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Krzyzanski W, Stockard B, Gaedigk A, Scott A, Nolte W, Gibson K, Leeder JS, Lewis T. Developmental pharmacokinetics of indomethacin in preterm neonates: Severely decreased drug clearance in the first week of life. CPT Pharmacometrics Syst Pharmacol 2022; 12:110-121. [PMID: 36309972 PMCID: PMC9835126 DOI: 10.1002/psp4.12881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/28/2022] [Accepted: 10/16/2022] [Indexed: 11/07/2022] Open
Abstract
Indomethacin is used commonly in preterm neonates for the prevention of intracranial hemorrhage and closure of an abnormally open cardiac vessel. Due to biomedical advances, the infants who receive this drug in the neonatal intensive care unit setting have become younger, smaller, and less mature (more preterm) at the time of treatment. To develop a pharmacokinetics (PK) model to aid future dosing, we designed a prospective cohort study to characterize indomethacin PK in a dynamically changing patient population. A population PK base model was created using NONMEM, and a covariate model was developed in a primary development cohort and subsequently was tested for accuracy in a validation cohort. Postnatal age was a significant covariate for hepatic clearance (CLH ) and renal clearance (CLR ). The typical value of the total clearance (CL, the sum of CLR and CLH ) was 3.09 ml/h and expressed as CL/WTmedian = 3.96 ml/h/kg, where WTmedian is the median body weight. The intersubject variability of CLR and CLH were 61% and 207%, respectively. The typical value of the volume of distribution Vp = 366 ml (Vp /WTmedian = 470 ml/kg), and its intersubject variability was 38.8%. Half-life was 82.1 h. Compared with more mature and older preterm populations studied previously, indomethacin CL is considerably lower in this contemporary population. Model-informed precision dosing incorporating important covariates other than weight alone offers an opportunity to individualize dosing in a susceptible patient undergoing rapid change.
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Affiliation(s)
- Wojciech Krzyzanski
- Department of Pharmaceutical SciencesThe State University of New York at BuffaloBuffaloNew YorkUSA
| | - Bradley Stockard
- Department of PediatricsUniversity of Missouri Kansas City School of MedicineKansas CityMissouriUSA
| | - Andrea Gaedigk
- Department of PediatricsUniversity of Missouri Kansas City School of MedicineKansas CityMissouriUSA,Division of Clinical PharmacologyToxicology and Therapeutic Innovation, Children's Mercy HospitalKansas CityMissouriUSA
| | - Allison Scott
- Division of NeonatologyChildren's Mercy HospitalKansas CityMissouriUSA
| | - Whitney Nolte
- Division of Clinical PharmacologyToxicology and Therapeutic Innovation, Children's Mercy HospitalKansas CityMissouriUSA
| | - Kim Gibson
- Division of Clinical PharmacologyToxicology and Therapeutic Innovation, Children's Mercy HospitalKansas CityMissouriUSA
| | - J. Steven Leeder
- Department of PediatricsUniversity of Missouri Kansas City School of MedicineKansas CityMissouriUSA,Division of Clinical PharmacologyToxicology and Therapeutic Innovation, Children's Mercy HospitalKansas CityMissouriUSA
| | - Tamorah Lewis
- Department of PediatricsUniversity of Missouri Kansas City School of MedicineKansas CityMissouriUSA,Division of Clinical PharmacologyToxicology and Therapeutic Innovation, Children's Mercy HospitalKansas CityMissouriUSA,Division of NeonatologyChildren's Mercy HospitalKansas CityMissouriUSA
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Backes CH, Hill KD, Shelton EL, Slaughter JL, Lewis TR, Weisz DE, Mah ML, Bhombal S, Smith CV, McNamara PJ, Benitz WE, Garg V. Patent Ductus Arteriosus: A Contemporary Perspective for the Pediatric and Adult Cardiac Care Provider. J Am Heart Assoc 2022; 11:e025784. [PMID: 36056734 PMCID: PMC9496432 DOI: 10.1161/jaha.122.025784] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The burden of patent ductus arteriosus (PDA) continues to be significant. In view of marked differences in preterm infants versus more mature, term counterparts (viewed on a continuum with adolescent and adult patients), mechanisms regulating ductal patency, genetic contributions, clinical consequences, and diagnostic and treatment thresholds are discussed separately, when appropriate. Among both preterm infants and older children and adults, a range of hemodynamic profiles highlighting the markedly variable consequences of the PDA are provided. In most contemporary settings, transcatheter closure is preferable over surgical ligation, but data on longer-term outcomes, particularly among preterm infants, are lacking. The present review provides recommendations to identify gaps in PDA diagnosis, management, and treatment on which subsequent research can be developed. Ultimately, the combination of refined diagnostic thresholds and expanded treatment options provides the best opportunities to address the burden of PDA. Although fundamental gaps remain unanswered, the present review provides pediatric and adult cardiac care providers with a contemporary framework in PDA care to support the practice of evidence-based medicine.
