total number of eligible studies in the first search strategy. Results: The comprehensive search of databases and the manual search of included references yielded a total of 29 studies included in the qualitative synthesis of our systematic review. Nearly all 29 studies had utilized a PK model, whereas only two studies developed a PD model to evaluate the effectiveness of medications. In total, 16 out of 29 studies (55.1%) used a PK/PD model in the observational setting to study effect modification. The utilization of PK/PD modeling in observational studies was calculated as 0.42%. Conclusion: PK/PD modeling techniques were substantially underutilized in observational studies of antiarrhythmic and glucose-lowering drugs during the past decade.
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Affiliation(s)
- Soroush Mohammadi Jouabadi
- Department of Epidemiology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Division of Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Mitra Nekouei Shahraki
- Department of Epidemiology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Payam Peymani
- Department of Epidemiology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Bruno H. Stricker
- Department of Epidemiology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
- *Correspondence: Bruno H. Stricker,
| | - Fariba Ahmadizar
- Department of Epidemiology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Julius Global Health, University Medical Center Utrecht, Utrecht, Netherlands
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21
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Morse JD, Cortinez LI, Anderson BJ. Pharmacokinetic Pharmacodynamic Modelling Contributions to Improve Paediatric Anaesthesia Practice. J Clin Med 2022; 11:jcm11113009. [PMID: 35683399 PMCID: PMC9181587 DOI: 10.3390/jcm11113009] [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: 04/26/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 12/10/2022] Open
Abstract
The use of pharmacokinetic-pharmacodynamic models has improved anaesthesia practice in children through a better understanding of dose-concentration-response relationships, developmental pharmacokinetic changes, quantification of drug interactions and insights into how covariates (e.g., age, size, organ dysfunction, pharmacogenomics) impact drug prescription. Simulation using information from these models has enabled the prediction and learning of beneficial and adverse effects and decision-making around clinical scenarios. Covariate information, including the use of allometric size scaling, age and consideration of fat mass, has reduced population parameter variability. The target concentration approach has rationalised dose calculation. Paediatric pharmacokinetic-pharmacodynamic insights have led to better drug delivery systems for total intravenous anaesthesia and an expectation about drug offset when delivery is stopped. Understanding concentration-dependent adverse effects have tempered dose regimens. Quantification of drug interactions has improved the understanding of the effects of drug combinations. Repurposed drugs (e.g., antiviral drugs used for COVID-19) within the community can have important effects on drugs used in paediatric anaesthesia, and the use of simulation educates about these drug vagaries.
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Affiliation(s)
- James D. Morse
- Department of Anaesthesiology, University of Auckland, Park Road, Auckland 1023, New Zealand;
| | - Luis Ignacio Cortinez
- División Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, San Diego de Chile 8331150, Chile;
| | - Brian J. Anderson
- Department of Anaesthesiology, University of Auckland, Park Road, Auckland 1023, New Zealand;
- Correspondence: ; Tel.: +64-9-3074903; Fax: +64-9-3078986
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22
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Schneider F, Gessner A, El-Najjar N. Efficacy of Vancomycin and Meropenem in Central Nervous System Infections in Children and Adults: Current Update. Antibiotics (Basel) 2022; 11:antibiotics11020173. [PMID: 35203776 PMCID: PMC8868565 DOI: 10.3390/antibiotics11020173] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 11/16/2022] Open
Abstract
The current antimicrobial therapy of bacterial infections of the central nervous system (CNS) in adults and pediatric patients is faced with many pitfalls as the drugs have to reach necessary levels in serum and cross the blood-brain barrier. Furthermore, several studies report that different factors such as the structure of the antimicrobial agent, the severity of disease, or the degree of inflammation play a significant role. Despite the available attempts to establish pharmacokinetic (PK) modeling to improve the required dosing regimen for adults and pediatric patients, conclusive recommendations for the best therapeutic strategies are still lacking. For instance, bacterial meningitis, the most common CNS infections, and ventriculitis, a severe complication of meningitis, are still associated with 10% and 30% mortality, respectively. Several studies report on the use of vancomycin and meropenem to manage meningitis and ventriculitis; therefore, this review aims to shed light on the current knowledge about their use in adults and pediatric patients. Consequently, studies published from 2015 until mid-July 2021 are included, and data about the study population, levels of drugs in serum and cerebrospinal fluid (CSF), and measured PK data in serum and CSF are provided. The overall aim is to provide the readers a recent reference that summarizes the pitfalls and success of the current therapy and emphasizes the importance of performing more studies to improve the clinical outcome of the current therapeutical approach.
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23
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Weld ED, Waitt C, Barnes K, Garcia Bournissen F. Twice neglected? Neglected diseases in neglected populations. Br J Clin Pharmacol 2021; 88:367-373. [PMID: 34888909 DOI: 10.1111/bcp.15148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 01/20/2023] Open
Abstract
It is unfortunately true that clinicians lack the necessary evidence to know how to use medications properly in large sections of the population and do not have optimal treatments to use for many neglected tropical diseases (NTDs). NTDs often disproportionately affect neglected populations that are left out of research efforts, such as children and pregnant women. As reliable access to safe, effective preventives and treatments can break the cycle of poverty, illness, and ensuing debility that further perpetuates poverty, it is of paramount importance to investigate and develop new medicines for neglected populations suffering from NTDs. Furthermore, there is not only a need to develop and evaluate novel therapies, but also to ensure that these are affordable, available, and adapted to the communities who need them. The NIH has proposed a "4 C's" framework which is relevant for neglected diseases and populations and should be leveraged for the study of the Twice Neglected: Consider inclusion; Collect data from neglected populations with neglected conditions; Characterize differences through meaningful analysis; Communicate findings pertaining to neglected diseases and populations. With this editorial, the British Journal of Clinical Pharmacology hereby launches a call for high-quality articles focusing on NTDs in special populations, to facilitate and encourage the reversal of this dual neglect.
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Affiliation(s)
- Ethel D Weld
- Department of Medicine, Division of Infectious Diseases and Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Catriona Waitt
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Infectious Disease Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Royal Liverpool University Hospital, Liverpool, UK
| | - Karen Barnes
- Division of Clinical Pharmacology, The University of Cape Town, Cape Town, South Africa
| | - Facundo Garcia Bournissen
- Division of Pediatric Clinical Pharmacology, Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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24
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Soeorg H, Sverrisdóttir E, Andersen M, Lund TM, Sessa M. The PHARMACOM-EPI Framework for Integrating Pharmacometric Modelling Into Pharmacoepidemiological Research Using Real-World Data: Application to Assess Death Associated With Valproate. Clin Pharmacol Ther 2021; 111:840-856. [PMID: 34860420 DOI: 10.1002/cpt.2502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 11/17/2021] [Indexed: 01/14/2023]
Abstract
In pharmacoepidemiology, it is usually expected that the observed association should be directly or indirectly related to the pharmacological effects of the drug/s under investigation. Pharmacological effects are, in turn, strongly connected to the pharmacokinetic and pharmacodynamic properties of a drug, which can be characterized and investigated using pharmacometric models. Recently, the use of pharmacometrics has been proposed to provide pharmacological substantiation of pharmacoepidemiological findings derived from real-world data. However, validated frameworks suggesting how to combine these two disciplines for the aforementioned purpose are missing. Therefore, we propose PHARMACOM-EPI, a framework that provides a structured approach on how to identify, characterize, and apply pharmacometric models with practical details on how to choose software, format dataset, handle missing covariates/dosing data, how to perform the external evaluation of pharmacometric models in real-world data, and how to provide pharmacological substantiation of pharmacoepidemiological findings. PHARMACOM-EPI was tested in a proof-of-concept study to pharmacologically substantiate death associated with valproate use in the Danish population aged ≥ 65 years. Pharmacological substantiation of death during a follow-up period of 1 year showed that in all individuals who died (n = 169) individual predictions were within the subtherapeutic range compared with 52.8% of those who did not die (n = 1,084). Of individuals who died, 66.3% (n = 112) had a cause of death possibly related to valproate and 33.7% (n = 57) with well-defined cause of death unlikely related to valproate. This proof-of-concept study showed that PHARMACOM-EPI was able to provide pharmacological substantiation for death associated with valproate use in the study population.
