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Millen GC, Lawford A, Duncan C, Jenkinson H, Veal GJ, Barnett S. Utility of carboplatin therapeutic drug monitoring for the treatment of neonate and infant retinoblastoma patients in the United Kingdom. Br J Cancer 2024; 131:491-497. [PMID: 38871807 PMCID: PMC11300439 DOI: 10.1038/s41416-024-02728-1] [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: 02/12/2024] [Revised: 05/12/2024] [Accepted: 05/16/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Retinoblastoma is the most common intra-ocular malignancy in children and frequently presents in very young patients who commonly require intravenous carboplatin. Delivering this is challenging due to a lack of uniform dosing recommendations, rapid changes in physiological function and the risk of side-effects. METHODS We conducted a retrospective review of neonates and infants in the UK with retinoblastoma, who have undergone carboplatin therapeutic drug monitoring (TDM). We report on the pharmacokinetic, treatment efficacy and toxicity data. RESULTS In total, 29 patients (median age 5 weeks at treatment onset) underwent a total of 74 TDM guided cycles of chemotherapy, involving real time sampling and dose adjustment. An additional 13 patients underwent TDM sampling to modify doses between cycles. Without the adoption of TDM guided dosing, carboplatin exposures would have been ≥20% outside the target AUC in 38/78 (49%) of treatment cycles. Excellent responses and a reassuringly low incidence of toxicities were observed following dose adjustment, despite the young patient age and the implementation of dose increases in the majority of cases. CONCLUSIONS Real time TDM is safe, effective and deliverable for neonates and infants receiving carboplatin for retinoblastoma and should be considered standard of care up to the age of 6 months.
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Affiliation(s)
- Gerard C Millen
- Department of Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK.
| | - Alice Lawford
- Department of Paediatric Oncology, Great Ormond Street Hospital, London, UK
| | - Catriona Duncan
- Department of Paediatric Oncology, Great Ormond Street Hospital, London, UK
| | - Helen Jenkinson
- Department of Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK
| | - Gareth J Veal
- Translational & Clinical Research Institute, Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
| | - Shelby Barnett
- Translational & Clinical Research Institute, Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK.
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Barnett S, Makin G, Tweddle DA, Osborne C, Veal GJ. Generation of evidence-based carboplatin dosing guidelines for neonates and infants. Br J Cancer 2023; 129:1773-1779. [PMID: 37816842 PMCID: PMC10667364 DOI: 10.1038/s41416-023-02456-y] [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: 05/24/2023] [Revised: 09/15/2023] [Accepted: 09/26/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND To optimally dose childhood cancer patients it is essential that we apply evidence-based dosing approaches. Carboplatin is commonly dosed to achieve a cumulative target exposure (AUC) in children, with target AUC values of 5.2-7.8 mg/ml.min defined. To achieve these exposures patients are dosed at 6.6 mg/kg/day or 4.4 mg/kg for patients <5 kg. The current study uses real world clinical pharmacology data to optimise body weight-based doses to effectively target AUCs of 5.2-7.8 mg/ml.min in infants. METHODS Carboplatin exposures were determined across 165 treatment cycles in 82 patients ≤10 kg. AUC and clearance values were determined by Bayesian modelling from samples collected on day 1. These parameters were utilised to assess current dosing variability, determine doses required to achieve target AUC values and predict change in AUC using the modified dose. RESULTS No significant differences in clearance were identified between patients <5 kg and 5-10 kg. Consequently, for patients <5 kg, 4.4 mg/kg dosing was not sufficient to achieve a target AUC of 5.2 mg/ml.min, with <55% of patients within 25% of this target. Optimised daily doses for patients ≤10 kg were 6 mg/kg and 9 mg/kg for cumulative carboplatin target exposures of 5.2 and 7.8 mg/ml.min, respectively. CONCLUSIONS Adoption of these evidence-based carboplatin doses in neonates and infants will reduce drug exposure variability and positively impact treatment.
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Affiliation(s)
- Shelby Barnett
- Translational & Clinical Research Institute, Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK.