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Affiliation(s)
- Carl H Backes
- Center for Perinatal Research The Abigail Wexner Research Institute at Nationwide Children's Hospital Columbus OH
- Division of Neonatology Nationwide Children's Hospital Columbus OH
- Department of Pediatrics The Ohio State University College of Medicine Columbus OH
- The Heart Center Nationwide Children's Hospital Columbus OH
| | - Kevin D Hill
- Duke University Pediatric and Congenital Heart Disease Center Durham NC
- Duke Clinical Research Institute Durham NC
| | - Elaine L Shelton
- Department of Pediatrics Vanderbilt University Medical Center Nashville TN
- Department of Pharmacology Vanderbilt University Medical Center Nashville TN
| | - Jonathan L Slaughter
- Center for Perinatal Research The Abigail Wexner Research Institute at Nationwide Children's Hospital Columbus OH
- Division of Neonatology Nationwide Children's Hospital Columbus OH
- Department of Pediatrics The Ohio State University College of Medicine Columbus OH
- Division of Epidemiology, College of Public Health The Ohio State University Columbus OH
| | - Tamorah R Lewis
- Division of Neonatology Children's Mercy-Kansas City Kansas City MO
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation Children's Mercy-Kansas City Kansas City MO
- Department of Pediatrics University of Missouri-Kansas City School of Medicine Kansas City MO
| | - Dany E Weisz
- Department of Paediatrics University of Toronto Ontario Canada
- Department of Newborn and Developmental Paediatrics Sunnybrook Health Science Center Toronto Ontario Canada
| | - May Ling Mah
- Department of Pediatrics The Ohio State University College of Medicine Columbus OH
- The Heart Center Nationwide Children's Hospital Columbus OH
| | - Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Department of Pediatrics Stanford University School of Medicine, Lucille Packard Children's Hospital Stanford CA
| | - Charles V Smith
- Center for Integrated Brain Research University of Washington School of Medicine Seattle WA
| | - Patrick J McNamara
- Department of Pediatrics University of Iowa Iowa City IA
- Department of Internal Medicine University of Iowa Iowa City IA
| | - William E Benitz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics Stanford University School of Medicine, Lucille Packard Children's Hospital Stanford CA
| | - Vidu Garg
- Department of Pediatrics The Ohio State University College of Medicine Columbus OH
- The Heart Center Nationwide Children's Hospital Columbus OH
- Center for Cardiovascular Research The Abigail Wexner Research Institute at Nationwide Children's Hospital Columbus OH
- Department of Molecular Genetics The Ohio State University Columbus OH
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3
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Intensive and prolonged urine collection in preterm infants reveals three distinct indomethacin metabolic patterns: potential implications for drug dosing. Pediatr Res 2018; 84:325-327. [PMID: 29967531 PMCID: PMC6258260 DOI: 10.1038/s41390-018-0051-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/19/2018] [Accepted: 04/23/2018] [Indexed: 11/08/2022]
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Lewis TR, Shelton EL, Van Driest SL, Kannankeril PJ, Reese J. Genetics of the patent ductus arteriosus (PDA) and pharmacogenetics of PDA treatment. Semin Fetal Neonatal Med 2018; 23:232-238. [PMID: 29510900 PMCID: PMC6098727 DOI: 10.1016/j.siny.2018.02.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patent ductus arteriosus (PDA) is a frequent, complex, and difficult to treat clinical syndrome among preterm infants in the neonatal intensive care unit. In addition to known clinical risk factors, there are emerging data about genetic predisposition to PDA in both animal and human models. Clinical response and toxicity from drugs used to treat PDA are highly variable. Developmental and genetic aspects of pharmacokinetics and pharmacodynamics influence exposure and response to pharmacologic therapies. Given the variable efficacy and toxicity of known drug therapies, novel therapeutic targets for PDA treatment offer the promise of precision medicine. This review addresses the known genetic contributions to prolonged ductal patency, variability in response to drug therapy for PDA, and potential novel drug targets for future PDA treatment discovery.