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Affiliation(s)
- Hiie Soeorg
- Department of Drug Design and Pharmacology, Pharmacovigilance Research Center, University of Copenhagen, Copenhagen, Denmark.,Department of Drug Design and Pharmacology, Pharmacometrics Research Group, University of Copenhagen, Copenhagen, Denmark
| | - Eva Sverrisdóttir
- Department of Drug Design and Pharmacology, Pharmacometrics Research Group, University of Copenhagen, Copenhagen, Denmark
| | - Morten Andersen
- Department of Drug Design and Pharmacology, Pharmacovigilance Research Center, University of Copenhagen, Copenhagen, Denmark
| | - Trine Meldgaard Lund
- Department of Drug Design and Pharmacology, Pharmacometrics Research Group, University of Copenhagen, Copenhagen, Denmark
| | - Maurizio Sessa
- Department of Drug Design and Pharmacology, Pharmacovigilance Research Center, University of Copenhagen, Copenhagen, Denmark
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Population pharmacokinetic-pharmacodynamic modeling of acetaminophen in preterm neonates with hemodynamically significant patent ductus arteriosus. Eur J Pharm Sci 2021; 167:106023. [PMID: 34592463 DOI: 10.1016/j.ejps.2021.106023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/12/2021] [Accepted: 09/25/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Pharmacokinetics (PK) of intravenous acetaminophen has not been assessed in preterm neonates with hemodynamically significant patent ductus arteriosus (PDA). Moreover, there is a lack of data evaluating the association between PK and pharmacodynamics (PD) of acetaminophen in hemodynamically significant PDA. Hence, we performed a population PK-PD modeling of acetaminophen in preterm neonates with hemodynamically significant PDA. METHODS A prospective, observational study was carried out in preterm neonates with hemodynamically significant PDA receiving intravenous acetaminophen (15 mg/kg six hourly) for maximum of nine days. The diameter of the ductus arteriosus was measured using General Electric Vivid 7® (echocardiography) and was the PD measure. The PK-PD modeling was performed using Monolix 2019R2. We performed Monte Carlo (MC) simulations to determine the probability of ductus arteriosus closure from first to the ninth day of acetaminophen treatment. RESULTS Fifty-five neonates were recruited. A one-compartment model with first-order elimination described well the PK of acetaminophen. Clearance (CL) and volume of distribution (Vd) for typical neonate weighing 0.98 kg was 0.0452 L/h and 1.18 L, respectively. A combination of an Imax model with effect compartment and an exponential disease progression model described well the PD of acetaminophen. The average baseline diameter of the ductus arteriosus (E0) was 2.53 mm while IC50 was 0.477 µg/mL. The disease progression rate constant (Kprog) and effect compartment transfer rate constant (ke0) were 0.00425 h-1 and 0.000103 h-1, respectively. MC simulations of the current dosing regimen revealed a probability of 73.7% ductus arteriosus closure compared to 83.8% with 20 mg/kg six hourly dose. CONCLUSION The PK-PD model developed can be used for dosing acetaminophen in premature neonates with hemodynamically significant PDA. Intravenous dose of 20 mg/kg intravenously every six hours is likely to provide a better therapeutic effect than the existing dosing regimen.
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Aziz S, Harun SN, Sulaiman SAS, Ghadzi SMS. Pharmacometrics Approaches and its Applications in Diabetes: An Overview. J Pharm Bioallied Sci 2021; 13:335-340. [PMID: 35399800 PMCID: PMC8985840 DOI: 10.4103/jpbs.jpbs_399_21] [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: 05/17/2021] [Revised: 09/08/2021] [Accepted: 09/08/2021] [Indexed: 11/04/2022] Open
Abstract
Type 2 diabetes mellitus is the most prevalent and progressive in nature. As the time progress, the multifaceted complications and comorbidities associated to diabetes worsen in the form of macrovascular or microvascular or both. Pharmacometrics modeling is a step forward in minimizing the risk or at least understanding the factors associated to its progression with the passage of time. These models investigate diabetes treatments effects and the progression factors with different viewpoints incorporating insulin-glucose dynamics, dose-response and pharmacokinetics, and pharmacodynamics relationships. Pharmacometrics modeling is an innovative approach in a sense that it is taking us away from the conventional analysis by providing all the opportunities in improving the decision-making in health sector. It has been suggested that we can achieve greater statistical power for determining drug effects through model-based evaluation than through traditional evaluations. The main aim of this review was to evaluate pharmacometrics approaches used in modeling diabetes progression through time and also the integrated models describing glucose-insulin dynamics.
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Affiliation(s)
- Sohail Aziz
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Sabariah Noor Harun
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Syed Azhar Syed Sulaiman
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
- Advanced Medical and Dental Institute, Universiti Sains Malaysia, Kepala Batas, Penang, Malaysia
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27
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Truong VT, Baverel PG, Lythe GD, Vicini P, Yates JWT, Dubois VFS. Step-by-step comparison of ordinary differential equation and agent-based approaches to pharmacokinetic-pharmacodynamic models. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2021; 11:133-148. [PMID: 34399036 PMCID: PMC8846629 DOI: 10.1002/psp4.12703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/28/2021] [Accepted: 05/14/2021] [Indexed: 12/03/2022]
Abstract
Mathematical models in oncology aid in the design of drugs and understanding of their mechanisms of action by simulation of drug biodistribution, drug effects, and interaction between tumor and healthy cells. The traditional approach in pharmacometrics is to develop and validate ordinary differential equation models to quantify trends at the population level. In this approach, time‐course of biological measurements is modeled continuously, assuming a homogenous population. Another approach, agent‐based models, focuses on the behavior and fate of biological entities at the individual level, which subsequently could be summarized to reflect the population level. Heterogeneous cell populations and discrete events are simulated, and spatial distribution can be incorporated. In this tutorial, an agent‐based model is presented and compared to an ordinary differential equation model for a tumor efficacy model inhibiting the pERK pathway. We highlight strengths, weaknesses, and opportunities of each approach.
