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Shuai W, Cao J, Qian M, Tang Z. Physiologically Based Pharmacokinetic Modeling of Vancomycin in Critically Ill Neonates: Assessing the Impact of Pathophysiological Changes. J Clin Pharmacol 2024. [PMID: 39092894 DOI: 10.1002/jcph.6107] [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: 06/18/2024] [Accepted: 07/18/2024] [Indexed: 08/04/2024]
Abstract
Dosing vancomycin for critically ill neonates is challenging owing to substantial alterations in pharmacokinetics (PKs) caused by variability in physiology, disease, and clinical interventions. Therefore, an adequate PK model is needed to characterize these pathophysiological changes. The intent of this study was to develop a physiologically based pharmacokinetic (PBPK) model that reflects vancomycin PK and pathophysiological changes in neonates under intensive care. PK-sim software was used for PBPK modeling. An adult model (model 0) was established and verified using PK profiles from previous studies. A neonatal model (model 1) was then extrapolated from model 0 by scaling age-dependent parameters. Another neonatal model (model 2) was developed based not only on scaled age-dependent parameters but also on quantitative information on pathophysiological changes obtained via a comprehensive literature search. The predictive performances of models 1 and 2 were evaluated using a retrospectively collected dataset from neonates under intensive care (chictr.org.cn, ChiCTR1900027919), comprising 65 neonates and 92 vancomycin serum concentrations. Integrating literature-based parameter changes related to hypoalbuminemia, small-for-gestational-age, and co-medication, model 2 offered more optimized precision than model 1, as shown by a decrease in the overall mean absolute percentage error (50.6% for model 1; 37.8% for model 2). In conclusion, incorporating literature-based pathophysiological changes effectively improved PBPK modeling for critically ill neonates. Furthermore, this model allows for dosing optimization before serum concentration measurements can be obtained in clinical practice.
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Affiliation(s)
- Weiwei Shuai
- Department of Pharmacy, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, Nanjing, Jiangsu, P. R. China
| | - Jing Cao
- Department of Pharmacy, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, Nanjing, Jiangsu, P. R. China
| | - Miao Qian
- Department of Neonatology, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, Nanjing, Jiangsu, P. R. China
| | - Zhe Tang
- Department of Pharmacy, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, Nanjing, Jiangsu, P. R. China
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2
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Blouin M, Métras MÉ, El Hassani M, Yaliniz A, Marsot A. Optimization of Vancomycin Initial Dosing Regimen in Neonates Using an Externally Evaluated Population Pharmacokinetic Model. Ther Drug Monit 2024:00007691-990000000-00235. [PMID: 38857472 DOI: 10.1097/ftd.0000000000001226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/27/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Vancomycin therapeutic monitoring guidelines were revised in March 2020, and a population pharmacokinetics-guided Bayesian approach to estimate the 24-hour area under the concentration-time curve to the minimum inhibitory concentration ratio has since been recommended instead of trough concentrations. To comply with these latest guidelines, we evaluated published population pharmacokinetic models of vancomycin using an external dataset of neonatal patients and selected the most predictive model to develop a new initial dosing regimen. METHODS The models were identified from the literature and tested using a retrospective dataset of Canadian neonates. Their predictive performance was assessed using prediction- and simulation-based diagnostics. Monte Carlo simulations were performed to develop the initial dosing regimen with the highest probability of therapeutic target attainment. RESULTS A total of 144 vancomycin concentrations were derived from 63 neonates in the external population. Five of the 28 models retained for evaluation were found predictive with a bias of 15% and an imprecision of 30%. Overall, the Grimsley and Thomson model performed best, with a bias of -0.8% and an imprecision of 20.9%; therefore, it was applied in the simulations. A novel initial dosing regimen of 15 mg/kg, followed by 11 mg/kg every 8 hours should favor therapeutic target attainment. CONCLUSIONS A predictive population pharmacokinetic model of vancomycin was identified after an external evaluation and used to recommend a novel initial dosing regimen. The implementation of these model-based tools may guide physicians in selecting the most appropriate initial vancomycin dose, leading to improved clinical outcomes.
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Affiliation(s)
- Mathieu Blouin
- STP Laboratory, Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
| | - Marie-Élaine Métras
- Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Department of Pharmacy, Centre Hospitalier Universitaire Sainte-Justine, Montréal (QC), Canada; and
| | - Mehdi El Hassani
- STP Laboratory, Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
| | - Aysenur Yaliniz
- STP Laboratory, Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
| | - Amélie Marsot
- STP Laboratory, Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Research Center, Centre Hospitalier Universitaire Sainte-Justine, Montréal (QC), Canada
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Wu Y, Allegaert K, Flint RB, Goulooze SC, Välitalo PAJ, de Hoog M, Mulla H, Sherwin CMT, Simons SHP, Krekels EHJ, Knibbe CAJ, Völler S. When will the Glomerular Filtration Rate in Former Preterm Neonates Catch up with Their Term Peers? Pharm Res 2024; 41:637-649. [PMID: 38472610 PMCID: PMC11024008 DOI: 10.1007/s11095-024-03677-3] [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: 12/11/2023] [Accepted: 02/10/2024] [Indexed: 03/14/2024]
Abstract
AIMS Whether and when glomerular filtration rate (GFR) in preterms catches up with term peers is unknown. This study aims to develop a GFR maturation model for (pre)term-born individuals from birth to 18 years of age. Secondarily, the function is applied to data of different renally excreted drugs. METHODS We combined published inulin clearance values and serum creatinine (Scr) concentrations in (pre)term born individuals throughout childhood. Inulin clearance was assumed to be equal to GFR, and Scr to reflect creatinine synthesis rate/GFR. We developed a GFR function consisting of GFRbirth (GFR at birth), and an Emax model dependent on PNA (with GFRmax, PNA50 (PNA at which half ofGFR max is reached) and Hill coefficient). The final GFR model was applied to predict gentamicin, tobramycin and vancomycin concentrations. RESULT In the GFR model, GFRbirth varied with birthweight linearly while in the PNA-based Emax equation, GA was the best covariate for PNA50, and current weight for GFRmax. The final model showed that for a child born at 26 weeks GA, absolute GFR is 18%, 63%, 80%, 92% and 96% of the GFR of a child born at 40 weeks GA at 1 month, 6 months, 1 year, 3 years and 12 years, respectively. PopPK models with the GFR maturation equations predicted concentrations of renally cleared antibiotics across (pre)term-born neonates until 18 years well. CONCLUSIONS GFR of preterm individuals catches up with term peers at around three years of age, implying reduced dosages of renally cleared drugs should be considered below this age.
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Affiliation(s)
- Yunjiao Wu
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, 2333CC, Leiden, The Netherlands
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Development and Regeneration, and Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Robert B Flint
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sebastiaan C Goulooze
- Leiden Experts On Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Pyry A J Välitalo
- School of Pharmacy, University of Eastern Finland, Yliopistonranta 1 C, 70210, Kuopio, Finland
- Finnish Medicines Agency, Hallituskatu 12-14, 70100, Kuopio, Finland
| | - Matthijs de Hoog
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Hussain Mulla
- Department of Pharmacy, University Hospitals of Leicester, Glenfield Hospital, Leicester, LE39QP, England
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University Boonshoft School of Medicine/Dayton Children's Hospital, One Children's Plaza, Dayton, OH, USA
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Elke H J Krekels
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, 2333CC, Leiden, The Netherlands
- Certara Inc, Princeton, NJ, USA
| | - Catherijne A J Knibbe
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, 2333CC, Leiden, The Netherlands
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Swantje Völler
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, 2333CC, Leiden, The Netherlands.
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.
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Alrahahleh D, Thoma Y, Van Daele R, Nguyen T, Halena S, Luig M, Stocker S, Kim HY, Alffenaar JW. Bayesian Vancomycin Model Selection for Therapeutic Drug Monitoring in Neonates. Clin Pharmacokinet 2024; 63:367-380. [PMID: 38416322 PMCID: PMC10954945 DOI: 10.1007/s40262-024-01353-8] [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: 01/31/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND AND OBJECTIVE Pharmacokinetic models can inform drug dosing of vancomycin in neonates to optimize therapy. However, the model selected needs to describe the intended population to provide appropriate dose recommendations. Our study aims to identify the population pharmacokinetic (PopPK) model(s) with the best performance to predict vancomycin exposure in neonates in our hospital. METHODS Relevant published PopPK models for vancomycin in neonates were selected based on demographics and vancomycin dosing strategy. The predictive performance of the models was evaluated in Tucuxi using a local cohort of 69 neonates. Mean absolute error (MAE), relative bias (rBias) and relative root mean square error (rRMSE) were used to quantify the accuracy and precision of the predictive performance of each model for three different approaches: a priori, a posteriori, and Bayesian forecasting for the next course of therapy based on the previous course predictions. A PopPK model was considered clinically acceptable if rBias was between ± 20 and 95% confidence intervals included zero. RESULTS A total of 25 PopPK models were identified and nine were considered suitable for further evaluation. The model of De Cock et al. 2014 was the only clinically acceptable model based on a priori [MAE 0.35 mg/L, rBias 0.8 % (95% confidence interval (CI) - 7.5, 9.1%), and rRMSE 8.9%], a posteriori [MAE 0.037 mg/L, rBias - 0.23% (95% CI - 1.3, 0.88%), and rRMSE 6.02%] and Bayesian forecasting for the next courses [MAE 0.89 mg/L, rBias 5.45% (95% CI - 8.2, 19.1%), and rRMSE 38.3%) approaches. CONCLUSIONS The De Cock model was selected based on a comprehensive approach of model selection to individualize vancomycin dosing in our neonates.