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Affiliation(s)
- Tamorah R Lewis
- Department of Pediatrics, Children's Mercy Hospitals & Clinics, University of Missouri, Kansas City School of Medicine, Kansas City, MO, USA
| | - Elaine L Shelton
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara L Van Driest
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN, USA; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Prince J Kannankeril
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeff Reese
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN, USA; Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA.
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5
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Autmizguine J, Melloni C, Hornik CP, Dallefeld S, Harper B, Yogev R, Sullivan JE, Atz AM, Al-Uzri A, Mendley S, Poindexter B, Mitchell J, Lewandowski A, Delmore P, Cohen-Wolkowiez M, Gonzalez D. Population Pharmacokinetics of Trimethoprim-Sulfamethoxazole in Infants and Children. Antimicrob Agents Chemother 2018; 62:e01813-17. [PMID: 29084742 PMCID: PMC5740321 DOI: 10.1128/aac.01813-17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 10/07/2017] [Indexed: 11/20/2022] Open
Abstract
Trimethoprim (TMP)-sulfamethoxazole (SMX) is used to treat various types of infections, including community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and Pneumocystis jirovecii infections in children. Pharmacokinetic (PK) data for infants and children are limited, and the optimal dosing is not known. We performed a multicenter, prospective PK study of TMP-SMX in infants and children. Separate population PK models were developed for TMP and SMX administered by the enteral route using nonlinear mixed-effects modeling. Optimal dosing was determined on the basis of the matching adult TMP exposure and attainment of the surrogate pharmacodynamic (PD) target for efficacy, a free TMP concentration above the MIC over 50% of the dosing interval. Data for a total of 153 subjects (240 samples for PK analysis) with a median postnatal age of 8 years (range, 0.1 to 20 years) contributed to the analysis for both drugs. A one-compartment model with first-order absorption and elimination characterized the TMP and SMX PK data well. Weight was included in the base model for clearance (CL/F) and volume of distribution (V/F). Both TMP and SMX CL/F increased with age. In addition, TMP and SMX CL/F were inversely related to the serum creatinine and albumin concentrations, respectively. The exposure achieved in children after oral administration of TMP-SMX at 8/40 mg/kg of body weight/day divided into administration every 12 h matched the exposure achieved in adults after administration of TMP-SMX at 320/1,600 mg/day divided into administration every 12 h and achieved the PD target for bacteria with an MIC of 0.5 mg/liter in >90% of infants and children. The exposure achieved in children after oral administration of TMP-SMX at 12/60 and 15/75 mg/kg/day divided into administration every 12 h matched the exposure achieved in adults after administration of TMP-SMX at 640/3,200 mg/day divided into administration every 12 h in subjects 6 to <21 years and 0 to <6 years of age, respectively, and was optimal for bacteria with an MIC of up to 1 mg/liter.
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Affiliation(s)
- Julie Autmizguine
- Research Center, CHU Sainte-Justine, and Department of Pharmacology and Physiology, Université de Montréal, Montreal, Quebec, Canada
| | - Chiara Melloni
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | | | - Barrie Harper
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Ram Yogev
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Janice E Sullivan
- University of Louisville, Norton Children's Hospital and Kosair Charities Pediatric Clinical Research Unit, Louisville, Kentucky, USA
| | - Andrew M Atz
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Amira Al-Uzri
- Oregon Health and Science University, Portland, Oregon, USA
| | - Susan Mendley
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Brenda Poindexter
- Perinatal Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | | | | | | | | | - Daniel Gonzalez
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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6
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Smith CJ, Ryckman KK, Bahr TM, Dagle JM. Polymorphisms in CYP2C9 are associated with response to indomethacin among neonates with patent ductus arteriosus. Pediatr Res 2017; 82:776-780. [PMID: 28609430 PMCID: PMC5645220 DOI: 10.1038/pr.2017.145] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 04/15/2017] [Indexed: 11/09/2022]
Abstract
BackgroundPatent ductus arteriosus (PDA) is a common complication seen in preterm infants. Indomethacin is routinely used to treat PDA. Evidence suggests that the response of indomethacin is highly heritable. This study investigated the association between single-nucleotide polymorphisms (SNPs) in CYP2C9 and the closure of PDA in response to indomethacin.MethodsSix SNPs in CYP2C9 were analyzed for association with indomethacin response. A case-control analysis was performed among neonates who responded to indomethacin (responders) and among those who required surgical ligation (non-responders). Independent transmission disequilibrium tests were performed among parent-child trios of responders and non-responders.ResultsThe G allele of rs2153628 was associated with increased odds of response to indomethacin in the case-control analysis (odds ratios (OR): 1.918, 95% confidence interval (CI): 1.056, 3.483). Among indomethacin responders, the G allele of rs2153628 and the T allele of rs1799853 were overtransmitted from the parents to their child (OR: 2.667, 95% CI: 1.374, 5.177 and OR: 2.375, 95% CI: 1.040, 5.425, respectively), consistent with the case-control analysis.ConclusionWe identified an association between two SNPs in CYP2C9, rs2153628 and rs1799853, and indomethacin response for the treatment of PDA. These findings suggest that response to indomethacin in the closure of PDA may be influenced by polymorphisms associated with altered indomethacin metabolism.