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Affiliation(s)
- Van Thuy Truong
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, AstraZeneca, Aaron Klug Building, Granta Park, Cambridge, CB21 6GH, UK.,Department of Applied Mathematics, University of Leeds, Leeds, United Kingdom
| | - Paul G Baverel
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, AstraZeneca, Aaron Klug Building, Granta Park, Cambridge, CB21 6GH, UK.,Roche Pharma Research and Early Development, Clinical Pharmacology, Pharmaceutical Sciences, Roche Innovation Center Basel F. Hoffmann-La Roche Ltd, Switzerland
| | - Grant D Lythe
- Department of Applied Mathematics, University of Leeds, Leeds, United Kingdom
| | - Paolo Vicini
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, AstraZeneca, Aaron Klug Building, Granta Park, Cambridge, CB21 6GH, UK.,Confo Therapeutics, Technologiepark 94, 9052, Ghent (Zwijnaarde), Belgium
| | | | - Vincent F S Dubois
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, AstraZeneca, Aaron Klug Building, Granta Park, Cambridge, CB21 6GH, UK
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28
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Chen YT, Wang CY, Yin YW, Li ZR, Lin WW, Zhu M, Jiao Z. Population pharmacokinetics of oxcarbazepine: a systematic review. Expert Rev Clin Pharmacol 2021; 14:853-864. [PMID: 33851561 DOI: 10.1080/17512433.2021.1917377] [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] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Oxcarbazepine is commonly used as first-line treatment for partial and generalized tonic-clonic seizures. Owing to the high pharmacokinetic variability, several population pharmacokinetic models have been developed for oxcarbazepine to explore potential covariates that affect its pharmacokinetic variation. AREAS COVERED This review summarizes the published population pharmacokinetic studies of oxcarbazepine in children and adults available in PubMed and Embase databases. The quality of the retrieved studies was evaluated, and significant covariates that may have an impact on the dosage regimen of oxcarbazepine were explored. EXPERT OPINION The pharmacokinetics of oxcarbazepine was founded to be affected by body weight and co-administration with enzyme inducers. Pediatric patients require a higher dose per kilogram than adults because children generally have a higher clearance than adults. Moreover, to maintain the target concentration, patients co-administrate with enzyme inducers need a higher dose than monotherapy due to higher clearance in those patients. Because limited information is available for exposure-response relationship, additional pharmacokinetic/pharmacodynamics investigations of oxcarbazepine need to be conducted to optimize the dosage regimen in clinical practice.
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Affiliation(s)
- Yue-Ting Chen
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Chen-Yu Wang
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yi-Wei Yin
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zi-Ran Li
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Wei-Wei Lin
- Department of Pharmacy, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Min Zhu
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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29
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Hartung N, Wahl M, Rastogi A, Huisinga W. Nonparametric goodness-of-fit testing for parametric covariate models in pharmacometric analyses. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2021; 10:564-576. [PMID: 33755347 PMCID: PMC8213422 DOI: 10.1002/psp4.12614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/02/2021] [Accepted: 03/08/2021] [Indexed: 11/12/2022]
Abstract
The characterization of covariate effects on model parameters is a crucial step during pharmacokinetic/pharmacodynamic analyses. Although covariate selection criteria have been studied extensively, the choice of the functional relationship between covariates and parameters, however, has received much less attention. Often, a simple particular class of covariate‐to‐parameter relationships (linear, exponential, etc.) is chosen ad hoc or based on domain knowledge, and a statistical evaluation is limited to the comparison of a small number of such classes. Goodness‐of‐fit testing against a nonparametric alternative provides a more rigorous approach to covariate model evaluation, but no such test has been proposed so far. In this manuscript, we derive and evaluate nonparametric goodness‐of‐fit tests for parametric covariate models, the null hypothesis, against a kernelized Tikhonov regularized alternative, transferring concepts from statistical learning to the pharmacological setting. The approach is evaluated in a simulation study on the estimation of the age‐dependent maturation effect on the clearance of a monoclonal antibody. Scenarios of varying data sparsity and residual error are considered. The goodness‐of‐fit test correctly identified misspecified parametric models with high power for relevant scenarios. The case study provides proof‐of‐concept of the feasibility of the proposed approach, which is envisioned to be beneficial for applications that lack well‐founded covariate models.
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Affiliation(s)
- Niklas Hartung
- Institute of Mathematics, Universität Potsdam, Potsdam, Germany
| | - Martin Wahl
- Institute of Mathematics, Humboldt-Universität zu Berlin, Berlin, Germany
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30
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Solans BP, Garrido MJ, Trocóniz IF. Drug Exposure to Establish Pharmacokinetic-Response Relationships in Oncology. Clin Pharmacokinet 2021; 59:123-135. [PMID: 31654368 DOI: 10.1007/s40262-019-00828-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In the oncology field, understanding the relationship between the dose administered and the exerted effect is particularly important because of the narrow therapeutic index associated with anti-cancer drugs and the high interpatient variability. Therefore, in this review, we provide a critical perspective of the different methods of characterising treatment exposure in the oncology setting. The increasing number of modelling applications in oncology reflects the applicability and the impact of pharmacometrics on all phases of the drug development process and patient management as well. Pharmacometric modelling is a worthy component within the current paradigm of model-based drug development, but pharmacometric modelling techniques are also accessible for the clinician in the optimisation of current oncology therapies. Consequently, the application of population models in a hospital setting by generating close collaborations between physicians and pharmacometricians is highly recommended, providing a systematic means of developing and assessing model-based metrics as 'drivers' for various responses to treatments, which can then be evaluated as predictors for treatment success. Characterising the key determinants of variability in exposure is of particular importance for anticancer agents, as efficacy and toxicity are associated with exposure. We present the different strategies to describe and predict drug exposure that can be applied depending on the data available, with the objective of obtaining the most useful information in the patients' favour throughout the full drug cycle. Therefore, the objective of the present article is to review the different approaches used to characterise a patient's exposure to oncology drugs, which will result in a better understanding of the time course of the response and the magnitude of interpatient variability.
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Affiliation(s)
- Belén P Solans
- Pharmacometrics & Systems Pharmacology, Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Navarra, C/Irunlarrea s/n, 31008, Pamplona, Navarra, Spain. .,Navarra Institute for Health Research (IdisNA), University of Navarra, Pamplona, Spain.
| | - María Jesús Garrido
- Pharmacometrics & Systems Pharmacology, Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Navarra, C/Irunlarrea s/n, 31008, Pamplona, Navarra, Spain.,Navarra Institute for Health Research (IdisNA), University of Navarra, Pamplona, Spain
| | - Iñaki F Trocóniz
- Pharmacometrics & Systems Pharmacology, Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Navarra, C/Irunlarrea s/n, 31008, Pamplona, Navarra, Spain. .,Navarra Institute for Health Research (IdisNA), University of Navarra, Pamplona, Spain.
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Germovsek E, Cheng M, Giragossian C. Allometric scaling of therapeutic monoclonal antibodies in preclinical and clinical settings. MAbs 2021; 13:1964935. [PMID: 34530672 PMCID: PMC8463036 DOI: 10.1080/19420862.2021.1964935] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/19/2021] [Accepted: 08/03/2021] [Indexed: 02/06/2023] Open
Abstract
Constant technological advancement enabled the production of therapeutic monoclonal antibodies (mAbs) and will continue to contribute to their rapid expansion. Compared to small-molecule drugs, mAbs have favorable characteristics, but also more complex pharmacokinetics (PK), e.g., target-mediated nonlinear elimination and recycling by neonatal Fc-receptor. This review briefly discusses mAb biology, similarities and differences in PK processes across species and within human, and provides a detailed overview of allometric scaling approaches for translating mAb PK from preclinical species to human and extrapolating from adults to children. The approaches described here will remain vital in mAb drug development, although more data are needed, for example, from very young patients and mAbs with nonlinear PK, to allow for more confident conclusions and contribute to further growth of this field. Improving mAb PK predictions will facilitate better planning of (pediatric) clinical studies and enable progression toward the ultimate goal of expediting drug development.