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Affiliation(s)
- Dua'a Alrahahleh
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Pharmacy Building (A15), Camperdown, NSW, 2006, Australia
- Westmead Hospital, Westmead, NSW, Australia
- The University Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Westmead, NSW, Australia
| | - Yann Thoma
- School of Engineering and Management Vaud, HES-SO University of Applied Sciences and Arts Western Switzerland, 1400, Yverdon-les-Bains, Switzerland
| | - Ruth Van Daele
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000, Leuven, Belgium
- Pharmacy Department, University Hospitals Leuven, 3000, Leuven, Belgium
| | - Thi Nguyen
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Pharmacy Building (A15), Camperdown, NSW, 2006, Australia
- Westmead Hospital, Westmead, NSW, Australia
- The University Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Westmead, NSW, Australia
| | - Stephanie Halena
- Department of Pharmacy, Westmead Hospital, NSW, Westmead, Australia
| | - Melissa Luig
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
| | - Sophie Stocker
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Pharmacy Building (A15), Camperdown, NSW, 2006, Australia
- Westmead Hospital, Westmead, NSW, Australia
- The University Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Westmead, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, Sydney, Australia
| | - Hannah Yejin Kim
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Pharmacy Building (A15), Camperdown, NSW, 2006, Australia
- The University Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Westmead, NSW, Australia
- Department of Pharmacy, Westmead Hospital, NSW, Westmead, Australia
| | - Jan-Willem Alffenaar
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Pharmacy Building (A15), Camperdown, NSW, 2006, Australia.
- Westmead Hospital, Westmead, NSW, Australia.
- The University Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Westmead, NSW, Australia.
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Regazzi M, Berardi A, Picone S, Tzialla C. Pharmacokinetic and Pharmacodynamic Considerations of Antibiotic Use in Neonates. Antibiotics (Basel) 2023; 12:1747. [PMID: 38136781 PMCID: PMC10740758 DOI: 10.3390/antibiotics12121747] [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: 11/13/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023] Open
Abstract
The selection of an appropriate dose of a given antibiotic for a neonate not only requires knowledge of the drug's basic pharmacokinetic (PK) and pharmacodynamic (PD) properties but also the profound effects that organ development might have on the volume of distribution and clearance, both of which may affect the PK/PD of a drug. Interest has grown in alternative antibiotic dosing strategies that are better aligned with the antibiotic's PK and PD properties. These strategies should be used in conjunction with minimum inhibitory concentration measurements and therapeutic drug monitoring to measure their potential success. They can also guide the clinician in tailoring the delivery of antibiotics to suit an individual patient's needs. Model-informed precision dosing, such as Bayesian forecasting dosing software (which incorporates PK/PD population models), may be utilized to optimize antibiotic exposure in neonatal populations. Consequently, optimizing the antibiotic dose and exposure in each newborn requires expertise in different fields. It drives the collaboration of physicians together with lab technicians and quantitative clinical pharmacologists.
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Affiliation(s)
- Mario Regazzi
- S.I.F.E.B, Italian Society of Pharmacokinetics and Biopharmaceutics, 27100 Pavia, Italy
| | - Alberto Berardi
- Neonatal Intensive Care Unit, University Hospital of Modena, 41124 Modena, Italy;
| | - Simonetta Picone
- Neonatology and Neonatal Intensive Care Unit, Policlinico Casilino, 00169 Rome, Italy;
| | - Chryssoula Tzialla
- Neonatal and Pediatric Unit, Ospedale Civile Voghera, ASST Pavia, 27100 Pavia, Italy;
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6
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Chung E, Seto W. Using population pharmacokinetics to optimize initial vancomycin dosing guidelines for neonates to treat sepsis caused by coagulase-negative staphylococcus. Pharmacotherapy 2023; 43:1262-1276. [PMID: 37574774 DOI: 10.1002/phar.2865] [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: 03/17/2023] [Revised: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Vancomycin dosing tailored for newborns is challenging due to the significant influence of maturation and organ function on pharmacokinetics. Population pharmacokinetic (popPK) models can be used to improve target attainment in neonates. OBJECTIVES The primary objective was to derive and evaluate a popPK model of intravenous vancomycin for neonates. Second, the predictive performance of this popPK model was compared with published popPK models. METHODS This is a retrospective cohort study of neonates admitted to the neonatal intensive care unit receiving intravenous vancomycin. A popPK model was derived with 70% of the dataset using a nonlinear mixed effects modeling method. The predictive performance of the current popPK model was validated and compared with 22 published popPK models using the remaining 30% of the dataset. Monte Carlo simulations (MCS) were performed to derive optimal dosing regimens to treat neonatal sepsis caused by coagulase-negative staphylococci (CoNS). RESULTS Among 655 vancomycin courses from 448 neonates, 78% of vancomycin trough concentrations were outside target range (10-15 mg/L) for central nervous system infections and 43% were outside target range (5-12 mg/L) for other infections using the institution's vancomycin dosing. A one-compartment model best described the observed data with a mean clearance of 0.11 ± 0.03 L/kg/h and volume of distribution (V) of 1.02 ± 0.08 L/kg. Body weight (WT), postmenstrual age (PMA), and serum creatinine (SCr) were significant covariates associated with clearance (p < 0.001) and body WT was a significant covariate associated with V (p = 0.009). Our study's popPK model has similar or better accuracy and precision than other published models. MCS-derived vancomycin doses from the validated model achieved >90% target attainment for a steady state through target range of 10-15 mg/L in the majority of PMA and SCr categories (78%) to treat CoNS sepsis. CONCLUSION A vancomycin dosing guideline derived from a validated popPK model in neonates with CoNS sepsis is recommended to improve target attainment.
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Affiliation(s)
- Erin Chung
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Winnie Seto
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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7
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Yoon S, Guk J, Lee SG, Chae D, Kim JH, Park K. Model-informed precision dosing in vancomycin treatment. Front Pharmacol 2023; 14:1252757. [PMID: 37876732 PMCID: PMC10593454 DOI: 10.3389/fphar.2023.1252757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/11/2023] [Indexed: 10/26/2023] Open
Abstract
Introduction: While vancomycin remains a widely prescribed antibiotic, it can cause ototoxicity and nephrotoxicity, both of which are concentration-associated. Overtreatment can occur when the treatment lasts for an unnecessarily long time. Using a model-informed precision dosing scheme, this study aims to develop a population pharmacokinetic (PK) and pharmacodynamic (PD) model for vancomycin to determine the optimal dosage regimen and treatment duration in order to avoid drug-induced toxicity. Methods: The data were obtained from electronic medical records of 542 patients, including 40 children, and were analyzed using NONMEM software. For PK, vancomycin concentrations were described with a two-compartment model incorporating allometry scaling. Results and discussion: This revealed that systemic clearance decreased with creatinine and blood urea nitrogen levels, history of diabetes and renal diseases, and further decreased in women. On the other hand, the central volume of distribution increased with age. For PD, C-reactive protein (CRP) plasma concentrations were described by transit compartments and were found to decrease with the presence of pneumonia. Simulations demonstrated that, given the model informed optimal doses, peak and trough concentrations as well as the area under the concentration-time curve remained within the therapeutic range, even at doses smaller than routine doses, for most patients. Additionally, CRP levels decreased more rapidly with the higher dose starting from 10 days after treatment initiation. The developed R Shiny application efficiently visualized the time courses of vancomycin and CRP concentrations, indicating its applicability in designing optimal treatment schemes simply based on visual inspection.
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Affiliation(s)
- Sukyong Yoon
- Department of Pharmacology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Brain Korea 21 Plus Project for Medical Science, Yonsei University, Seoul, Republic of Korea
| | - Jinju Guk
- Department of Pharmacology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Brain Korea 21 Plus Project for Medical Science, Yonsei University, Seoul, Republic of Korea
| | - Sang-Guk Lee
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dongwoo Chae
- Department of Pharmacology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Ho Kim
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyungsoo Park
- Department of Pharmacology, Yonsei University College of Medicine, Seoul, Republic of Korea
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Zhang L, Liu M, Qin W, Shi D, Mao J, Li Z. Modeling the protein binding non-linearity in population pharmacokinetic model of valproic acid in children with epilepsy: a systematic evaluation study. Front Pharmacol 2023; 14:1228641. [PMID: 37869748 PMCID: PMC10587682 DOI: 10.3389/fphar.2023.1228641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
Background: Several studies have investigated the population pharmacokinetics (popPK) of valproic acid (VPA) in children with epilepsy. However, the predictive performance of these models in the extrapolation to other clinical environments has not been studied. Hence, this study evaluated the predictive abilities of pediatric popPK models of VPA and identified the potential effects of protein binding modeling strategies. Methods: A dataset of 255 trough concentrations in 202 children with epilepsy was analyzed to assess the predictive performance of qualified models, following literature review. The evaluation of external predictive ability was conducted by prediction- and simulation-based diagnostics as well as Bayesian forecasting. Furthermore, five popPK models with different protein binding modeling strategies were developed to investigate the discrepancy among the one-binding site model, Langmuir equation, dose-dependent maximum effect model, linear non-saturable binding equation and the simple exponent model on model predictive ability. Results: Ten popPK models were identified in the literature. Co-medication, body weight, daily dose, and age were the four most commonly involved covariates influencing VPA clearance. The model proposed by Serrano et al. showed the best performance with a median prediction error (MDPE) of 1.40%, median absolute prediction error (MAPE) of 17.38%, and percentages of PE within 20% (F20, 55.69%) and 30% (F30, 76.47%). However, all models performed inadequately in terms of the simulation-based normalized prediction distribution error, indicating unsatisfactory normality. Bayesian forecasting enhanced predictive performance, as prior observations were available. More prior observations are needed for model predictability to reach a stable state. The linear non-saturable binding equation had a higher predictive value than other protein binding models. Conclusion: The predictive abilities of most popPK models of VPA in children with epilepsy were unsatisfactory. The linear non-saturable binding equation is more suitable for modeling non-linearity. Moreover, Bayesian forecasting with prior observations improved model fitness.