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Affiliation(s)
- Caitlin J. Smith
- Department of Epidemiology, University of Iowa, Iowa City, IA,Corresponding Author: Caitlin J. Smith, MS, Department of Epidemiology, University of Iowa, Office S471, 145 N. Riverside Drive, Iowa City, IA 52242. Tel: (319) 384-1572, Fax: (319) 384-4155.
| | - Kelli K. Ryckman
- Department of Epidemiology, University of Iowa, Iowa City, IA,Department of Pediatrics – Division of Neonatology, University of Iowa, Iowa City, IA
| | - Timothy M. Bahr
- Department of Pediatrics – Division of Neonatology, University of Iowa, Iowa City, IA
| | - John M. Dagle
- Department of Pediatrics – Division of Neonatology, University of Iowa, Iowa City, IA
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7
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Benitez-Medina GE, Amézquita-Valencia M, Cabrera A, Sharma P. Synthesis of 2,3-Disubstituted Indoles from α-Diketones and N-Substituted Anilines: One-Pot Pd-Catalyzed Reductive Amination. ChemCatChem 2017. [DOI: 10.1002/cctc.201601557] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- G. Eliad Benitez-Medina
- Instituto de Química; Universidad Nacional Autónoma de México; Ciudad Universitaria, Circuito Exterior, Coyoacán 04510 Ciudad de México México
| | - Manuel Amézquita-Valencia
- Instituto de Química; Universidad Nacional Autónoma de México; Ciudad Universitaria, Circuito Exterior, Coyoacán 04510 Ciudad de México México
| | - Armando Cabrera
- Instituto de Química; Universidad Nacional Autónoma de México; Ciudad Universitaria, Circuito Exterior, Coyoacán 04510 Ciudad de México México
| | - Pankaj Sharma
- Instituto de Química; Universidad Nacional Autónoma de México; Ciudad Universitaria, Circuito Exterior, Coyoacán 04510 Ciudad de México México
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Puhl AC, Milton FA, Cvoro A, Sieglaff DH, Campos JCL, Bernardes A, Filgueira CS, Lindemann JL, Deng T, Neves FAR, Polikarpov I, Webb P. Mechanisms of peroxisome proliferator activated receptor γ regulation by non-steroidal anti-inflammatory drugs. NUCLEAR RECEPTOR SIGNALING 2015; 13:e004. [PMID: 26445566 PMCID: PMC4594550 DOI: 10.1621/nrs.13004] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 08/10/2015] [Indexed: 12/31/2022]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) display anti-inflammatory, antipyretic and analgesic properties by inhibiting cyclooxygenases and blocking prostaglandin production. Previous studies, however, suggested that some NSAIDs also modulate peroxisome proliferator activated receptors (PPARs), raising the possibility that such off target effects contribute to the spectrum of clinically relevant NSAID actions. In this study, we set out to understand how peroxisome proliferator activated receptor-γ (PPARγ/PPARG) interacts with NSAIDs using X-ray crystallography and to relate ligand binding modes to effects on receptor activity. We find that several NSAIDs (sulindac sulfide, diclofenac, indomethacin and ibuprofen) bind PPARγ and modulate PPARγ activity at pharmacologically relevant concentrations. Diclofenac acts as a partial agonist and binds to the PPARγ ligand binding pocket (LBP) in typical partial agonist mode, near the β-sheets and helix 3. By contrast, two copies of indomethacin and sulindac sulfide bind the LBP and, in aggregate, these ligands engage in LBP contacts that resemble agonists. Accordingly, both compounds, and ibuprofen, act as strong partial agonists. Assessment of NSAID activities in PPARγ-dependent 3T3-L1 cells reveals that NSAIDs display adipogenic activities and exclusively regulate PPARγ-dependent target genes in a manner that is consistent with their observed binding modes. Further, PPARγ knockdown eliminates indomethacin activities at selected endogenous genes, confirming receptor-dependence of observed effects. We propose that it is important to consider how individual NSAIDs interact with PPARγ to understand their activities, and that it will be interesting to determine whether high dose NSAID therapies result in PPAR activation.