| | - Guy Makin
- Division of Cancer Sciences, University of Manchester, Manchester, UK
- Royal Manchester Children's Hospital, Manchester, UK
| | - Deborah A Tweddle
- Translational & Clinical Research Institute, Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
- Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Caroline Osborne
- Pharmacy Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Gareth J Veal
- Translational & Clinical Research Institute, Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
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van der Heijden LT, Uittenboogaard A, Nijstad AL, Gebretensae A, Kaspers GJL, Beijnen JH, Huitema ADR, Rosing H. A sensitive liquid chromatographic-mass spectrometry method for the quantification of vincristine in whole blood collected with volumetric absorptive microsampling. J Pharm Biomed Anal 2023; 225:115232. [PMID: 36608428 DOI: 10.1016/j.jpba.2023.115232] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/23/2022] [Accepted: 01/01/2023] [Indexed: 01/04/2023]
Abstract
Vincristine is a well-established cytotoxic drug. In paediatric populations blood collection via venipuncture is not always feasible. Volumetric absorptive microsampling (VAMS) is a less invasive method for blood collection. Furthermore, VAMS lacks the haematocrit effect on the recovery known with dried blood spots. Therefore, a liquid chromatography tandem-mass spectrometry method was developed and validated for the quantification of vincristine in whole blood collected with VAMS devices. Sample preparation consisted of solid-liquid extraction with 0.2% formic acid in water and acetonitrile. The final extract was injected on a C18 column (2.0 ×50 mm, 5 µm). Gradient elution was used and quantification was accomplished with a triple quadruple mass spectrometer operating in the positive mode. The validated concentration range was from 1 to 50 ng/mL with an intra- and inter-accuracy and precision of ± 10.3% and ≤ 7.3%, respectively. This method was able to successfully quantify vincristine concentrations in whole blood collected with VAMS from paediatric oncology patients. Vincristine concentrations in whole blood were non-linearly associated with plasma concentrations, which could be described with a saturable binding equilibrium model.
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Affiliation(s)
- Lisa T van der Heijden
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, the Netherlands; Division of Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, the Netherlands.
| | - Aniek Uittenboogaard
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam Paediatric Oncology, 1081 HV Amsterdam, the Netherlands; Department of Pharmacology, Princess Maxima Center for Paediatric Oncology, Utrecht, the Netherlands
| | - A Laura Nijstad
- Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Pharmacology, Princess Maxima Center for Paediatric Oncology, Utrecht, the Netherlands
| | - Abadi Gebretensae
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Gertjan J L Kaspers
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam Paediatric Oncology, 1081 HV Amsterdam, the Netherlands; Dutch Childhood Oncology Group, Utrecht, the Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, the Netherlands; Division of Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, the Netherlands; Division of Pharmaco-epidemiology and Clinical Pharmacology, Faculty of Science, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, the Netherlands; Division of Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Pharmacology, Princess Maxima Center for Paediatric Oncology, Utrecht, the Netherlands
| | - Hilde Rosing
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, the Netherlands
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Nijstad AL, Barnett S, Lalmohamed A, Bérénos IM, Parke E, Carruthers V, Tweddle DA, Kong J, Zwaan CM, Huitema ADR, Veal GJ. Clinical pharmacology of cytotoxic drugs in neonates and infants: Providing evidence-based dosing guidance. Eur J Cancer 2022; 164:137-154. [PMID: 34865945 PMCID: PMC8914347 DOI: 10.1016/j.ejca.2021.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/11/2021] [Accepted: 11/01/2021] [Indexed: 01/29/2023]
Abstract
Cancer in neonates and infants is a rare but challenging entity. Treatment is complicated by marked physiological changes during the first year of life, excess rates of toxicity, mortality, and late effects. Dose optimisation of chemotherapeutics may be an important step to improving outcomes. Body size-based dosing is used for most anticancer drugs used in infants. However, dose regimens are generally not evidence based, and dosing strategies are frequently inconsistent between tumour types and treatment protocols. In this review, we collate available pharmacological evidence supporting dosing regimens in infants for a wide range of cytotoxic drugs. A systematic review was conducted, and available data ranked by a level of evidence (1-5) and a grade of recommendation (A-D) provided on a consensus basis, with recommended dosing approaches indicated as appropriate. For 9 of 29 drugs (busulfan, carboplatin, cyclophosphamide, daunorubicin, etoposide, fludarabine, isotretinoin, melphalan and vincristine), grade A was scored, indicating sufficient pharmacological evidence to recommend a dosing algorithm for infants. For busulfan and carboplatin, sufficient data were available to recommend therapeutic drug monitoring in infants. For eight drugs (actinomycin D, blinatumomab, dinutuximab, doxorubicin, mercaptopurine, pegaspargase, thioguanine and topotecan), some pharmacological evidence was available to guide dosing (graded as B). For the remaining drugs, including commonly used agents such as cisplatin, cytarabine, ifosfamide, and methotrexate, pharmacological evidence for dosing in infants was limited or non-existent: grades C and D were scored for 10 and 2 drugs, respectively. The review provides clinically relevant evidence-based dosing guidance for cytotoxic drugs in neonates and infants.
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Affiliation(s)
- A Laura Nijstad
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands.
| | - Shelby Barnett
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK
| | - Arief Lalmohamed
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, the Netherlands
| | - Inez M Bérénos
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, the Netherlands
| | - Elizabeth Parke
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK
| | - Vickyanne Carruthers
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK
| | - Deborah A Tweddle
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK; Great North Children's Hospital, NE1 4LP Newcastle Upon Tyne, UK
| | - Jordon Kong
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - C Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Department of Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Gareth J Veal
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK.