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Affiliation(s)
- Lina Zhang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Maochang Liu
- Department of Pharmacy, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Weiwei Qin
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Dandan Shi
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junjun Mao
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Zeyun Li
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Alsultan A, Al Munjem MF, Atiq KM, Aljehani ZK, Al Muqati H, Almohaizeie A, Ballal DA, Refaei TM, Al Jeraisy M, Assiri A, Abouelkheir M. Population pharmacokinetics of vancomycin in very low birth weight neonates. Front Pediatr 2023; 11:1093171. [PMID: 37063687 PMCID: PMC10101232 DOI: 10.3389/fped.2023.1093171] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/03/2023] [Indexed: 04/18/2023] Open
Abstract
Introduction Vancomycin dosing in very low birth weight (VLBW) neonates is challenging. Compared with the general neonatal population, VLBW neonates are less likely to achieve the vancomycin therapeutic targets. Current dosing recommendations are based on studies of the general neonatal population, as only a very limited number of studies have evaluated vancomycin pharmacokinetics in VLBW neonates. The main aim of this study was to develop a vancomycin population pharmacokinetic model to optimize vancomycin dosing in VLBW neonates. Methods This multicenter study was conducted at six major hospitals in Saudi Arabia. The study included VLBW neonates who received vancomycin and had at least one vancomycin serum trough concentration measurement at a steady state. We developed a pharmacokinetic model and performed Monte Carlo simulations to develop an optimized dosing regimen for VLBW infants. We evaluated two different targets: AUC0-24 of 400-600 or 400-800 µg. h/mL. We also estimated the probability of trough concentrations >15 and 20 µg/mL. Results In total, we included 236 neonates, 162 in the training dataset, and 74 in the validation dataset. A one-compartment model was used, and the distribution volume was significantly associated only with weight, whereas clearance was significantly associated with weight, postmenstrual age (PMA), and serum creatinine (Scr). Discussion We developed dosing regimens for VLBW neonates, considering the probability of achieving vancomycin therapeutic targets, as well as different toxicity thresholds. The dosing regimens were classified according to PMA and Scr. These dosing regimens can be used to optimize the initial dose of vancomycin in VLBW neonates.
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Affiliation(s)
- Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Correspondence: Abdullah Alsultan Manal Abouelkheir
| | | | | | - Zekra Kamel Aljehani
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Hessa Al Muqati
- Pharmacy Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abdullah Almohaizeie
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Dalia Ahmed Ballal
- Pharmaceutical Care Administration, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
| | - Tahani Makki Refaei
- Pharmaceutical Care Administration, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
| | - Majed Al Jeraisy
- Pharmacy Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdulmohsen Assiri
- Pharmaceutical Care Administration, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
| | - Manal Abouelkheir
- Department of Clinical Pharmacy, Faculty of Pharmacy, Misr International University, Cairo, Egypt
- Correspondence: Abdullah Alsultan Manal Abouelkheir
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10
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Hughes JH, Tong DMH, Faldasz JD, Frymoyer A, Keizer RJ. Evaluation of Neonatal and Paediatric Vancomycin Pharmacokinetic Models and the Impact of Maturation and Serum Creatinine Covariates in a Large Multicentre Data Set. Clin Pharmacokinet 2023; 62:67-76. [PMID: 36404388 PMCID: PMC9898357 DOI: 10.1007/s40262-022-01185-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Infants and neonates present a clinical challenge for dosing drugs with high interindividual variability due to these patients' rapid growth and the interplay between maturation and organ function. Model-informed precision dosing (MIPD), which can account for interindividual variability via patient characteristics and Bayesian forecasting, promises to improve individualized dosing strategies in this complex population. Here, we assess the predictive performance of published population pharmacokinetic models describing vancomycin in neonates and infants, and analyze the robustness of these models in the face of clinical uncertainty surrounding covariate values. METHODS The predictive precision and bias of nine pharmacokinetic models were compared in a large multi-site data set (N = 2061 patients, 5794 drug levels, 28 institutions) of patients aged 0-365 days. The robustness of model predictions to errors in serum creatinine measurements and gestational age was assessed by using recorded values or by replacing covariate values with 0.3, 0.5 or 0.8 mg/dL or with 40 weeks, respectively. RESULTS Of the nine models, two models (Dao and Jacqz-Aigrain) resulted in predicted concentrations within 2.5 mg/L or 15% of the measured values for at least 60% of population predictions. Within individual models, predictive performance often 2 differed in neonates (0-4 weeks) versus older infants (15-52 weeks). For preterm neonates, imputing gestational age as 40 weeks reduced the accuracy of model predictions. Measured values of serum creatinine improved model predictions compared to using imputed values even in neonates ≤1 week of age. CONCLUSIONS Several available pharmacokinetic models are suitable for MIPD in infants and neonates. Availability and accuracy of model covariates for patients will be important for guiding dose decision-making.
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Affiliation(s)
- Jasmine H Hughes
- InsightRX, 548 Market St. #88083, San Francisco, CA, 94104, USA.
| | | | | | - Adam Frymoyer
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Ron J Keizer
- InsightRX, 548 Market St. #88083, San Francisco, CA, 94104, USA
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11
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Samb A, De Kroon R, Dijkstra K, Van Den Brand M, Bos M, Van Den Dungen F, Veldkamp A, Wilhelm B, De Haan TR, Bijleveld YA, Tutu Van Furth M, Savelkoul P, Swart N, Mathot R, Van Weissenbruch M. Predicting treatment response to vancomycin using bacterial DNA load as a pharmacodynamic marker in premature and very low birth weight neonates: A population PKPD study. Front Pharmacol 2023; 14:1104482. [PMID: 36873984 PMCID: PMC9978179 DOI: 10.3389/fphar.2023.1104482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/18/2023] [Indexed: 02/18/2023] Open
Abstract
Background: While positive blood cultures are the gold standard for late-onset sepsis (LOS) diagnosis in premature and very low birth weight (VLBW) newborns, these results can take days, and early markers of possible treatment efficacy are lacking. The objective of the present study was to investigate whether the response to vancomycin could be quantified using bacterial DNA loads (BDLs) determined by real-time quantitative polymerase chain reaction (RT-qPCR). Methods: VLBW and premature neonates with suspected LOS were included in a prospective observational study. Serial blood samples were collected to measure BDL and vancomycin concentrations. BDLs were measured with RT-qPCR, whereas vancomycin concentrations were measured by LC-MS/MS. Population pharmacokinetic-pharmacodynamic modeling was performed with NONMEM. Results: Twenty-eight patients with LOS treated with vancomycin were included. A one-compartment model with post-menstrual age (PMA) and weight as covariates was used to describe the time PK profile of vancomycin concentrations. In 16 of these patients, time profiles of BDL could be described with a pharmacodynamic turnover model. The relationship between vancomycin concentration and first-order BDL elimination was described with a linear-effect model. Slope S increased with increasing PMA. In 12 patients, no decrease in BDL over time was observed, which corresponded with clinical non-response. Discussion: BDLs determined through RT-qPCR were adequately described with the developed population PKPD model, and treatment response to vancomycin using BDL in LOS can be assessed as early as 8 h after treatment initiation.
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Affiliation(s)
- Amadou Samb
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | | | - Koos Dijkstra
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Marre Van Den Brand
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, location VU Medical Center, Amsterdam, Netherlands
| | - Martine Bos
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, location VU Medical Center, Amsterdam, Netherlands.,InBiome BV, Amsterdam, Netherlands
| | | | - Agnes Veldkamp
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Bram Wilhelm
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Yuma A Bijleveld
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Marceline Tutu Van Furth
- Department of Pediatric Infectious Diseases and Immunology, Emma Children's Hospital, Amsterdam Institute for Infection and Immunity, Amsterdam, Netherlands
| | - Paul Savelkoul
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, location VU Medical Center, Amsterdam, Netherlands.,Department of Medical Microbiology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Noortje Swart
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands.,Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Ron Mathot
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Mirjam Van Weissenbruch
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
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12
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Aljutayli A, Thirion DJ, Nekka F. Critical assessment of the revised guidelines for vancomycin therapeutic drug monitoring. Biomed Pharmacother 2022; 155:113777. [DOI: 10.1016/j.biopha.2022.113777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/02/2022] Open
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13
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Simeoli R, Cairoli S, Decembrino N, Campi F, Dionisi Vici C, Corona A, Goffredo BM. Use of Antibiotics in Preterm Newborns. Antibiotics (Basel) 2022; 11:antibiotics11091142. [PMID: 36139921 PMCID: PMC9495226 DOI: 10.3390/antibiotics11091142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 11/16/2022] Open
Abstract
Due to complex maturational and physiological changes that characterize neonates and affect their response to pharmacological treatments, neonatal pharmacology is different from children and adults and deserves particular attention. Although preterms are usually considered part of the neonatal population, they have physiological and pharmacological hallmarks different from full-terms and, therefore, need specific considerations. Antibiotics are widely used among preterms. In fact, during their stay in neonatal intensive care units (NICUs), invasive procedures, including central catheters for parental nutrition and ventilators for respiratory support, are often sources of microbes and require antimicrobial treatments. Unfortunately, the majority of drugs administered to neonates are off-label due to the lack of clinical studies conducted on this special population. In fact, physiological and ethical concerns represent a huge limit in performing pharmacokinetic (PK) studies on these subjects, since they limit the number and volume of blood sampling. Therapeutic drug monitoring (TDM) is a useful tool that allows dose adjustments aiming to fit plasma concentrations within the therapeutic range and to reach specific drug target attainment. In this review of the last ten years’ literature, we performed Pubmed research aiming to summarize the PK aspects for the most used antibiotics in preterms.