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Affiliation(s)
- Ana C Puhl
- Instituto de Física de São Carlos, Universidade de São Paulo, Av. Trabalhador Saocarlense 400, São Carlos, SP, 13560-970, Brazil (ACP, JCLC, AB, IP)
| | - Flora A Milton
- Instituto de Física de São Carlos, Universidade de São Paulo, Av. Trabalhador Saocarlense 400, São Carlos, SP, 13560-970, Brazil (ACP, JCLC, AB, IP)
| | - Aleksandra Cvoro
- Instituto de Física de São Carlos, Universidade de São Paulo, Av. Trabalhador Saocarlense 400, São Carlos, SP, 13560-970, Brazil (ACP, JCLC, AB, IP)
| | - Douglas H Sieglaff
- Instituto de Física de São Carlos, Universidade de São Paulo, Av. Trabalhador Saocarlense 400, São Carlos, SP, 13560-970, Brazil (ACP, JCLC, AB, IP)
| | - Jéssica C L Campos
- Instituto de Física de São Carlos, Universidade de São Paulo, Av. Trabalhador Saocarlense 400, São Carlos, SP, 13560-970, Brazil (ACP, JCLC, AB, IP)
| | - Amanda Bernardes
- Instituto de Física de São Carlos, Universidade de São Paulo, Av. Trabalhador Saocarlense 400, São Carlos, SP, 13560-970, Brazil (ACP, JCLC, AB, IP)
| | - Carly S Filgueira
- Instituto de Física de São Carlos, Universidade de São Paulo, Av. Trabalhador Saocarlense 400, São Carlos, SP, 13560-970, Brazil (ACP, JCLC, AB, IP)
| | - Jan Lammel Lindemann
- Instituto de Física de São Carlos, Universidade de São Paulo, Av. Trabalhador Saocarlense 400, São Carlos, SP, 13560-970, Brazil (ACP, JCLC, AB, IP)
| | - Tuo Deng
- Instituto de Física de São Carlos, Universidade de São Paulo, Av. Trabalhador Saocarlense 400, São Carlos, SP, 13560-970, Brazil (ACP, JCLC, AB, IP)
| | - Francisco A R Neves
- Instituto de Física de São Carlos, Universidade de São Paulo, Av. Trabalhador Saocarlense 400, São Carlos, SP, 13560-970, Brazil (ACP, JCLC, AB, IP)
| | - Igor Polikarpov
- Instituto de Física de São Carlos, Universidade de São Paulo, Av. Trabalhador Saocarlense 400, São Carlos, SP, 13560-970, Brazil (ACP, JCLC, AB, IP)
| | - Paul Webb
- Instituto de Física de São Carlos, Universidade de São Paulo, Av. Trabalhador Saocarlense 400, São Carlos, SP, 13560-970, Brazil (ACP, JCLC, AB, IP)
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Clinical pharmacology of indomethacin in preterm infants: implications in patent ductus arteriosus closure. Paediatr Drugs 2013; 15:363-76. [PMID: 23754139 DOI: 10.1007/s40272-013-0031-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Indomethacin is a non-steroidal anti-inflammatory drug that is a potent inhibitor of prostaglandin E(2) synthesis. After birth, the ductus arteriosus closes spontaneously within 2-4 days in term infants. The major factor closing the ductus arteriosus is the tension of oxygen, which increases significantly after birth. Prostaglandin E(2) has the opposite effect to that of oxygen; it relaxes smooth muscle and tends to inhibit the closure of the ductus arteriosus. In preterm infants with respiratory distress syndrome, the ductus arteriosus fails to close (patent ductus arteriosus [PDA]) because the concentration of prostaglandin E2 is relatively high. PDA occurs in more than 70 % of neonates weighing less than 1,500 g at birth. The aim of this article was to review the published data on the clinical pharmacology of indomethacin in preterm infants in order to provide a critical analysis of the literature and a useful tool for physicians. The bibliographic search was performed electronically using the PubMed and EMBASE databases as search engines and February 2012 was the cutoff point. A remarkable interindividual variability was observed for the half-life (t(½)), clearance (CL), and volume of distribution (V(d)) of indomethacin. Prophylactic indomethacin consists of a continuous infusion of low levels of indomethacin and may be useful in preterm infants. Extremely preterm infants are less likely to respond to indomethacin. Infants with a postnatal age of 2 months do not respond to treatment with indomethacin. Indomethacin has several adverse effects, the most common of which is renal failure. An increase in serum creatinine of ≥0.5 % mg/dL after indomethacin was observed in about 10-15 % of the patients and creatinine returns to a normal level about 1 week after cessation of therapy. Indomethacin should be administered intravenously by syringe pump for at least 30 min to minimize adverse effects on cerebral, gastrointestinal, and renal blood flow velocities. A prolonged course of indomethacin appears to reduce the risk of severe intracranial hemorrhage and renal impairment in patients with PDA. In conclusion, indomethacin is a useful drug to treat PDA.