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Affiliation(s)
- Eva Germovsek
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Ming Cheng
- Development Biologicals, Drug Metabolism And Pharmacokinetics, Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, US
| | - Craig Giragossian
- Biotherapeutics Discovery, Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, US
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32
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Roganović M, Homšek A, Jovanović M, Topić-Vučenović V, Ćulafić M, Miljković B, Vučićević K. Concept and utility of population pharmacokinetic and pharmacokinetic/pharmacodynamic models in drug development and clinical practice. ARHIV ZA FARMACIJU 2021. [DOI: 10.5937/arhfarm71-32901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Due to frequent clinical trial failures and consequently fewer new drug approvals, the need for improvement in drug development has, to a certain extent, been met using model-based drug development. Pharmacometrics is a part of pharmacology that quantifies drug behaviour, treatment response and disease progression based on different models (pharmacokinetic - PK, pharmacodynamic - PD, PK/PD models, etc.) and simulations. Regulatory bodies (European Medicines Agency, Food and Drug Administration) encourage the use of modelling and simulations to facilitate decision-making throughout all drug development phases. Moreover, the identification of factors that contribute to variability provides a basis for dose individualisation in routine clinical practice. This review summarises current knowledge regarding the application of pharmacometrics in drug development and clinical practice with emphasis on the population modelling approach.
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33
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Darwich AS, Polasek TM, Aronson JK, Ogungbenro K, Wright DFB, Achour B, Reny JL, Daali Y, Eiermann B, Cook J, Lesko L, McLachlan AJ, Rostami-Hodjegan A. Model-Informed Precision Dosing: Background, Requirements, Validation, Implementation, and Forward Trajectory of Individualizing Drug Therapy. Annu Rev Pharmacol Toxicol 2020; 61:225-245. [PMID: 33035445 DOI: 10.1146/annurev-pharmtox-033020-113257] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Model-informed precision dosing (MIPD) has become synonymous with modern approaches for individualizing drug therapy, in which the characteristics of each patient are considered as opposed to applying a one-size-fits-all alternative. This review provides a brief account of the current knowledge, practices, and opinions on MIPD while defining an achievable vision for MIPD in clinical care based on available evidence. We begin with a historical perspective on variability in dose requirements and then discuss technical aspects of MIPD, including the need for clinical decision support tools, practical validation, and implementation of MIPD in health care. We also discuss novel ways to characterize patient variability beyond the common perceptions of genetic control. Finally, we address current debates on MIPD from the perspectives of the new drug development, health economics, and drug regulations.
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Affiliation(s)
- Adam S Darwich
- Logistics and Informatics in Health Care, School of Engineering Sciences in Chemistry, Biotechnology and Health (CBH), KTH Royal Institute of Technology, SE-141 57 Huddinge, Sweden
| | - Thomas M Polasek
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, South Australia 5000, Australia.,Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria 3052, Australia.,Certara, Princeton, New Jersey 08540, USA
| | - Jeffrey K Aronson
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Kayode Ogungbenro
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester M13 9PT, United Kingdom;
| | | | - Brahim Achour
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester M13 9PT, United Kingdom;
| | - Jean-Luc Reny
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, CH-1211 Geneva, Switzerland.,Division of General Internal Medicine, Geneva University Hospitals, CH-1211 Geneva, Switzerland
| | - Youssef Daali
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, CH-1211 Geneva, Switzerland
| | - Birgit Eiermann
- Inera AB, Swedish Association of Local Authorities and Regions, SE-118 93 Stockholm, Sweden
| | - Jack Cook
- Drug Safety Research & Development, Pfizer Inc., Groton, Connecticut 06340, USA
| | - Lawrence Lesko
- Center for Pharmacometrics and Systems Pharmacology, University of Florida, Orlando, Florida 32827, USA
| | - Andrew J McLachlan
- School of Pharmacy, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Amin Rostami-Hodjegan
- Certara, Princeton, New Jersey 08540, USA.,Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester M13 9PT, United Kingdom;
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Cheng Y, Wang CY, Li ZR, Pan Y, Liu MB, Jiao Z. Can Population Pharmacokinetics of Antibiotics be Extrapolated? Implications of External Evaluations. Clin Pharmacokinet 2020; 60:53-68. [PMID: 32960439 DOI: 10.1007/s40262-020-00937-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE External evaluation is an important issue in the population pharmacokinetic analysis of antibiotics. The purpose of this review was to summarize the current approaches and status of external evaluations and discuss the implications of external evaluation results for the future individualization of dosing regimens. METHODS We systematically searched the PubMed and EMBASE databases for external evaluation studies of population analysis and extracted the relevant information from these articles. A total of 32 studies were included in this review. RESULTS Vancomycin was investigated in 17 (53.1%) articles and was the most studied drug. Other studied drugs included gentamicin, tobramycin, amikacin, amoxicillin, ceftaroline, meropenem, fluconazole, voriconazole, and rifampicin. Nine (28.1%) studies were prospective, and the sample size varied widely between studies. Thirteen (40.6%) studies evaluated the population pharmacokinetic models by systematically searching for previous studies. Seven (21.9%) studies were multicenter studies, and 27 (84.4%) adopted the sparse sampling strategy. Almost all external evaluation studies of antibiotics (93.8%) used metrics for prediction-based diagnostics, while relatively fewer studies were based on simulations (46.9%) and Bayesian forecasting (25.0%). CONCLUSION The results of external evaluations in previous studies revealed the poor extrapolation performance of existing models of prediction- and simulation-based diagnostics, whereas the posterior Bayesian method could improve predictive performance. There is an urgent need for the development of standards and guidelines for external evaluation studies.
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Affiliation(s)
- Yu Cheng
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 West Huaihai Road, Shanghai, 200040, China.,Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Road, Gulou, Fuzhou, 350001, China
| | - Chen-Yu Wang
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 West Huaihai Road, Shanghai, 200040, China
| | - Zi-Ran Li
- College of Pharmacy, Fudan University, Shanghai, China
| | - Yan Pan
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 West Huaihai Road, Shanghai, 200040, China
| | - Mao-Bai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Road, Gulou, Fuzhou, 350001, China.
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 West Huaihai Road, Shanghai, 200040, China.
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Preijers T, Schütte LM, Kruip MJHA, Cnossen MH, Leebeek FWG, van Hest RM, Mathôt RAA. Population Pharmacokinetics of Clotting Factor Concentrates and Desmopressin in Hemophilia. Clin Pharmacokinet 2020; 60:1-16. [PMID: 32936401 PMCID: PMC7808974 DOI: 10.1007/s40262-020-00936-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hemophilia A and B are bleeding disorders caused by a deficiency of clotting factor VIII and IX, respectively. Patients with severe hemophilia (< 0.01 IU mL−1) and some patients with moderate hemophilia (0.01–0.05 IU mL−1) administer clotting factor concentrates prophylactically. Desmopressin (d-amino d-arginine vasopressin) can be applied in patients with non-severe hemophilia A. The aim of administration of factor concentrates or desmopressin is the prevention or cessation of bleeding. Despite weight-based dosing, it has been demonstrated that factor concentrates still exhibit considerable pharmacokinetic variability. Population pharmacokinetic analyses, in which this variability is quantified and explained, are increasingly performed in hemophilia research. These analyses can assist in the identification of important patient characteristics and can be applied to perform patient-tailored dosing. This review aims to present and discuss the population pharmacokinetic analyses that have been conducted to develop population pharmacokinetic models describing factor levels after administration of factor VIII or factor IX concentrates or d-amino d-arginine vasopressin. In total, 33 publications were retrieved from the literature. Two approaches were applied to perform population pharmacokinetic analyses, the standard two-stage approach and non-linear mixed-effect modeling. Using the standard two-stage approach, four population pharmacokinetic models were established describing factor VIII levels. In the remaining 29 analyses, the non-linear mixed-effect modeling approach was applied. NONMEM was the preferred software to establish population pharmacokinetic models. In total, 18 population pharmacokinetic analyses were conducted on the basis of data from a single product. From all available population pharmacokinetic analyses, 27 studies also included data from pediatric patients. In the majority of the population pharmacokinetic models, the population pharmacokinetic parameters were allometrically scaled using actual body weight. In this review, the available methods used for constructing the models, key features of these models, patient population characteristics, and established covariate relationships are described in detail.