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Affiliation(s)
- Raffaele Simeoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Sara Cairoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Nunzia Decembrino
- Neonatal Intensive Care Unit, University Hospital “Policlinico-San Marco” Catania, Integrated Department for Maternal and Child’s Health Protection, 95100 Catania, Italy
| | - Francesca Campi
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Carlo Dionisi Vici
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Alberto Corona
- ICU and Accident & Emergency Department, ASST Valcamonica, 25043 Breno, Italy
| | - Bianca Maria Goffredo
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
- Correspondence: ; Tel.: +39-0668592174; Fax: + 39-0668593009
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14
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Role of fluid status markers as risk factors for suboptimal vancomycin concentration during continuous infusion in neonates: an observational study. Eur J Pediatr 2022; 181:2935-2942. [PMID: 35581390 DOI: 10.1007/s00431-022-04500-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 05/04/2022] [Accepted: 05/06/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED Vancomycin is widely used in neonatal sepsis but proportion of newborn reaching recommended concentration is variable. Fluid status impact on vancomycin level remains understudied. We aimed to study fluid factors impacting vancomycin concentration at 24 h of treatment. We performed a prospective and retrospective observational monocentric study of NICU patients requiring a vancomycin treatment. We used a continuous infusion protocol, with age-appropriate loading and maintenance doses. Vancomycin target serum concentration after 24 h (C24h) was above 20 mg/L. Demographic, infections, and organ failure variables were analyzed as potential predictors of C24h. Over the study period, 70 infective episodes in 52 patients were included. At treatment initiation, the median post-natal age was 12.5 days (IQR 7-23), post menstrual age 30 weeks (IQR 28-35), and median weight 1140 g (IQR 835-1722). Germs isolated were mainly gram-positive with 73.5% being coagulase-negative Staphylococci. Median C24h was 18.7 mg/L (IQR 15.4-22.4). Overall, 41 (58.6%) treatments had a C24h < 20 mg/L. After multivariate analysis, higher creatinine level (OR 1.03 (95% CI 1.002-1.06)) was associated with C24h ≥ 20 mg/L; weight gain the day before infection (OR 0.21 (95% CI 0.05-0.79)) and positive biomarkers of inflammation (OR 0.22 (0.05-0.94)) were associated with C24h < 20 mg/L. CONCLUSION Vancomycin C24h was underdosed in 60% of patients and factors linked to changes in vancomycin pharmacokinetic such as volume of distribution and clearance, linked to creatinine level, inflammation, or weight gain, were identified. WHAT IS KNOWN • Adjustment of vancomycin regimen remains difficult due to inter- and intra-individual variability of vancomycin pharmacokinetics. • Impact of fluid status on vancomycin concentration in critically ill neonates is incompletely studied. WHAT IS NEW • Proportion of patients with adequate vancomycin concentration using a target adapted to nosocomial gram-positive bacteria MIC is low. • We confirmed the role of creatinine level and report two new factors associated with low vancomycin concentration: presence of systemic inflammation and weight gain.
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15
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Hui KHM, Lui CYG, Wu KLA, Chen J, Cheung YT, Lam TNT. Multi-center prospective population pharmacokinetic study and the performance of web-based individual dose optimization application of intravenous vancomycin for adults in Hong Kong: A study protocol. PLoS One 2022; 17:e0267894. [PMID: 35511796 PMCID: PMC9070875 DOI: 10.1371/journal.pone.0267894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 04/12/2022] [Indexed: 11/18/2022] Open
Abstract
A recent consensus guideline recommends migrating the therapeutic drug monitoring practice for intravenous vancomycin for the treatment of methicillin-resistant Staphylococcus aureus infection from the traditional trough-based approach to the Bayesian approach based on area under curve to improve clinical outcomes. To support the implementation of the new strategy for hospitals under Hospital Authority, Hong Kong, this study is being proposed to (1) estimate and validate a population pharmacokinetic model of intravenous vancomycin for local adults, (2) develop a web-based individual dose optimization application for clinical use, and (3) evaluate the performance of the application by comparing the treatment outcomes and clinical satisfaction against the traditional approach. 300 adult subjects prescribed with intravenous vancomycin and not on renal replacement therapy will be recruited for population pharmacokinetic model development and validation. Sex, age, body weight, serum creatinine level, intravenous vancomycin dosing records, serum vancomycin concentrations etc. will be collected from several electronic health record systems maintained by Hospital Authority. Parameter estimation will be performed using non-linear mixed-effect modeling techniques. The web-based individual dose optimization application is based on a previously reported application and is built using R and the package shiny. Data from another 50 subjects will be collected during the last three months of the study period and treated as informed by the developed application and compared against historical control for clinical outcomes. Since the study will incur extra blood-taking procedures from patients, informed consent is required. Other than that, recruited subjects should receive medical treatments as usual. Identifiable patient data will be available only to site investigators and clinicians in each hospital. The study protocol and informed consent forms have been approved by the Joint Chinese University of Hong Kong–New Territories East Cluster Clinical Research Ethics Committee (reference number: NTEC-2021-0215) and registered at the Chinese Clinical Trial Registry (registration number: ChiCTR2100048714).
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Affiliation(s)
- Ka Ho Matthew Hui
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Chung Yan Grace Lui
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Ka Lun Alan Wu
- Department of Clinical Pathology, Pamela Youde Nethersole Eastern Hospital, Hong Kong East Cluster, Hospital Authority of Hong Kong, Hong Kong, China
| | - Jason Chen
- Department of Pharmacy, Ruttonjee and Tang Shiu Kin Hospitals, Hong Kong East Cluster, Hospital Authority, Hong Kong, China
| | - Yin Ting Cheung
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
- * E-mail: (TNTL); (YTC)
| | - Tai Ning Teddy Lam
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
- * E-mail: (TNTL); (YTC)
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16
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Chuphan C, Sukarnjanaset W, Puthanakit T, Wattanavijitkul T. Population Pharmacokinetics and Pharmacodynamics of Vancomycin in Pediatric Patients With Various Degrees of Renal Function. J Pediatr Pharmacol Ther 2022; 27:419-427. [DOI: 10.5863/1551-6776-27.5.419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/18/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
Although vancomycin dosage recommendations in the pediatric setting for methicillin-resistant Staphylococcus aureus (MRSA) infection indicate that ≥60 mg/kg/day is correlated to a desired area under the vancomycin concentration time curve from 0 to 24 hours to minimum inhibitory concentration ratio (AUC0–24 hr/MIC) ≥400, for some patients this dosage is inadequate or relates to toxicity. This study purposed to explore vancomycin dosing for pediatrics with various degrees of renal function.
METHODS
Routine monitoring data were retrospectively collected from patients, aged 1 month to 18 years. Population pharmacokinetic analysis was performed by using non-linear mixed-effect model with NONMEM software, and Monte Carlo simulation was conducted by using Crystal Ball software.
RESULTS
Two hundred twelve patients with 348 vancomycin serum concentrations were included. Median age was 3.5 years (IQR, 0.9–10.9), median weight was 14.0 kg (IQR, 7.2–30.4), with baseline estimated glomerular filtration rate (eGFR) ranging from 15.5 to 359.3 mL/min/1.73 m2. A 1-compartment model with first-order elimination sufficiently described vancomycin PK. The dosing targeting AUC0–24hr/MIC ≥400 and AUC0–24hr <800 mg•h/L for pediatric patients with eGFRs of 15 to 29, 30 to 59, 60 to 89, 90 to 129, and 130 to 160 mL/min/1.73 m2 was 12.5, 25, 40, 60, and 70 mg/kg/day, respectively. All vancomycin dosing obtained >85% of the cumulative fraction of response across the MIC distribution of MRSA.
CONCLUSIONS
Vancomycin dosing of 12.5, 25, 40, 60, and 70 mg/kg/day is suggested for pediatric patients with eGFRs of 15 to 29, 30 to 59, 60 to 89, 90 to 129, and 130 to 160 mL/min/1.73 m2, respectively.
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Affiliation(s)
- Chanika Chuphan
- Department of Pharmacy Practice (CC, TW), Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | | | - Thanyawee Puthanakit
- Department of Pediatrics (TP), Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thitima Wattanavijitkul
- Department of Pharmacy Practice (CC, TW), Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
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17
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Han J, Sauberan J, Tran MT, Adler-Shohet FC, Michalik DE, Tien TH, Tran L, DO DH, Bradley JS, Le J. Implementation of Vancomycin Therapeutic Monitoring Guidelines: Focus on Bayesian Estimation Tools in Neonatal and Pediatric Patients. Ther Drug Monit 2022; 44:241-252. [PMID: 34145165 DOI: 10.1097/ftd.0000000000000910] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The 2020 consensus guidelines for vancomycin therapeutic monitoring recommend using Bayesian estimation targeting the ratio of the area under the curve over 24 hours to minimum inhibitory concentration as an optimal approach to individualize therapy in pediatric patients. To support institutional guideline implementation in children, the objective of this study was to comprehensively assess and compare published population-based pharmacokinetic (PK) vancomycin models and available Bayesian estimation tools, specific to neonatal and pediatric patients. METHODS PubMed and Embase databases were searched from January 1994 to December 2020 for studies in which a vancomycin population PK model was developed to determine clearance and volume of distribution in neonatal and pediatric populations. Available Bayesian software programs were identified and assessed from published articles, software program websites, and direct communication with the software company. In the present review, 14 neonatal and 20 pediatric models were included. Six programs (Adult and Pediatric Kinetics, BestDose, DoseMeRx, InsightRx, MwPharm++, and PrecisePK) were evaluated. RESULTS Among neonatal models, Frymoyer et al and Capparelli et al used the largest PK samples to generate their models, which were externally validated. Among the pediatric models, Le et al used the largest sample size, with multiple external validations. Of the Bayesian programs, DoseMeRx, InsightRx, and PrecisePK used clinically validated neonatal and pediatric models. CONCLUSIONS To optimize vancomycin use in neonatal and pediatric patients, clinicians should focus on selecting a model that best fits their patient population and use Bayesian estimation tools for therapeutic area under the -curve-targeted dosing and monitoring.
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Affiliation(s)
- Jihye Han
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, Louisiana Jolla
| | - Jason Sauberan
- Neonatal Research Institute, SHARP Mary Birch Hospital for Women and Newborns, San Diego
| | | | | | - David E Michalik
- MemorialCare Miller Children's and Women's Hospital Long Beach, Long Beach, California
| | | | - Lan Tran
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, Louisiana Jolla
| | | | - John S Bradley
- Division of Infectious Diseases, University of California at San Diego, Louisiana Jolla; and
- Rady Children's Hospital-San Diego, San Diego, California
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, Louisiana Jolla
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18
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Munir MM, Rasheed H, Khokhar MI, Khan RR, Saeed HA, Abbas M, Ali M, Bilal R, Nawaz HA, Khan AM, Qamar S, Anjum SM, Usman M. Dose Tailoring of Vancomycin Through Population Pharmacokinetic Modeling Among Surgical Patients in Pakistan. Front Pharmacol 2021; 12:721819. [PMID: 34858169 PMCID: PMC8632000 DOI: 10.3389/fphar.2021.721819] [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: 06/07/2021] [Accepted: 10/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Vancomycin is a narrow therapeutic agent, and it is necessary to optimize the dose to achieve safe therapeutic outcomes. The purpose of this study was to identify the significant covariates for vancomycin clearance and to optimize the dose among surgical patients in Pakistan. Methods: Plasma concentration data of 176 samples collected from 58 surgical patients treated with vancomycin were used in this study. A population pharmacokinetic model was developed on NONMEM® using plasma concentration-time data. The effect of all available covariates was evaluated on the pharmacokinetic parameters of vancomycin by stepwise covariate modeling. The final model was evaluated using bootstrap, goodness-of-fit plots, and visual predictive checks. Results: The pharmacokinetics of vancomycin followed a one-compartment model with first-order elimination. The vancomycin clearance (CL) and volume of distribution (Vd) were 2.45 L/h and 22.6 l, respectively. Vancomycin CL was influenced by creatinine clearance (CRCL) and body weight of the patients; however, no covariate was significant for its effect on the volume of distribution. Dose tailoring was performed by simulating dosage regimens at a steady state based on the CRCL of the patients. The tailored doses were 400, 600, 800, and 1,000 mg for patients with a CRCL of 20, 60, 100, and 140 ml/min, respectively. Conclusion: Vancomycin CL is influenced by CRCL and body weight of the patient. This model can be helpful for the dose tailoring of vancomycin based on renal status in Pakistani patients.