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10
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Holford N, Heo YA, Anderson B. A pharmacokinetic standard for babies and adults. J Pharm Sci 2013; 102:2941-52. [PMID: 23650116 DOI: 10.1002/jps.23574] [Citation(s) in RCA: 257] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 04/12/2013] [Accepted: 04/12/2013] [Indexed: 01/01/2023]
Abstract
The pharmacokinetic behavior of medicines used in humans follows largely predictable patterns across the human age range from premature babies to elderly adults. Most of the differences associated with age are in fact due to differences in size. Additional considerations are required to describe the processes of maturation of clearance processes and postnatal changes in body composition. Application of standard approaches to reporting pharmacokinetic parameters is essential for comparative human pharmacokinetic studies from babies to adults. A standardized comparison of pharmacokinetic parameters obtained in children and adults is shown for 46 drugs. Appropriate size scaling shows that children (over 2 years old) are similar to adults. Maturation changes are generally completed within the first 2 years of postnatal life; consequently babies may be considered as immature children, whereas children are just small adults.
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Affiliation(s)
- Nick Holford
- Department of Pharmacology & Clinical Pharmacology, University of Auckland, New Zealand.
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11
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Marsot A, Boulamery A, Bruguerolle B, Simon N. Population pharmacokinetic analysis during the first 2 years of life: an overview. Clin Pharmacokinet 2013. [PMID: 23179579 DOI: 10.1007/s40262-012-0015-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Three decades after its introduction, pharmacokinetic population approaches have become a reference method for drug modelling, particularly in paediatrics. The main practical limitation in this specific population is the collected blood volume. Pharmacokinetic population approaches using sparse sampling may resolve this issue. The pharmacokinetics of many drugs have been studied during the last 25 years using such methods. This review summarizes all of the published studies concerning population pharmacokinetic approaches in paediatric subjects from neonate to 2 years old. A literature search was conducted using the PubMed database, from 1985 to December 2010, using the following terms: pharmacokinetic(s), population, paediatric/pediatric and neonate(s). Articles were excluded if they were not pertinent according to our criteria. References of all relevant articles were also evaluated. Ninety-eight studies were included in this review. The following information was extracted from the articles: drug name, therapeutic class, population size, age of patients, number of samples per patient, covariates used for clearance and volume of distribution estimates, software used for modelling and validation methods. An increasing rate of publications over the years was observed; 44 different drugs were studied using a pharmacokinetic population approach. Antibacterials were the most studied class of drugs, including a large number of studies devoted to vancomycin and gentamicin. It must be underlined that few studies have been performed on anticonvulsant drugs and anaesthetics used in clinical daily practice conditions.
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Affiliation(s)
- Amélie Marsot
- Service de Pharmacologie Médicale et Clinique, Aix Marseille Université, France.
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12
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Johnston PG, Gillam-Krakauer M, Fuller MP, Reese J. Evidence-based use of indomethacin and ibuprofen in the neonatal intensive care unit. Clin Perinatol 2012; 39:111-36. [PMID: 22341541 PMCID: PMC3598606 DOI: 10.1016/j.clp.2011.12.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Indomethacin and ibuprofen are potent inhibitors of prostaglandin synthesis. Neonates have been exposed to these compounds for more than 3 decades. Indomethacin is commonly used to prevent intraventricular hemorrhage (IVH), and both drugs are prescribed for the treatment or prevention of patent ductus arteriosus (PDA). This review examines the basis for indomethacin and ibuprofen use in the neonatal intensive care population. Despite the call for restrained use of each drug, the most immature infants are likely to need pharmacologic approaches to reduce high-grade IVH, avoid the need for PDA ligation, and preserve the opportunity for an optimal outcome.
