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Moreno G, Carbonell R, Díaz E, Martín-Loeches I, Restrepo MI, Reyes LF, Solé-Violán J, Bodí M, Canadell L, Guardiola J, Trefler S, Vidaur L, Papiol E, Socias L, Correig E, Marín-Corral J, Rodríguez A. Effectiveness of prolonged versus standard-course of oseltamivir in critically ill patients with severe influenza infection: A multicentre cohort study. J Med Virol 2023; 95:e29010. [PMID: 37537755 DOI: 10.1002/jmv.29010] [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: 05/03/2023] [Revised: 07/04/2023] [Accepted: 07/16/2023] [Indexed: 08/05/2023]
Abstract
The aim of this study is to investigate the effectiveness of prolonged versus standard course oseltamivir treatment among critically ill patients with severe influenza. A retrospective study of a prospectively collected database including adults with influenza infection admitted to 184 intensive care units (ICUs) in Spain from 2009 to 2018. Prolonged oseltamivir was defined if patients received the treatment beyond 5 days, whereas the standard-course group received oseltamivir for 5 days. The primary outcome was all-cause ICU mortality. Propensity score matching (PSM) was constructed, and the outcome was investigated through Cox regression and RCSs. Two thousand three hundred and ninety-seven subjects were included, of whom 1943 (81.1%) received prolonged oseltamivir and 454 (18.9%) received standard treatment. An optimal full matching algorithm was performed by matching 2171 patients, 1750 treated in the prolonged oseltamivir group and 421 controls in the standard oseltamivir group. After PSM, 387 (22.1%) patients in the prolonged oseltamivir and 119 (28.3%) patients in the standard group died (p = 0.009). After adjusting confounding factors, prolonged oseltamivir significantly reduced ICU mortality (odds ratio [OR]: 0.53, 95% confidence interval [CI]: 0.40-0.69). Prolonged oseltamivir may have protective effects on survival at Day 10 compared with a standard treatment course. Sensitivity analysis confirmed these findings. Compared with standard treatment, prolonged oseltamivir was associated with reduced ICU mortality in critically ill patients with severe influenza. Clinicians should consider extending the oseltamivir treatment duration to 10 days, particularly in higher-risk groups of prolonged viral shedding. Further randomized controlled trials are warranted to confirm these findings.
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Affiliation(s)
- Gerard Moreno
- Critical Care Department, Institut d'Investigació Sanitaria Pere Virgili (IISPV)/Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Raquel Carbonell
- Critical Care Department, Institut d'Investigació Sanitaria Pere Virgili (IISPV)/Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Emili Díaz
- Critical Care Department, Universitat Autónoma de Barcelona (UAB), Hospital Parc Taulí, Sabadell, Spain
| | - Ignacio Martín-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | - Marcos I Restrepo
- Department of Medicine, South Texas Veterans Health Care System and University of Texas Health, San Antonio, Texas, USA
| | - Luis F Reyes
- Infectious Diseases Department, Universidad de La Sabana, Chía, Colombia
| | - Jordi Solé-Violán
- Critical Care Department, Universidad Fernando Pessoa Canarias, Hospital Universitario Doctor Negrín, Gran Canaria, Spain
| | - María Bodí
- Critical Care Department, Institut d'Investigació Sanitaria Pere Virgili (IISPV)/Hospital Universitari Joan XXIII, Tarragona, Spain
- Universitat Rovira i Virgili (URV)/Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Tarragona, Spain
| | - Laura Canadell
- Pharmacology Department, Universitat Rovira I Virgili (URV)/Institut d'Investigació Sanitaria Pere Virgili (IISPV), Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Juan Guardiola
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Louisville and Robley Rex VA Medical Center, Louisville, Kentucky, USA
| | - Sandra Trefler
- Critical Care Department, Institut d'Investigació Sanitaria Pere Virgili (IISPV)/Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Loreto Vidaur
- Critical Care Deptartment, Instituto de Investigación Sanitaria Biodonostia, Hospital Universitario de Donostia, San Sebastián, Spain
| | - Elisabeth Papiol
- Critical Care Department, Hospital Univesitari Vall d'Hebrón, Barcelona, Spain
| | - Lorenzo Socias
- Critical Care Department, Hospital Son Llàtzer, Palma de Mallorca, Spain
| | - Eudald Correig
- Department of Biostatistics, Universitat Rovira i Virgili (URV), Reus, Spain
| | - Judith Marín-Corral
- Critical Care Department, Research Group in Critical Disorders (GREPAC), IMIM, Hospital Del Mar, Barcelona, Spain