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Affiliation(s)
- Muhammad Muaaz Munir
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Huma Rasheed
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Muhammad Imran Khokhar
- Ameer-ud-Din Medical College, Post-Graduate Medical Institute (PGMI), Lahore General Hospital, Lahore, Pakistan
| | - Rizwan Rasul Khan
- Department of Medicine, Aziz Fatima Medical and Dental College, Faisalabad, Pakistan
| | | | - Mateen Abbas
- Quality Operation Laboratory, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Mohsin Ali
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Govt College University, Faisalabad, Pakistan
| | - Rabiea Bilal
- CMH Lahore Medical College and IOD, NUMS, Lahore, Pakistan
| | - Hafiz Awais Nawaz
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Abdul Muqeet Khan
- Quality Operation Laboratory, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Shaista Qamar
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Syed Muneeb Anjum
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Muhammad Usman
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
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19
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Barrett JS, Barrett RF, Vinks AA. Status Toward the Implementation of Precision Dosing in Children. J Clin Pharmacol 2021; 61 Suppl 1:S36-S51. [PMID: 34185896 DOI: 10.1002/jcph.1830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/04/2021] [Indexed: 01/19/2023]
Abstract
Precision dosing is progressing beyond the conceptual and proof-of-concept stages toward implementation. As the availability of dosing algorithms, tools, and platforms increases, so do the investment in technology services and actual implementation of clinical services offering these solutions to patients. Nowhere is this needed more than in pediatric populations, which are still reliant on adult drug development and bridging strategies to support dosing, often in the absence of actual dose-finding studies in the target pediatric population. Still, there is more work to be done to ensure that proper governance of these services is maintained, and that sustainability of these early implementations is guided by new science as it evolves and meaningful outcome data to confirm that such services deliver on both clinical and economic return on investment. In addition, the field should ensure that all approaches beyond a therapeutic drug monitoring-driven, pharmacokinetic-centric approach should be considered as the tools and services evolve, especially when pediatric-specific pharmacokinetic/pharmacodyamic and pharmacogenetic data are available and shown to be useful to guide dosing. This review evaluates current pediatric precision dosing efforts, highlighting their utility, longevity, and sustainability and assesses the current process for implementing such approaches examining current barriers that stand in the way of broader implementation and the stakeholders that must engage to ensure its ultimate success.
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Affiliation(s)
- Jeffrey S Barrett
- Quantitative Medicine, Critical Path Institute, Tucson, Arizona, USA
| | - Ryan F Barrett
- College of Chemical and Biological Engineering, Drexel University, Philadelphia, Pennsylvania, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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20
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Li Z, Li H, Wang C, Jiao Z, Xu F, Sun H. Establishment of a population pharmacokinetics model of vancomycin in 94 infants with septicemia and its application in individualized therapy. BMC Pharmacol Toxicol 2021; 22:26. [PMID: 33947475 PMCID: PMC8097779 DOI: 10.1186/s40360-021-00489-8] [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: 08/05/2020] [Accepted: 04/15/2021] [Indexed: 11/16/2022] Open
Abstract
Background We aim to develop a population pharmacokinetics (PopPK) model of vancomycin for the treatment of septicemia in infants younger than one year. Factors influence of the PK was investigated to optimize vancomycin dosing regimen. Methods The nonlinear mixed effects modelling software (NONMEM) was used to develop the PopPK model of vancomycin. The stability and predictive ability of the final model were assessed by using normalized prediction distribution errors (NPDE) and bootstrap methods. The final model was subjected to Monte Carlo simulation in order to determine the optimal dose. Results A total of 205 trough and peak concentrations in 94 infants (0–1 year of age) with septicemia were analyzed. The interindividual variability of the PK parameter was described by the exponential model. Residual error was better described by the proportional model than the mixed proportional and addition models. Serum creatinine concentration and body weight are the major factors that affect the PK parameters of vancomycin. The clearance was shown to be higher when ceftriaxone was co-treated. More than two model evaluation methods showed better stability than the base model, with superior predictive performance, which can develop individualized dosing regimens for clinical reference. Through prediction of final model, the trough concentration was more likely < 5 mg/L when a routine dose of 10 mg/kg is administered every 6 h to 3–9-month-old infants. Therefore, the dose should be increased in the treatment of infant septicemia. Conclusions The stable and effective PopPK model of vancomycin in Chinese infants with septicemia was established. This model has satisfactory predictive ability for clinically individualized dosing regimens in this vulnerable population.
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Affiliation(s)
- Zhiling Li
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, No. 355 Luding Road, Putuo District, Shanghai, 200062, China
| | - Hongjing Li
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, No. 355 Luding Road, Putuo District, Shanghai, 200062, China
| | - Chenyu Wang
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.
| | - Feng Xu
- Fengxian Hospital, Southern Medical University, Shanghai, China.
| | - Huajun Sun
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, No. 355 Luding Road, Putuo District, Shanghai, 200062, China.
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Hui KHM, Lam HS, Chow CHT, Li YSJ, Leung PHT, Chan LYB, Lee CP, Ewig CLY, Cheung YT, Lam TNT. Personalized Dosing of Intravenous Vancomycin Among Critically Ill Neonates in Hong Kong: Harnessing Electronic Health Records to Develop a Web-Based Dosing Interface (Preprint). JMIR Med Inform 2021; 10:e29458. [PMID: 35099393 PMCID: PMC8844994 DOI: 10.2196/29458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/06/2021] [Accepted: 01/02/2022] [Indexed: 11/15/2022] Open
Abstract
Background Intravenous (IV) vancomycin is used in the treatment of severe infection in neonates. However, its efficacy is compromised by elevated risks of acute kidney injury. The risk is even higher among neonates admitted to the neonatal intensive care unit (NICU), in whom the pharmacokinetics of vancomycin vary widely. Therapeutic drug monitoring is an integral part of vancomycin treatment to balance efficacy against toxicity. It involves individual dose adjustments based on the observed serum vancomycin concentration (VCs). However, the existing trough-based approach shows poor evidence for clinical benefits. The updated clinical practice guideline recommends population pharmacokinetic (popPK) model–based approaches, targeting area under curve, preferably through the Bayesian approach. Since Bayesian methods cannot be performed manually and require specialized computer programs, there is a need to provide clinicians with a user-friendly interface to facilitate accurate personalized dosing recommendations for vancomycin in critically ill neonates. Objective We used medical data from electronic health records (EHRs) to develop a popPK model and subsequently build a web-based interface to perform model-based individual dose optimization of IV vancomycin for NICU patients in local medical institutions. Methods Medical data of subjects prescribed IV vancomycin in the NICUs of Prince of Wales Hospital and Queen Elizabeth Hospital in Hong Kong were extracted from EHRs, namely the Clinical Information System, In-Patient Medication Order Entry, and electronic Patient Record. Patient demographics, such as body weight and postmenstrual age (PMA), serum creatinine (SCr), vancomycin administration records, and VCs were collected. The popPK model employed a 2-compartment infusion model. Various covariate models were tested against body weight, PMA, and SCr, and were evaluated for the best goodness of fit. A previously published web-based dosing interface was adapted to develop the interface in this study. Results The final data set included EHR data extracted from 207 subjects, with a total of 689 VCs measurements. The final model chosen explained 82% of the variability in vancomycin clearance. All parameter estimates were within the bootstrapping CIs. Predictive plots, residual plots, and visual predictive checks demonstrated good model predictability. Model approximations showed that the model-based Bayesian approach consistently promoted a probability of target attainment (PTA) above 75% for all subjects, while only half of the subjects could achieve a PTA over 50% with the trough-based approach. The dosing interface was developed with the capability to optimize individual doses with the model-based empirical or Bayesian approach. Conclusions Using EHRs, a satisfactory popPK model was verified and adopted to develop a web-based individual dose optimization interface. The interface is expected to improve treatment outcomes of IV vancomycin for severe infections among critically ill neonates. This study provides the foundation for a cohort study to demonstrate the utility of the new approach compared with previous dosing methods.