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Barnett S, Holden V, Campbell-Hewson Q, Veal GJ. Perspectives and Expertise in Establishing a Therapeutic Drug Monitoring Programme for Challenging Childhood Cancer Patient Populations. Front Oncol 2022; 11:815040. [PMID: 35071019 PMCID: PMC8770741 DOI: 10.3389/fonc.2021.815040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
The utility of Therapeutic Drug Monitoring (TDM) in the setting of childhood cancer is a largely underused tool, despite the common use of cytotoxic chemotherapeutics. While it is encouraging that modern advances in chemotherapy have transformed outcomes for children diagnosed with cancer, this has come at the cost of an elevated risk of life-changing long-term morbidity and late effects. This concern can limit the intensity at which these drugs are used. Widely used chemotherapeutics exhibit marked inter-patient variability in drug exposures following standard dosing, with fine margins between exposures resulting in toxicity and those resulting in potentially suboptimal efficacy, thereby fulfilling criteria widely accepted as fundamental for TDM approaches. Over the past decade in the UK, the paediatric oncology community has increasingly embraced the potential benefits of utilising TDM for particularly challenging patient groups, including infants, anephric patients and those receiving high dose chemotherapy. This has been driven by a desire from paediatric oncologists to have access to clinical pharmacology information to support dosing decisions being made. This provides the potential to modify doses between treatment cycles based on a comprehensive set of clinical information, with individual patient drug exposures being used alongside clinical response and tolerability data to inform dosing for subsequent cycles. The current article provides an overview of recent experiences of conducting TDM in a childhood cancer setting, from the perspectives of the clinicians, scientists and pharmacists implementing TDM-based dosing recommendations. The ongoing programme of work has facilitated investigations into the validity of current approaches to dosing for some of the most challenging childhood cancer patient groups, with TDM approaches now being expanded from well-established cytotoxic drugs through to newer targeted treatments.
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Affiliation(s)
- Shelby Barnett
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | | | - Gareth J Veal
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, United Kingdom
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Barnett S, Hellmann F, Parke E, Makin G, Tweddle DA, Osborne C, Hempel G, Veal GJ. Vincristine dosing, drug exposure and therapeutic drug monitoring in neonate and infant cancer patients. Eur J Cancer 2021; 164:127-136. [PMID: 34657763 PMCID: PMC8914346 DOI: 10.1016/j.ejca.2021.09.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/02/2021] [Accepted: 09/16/2021] [Indexed: 01/12/2023]
Abstract
Background The anticancer drug vincristine is associated with potentially dose-limiting side-effects, including neurotoxicity and myelosuppression. However, there currently exists a lack of published clinical pharmacology data relating to its use in neonate and infant patients. We report a study investigating vincristine dosing and drug exposure, alongside the feasibility and impact of a therapeutic drug monitoring treatment approach, in this challenging patient population. Patients and methods Vincristine pharmacokinetic data from a total of 57 childhood cancer patients, including 26 neonates and infants, were used to characterise a population pharmacokinetic model. Vincristine was administered at doses of 0.02–0.05 mg/kg or 0.75–1.5 mg/m2 in neonates and infants aged <1 year or ≤12 kg and doses of 1.5 mg/m2 in older children. Results A two-compartment model provided the best fit for the population analysis. There was no significant difference in vincristine clearance normalised for body surface area between neonates/infants and older children. Lower doses administered to neonates and infants resulted in significantly lower drug exposures (area under the curve [AUC]), compared with older children (p = 0.047). Vincristine doses of <0.05 mg/kg in neonates and infants resulted in significantly lower AUC values than observed in those receiving doses of ≥0.05 mg/kg (p ≤ 0.0001). Therapeutic drug monitoring was shown to be feasible, effective and well tolerated in neonates and infants experiencing suboptimal drug exposures. Conclusion Doses of <0.05 mg/kg should not be used in neonate and infant patients because of a high risk of patients experiencing potentially suboptimal drug exposures. Therapeutic drug monitoring approaches in neonates and infants are supported by the data generated, with a proposed target therapeutic window of 50–100 μg/l∗h. Vincristine dosing and drug exposure was investigated in neonates and infants. Vincristine concentrations were quantified in 210 plasma samples from 57 children. Lower drug exposures were observed in infants and neonates compared with older children. Therapeutic drug monitoring can be used to avoid suboptimal vincristine drug exposures. Vincristine dosing guidance is provided for treatment of neonate and infant patients.
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Affiliation(s)
- Shelby Barnett
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
| | - Farina Hellmann
- Department of Pharmaceutical and Medical Chemistry, University of Münster, Münster, Germany
| | - Elizabeth Parke
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
| | - Guy Makin
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Royal Manchester Children's Hospital, Manchester, UK
| | - Deborah A Tweddle
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK; Great North Children's Hospital, Newcastle, UK
| | - Caroline Osborne
- Pharmacy Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, University of Münster, Münster, Germany
| | - Gareth J Veal
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK.
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