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Affiliation(s)
- Tim Preijers
- Hospital Pharmacy-Clinical Pharmacology, Academic University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Lisette M Schütte
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Reinier M van Hest
- Hospital Pharmacy-Clinical Pharmacology, Academic University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy-Clinical Pharmacology, Academic University Medical Centers, Location AMC, Amsterdam, The Netherlands. .,Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands.
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Kim SW, Kim DJ, Zang DY, Lee DH. Impact of Sampling Period on Population Pharmacokinetic Analysis of Antibiotics: Why do You Take Blood Samples Following the Fourth Dose? Pharmaceuticals (Basel) 2020; 13:ph13090249. [PMID: 32947890 PMCID: PMC7558941 DOI: 10.3390/ph13090249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/06/2020] [Accepted: 09/14/2020] [Indexed: 12/15/2022] Open
Abstract
To date, many population pharmacokinetic models of antibiotics have been developed using blood sampling data after the fourth or fifth dose, which represents steady-state levels. However, if a model developed using blood sampled after the first dose is equivalent to that using blood sampled after the fourth dose, it would be advantageous to utilize the former. The aim of this study was to investigate the effect of blood sampling after the first and/or fourth drug administration on the accuracy and precision of parameter estimates. A previously reported robust, two-compartment model of vancomycin was used for simulation to evaluate the performances of the parameter estimates. The parameter estimation performances were assessed using relative bias and relative root mean square error. Performance was investigated in 72 scenarios consisting of a combination of two blood sampling periods (the first and fourth dose), two total clearances, three infusion times, and four sample sizes. The population pharmacokinetic models from data collected at the first dose and those collected at the fourth dose produced parameter estimates that were similar in accuracy and precision. This study will contribute to increasing the efficiency and simplicity of antibiotic pharmacokinetic studies.
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Affiliation(s)
- So Won Kim
- Department of Pharmacology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea;
| | - Dong Jin Kim
- Drug Evaluation Department, National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Osong, Cheongju 28159, Korea;
| | - Dae Young Zang
- Division of Hematology-Oncology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang 14066, Korea;
| | - Dong-Hwan Lee
- Department of Clinical Pharmacology, Hallym University Sacred Heart Hospital, Anyang 14066, Korea
- Correspondence: ; Tel.: +82-31-380-4778
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Alsultan A, Alghamdi WA, Alghamdi J, Alharbi AF, Aljutayli A, Albassam A, Almazroo O, Alqahtani S. Clinical pharmacology applications in clinical drug development and clinical care: A focus on Saudi Arabia. Saudi Pharm J 2020; 28:1217-1227. [PMID: 33132716 PMCID: PMC7584801 DOI: 10.1016/j.jsps.2020.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 08/14/2020] [Indexed: 01/10/2023] Open
Abstract
Drug development, from preclinical to clinical studies, is a lengthy and complex process. There is an increased interest in the Kingdom of Saudi Arabia (KSA) to promote innovation, research and local content including clinical trials (Phase I-IV). Currently, there are over 650 registered clinical trials in Saudi Arabia, and this number is expected to increase. An important part of drug development and clinical trials is to assure the safe and effective use of drugs. Clinical pharmacology plays a vital role in informed decision making during the drug development stage as it focuses on the effects of drugs in humans. Disciplines such as pharmacokinetics, pharmacodynamics and pharmacogenomics are components of clinical pharmacology. It is a growing discipline with a range of applications in all phases of drug development, including selecting optimal doses for Phase I, II and III studies, evaluating bioequivalence and biosimilar studies and designing clinical studies. Incorporating clinical pharmacology in research as well as in the requirements of regulatory agencies will improve the drug development process and accelerate the pipeline. Clinical pharmacology is also applied in direct patient care with the goal of personalizing treatment. Tools such as therapeutic drug monitoring, pharmacogenomics and model informed precision dosing are used to optimize dosing for patients at an individual level. In KSA, the science of clinical pharmacology is underutilized and we believe it is important to raise awareness and educate the scientific community and healthcare professionals in terms of its applications and potential. In this review paper, we provide an overview on the use and applications of clinical pharmacology in both drug development and clinical care.
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Affiliation(s)
- Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.,Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Wael A Alghamdi
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | - Jahad Alghamdi
- The Saudi Biobank, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abeer F Alharbi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh 11426, Saudi Arabia
| | | | - Ahmed Albassam
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | | | - Saeed Alqahtani
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.,Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia
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38
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Derbalah A, Al‐Sallami H, Hasegawa C, Gulati A, Duffull SB. A framework for simplification of quantitative systems pharmacology models in clinical pharmacology. Br J Clin Pharmacol 2020; 88:1430-1440. [DOI: 10.1111/bcp.14451] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/13/2020] [Accepted: 06/22/2020] [Indexed: 12/12/2022] Open
Affiliation(s)
| | | | | | - Abhishek Gulati
- Clinical Pharmacology and Exploratory Development, Astellas Pharma Global Development Northbrook Illinois USA
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Stillhart C, Vučićević K, Augustijns P, Basit AW, Batchelor H, Flanagan TR, Gesquiere I, Greupink R, Keszthelyi D, Koskinen M, Madla CM, Matthys C, Miljuš G, Mooij MG, Parrott N, Ungell AL, de Wildt SN, Orlu M, Klein S, Müllertz A. Impact of gastrointestinal physiology on drug absorption in special populations––An UNGAP review. Eur J Pharm Sci 2020; 147:105280. [PMID: 32109493 DOI: 10.1016/j.ejps.2020.105280] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 02/10/2020] [Accepted: 02/24/2020] [Indexed: 02/07/2023]
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40
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Centanni M, Friberg LE. Model-Based Biomarker Selection for Dose Individualization of Tyrosine-Kinase Inhibitors. Front Pharmacol 2020; 11:316. [PMID: 32226388 PMCID: PMC7080977 DOI: 10.3389/fphar.2020.00316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 03/03/2020] [Indexed: 11/17/2022] Open
Abstract
Tyrosine-kinase inhibitors (TKIs) demonstrate high inter-individual variability with respect to safety and efficacy and would therefore benefit from dose or schedule adjustments. This study investigated the efficacy, safety, and economical aspects of alternative dosing options for sunitinib in gastro-intestinal stromal tumors (GIST) and axitinib in metastatic renal cell carcinoma (mRCC). Dose individualization based on drug concentration, adverse effects, and sVEGFR-3 was explored using a modeling framework connecting pharmacokinetic and pharmacodynamic models, as well as overall survival. Model-based simulations were performed to investigate four different scenarios: (I) the predicted value of high-dose pulsatile schedules to improve clinical outcomes as compared to regular daily dosing, (II) the potential of biomarkers for dose individualizations, such as drug concentrations, toxicity measurements, and the biomarker sVEGFR-3, (III) the cost-effectiveness of biomarker-guided dose-individualizations, and (IV) model-based dosing approaches versus standard sample-based methods to guide dose adjustments in clinical practice. Simulations from the axitinib and sunitinib frameworks suggest that weekly or once every two weeks high-dosing result in lower overall survival in patients with mRCC and GIST, compared to continuous daily dosing. Moreover, sVEGFR-3 appears a safe and cost-effective biomarker to guide dose adjustments and improve overall survival (€36 784.- per QALY). Model-based estimations were for biomarkers in general found to correctly predict dose adjustments similar to or more accurately than single clinical measurements and might therefore guide dose adjustments. A simulation framework represents a rapid and resource saving method to explore various propositions for dose and schedule adjustments of TKIs, while accounting for complicating factors such as circulating biomarker dynamics and inter-or intra-individual variability.