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Affiliation(s)
- Ka Ho Matthew Hui
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Hugh Simon Lam
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Cheuk Hin Twinny Chow
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yuen Shun Janice Li
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Pok Him Tom Leung
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Long Yin Brian Chan
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Chui Ping Lee
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
- Department of Pharmacy, Prince of Wales Hospital, Hospital Authority, Hong Kong, Hong Kong
| | - Celeste Lom Ying Ewig
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
- Department of Pharmacy, Prince of Wales Hospital, Hospital Authority, Hong Kong, Hong Kong
| | - Yin Ting Cheung
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Tai Ning Teddy Lam
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
- Department of Pharmacy, Prince of Wales Hospital, Hospital Authority, Hong Kong, Hong Kong
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22
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Lee SM, Yang S, Kang S, Chang MJ. Population pharmacokinetics and dose optimization of vancomycin in neonates. Sci Rep 2021; 11:6168. [PMID: 33731764 PMCID: PMC7969932 DOI: 10.1038/s41598-021-85529-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 02/26/2021] [Indexed: 01/12/2023] Open
Abstract
The pharmacokinetics of vancomycin vary among neonates, and we aimed to conduct population pharmacokinetic analysis to determine the optimal dosage of vancomycin in Korean neonates. From a retrospective chart review, neonates treated with vancomycin from 2008 to 2017 in a neonatal intensive care unit (NICU) were included. Vancomycin concentrations were collected based on therapeutic drug monitoring, and other patient characteristics were gathered through electronic medical records. We applied nonlinear mixed-effect modeling to build the population pharmacokinetic model. One- and two-compartment models with first-order elimination were evaluated as potential structural pharmacokinetic models. Allometric and isometric scaling was applied to standardize pharmacokinetic parameters for clearance and volume of distribution, respectively, using fixed powers (0.75 and 1, respectively, for clearance and volume). The predictive performance of the final model was developed, and dosing strategies were explored using Monte Carlo simulations with AUC0–24 targets 400–600. The patient cohort included 207 neonates, and 900 vancomycin concentrations were analyzed. Only 37.4% of the analyzed concentrations were within trough concentrations 5–15 µg/mL. A one-compartment model with first-order elimination best described the vancomycin pharmacokinetics in neonates. Postmenstrual age (PMA) and creatinine clearance (CLcr) affected the clearance of vancomycin, and model evaluation confirmed the robustness of the final model. Population pharmacokinetic modeling and dose optimization of vancomycin in Korean neonates showed that vancomycin clearance was related to PMA and CLcr, as well as body weight. A higher dosage regimen than the typical recommendation is suggested.
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Affiliation(s)
- Soon Min Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Seungwon Yang
- Department of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, Republic of Korea
| | - Soyoung Kang
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Veritas Hall D #214, Yonsei University International Campus, Songdogwahak-ro 85, Yeonsu-gu, Incheon, Korea
| | - Min Jung Chang
- Department of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, Republic of Korea. .,Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Veritas Hall D #214, Yonsei University International Campus, Songdogwahak-ro 85, Yeonsu-gu, Incheon, Korea.
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23
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Tang Z, Guan J, Li J, Yu Y, Qian M, Cao J, Shuai W, Jiao Z. Determination of vancomycin exposure target and individualised dosing recommendations for neonates: model-informed precision dosing. Int J Antimicrob Agents 2021; 57:106300. [PMID: 33567334 DOI: 10.1016/j.ijantimicag.2021.106300] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/18/2021] [Accepted: 01/30/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Few studies incorporating population pharmacokinetic/pharmacodynamic (Pop-PK/PD) modelling have been conducted to quantify the exposure target of vancomycin in neonates. A retrospective observational cohort study was undertaken in neonates to determine this target and dosing recommendations (chictr.org.cn, ChiCTR1900027919). METHODS A Pop-PK model was developed to estimate PK parameters. Causalities between acute kidney injury (AKI) occurrence and vancomycin use were verified using Naranjo criteria. Thresholds of vancomycin exposure in predicting AKI or efficacy were identified via classification and regression tree analysis. Associations between exposure thresholds and clinical outcomes, including AKI and efficacy, were analysed by logistic regression. Dosing recommendations were designed using Monte Carlo simulations based on the optimised exposure target. RESULTS Pop-PK modelling included 182 neonates with 411 observations. On covariate analysis, neonatal physiological maturation, renal function and concomitant use of vasoactive agents (VAS) significantly affected vancomycin PK. Seven cases of vancomycin-induced AKI were detected. Area under the concentration-time curve from 0-24 hours (AUC0-24) ≥ 485 mg•h/L was an independent risk factor for AKI after adjusting for VAS co-administration. The clinical efficacy of vancomycin was analysed in 42 patients with blood culture-proven staphylococcal sepsis. AUC0-24 to minimum inhibitory concentration (AUC0-24/MIC) ≥ 234 was the only significant predictor of clinical effectiveness. Monte Carlo simulations indicated that regimens in Neonatal Formulary 7 and Red Book (2018) were unsuitable for all neonates. CONCLUSION An AUC0-24 of 240-480 (assuming MIC = 1 mg/L) is a recommended exposure target of vancomycin in neonates. Model-informed dosing regimens are valuable in clinical practice.
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Affiliation(s)
- Zhe Tang
- Department of Pharmacy, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Jing Guan
- Department of Pharmacy, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Jingjing Li
- Department of Pharmacy, Suzhou Municipal Hospital, Suzhou, China
| | - Yanxia Yu
- Department of Pharmacy, Suzhou Municipal Hospital, Suzhou, China
| | - Miao Qian
- Department of Neonatology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Jing Cao
- Department of Pharmacy, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Weiwei Shuai
- Department of Pharmacy, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.
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24
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Jacqz-Aigrain E, Leroux S, Thomson AH, Allegaert K, Capparelli EV, Biran V, Simon N, Meibohm B, Lo YL, Marques R, Peris JE, Lutsar I, Saito J, Nakamura H, van den Anker JN, Sharland M, Zhao W. Population pharmacokinetic meta-analysis of individual data to design the first randomized efficacy trial of vancomycin in neonates and young infants. J Antimicrob Chemother 2020; 74:2128-2138. [PMID: 31049551 DOI: 10.1093/jac/dkz158] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/26/2019] [Accepted: 03/16/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES In the absence of consensus, the present meta-analysis was performed to determine an optimal dosing regimen of vancomycin for neonates. METHODS A 'meta-model' with 4894 concentrations from 1631 neonates was built using NONMEM, and Monte Carlo simulations were performed to design an optimal intermittent infusion, aiming to reach a target AUC0-24 of 400 mg·h/L at steady-state in at least 80% of neonates. RESULTS A two-compartment model best fitted the data. Current weight, postmenstrual age (PMA) and serum creatinine were the significant covariates for CL. After model validation, simulations showed that a loading dose (25 mg/kg) and a maintenance dose (15 mg/kg q12h if <35 weeks PMA and 15 mg/kg q8h if ≥35 weeks PMA) achieved the AUC0-24 target earlier than a standard 'Blue Book' dosage regimen in >89% of the treated patients. CONCLUSIONS The results of a population meta-analysis of vancomycin data have been used to develop a new dosing regimen for neonatal use and to assist in the design of the model-based, multinational European trial, NeoVanc.
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Affiliation(s)
- Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France.,Clinical Investigation Center CIC1426, Hôpital Robert Debré, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Stéphanie Leroux
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France.,Clinical Investigation Center CIC1426, Hôpital Robert Debré, Paris, France.,Division of Neonatology, Department of Child and Adolescent Medicine, CHU de Rennes, Rennes, France
| | - Alison H Thomson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK.,Pharmacy Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Edmund V Capparelli
- Pediatric Pharmacology and Drug Discovery, University of California, San Diego, CA, USA
| | - Valérie Biran
- Neonatal Intensive Care Unit, Hôpital Robert Debré, Paris, France
| | - Nicolas Simon
- Department of Pharmacology, Hôpital de la Timone, APHM, Université de la Méditerranée, Marseille, France.,Service de Pharmacologie Clinique, Hôpital Sainte marguerite, CAP-TV, 13274 Marseille, France.,Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France
| | - Bernd Meibohm
- Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yoke-Lin Lo
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,School of Pharmacy, International Medical University, Kuala Lumpur, Malaysia
| | - Remedios Marques
- Department of Pharmacy Services, La Fe Hospital, Valencia, Spain
| | - José-Esteban Peris
- Department of Pharmacy and Pharmaceutical Technology, University of Valencia, Valencia, Spain
| | - Irja Lutsar
- Institute of Medical Microbiology, University of Tartu, Tartu, Estonia
| | - Jumpei Saito
- Department of Pharmacy, National Children's Hospital National Center for Child Health and Development, Tokyo, Japan
| | - Hidefumi Nakamura
- Department of Development Strategy, Center for Clinical Research and Development, National Center for Child Health and Development, Tokyo, Japan
| | - Johannes N van den Anker
- Pharmacy Department, Glasgow Royal Infirmary, Glasgow, UK.,Division of Clinical Pharmacology, Children's National Medical Center, Washington, DC, USA.,Departments of Pediatrics, Pharmacology & Physiology, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA.,Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Basel, Switzerland
| | - Mike Sharland
- Paediatric Infectious Disease Unit, St George's Hospital, London, UK
| | - Wei Zhao
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France.,Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
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25
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Salem F, Johnson TN, Hodgkinson ABJ, Ogungbenro K, Rostami‐Hodjegan A. Does "Birth" as an Event Impact Maturation Trajectory of Renal Clearance via Glomerular Filtration? Reexamining Data in Preterm and Full-Term Neonates by Avoiding the Creatinine Bias. J Clin Pharmacol 2020; 61:159-171. [PMID: 32885464 PMCID: PMC7818478 DOI: 10.1002/jcph.1725] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/30/2020] [Indexed: 12/12/2022]
Abstract
Glomerular filtration rate (GFR) is an important measure of renal function. Various models for its maturation have recently been compared; however, these have used markers, which are subject to different renal elimination processes. Inulin clearance data (a purer probe of GFR) collected from the literature were used to determine age‐related changes in GFR aspects of renal drug excretion in pediatrics. An ontogeny model was derived using a best‐fit model with various combinations of covariates such as postnatal age, gestational age at birth, and body weight. The model was applied to the prediction of systemic clearance of amikacin, gentamicin, vancomycin, and gadobutrol. During neonatal life, GFR increased as a function of both gestational age at birth and postnatal age, hence implying an impact of birth and a discrepancy in GFR for neonates with the same postmenstrual age depending on gestational age at birth (ie, neonates who were outside the womb longer had higher GFR, on average). The difference in GFR between pre‐term and full‐term neonates with the same postmenstrual age was negligible from beyond 1.25 years. Considering both postnatal age and gestational age at birth in GFR ontogeny models is important because postmenstrual age alone ignores the impact of birth. Most GFR models use covariates of body size in addition to age. Therefore, prediction from these models will also depend on the change in anthropometric characteristics with age. The latter may not be similar in various ethnic groups, and this makes the head‐to‐head comparison of models very challenging.