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Affiliation(s)
- Palmer G. Johnston
- Neonatal-Perinatal Medicine, Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children’s Way, Doctor’s Office Tower 11111, Nashville, TN 37232-9544, USA
| | - Maria Gillam-Krakauer
- Neonatal-Perinatal Medicine, Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children’s Way, Doctor’s Office Tower 11111, Nashville, TN 37232-9544, USA
| | - M. Paige Fuller
- Department of Pharmacy, Monroe Carell Jr. Children’s Hospital at Vanderbilt, 2200 Children’s Way, Room 4508, Nashville, TN 37232, USA
| | - Jeff Reese
- Neonatal-Perinatal Medicine, Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children’s Way, Doctor’s Office Tower 11111, Nashville, TN 37232-9544, USA,Department of Cell and Developmental Biology, Vanderbilt University Medical Center, U-3218 MRB III Building, Nashville, TN 37232-8240, USA,Corresponding author. Department of Cell and Developmental Biology, Vanderbilt University Medical Center, U-3218 MRB III Building, Nashville, TN 37232-8240.,
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Development and validation of a dried blood spot–HPLC assay for the determination of metronidazole in neonatal whole blood samples. Anal Bioanal Chem 2010; 397:687-93. [DOI: 10.1007/s00216-010-3571-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 01/05/2010] [Accepted: 02/11/2010] [Indexed: 10/19/2022]
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Golombek S, Sola A, Baquero H, Borbonet D, Cabañas F, Fajardo C, Goldsmit G, Lemus L, Miura E, Pellicer A, Pérez J, Rogido M, Zambosco G, van Overmeire B. Primer consenso clínico de SIBEN: enfoque diagnóstico y terapéutico del ductus arterioso permeable en recién nacidos pretérmino. An Pediatr (Barc) 2008. [DOI: 10.1157/13128002] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Orogastric and Intravenous Indomethacin Administration to Very Premature Neonates With Patent Ductus Arteriosus: Population Pharmacokinetics, Absolute Bioavailability, and Treatment Outcome. Ther Drug Monit 2007; 29:807-14. [DOI: 10.1097/ftd.0b013e31815b3e13] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Capparelli EV. Pharmacologic, pharmacodynamic, and pharmacokinetic considerations with intravenous Ibuprofen lysine. J Pediatr Pharmacol Ther 2007; 12:158-70. [PMID: 23055851 PMCID: PMC3462098 DOI: 10.5863/1551-6776-12.3.158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Patent ductus arteriosus (PDA) is a common complication in preterm infants. An intravenous (IV) cyclooxygenase (COX) inhibitor is the pharmacotherapy of choice. Concerns over adverse effects associated with the traditional treatment, IV indomethacin, have led to the investigation of other COX inhibitors to assist closure of PDA. IV ibuprofen lysine is a COX inhibitor that demonstrates similar efficacy to indomethacin with few adverse effects. In addition, IV ibuprofen lysine does not cause reductions in cerebral, renal, and mesenteric blood flow that can be seen with indomethacin, and thus ibuprofen therapy is not associated with reduced renal function. Ibuprofen is primarily metabolized by cytochrome P450 (CYP) 2C9. The immaturity of neonatal biotransformation pathways has a pronounced effect on the pharmacokinetic parameters of ibuprofen, particularly because CYP2C9 enzyme activity is known to be very low at birth and to increase rapidly over the first several days of life. Ibuprofen is highly bound to albumin, raising concern that ibuprofen may displace bilirubin and subsequently increase free bilirubin concentrations. However, the ibuprofen concentrations achieved with approved dosing with IV ibuprofen lysine are lower than those expected to result in displacement of bilirubin and related adverse effects. Factors such as gestational age and CYP2C9 polymorphism may affect ibuprofen metabolism and therefore optimal dosing, but further clinical investigation is needed in these areas. Other areas for future investigation include prolonged dosing regimens, prophylactic administration, and alternate indications. At the approved dose, IV ibuprofen lysine is a safe, effective pharmacologic agent to promote closure of PDAs in preterm infants.
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Affiliation(s)
- Edmund V. Capparelli
- University of California, San Diego, Division of Pharmacology and Drug Discovery, School of Medicine, Department of Pediatrics and Skagg's School of Pharmacy & Pharmaceutical Sciences, San Diego, California
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Abstract
The non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (paracetamol) are the most common analgesic drugs used in neonates and infants despite limited pharmacodynamic data. Both drugs act through inhibition of cyclooxygenase enzymes. Neonatal acetaminophen clearance is reduced in premature neonates (0.7 L h(-1) x 70 kg(-1)) and increases to 5 L h(-1) x 70 kg(-1) at term (40% adult rates); adult rates are reached within the first year of life; NSAID clearance follows similar trends. Volume of distribution is increased in the neonatal period. Dosing of both drug groups is tempered by concerns about toxicity. Acetaminophen hepatotoxicity is less common in neonates than in older children and adults, possibly due to reduced oxidative enzyme activity (e.g. CYP 2E1). Data concerning NSAID adverse effects in the neonatal period are few. Renal function is reduced 20% after NSAID use for patent ductus arteriosus closure in premature neonates and there is no increased frequency of intraventricular haemorrhage. No significant difference in the change in cerebral blood volume, change in cerebral blood flow, or tissue oxygenation index was found between administration of ibuprofen or placebo in neonates. Future studies should define concentration-response relationships for these drugs that are age and pathology specific.