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Affiliation(s)
- Maddalena Centanni
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Lena E Friberg
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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41
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Factors Influencing Drug Disposition of Monoclonal Antibodies in Inflammatory Bowel Disease: Implications for Personalized Medicine. BioDrugs 2020; 33:453-468. [PMID: 31301024 DOI: 10.1007/s40259-019-00366-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Monoclonal antibody (mAb) therapies have revolutionized the treatment of several chronic inflammatory diseases, including the inflammatory bowel diseases (IBD), Crohn's disease, and ulcerative colitis. While efficacious, responses to these therapies vary considerably from patient to patient, due in part to inter- and intra-individual variability in pharmacokinetics (PK) and drug exposure. The concept of personalized medicine to monitor drug exposure and to adjust dosing in individual patients is consequently gaining acceptance as a powerful tool to optimize mAb therapy for improved outcomes in IBD. This review provides a brief overview of the different mAbs currently approved or in development for the treatment of IBD, including their presumed mechanisms of action and PK properties. Specifically described are (1) the factors known to affect mAb PK and drug exposure in patients with IBD, (2) the value of population PK/pharmacodynamic (PD) modeling to identify and understand the influence of these factors on drug exposure and effect, and (3) the clinical evidence for the potential of therapeutic drug monitoring (TDM) to improve IBD outcomes in response to mAb-based therapy. Incorporation of PK/PD parameters into clinical decision support tools has the potential to guide therapeutic decision making and aid implementation of personalized medicine strategies in patients with IBD.
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42
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Kerr SM, Jorgensen NW, Hong BJ, Friedland-Little JM, Albers EL, Newland DM, Law YM, Kemna MS. Assessment of rejection risk following subtherapeutic calcineurin inhibitor levels after pediatric heart transplantation. Pediatr Transplant 2020; 24:e13616. [PMID: 31820529 DOI: 10.1111/petr.13616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 09/24/2019] [Accepted: 10/22/2019] [Indexed: 11/29/2022]
Abstract
CNIs are the mainstay of immunosuppressive therapy after pediatric HTx. While regular laboratory surveillance is performed to ensure blood levels are within targeted range, the risk of acute rejection associated with subtherapeutic CNI levels has never been quantified. This is a retrospective single-center review of 8413 CNI trough levels in 138 pediatric HTx recipients who survived >1 year after HTx. Subtherapeutic CNI levels were defined as <50% of the lower limit of target range. The risk of acute, late (>12 months post-transplant) rejection following recipients' subtherapeutic CNI levels was assessed using time-varying multivariable Cox proportional hazards analysis. We found that 79 of 138 recipients (57%) had at least one subtherapeutic CNI level on routine surveillance laboratories during a mean follow-up of 5.5 ± 3.6 years. Following an episode of subtherapeutic levels, 17 recipients (22%) had biopsy-proven rejection within the next 3 months; the majority (9/17) within the first 2 weeks. After presenting with subtherapeutic CNI levels, recipients incurred a 6.1 times increased risk of acute rejection in the following 3 months (HR = 6.11 [2.41, 15.51], P = <.001). Age at HTx, HLA sensitization, or positive crossmatch were not associated with acute late rejection, but rejection in the first post-transplant year was (HR 2.61 [1.27, 5.35], P = .009). Thus, maintaining therapeutic CNI levels is the most important factor in preventing acute rejection in recipients who are >12 months after pediatric HTx. Recipients who present with subtherapeutic CNI levels on surveillance monitoring are 6.1 times more likely to develop rejection in the following 3 months.
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Affiliation(s)
- Sarah M Kerr
- School of Medicine, University of Washington, Seattle, Washington
| | - Neal W Jorgensen
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Borah J Hong
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Joshua M Friedland-Little
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - David M Newland
- Pharmacy, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Yuk M Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
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Pan S, Tsakok T, Dand N, Lonsdale DO, Loeff FC, Bloem K, de Vries A, Baudry D, Duckworth M, Mahil S, Pushpa-Rajah A, Russell A, Alsharqi A, Becher G, Murphy R, Wahie S, Wright A, Griffiths CEM, Reynolds NJ, Barker J, Warren RB, David Burden A, Rispens T, Standing JF, Smith CH. Using Real-World Data to Guide Ustekinumab Dosing Strategies for Psoriasis: A Prospective Pharmacokinetic-Pharmacodynamic Study. Clin Transl Sci 2020; 13:400-409. [PMID: 31995663 PMCID: PMC7070790 DOI: 10.1111/cts.12725] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/14/2019] [Indexed: 12/13/2022] Open
Abstract
Variation in response to biologic therapy for inflammatory diseases, such as psoriasis, is partly driven by variation in drug exposure. Real‐world psoriasis data were used to develop a pharmacokinetic/pharmacodynamic (PK/PD) model for the first‐line therapeutic antibody ustekinumab. The impact of differing dosing strategies on response was explored. Data were collected from a UK prospective multicenter observational cohort (491 patients on ustekinumab monotherapy, drug levels, and anti‐drug antibody measurements on 797 serum samples, 1,590 measurements of Psoriasis Area Severity Index (PASI)). Ustekinumab PKs were described with a linear one‐compartment model. A maximum effect (Emax) model inhibited progression of psoriatic skin lesions in the turnover PD mechanism describing PASI evolution while on treatment. A mixture model on half‐maximal effective concentration identified a potential nonresponder group, with simulations suggesting that, in future, the model could be incorporated into a Bayesian therapeutic drug monitoring “dashboard” to individualize dosing and improve treatment outcomes.
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Affiliation(s)
- Shan Pan
- St. John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Teresa Tsakok
- St. John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,St. John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Nick Dand
- Department of Medical & Molecular Genetics, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Dagan O Lonsdale
- Institute of Infection and Immunity, St. George's, University of London, London, UK
| | - Floris C Loeff
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Karien Bloem
- Biologics Lab, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - Annick de Vries
- Biologics Lab, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - David Baudry
- St. John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Michael Duckworth
- St. John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Satveer Mahil
- St. John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,St. John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Angela Pushpa-Rajah
- St. John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Alice Russell
- St. John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Ali Alsharqi
- Dermatology Department, Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, UK
| | | | - Ruth Murphy
- Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, UK
| | - Shyamal Wahie
- Dermatology Department, University Hospital of North Durham, Durham, UK
| | - Andrew Wright
- Centre for Skin Sciences, University of Bradford, Bradford, UK
| | - Christopher E M Griffiths
- Dermatology Centre, Salford Royal National Health Service Foundation Trust, Manchester, UK.,The University of Manchester, Manchester Academic Health Science Centre, National Institute for Health Research Manchester Biomedical Research Centre, Manchester, UK
| | - Nick J Reynolds
- Dermatological Sciences, Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, UK.,Department of Dermatology, Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jonathan Barker
- St. John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,St. John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Richard B Warren
- Dermatology Centre, Salford Royal National Health Service Foundation Trust, Manchester, UK
| | - A David Burden
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Theo Rispens
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Joseph F Standing
- Infection, Immunity, Inflammation Section, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Catherine H Smith
- St. John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,St. John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
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Gastine S, Rashed AN, Hsia Y, Jackson C, Barker CIS, Mathur S, Tomlin S, Lutsar I, Bielicki J, Standing JF, Sharland M. GAPPS (Grading and Assessment of Pharmacokinetic-Pharmacodynamic Studies) a critical appraisal system for antimicrobial PKPD studies - development and application in pediatric antibiotic studies. Expert Rev Clin Pharmacol 2019; 12:1091-1098. [PMID: 31747323 DOI: 10.1080/17512433.2019.1695600] [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] [Indexed: 12/13/2022]
Abstract
Introduction: There are limited data on optimal dosing of antibiotics in different age groups for neonates and children. Clinicians usually consult pediatric formularies or online databases for dose selection, but these have variable recommendations, are usually based on expert opinion and are not graded based on the existing pharmacokinetic-pharmacodynamic (PKPD) studies. We describe here a potential new tool that could be used to grade the strength of evidence emanating from PKPD studies.Areas covered: A scoring system was developed (GAPPS tool) to quantify the strength of each PK assessment and rate the studies quality in already published articles. GAPPS was evaluated by applying it to pediatric PKPD studies of antibiotics from the 2019 Essential Medicines List for children (EMLC), identified through a search of PubMed.Expert opinion: Evidence for most antibiotic dose selection decisions was generally weak, coming from individual PK studies and lacked PKPD modeling and simulations. However, the quality of evidence appears to have improved over the last two decades.Incorporating a formal grading system, such as GAPPS, into formulary development will provide a transparent tool to support decision-making in clinical practice and guideline development, and guide PKPD authors on study designs most likely to influence guidelines.