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Affiliation(s)
| | | | | | - Kayode Ogungbenro
- Centre for Applied Pharmacokinetic ResearchDivision of Pharmacy and OptometrySchool of Health SciencesFaculty of BiologyMedicine and HealthManchester Academic Health Science CentreUniversity of ManchesterManchesterUK
| | - Amin Rostami‐Hodjegan
- Certara UK Ltd, Simcyp DivisionSheffieldUK
- Centre for Applied Pharmacokinetic ResearchDivision of Pharmacy and OptometrySchool of Health SciencesFaculty of BiologyMedicine and HealthManchester Academic Health Science CentreUniversity of ManchesterManchesterUK
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26
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Hartman SJF, Orriëns LB, Zwaag SM, Poel T, de Hoop M, de Wildt SN. External Validation of Model-Based Dosing Guidelines for Vancomycin, Gentamicin, and Tobramycin in Critically Ill Neonates and Children: A Pragmatic Two-Center Study. Paediatr Drugs 2020; 22:433-444. [PMID: 32507958 PMCID: PMC7383037 DOI: 10.1007/s40272-020-00400-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Dutch Pediatric Formulary (DPF) increasingly bases its guidelines on model-based dosing simulations from pharmacokinetic studies. This resulted in nationwide dose changes for vancomycin, gentamicin, and tobramycin in 2015. OBJECTIVE We aimed to evaluate target attainment of these altered, model-based doses in critically ill neonates and children. METHODS This was a retrospective cohort study in neonatal intensive care unit (NICU) and pediatric ICU (PICU) patients receiving vancomycin, gentamicin, or tobramycin between January 2015 and March 2017 in two university hospitals. The first therapeutic drug monitoring concentration for each patient was collected, as was clinical and dosing information. Vancomycin and tobramycin target trough concentrations were 10-15 and ≤ 1 mg/L, respectively. Target gentamicin trough and peak concentrations were < 1 and 8-12 mg/L, respectively. RESULTS In total, 482 patients were included (vancomycin [PICU] n = 62, [NICU] n = 102; gentamicin [NICU] n = 97; tobramycin [NICU] n = 221). Overall, median trough concentrations were within the target range for all cohorts but showed large interindividual variability, causing nontarget attainment. Trough concentrations were outside the target range in 66.1%, 60.8%, 14.7%, and 23.1% of patients in these four cohorts, respectively. Gentamicin peak concentrations were outside the range in 69% of NICU patients (term neonates 87.1%, preterm infants 57.1%). Higher creatinine concentrations were associated with higher vancomycin and tobramycin trough concentrations. CONCLUSION This study illustrates the need to validate model-based dosing advice in the real-world setting as both sub- and supratherapeutic concentrations of vancomycin, gentamicin, and tobramycin were very prevalent. Our data underline the necessity for further individualization by addressing the high interindividual variability to improve target attainment.
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Affiliation(s)
- Stan J. F. Hartman
- grid.10417.330000 0004 0444 9382Department of Pharmacology and Toxicology and Department of Intensive Care, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Lynn B. Orriëns
- grid.10417.330000 0004 0444 9382Department of Pharmacology and Toxicology and Department of Intensive Care, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Samanta M. Zwaag
- grid.10417.330000 0004 0444 9382Department of Pharmacology and Toxicology and Department of Intensive Care, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Tim Poel
- grid.10417.330000 0004 0444 9382Department of Pharmacology and Toxicology and Department of Intensive Care, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Marika de Hoop
- grid.489189.50000 0001 0708 7338Royal Dutch Pharmacists Association (KNMP), Den Haag, The Netherlands ,Dutch Knowledge Center Pharmacotherapy for Children, The Hague, The Netherlands
| | - Saskia N. de Wildt
- grid.10417.330000 0004 0444 9382Department of Pharmacology and Toxicology and Department of Intensive Care, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands ,grid.5645.2000000040459992XIntensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands ,Dutch Knowledge Center Pharmacotherapy for Children, The Hague, The Netherlands
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27
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Borella E, Oosterholt S, Magni P, Della Pasqua O. Use of prior knowledge and extrapolation in paediatric drug development: A case study with deferasirox. Eur J Pharm Sci 2019; 136:104931. [PMID: 31108206 DOI: 10.1016/j.ejps.2019.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 03/09/2019] [Accepted: 05/13/2019] [Indexed: 01/19/2023]
Abstract
The characterisation of pharmacokinetics, pharmacodynamics and dose-exposure-response relationships requires data arising from well-designed study protocols and a relatively large sample from the target patient population. Such a prerequisite is unrealistic for paediatric rare diseases, where the patient population is often vulnerable and very small. In such cases, different sources of data and knowledge need to be considered to ensure trial designs are truly informative and oncoming data can be analysed efficiently. Here, we use clinical trial simulations to assess the contribution of historical data for (1) the analysis of sparse samples from a limited number of children and (2) the optimisation of study design when an increase in the number of subjects is not feasible. The evaluation of the pharmacokinetics of deferasirox in paediatric patients affected by haemoglobinopathies was used as case study. Our investigation shows that the incorporation of prior knowledge increases parameter precision and probability of successful convergence from only 12% with no priors to 56% and 75% for weakly and highly informative priors, respectively. In addition, results suggest that even when only one sample is collected per subject, as implemented in the original trial and in many other examples in clinical research, there is a 60% probability of biased parameter estimates (>25%). In conjunction with adult prior information and optimisation techniques, the probability of bias could be limited to <20% by increasing the number of samples/subject from 1 to 3. The methodology described here can be easily applied to other studies in small populations.
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Affiliation(s)
- Elisa Borella
- Dipart. Ingegneria Industriale e dell'Informazione, Università degli Studi di Pavia, Pavia, Italy
| | - Sean Oosterholt
- Clinical Pharmacology & Therapeutics Group, University College London, London, UK
| | - Paolo Magni
- Dipart. Ingegneria Industriale e dell'Informazione, Università degli Studi di Pavia, Pavia, Italy
| | - Oscar Della Pasqua
- Clinical Pharmacology & Therapeutics Group, University College London, London, UK; Clinical Pharmacology Modelling & Simulation, GlaxoSmithKline, Uxbridge, UK.
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28
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Corum O, Yildiz R, Ider M, Altan F, Ok M, Uney K. Pharmacokinetics and bioavailability of cefquinome and ceftriaxone in premature calves. J Vet Pharmacol Ther 2019; 42:632-639. [PMID: 31197850 DOI: 10.1111/jvp.12789] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/25/2019] [Accepted: 05/21/2019] [Indexed: 12/01/2022]
Abstract
The aim of this study was to evaluate the pharmacokinetics and bioavailability of cefquinome (CFQ) and ceftriaxone (CTX) following intravenous (IV) and intramuscular (IM) administrations in premature calves. Using a parallel design, 24 premature calves were randomly divided into the two antibiotic groups. Each of the six animals in the first group received CFQ (2 mg/kg) through IV or IM administration. The second group received CTX (20 mg/kg) via the same administration route. Plasma concentrations of the drugs were analyzed by high-performance liquid chromatography and noncompartmental methods. Mean pharmacokinetic parameters of CFQ and CTX following IV administration were as follows: elimination half-life (t1/2λz ) 1.85 and 3.31 hr, area under the plasma concentration-time curve (AUC0-∞ ) 15.74 and 174 hr * μg/ml, volume of distribution at steady-state 0.37 and 0.45 L/kg, and total body clearance 0.13 and 0.12 L hr-1 kg-1 , respectively. Mean pharmacokinetic parameters of CFQ and CTX after IM injection were as follows: peak concentration 4.56 and 25.04 μg/ml, time to reach peak concentration 1 and 1.5 hr, t1/2λz 4.74 and 3.62 hr, and AUC0-∞ 22.75 and 147 hr * μg/ml, respectively. The bioavailability of CFQ and CTX after IM injection was 141% and 79%, respectively. IM administration of CFQ (2 mg/kg) and CTX (20 mg/kg) can be recommended at 12-hr interval for treating infections caused by susceptible bacteria, with minimum inhibitory concentration values of ≤0.5 and ≤4 μg/ml, respectively, in premature calves. However, further research is indicated to assess the pharmacokinetic parameters following multiple doses of the drug in premature calves.
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Affiliation(s)
- Orhan Corum
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Kastamonu, Kastamonu, Turkey
| | - Ramazan Yildiz
- Department of Internal Medicine, Faculty of Veterinary Medicine, University of Mehmet Akif Ersoy, Burdur, Turkey
| | - Merve Ider
- Department of Internal Medicine, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkey
| | - Feray Altan
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Dicle, Diyarbakir, Turkey
| | - Mahmut Ok
- Department of Internal Medicine, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkey
| | - Kamil Uney
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkey
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29
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Corum O, Altan F, Yildiz R, Ider M, Ok M, Uney K. Pharmacokinetics of enrofloxacin and danofloxacin in premature calves. J Vet Pharmacol Ther 2019; 42:624-631. [PMID: 31190327 DOI: 10.1111/jvp.12787] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/05/2019] [Accepted: 05/14/2019] [Indexed: 01/02/2023]
Abstract
The aim of this study was to determine the pharmacokinetics/pharmacodynamics of enrofloxacin (ENR) and danofloxacin (DNX) following intravenous (IV) and intramuscular (IM) administrations in premature calves. The study was performed on twenty-four calves that were determined to be premature by anamnesis and general clinical examination. Premature calves were randomly divided into four groups (six premature calves/group) according to a parallel pharmacokinetic (PK) design as follows: ENR-IV (10 mg/kg, IV), ENR-IM (10 mg/kg, IM), DNX-IV (8 mg/kg, IV), and DNX-IM (8 mg/kg, IM). Plasma samples were collected for the determination of tested drugs by high-pressure liquid chromatography with UV detector and analyzed by noncompartmental methods. Mean PK parameters of ENR and DNX following IV administration were as follows: elimination half-life (t1/2λz ) 11.16 and 17.47 hr, area under the plasma concentration-time curve (AUC0-48 ) 139.75 and 38.90 hr*µg/ml, and volume of distribution at steady-state 1.06 and 4.45 L/kg, respectively. Total body clearance of ENR and DNX was 0.07 and 0.18 L hr-1 kg-1 , respectively. The PK parameters of ENR and DNX following IM injection were t1/2λz 21.10 and 28.41 hr, AUC0-48 164.34 and 48.32 hr*µg/ml, respectively. The bioavailability (F) of ENR and DNX was determined to be 118% and 124%, respectively. The mean AUC0-48CPR /AUC0-48ENR ratio was 0.20 and 0.16 after IV and IM administration, respectively, in premature calves. The results showed that ENR (10 mg/kg) and DNX (8 mg/kg) following IV and IM administration produced sufficient plasma concentration for AUC0-24 /minimum inhibitory concentration (MIC) and maximum concentration (Cmax )/MIC ratios for susceptible bacteria, with the MIC90 of 0.5 and 0.03 μg/ml, respectively. These findings may be helpful in planning the dosage regimen for ENR and DNX, but there is a need for further study in naturally infected premature calves.