| | - Alejandro Rodríguez
- Critical Care Department, Institut d'Investigació Sanitaria Pere Virgili (IISPV)/Hospital Universitari Joan XXIII, Tarragona, Spain
- Universitat Rovira i Virgili (URV)/Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Tarragona, Spain
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Pai MP, Crass RL. Translation of Pharmacodynamic Biomarkers of Antibiotic Efficacy in Specific Populations to Optimize Doses. Antibiotics (Basel) 2021; 10:antibiotics10111368. [PMID: 34827306 PMCID: PMC8614818 DOI: 10.3390/antibiotics10111368] [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: 09/29/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 11/16/2022] Open
Abstract
Antibiotic efficacy determination in clinical trials often relies on non-inferiority designs because they afford smaller study sample sizes. These efficacy studies tend to exclude patients within specific populations or include too few patients to discern potential differences in their clinical outcomes. As a result, dosing guidance in patients with abnormal liver and kidney function, age across the lifespan, and other specific populations relies on drug exposure-matching. The underlying assumption for exposure-matching is that the disease course and the response to the antibiotic are similar in patients with and without the specific condition. While this may not be the case, clinical efficacy studies are underpowered to ensure this is true. The current paper provides an integrative review of the current approach to dose selection in specific populations. We review existing clinical trial endpoints that could be measured on a more continuous rather than a discrete scale to better inform exposure-response relationships. The inclusion of newer systemic biomarkers of efficacy can help overcome the current limitations. We use a modeling and simulation exercise to illustrate how an efficacy biomarker can inform dose selection better. Studies that inform response-matching rather than exposure-matching only are needed to improve dose selection in specific populations.
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Affiliation(s)
- Manjunath P. Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Rm 2568, 428 Church St., Ann Arbor, MI 48109, USA
- Correspondence: ; Tel.: +1-734-647-0006
| | - Ryan L. Crass
- Ann Arbor Pharmacometrics Group, Ann Arbor, MI 48108, USA;
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Jordie EB, Gibiansky L, Knab T, Lemenuel-Diot A, Ravva P, Zwanziger E, Jolivet S, Bhardwaj R, Hernández-Sánchez J, Nasmyth-Miller C, Sturm S. Dosing regimen optimisation for oseltamivir in immunocompromised paediatric patients with influenza: Extrapolation of efficacy. Br J Clin Pharmacol 2021; 88:1189-1201. [PMID: 34449090 DOI: 10.1111/bcp.15059] [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: 02/15/2021] [Revised: 08/12/2021] [Accepted: 08/16/2021] [Indexed: 11/29/2022] Open
Abstract
AIMS To optimise the dosing regimen of oseltamivir for immunocompromised (IC) paediatric patients (<18 years) with influenza, we used an extrapolation approach alongside clinical data. METHODS Efficacy was extrapolated from adult IC patients to paediatric IC patients by leveraging existing efficacy, safety, pharmacokinetic (PK)/pharmacodynamic (PD), and disease-progression models of oseltamivir and oseltamivir carboxylate (OC). Data of IC paediatric patients from two studies (NV25719 and NV20234) were included in the population PK (n = 30), PK/PD analysis (n = 22) and disease modelling approach (n = 36). Simulations were performed to identify the optimal dosing regimen. RESULTS Clearance of oseltamivir (CL) and OC (CLM ) were similar in IC and otherwise-healthy (OwH) patients <10 years, but decreased by 44.4% (95% CI: 26.8-62.0) and 49.1% (95% CI: 34.5-63.8), respectively, in IC patients aged 10-17 years versus OwH patients. There were no notable exposure-response relationships for any of the virologic PD analyses. Thus, no additional benefit was seen with oseltamivir carboxylate exposures higher than achieved with the conventional dose (75 mg twice daily, age- and weight-adjusted for children <13 years). The disease model illustrated that doses above the conventional oseltamivir dose had limited impact on viral kinetics in IC paediatric patients and a prolonged treatment duration of 10 days was favoured to limit potential viral rebound. CONCLUSION An oseltamivir dosage recommendation (conventional dose, twice daily for 10 days) was established in IC paediatric patients with influenza, based on extrapolation of efficacy from IC adults, leveraging population PK, PK/PD, and disease modelling, whilst taking resistance and safety data into account.