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Affiliation(s)
- Silke Gastine
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Asia N Rashed
- Pharmacy Department, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Institute of Pharmaceutical Science, King's College London, London, UK
| | - Yingfen Hsia
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Charlotte Jackson
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Charlotte I S Barker
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Shrey Mathur
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Stephen Tomlin
- Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Irja Lutsar
- Department of Microbiology, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Julia Bielicki
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,Paediatric Pharmacology Group, University of Basel Children's Hospital, Basel, Switzerland
| | - Joseph F Standing
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
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45
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Rashed AN, Jackson C, Gastine S, Hsia Y, Bielicki J, Standing JF, Tomlin S, Sharland M. Pediatric pharmacokinetics of the antibiotics in the access and watch groups of the 2019 WHO model list of essential medicines for children: a systematic review. Expert Rev Clin Pharmacol 2019; 12:1099-1106. [PMID: 31760892 DOI: 10.1080/17512433.2019.1693257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Pharmacokinetic-pharmacodynamic (PK-PD) studies of antibiotics in pediatrics are limited. Pediatric dosing regimens for many antimicrobial drugs have been historically derived from adult pharmacokinetic data. Most pediatric formularies and dosing guidelines globally are expert-based and provide no rationale for the recommended doses, leading to heterogeneous guidance.Areas covered: We systematically reviewed the current dosing for 28 antibiotics listed in the Access and Watch groups of the 2019 World Health Organization (WHO) Essential Medicines List for children (EMLc). PubMed and EMBASE were searched for all PK-PD and pharmacological studies in pediatrics up to May 2018. In total, 262 pediatric related articles were deemed eligible. The most studied drugs were those where therapeutic drug monitoring is routine (aminoglycosides, glycopeptides) and study reporting detail was variable, with only 60.0% using the PK-PD results in make dosing recommendations. Based on this evidence, dose recommendations for each antibiotic were made.Expert opinion: We provide an up-to-date review of the limited available evidence on pediatric dosing for the 28 commonly prescribed antibiotics in the 2019 WHO EMLc. We propose synthesized dosing recommendations for those antibiotics administered systemically for the treatment of serious infections. Further PK-PD studies in children, particularly with underlying conditions, are needed.
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Affiliation(s)
- Asia N Rashed
- Institute of Pharmaceutical Science, King's College London, London, UK.,Pharmacy Department, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Charlotte Jackson
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Silke Gastine
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Yingfen Hsia
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Julia Bielicki
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,Paediatric Pharmacology Group, University of Basel Children's Hospital, Basel, Switzerland
| | - Joseph F Standing
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,Great Ormond Street Institute of Child Health, University College London, London, UK.,Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Stephen Tomlin
- Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
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46
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Thorsted A, Kristoffersson AN, Maarbjerg SF, Schrøder H, Wang M, Brock B, Nielsen EI, Friberg LE. Population pharmacokinetics of piperacillin in febrile children receiving cancer chemotherapy: the impact of body weight and target on an optimal dosing regimen. J Antimicrob Chemother 2019; 74:2984-2993. [PMID: 31273375 PMCID: PMC6916132 DOI: 10.1093/jac/dkz270] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 05/22/2019] [Accepted: 05/28/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The β-lactam antibiotic piperacillin (in combination with tazobactam) is commonly chosen for empirical treatment of suspected bacterial infections. However, pharmacokinetic variability among patient populations and across ages leads to uncertainty when selecting a dosing regimen to achieve an appropriate pharmacodynamic target. OBJECTIVES To guide dosing by establishing a population pharmacokinetic model for unbound piperacillin in febrile children receiving cancer chemotherapy, and to assess pharmacokinetic/pharmacodynamic target attainment (100% fT > 1×MIC and 50% fT > 4×MIC) and resultant exposure, across body weights. METHODS Forty-three children admitted for 89 febrile episodes contributed 482 samples to the pharmacokinetic analysis. The typical doses required for target attainment were compared for various dosing regimens, in particular prolonged infusions, across MICs and body weights. RESULTS A two-compartment model with inter-fever-episode variability in CL, and body weight included through allometry, described the data. A high CL of 15.4 L/h (70 kg) combined with high glomerular filtration rate (GFR) values indicated rapid elimination and hyperfiltration. The target of 50% fT > 4×MIC was achieved for an MIC of 4.0 mg/L in a typical patient with extended infusions of 2-3 (q6h) or 3-4 (q8h) h, at or below the standard adult dose (75 and 100 mg/kg/dose for q6h and q8h, respectively). Higher doses or continuous infusion were needed to achieve 100% fT > 1×MIC due to the rapid piperacillin elimination. CONCLUSIONS The licensed dose for children with febrile neutropenia (80 mg/kg q6h as a 30 min infusion) performs poorly for attainment of fT>MIC pharmacokinetic/pharmacodynamic targets. Given the population pharmacokinetic profile, feasible dosing regimens with reasonable exposure are continuous infusion (100% fT > 1×MIC) or prolonged infusions (50% fT > 4×MIC).
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Affiliation(s)
- Anders Thorsted
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | | | - Sabine F Maarbjerg
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Schrøder
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mikala Wang
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Birgitte Brock
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Elisabet I Nielsen
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Lena E Friberg
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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47
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Metz DK, Holford N, Kausman JY, Walker A, Cranswick N, Staatz CE, Barraclough KA, Ierino F. Optimizing Mycophenolic Acid Exposure in Kidney Transplant Recipients: Time for Target Concentration Intervention. Transplantation 2019; 103:2012-2030. [PMID: 31584924 PMCID: PMC6756255 DOI: 10.1097/tp.0000000000002762] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/29/2019] [Accepted: 04/03/2019] [Indexed: 12/24/2022]
Abstract
The immunosuppressive agent mycophenolate is used extensively in kidney transplantation, yet dosing strategy applied varies markedly from fixed dosing ("one-dose-fits-all"), to mycophenolic acid (MPA) trough concentration monitoring, to dose optimization to an MPA exposure target (as area under the concentration-time curve [MPA AUC0-12]). This relates in part to inconsistent results in prospective trials of concentration-controlled dosing (CCD). In this review, the totality of evidence supporting mycophenolate CCD is examined: pharmacological characteristics, observational data linking exposure to efficacy and toxicities, and randomized controlled trials of CCD, with attention to dose optimization method and exposure achieved. Fixed dosing of mycophenolate consistently leads to underexposure associated with rejection, as well as overexposure associated with toxicities. When CCD is driven by pharmacokinetic calculation to a target concentration (target concentration intervention), MPA exposure is successfully controlled and clinical benefits are seen. There remains a need for consensus on practical aspects of mycophenolate target concentration intervention in contemporary tacrolimus-containing regimens and future research to define maintenance phase exposure targets. However, given ongoing consequences of both overimmunosuppression and underimmunosuppression in kidney transplantation, impacting short- and long-term outcomes, these should be a priority. The imprecise "one-dose-fits-all" approach should be replaced by the clinically proven MPA target concentration strategy.