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Affiliation(s)
- Evelyne Jacqz-Aigrain
- Department of Paediatric Pharmacology, Robert Debré Hospital, 48 Boulevard Sérurier, 75019 Paris, France.
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Anderson BJ, Palmer GM. Recent pharmacological advances in paediatric analgesics. Biomed Pharmacother 2006; 60:303-9. [PMID: 16854558 DOI: 10.1016/j.biopha.2006.06.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2006] [Accepted: 06/12/2006] [Indexed: 11/22/2022] Open
Abstract
Growth and development are two linked processes that distinguish children from adults. The use of size as the primary covariate during pharmacokinetic (PK) analyses allows exploration of the effects of age. Allometric scaling models have assisted understanding of the developmental clearance changes in common analgesic drugs such as paracetamol, morphine, tramadol and local anaesthetics agents. Single nucleotide polymorphisms (pharmacogenomics [PG]) and their impact on hepatic drug metabolism for opioids, tramadol, non-steroidal anti-inflammatory drugs (NSAIDs) and drug receptor responses are increasingly reported. Altered chemical structure or formulations of common analgesics alter pharmacodynamic (PD) effects enhancing safety and efficacy for NSAIDs by stereoselectivity and the addition of nitric oxide, for intravenous paracetamol by formulation and structural difference from propacetamol and for local anaesthetics through stereoselectivity. This article focuses upon recent data for analgesics used in paediatric pain management including paracetamol, NSAIDs, morphine, tramadol, amide local anaesthetics and ketamine. It centres on PK and clinical studies in neonates, infants and children. PG studies are acknowledged as potentially allowing individual drug therapy tailoring through a decrease in between-patient population variability, although the impact of PG in the very young is less certain. There are few data describing age-related PD changes in children despite recognition that the number, affinity and type of receptors or the availability of natural ligands changes with age.
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Affiliation(s)
- B J Anderson
- University of Auckland, Auckland, New Zealand, and Department of Anaesthesia and Pain Management, Royal Children's Hospital, Victoria, Australia.
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Anderson BJ, Palmer GM. Recent developments in the pharmacological management of pain in children. Curr Opin Anaesthesiol 2006; 19:285-92. [PMID: 16735812 DOI: 10.1097/01.aco.0000192802.33291.6f] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review explores progress in developmental pharmacokinetics, pharmacogenomics and formulations of analgesic agents, and discusses potential implications for pain therapy. RECENT FINDINGS Characterization of the developmental pharmacokinetics of morphine, tramadol, paracetamol and nonsteroidal anti-inflammatory drugs has improved dosing in children. Oral sugar solutions have replaced the brandy/sugar pacifier and are effective for single painful events in neonates. Intravenous paracetamol offers increased dosing accuracy, and avoids absorption and bioavailability variability. New nitric-oxide-releasing versions of paracetamol and nonsteroidal anti-inflammatory drugs offer safer alternatives to their parent drugs with enhanced potency. Ketamine has come under a cloud for its possible effects on the neonatal developing brain, but it is being used increasingly in children to supplement opioids for pain after major surgery. Hopes that morphine analgesia may improve neurological outcome in premature babies have not materialized. Reports concerning chronic pain are generally case series and controlled trials are rare and nearly nonexistent in children. SUMMARY Unlicensed drug use in the very young will increase as familiarity increases. Pharmacogenomic studies have the potential to tailor drug therapy to the individual and decrease between-patient variability. Unfortunately, the pharmacodynamic knowledge in children of analgesic agents remains neglected and is usually extrapolated from adult data.
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Affiliation(s)
- Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand, and Department of Anaesthesia and Pain Management, Royal Children's Hospital, Victoria, Australia.
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Manzar S. High-dose indomethacin for patent ductus arteriosus closure: how strong is the evidence? Pediatrics 2006; 117:1863; author reply 1863-4. [PMID: 16651359 DOI: 10.1542/peds.2005-3087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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