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Affiliation(s)
- Eric Burroughs Jordie
- Translational & Systems Pharmacology, Metrum Research Group LLC, Tariffville, CT, USA
| | | | - Timothy Knab
- Translational & Systems Pharmacology, Metrum Research Group LLC, Tariffville, CT, USA
| | - Annabelle Lemenuel-Diot
- Roche Innovation Center Basel, Roche Pharmaceutical Research and Early Development, Basel, Switzerland
| | - Patanjali Ravva
- Roche Innovation Center New York, Roche Pharmaceutical Research and Early Development, New York, NY, USA
| | - Elke Zwanziger
- Roche Innovation Center Basel, Roche Pharmaceutical Research and Early Development, Basel, Switzerland
| | - Sebastien Jolivet
- Roche Innovation Center Basel, Roche Pharmaceutical Research and Early Development, Basel, Switzerland
| | - Rajinder Bhardwaj
- Integrated Drug Development, Certara Strategic Consulting, Parsippany, NJ, USA
| | | | | | - Stefan Sturm
- Roche Innovation Center Basel, Roche Pharmaceutical Research and Early Development, Basel, Switzerland
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Sturm S, Lemenuel-Diot A, Patel K, Gibiansky L, Bhardwaj R, Smith PF, Dang S, Zwanziger E, Nasmyth-Miller C, Ravva P. Pharmacologic effects of oseltamivir in immunocompromised adult patients as assessed by population PK/PD analysis and drug-disease modelling for dosing regimen optimization. Br J Clin Pharmacol 2020; 87:1359-1368. [PMID: 32808306 PMCID: PMC8246794 DOI: 10.1111/bcp.14523] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/29/2020] [Accepted: 08/04/2020] [Indexed: 01/04/2023] Open
Abstract
Aim Pharmacologic effects were analysed to determine a dose recommendation for oseltamivir in immunocompromised (IC) adults with influenza. Methods Quantitative clinical pharmacology methods were applied to data from 160 adult IC patients (aged 18‐78 years) from two studies (NV20234, 150 patients; NV25118, 10 patients) who received oseltamivir 75‐200 mg twice daily for up to 10 days. An established population‐pharmacokinetic (PK) model with additional effects on oseltamivir and oseltamivir carboxylate (OC) clearance described the PK characteristics of oseltamivir in IC patients versus otherwise healthy (OwH) patients from previous clinical trials. Estimated PK parameters were used to evaluate exposure‐response relationships for virologic endpoints (time to cessation of viral shedding, viral load measures and treatment‐emergent resistance). A drug‐disease model characterized the viral kinetics of influenza accounting for the effect of OC on viral production. Results Oseltamivir clearance was 32.5% lower (95% confidence interval [CI], 26.1‐38.8) and OC clearance was 33.7% lower (95% CI, 23.2‐44.1) in IC versus OwH patients. No notable exposure‐response relationships were identified for exposures higher than those achieved after conventional dose oseltamivir 75 mg, which appeared to be close to the maximum effect of oseltamivir. Simulations of the drug‐disease model predicted that initiating treatment within 48 hours of symptom onset had maximum impact, and a treatment duration of 10 days was favourable over 3‐5 days to limit viral rebound. Conclusions Our findings support the use of conventional‐dose oseltamivir 75 mg twice daily for 10 days in the treatment of IC adult patients with influenza.
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Affiliation(s)
- Stefan Sturm
- Roche Innovation Center Basel, Roche Pharmaceutical Research and Early Development, Basel, Switzerland
| | - Annabelle Lemenuel-Diot
- Roche Innovation Center Basel, Roche Pharmaceutical Research and Early Development, Basel, Switzerland
| | | | | | | | | | - Steve Dang
- Roche Innovation Center New York, Roche Pharmaceutical Research and Early Development, New York, NY, USA
| | - Elke Zwanziger
- Roche Innovation Center Basel, Roche Pharmaceutical Research and Early Development, Basel, Switzerland
| | | | - Patanjali Ravva
- Roche Innovation Center New York, Roche Pharmaceutical Research and Early Development, New York, NY, USA
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