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Affiliation(s)
- David K. Metz
- Department of Nephrology, Royal Children’s Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
- Clinical Pharmacology Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Nick Holford
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Joshua Y. Kausman
- Department of Nephrology, Royal Children’s Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
| | - Amanda Walker
- Department of Nephrology, Royal Children’s Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
| | - Noel Cranswick
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
- Clinical Pharmacology Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | | | - Katherine A. Barraclough
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Francesco Ierino
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Department of Nephrology, St Vincent’s Health, Melbourne, VIC, Australia
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48
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Wright DFB, Martin JH, Cremers S. Spotlight Commentary: Model-informed precision dosing must demonstrate improved patient outcomes. Br J Clin Pharmacol 2019; 85:2238-2240. [PMID: 31400011 DOI: 10.1111/bcp.14050] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 06/20/2019] [Accepted: 06/21/2019] [Indexed: 12/31/2022] Open
Affiliation(s)
| | - Jennifer H Martin
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Serge Cremers
- Departments of Pathology and Cell Biology, and Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
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49
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Nøhr‐Nielsen A, De Bruin ML, Thomsen M, Pipper CB, Lange T, Bjerrum OJ, Lund TM. Body of evidence and approaches applied in the clinical development programme of fixed-dose combinations in the European Union from 2010 to 2016. Br J Clin Pharmacol 2019; 85:1829-1840. [PMID: 31077427 PMCID: PMC6624404 DOI: 10.1111/bcp.13986] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 04/16/2019] [Accepted: 04/29/2019] [Indexed: 12/21/2022] Open
Abstract
AIMS To provide insights into the clinical development pathway for fixed-dose combinations (FDCs), to consider strategies, and to elucidate the path to approval by assessing the body of evidence, as summarized in the European Public Assessment Reports. METHODS The main resource was the European Public Assessment Reports for 36 FDCs, which included 239 clinical trials with 157 514 patients. The analyses focused on how prior knowledge of the active substances or combination, use of pharmacokinetic-pharmacodynamic modelling, and clinical trial design choice impact the size and strategy of the clinical development programme. RESULTS FDC products primarily comprised 2 previously approved components (21/36, 71%) and had only 1 approved combination (21/36, 71%). Utilizing previously approved active substances resulted in fewer clinical trials, arms and patients, but FDC doses studied in the clinical development programme. Furthermore, dose-finding trials were performed for less than half of FDCs consisting of 2 previously approved active substances. The standard approach to demonstrate contribution of active substances was through a factorial or single combination study. Finally, the use of pharmacokinetic modelling showed a significant decrease in the number of FDC doses studied. CONCLUSIONS The field of FDCs seems to be on the rise, utilizing new molecular entities, prior knowledge and re-profiling drugs. However, a way to move FDC development forward might be through new regulatory and scientific paradigms, in which it is encouraged to utilize model-based approaches to develop FDCs with multiple dose levels and dose ratios for exposure-based treatment that will enable personalization.
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Affiliation(s)
- Asbjørn Nøhr‐Nielsen
- Department of Drug Design and Pharmacology, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
- Copenhagen Centre for Regulatory ScienceUniversity of CopenhagenCopenhagenDenmark
| | | | | | | | - Theis Lange
- Department of Public HealthUniversity of CopenhagenCopenhagenDenmark
| | - Ole Jannik Bjerrum
- Department of Drug Design and Pharmacology, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Trine Meldgaard Lund
- Department of Drug Design and Pharmacology, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
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50
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Petrucci G, Zaccardi F, Giaretta A, Cavalca V, Capristo E, Cardillo C, Pitocco D, Porro B, Schinzari F, Toffolo G, Tremoli E, Rocca B. Obesity is associated with impaired responsiveness to once-daily low-dose aspirin and in vivo platelet activation. J Thromb Haemost 2019; 17:885-895. [PMID: 30933424 DOI: 10.1111/jth.14445] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 03/28/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The prevalence and degree of obesity is rising worldwide, increases cardiovascular risk, modifies body composition and organ function, and potentially affects the pharmacokinetics and/or pharmacodynamics of drugs. OBJECTIVES To investigate the pharmacodynamics of once-daily low-dose aspirin in healthy obese subjects, and to assess whether body weight (BW) and body mass index (BMI) affect the pharmacology of aspirin. PATIENTS/METHODS Otherwise healthy, obese (BMI > 30 kg/m2 ) subjects were studied before and after 3-4 weeks of 100-mg once-daily aspirin intake. Aspirin pharmacodynamics were assessed according to serum thromboxane (TX) B2 levels measured at 4 hours, 24 hours (i.e., posologic interval) and 48 hours after the last witnessed intake; age-matched and sex-matched non-obese controls were included. A previously calibrated pharmacokinetic/pharmacodynamic in silico model of aspirin was used to fit serum TXB2 data from obese subjects. At baseline, the major urinary TXA2 and prostacyclin metabolites, urinary isoprostane and plasma inflammatory biomarkers were measured. RESULTS In 16 obese subjects (aged 47 ± 11 years; BMI of 39.4 ± 5.1 kg/m2 ), residual serum TXB2 values between 4 and 48 hours after aspirin intake were increased 3- to 5-fold as compared with controls. At 24 hours, the residual serum TXB2 level was log-linearly associated with body size over a wide range of BMI and BW values, without any apparent threshold. The in silico model predicted that reduced aspirin bioavailability would be inversely related to body size and rescued by 200 mg of aspirin once daily or 85 mg twice daily. Baseline urinary TXA2 metabolite, isoprostane and plasma C-reactive protein levels were significantly increased in obese subjects. CONCLUSIONS Obesity is associated with impaired aspirin responsiveness, largely because of body size. Impaired inhibition of platelet activation by conventional low-dose aspirin may affect antithrombotic efficacy.
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Affiliation(s)
- Giovanna Petrucci
- Istituto di Farmacologia, Università Cattolica, Rome, Italy
- Fondazione Policlinico Universitario IRCCS, A. Gemelli, Rome, Italy
| | | | - Alberto Giaretta
- Department of Information Engineering, University of Padova, Padova, Italy
| | | | - Esmeralda Capristo
- Fondazione Policlinico Universitario IRCCS, A. Gemelli, Rome, Italy
- Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Carmine Cardillo
- Fondazione Policlinico Universitario IRCCS, A. Gemelli, Rome, Italy
- Istituto di Patologia Medica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Dario Pitocco
- Fondazione Policlinico Universitario IRCCS, A. Gemelli, Rome, Italy
- Diabetology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Francesca Schinzari
- Istituto di Patologia Medica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianna Toffolo
- Department of Information Engineering, University of Padova, Padova, Italy
| | | | - Bianca Rocca
- Istituto di Farmacologia, Università Cattolica, Rome, Italy
- Fondazione Policlinico Universitario IRCCS, A. Gemelli, Rome, Italy
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