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Affiliation(s)
- Orhan Corum
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Kastamonu, Kastamonu, Turkey
| | - Feray Altan
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Dicle, Diyarbakir, Turkey
| | - Ramazan Yildiz
- Department of Internal Medicine, Faculty of Veterinary Medicine, University of Mehmet Akif Ersoy, Burdur, Turkey
| | - Merve Ider
- Department of Internal Medicine, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkey
| | - Mahmut Ok
- Department of Internal Medicine, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkey
| | - Kamil Uney
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkey
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Krzyzanski W, Cook SF, Wilbaux M, Sherwin CMT, Allegaert K, Vermeulen A, van den Anker JN. Population Pharmacokinetic Modeling in the Presence of Missing Time-Dependent Covariates: Impact of Body Weight on Pharmacokinetics of Paracetamol in Neonates. AAPS JOURNAL 2019; 21:68. [PMID: 31140019 DOI: 10.1208/s12248-019-0331-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/06/2019] [Indexed: 11/30/2022]
Abstract
Body weight is the primary covariate in pharmacokinetics of many drugs and dramatically changes during the first weeks of life of neonates. The objective of this study is to determine if missing body weights in preterm and term neonates affect estimates of model parameters and which methods can be used to improve performance of a population pharmacokinetic model of paracetamol. Data for our analysis were obtained from previously published studies on the pharmacokinetics of intravenous paracetamol in neonates. We adopted a population model of body weight change in neonates to implement three previously introduced methods of handling missing covariates based on data imputation, likelihood function modification, and full random effects modeling. All models were implemented in NONMEM 7.4, and population parameters were estimated using the FOCE method. Our major finding was that missing body weights minimally affect population estimates of pharmacokinetic parameters but do affect the covariate relationship parameters, particularly the one describing dependence of clearance on body weight. None of the tested methods changed estimates of between-subject variability nor impacted the predictive performance of the model. Our analysis shows that a modeling approach towards handling missing covariates allows borrowing information gathered in various studies as long as they target the same population. This approach is particularly useful for handling time-dependent missing covariates.
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Affiliation(s)
- Wojciech Krzyzanski
- Department of Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA.
| | - Sarah F Cook
- Department of Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Melanie Wilbaux
- Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital (UKBB), Basel, Switzerland
| | - Catherine M T Sherwin
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - An Vermeulen
- Janssen Research & Development, a Division of Janssen Pharmaceutica N.V., Beerse, Belgium
| | - John N van den Anker
- Division of Clinical Pharmacology, Children's National Health System, Washington, District of Columbia, USA.,University of Basel Children's Hospital, Basel, Switzerland
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Revising Pediatric Vancomycin Dosing Accounting for Nephrotoxicity in a Pharmacokinetic-Pharmacodynamic Model. Antimicrob Agents Chemother 2019; 63:AAC.00067-19. [PMID: 30833429 DOI: 10.1128/aac.00067-19] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 02/20/2019] [Indexed: 12/14/2022] Open
Abstract
This study aimed to suggest an initial pediatric vancomycin dose regimen through population pharmacokinetic-pharmacodynamic modeling. A population pharmacokinetic approach was used to analyze vancomycin concentration-time data from a large pediatric cohort. Pharmacokinetic target attainment for patients with bloodstream isolates was compared with clinical outcome using logistic regression and classification and regression trees. Change in serum creatinine during treatment was used as an indicator of acute nephrotoxicity. Probability of acute kidney injury (50% increase from baseline) or kidney failure (75% increase from baseline) was evaluated using logistic regression. An initial dosing regimen was derived, personalized by age, weight, and serum creatinine, using stochastic simulations. Data from 785 hospitalized pediatric patients (1 day to 21 years of age) with suspected Gram-positive infections were collected. Estimated (relative standard error) typical clearance, volume of distribution 1, intercompartmental clearance, and volume of distribution 2 were (standardized to 70 kg) 4.84 (2.38) liters/h, 39.9 (8.15) liters, 3.85 (17.3) liters/h, and 37.8 (10.2) liters, respectively. While cumulative vancomycin exposure correlated positively with the development of nephrotoxicity (713 patients), no clear relationship between vancomycin area under the plasma concentration-time curve and efficacy was found (102 patients). Predicted probability of acute kidney injury and kidney failure with the optimized dosing regimen at day 5 was 10 to 15% and 5 to 10%, increasing by approximately 50% on day 7 and roughly 100% on day 10 across all age groups. This study presents the first data-driven pediatric dose selection to date accounting for nephrotoxicity, and it indicates that cumulative vancomycin exposure best describes risk of acute kidney injury and acute kidney failure.
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External Evaluation of Population Pharmacokinetic Models of Vancomycin in Large Cohorts of Intensive Care Unit Patients. Antimicrob Agents Chemother 2019; 63:AAC.02543-18. [PMID: 30833424 DOI: 10.1128/aac.02543-18] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 02/22/2019] [Indexed: 01/01/2023] Open
Abstract
Dosing of vancomycin is often guided by therapeutic drug monitoring and population pharmacokinetic models in the intensive care unit (ICU). The validity of these models is crucial, as ICU patients have marked pharmacokinetic variability. Therefore, we set out to evaluate the predictive performance of published population pharmacokinetic models of vancomycin in ICU patients. The PubMed database was used to search for population pharmacokinetic models of vancomycin in adult ICU patients. The identified models were evaluated in two independent data sets which were collected from two large hospitals in the Netherlands (Amsterdam UMC, Location VUmc, and OLVG Oost). We also tested a one-compartment model with fixed values for clearance and volume of distribution, in which a clinical standard dosage regimen (SDR) was mimicked to assess its predictive performance. Prediction error was calculated to assess the predictive performance of the models. Six models plus the SDR model were evaluated. The model of Roberts et al. (J. A. Roberts, F. S. Taccone, A. A. Udy, J.-L. Vincent, F. Jacobs, and J. Lipman, Antimicrob Agents Chemother 55:2704-2709, 2011, https://doi.org/10.1128/AAC.01708-10) performed satisfactorily, with mean and median values of prediction error of 5.1% and -7.5%, respectively, for Amsterdam UMC, Location VUmc, patients, and -12.6% and -17.2% respectively, for OLVG Oost patients. The other models, including the SDR model, yielded high mean values (-49.7% to 87.7%) and median values (-56.1% to 66.1%) for both populations. In conclusion, only the model of Roberts et al. was able to validly predict the concentrations of vancomycin for our data, whereas other models and standard dosing were largely inadequate. Extensive evaluation should precede the adoption of any model in clinical practice for ICU patients.
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Pokorná P, Šíma M, Černá O, Allegaert K, Tibboel D, Slanař O. Actual body weight-based vancomycin dosing in neonates. J Chemother 2019; 31:307-312. [PMID: 30983533 DOI: 10.1080/1120009x.2019.1599574] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This study aimed to explore vancomycin pharmacokinetics and its covariates in critically ill neonates and to propose an easy applicable dosing nomogram for initial treatment. Individual vancomycin pharmacokinetic parameters were calculated based on therapeutic drug monitoring data using a one-compartmental model. A linear regression model was used for examination of covariates. The mean (SD) volume of distribution (Vd) and clearance (CL) for vancomycin were 0.73 (0.31) L/kg and 0.052 (0.020) L/h/kg, respectively. Vd was related to actual body weight (ABW), gestational and postmenstrual age. CL was also associated with ABW, gestational, postmenstrual age and also creatinine clearance. ABW was the strongest predictor for vancomycin pharmacokinetics and consequently dosing. Loading dose (mg) of 11.81 × ABW (kg) + 7.86 and maintenance dose (mg/day) of 40.92 × ABW (kg) -22.18 most closely approximated pharmacokinetic target. Vancomycin pharmacokinetics was mainly influenced by ABW in neonates and a practical ABW-based dosing algorithm was developed.
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Affiliation(s)
- Pavla Pokorná
- Department of Pediatrics - PICU/NICU, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Prague , Czech Republic.,Department of Pharmacology, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Czech Republic , Prague , Czech Republic.,Intensive Care and Department of Pediatric Surgery, Erasmus MC and Department of Neonatology- Sophia Childrens Hospital , Rotterdam , The Netherlands
| | - Martin Šíma
- Department of Pharmacology, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Czech Republic , Prague , Czech Republic
| | - Olga Černá
- Department of Pediatrics - PICU/NICU, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Prague , Czech Republic
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC and Department of Neonatology- Sophia Childrens Hospital , Rotterdam , The Netherlands.,Department of development and regeneration , Katholieke Universiteit Leuven , Leuven , Belgium
| | - Dick Tibboel
- Department of Pediatrics - PICU/NICU, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Prague , Czech Republic.,Intensive Care and Department of Pediatric Surgery, Erasmus MC and Department of Neonatology- Sophia Childrens Hospital , Rotterdam , The Netherlands
| | - Ondřej Slanař
- Department of Pharmacology, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Czech Republic , Prague , Czech Republic
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Pokorná P, Šíma M, Černá O, Slanař O. Nomogram based on actual body weight for estimation of vancomycin maintenance dose in infants. Infect Dis (Lond) 2019; 51:334-339. [PMID: 30950674 DOI: 10.1080/23744235.2018.1541250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Vancomycin is the first-choice antibiotic for infants with β-lactam-resistant gram-positive bacterial infection. Despite long experience of prescribing of this drug optimal dosing is still challenging. This study aimed at investigating variables predicting vancomycin clearance in order to propose optimal maintenance dosing in infants treated for suspected or culture-proven sepsis. METHODS Vancomycin pharmacokinetics was calculated in a one-compartmental model based on serum concentrations. A linear regression model was used to explore relationships between vancomycin clearance and expected covariates. RESULTS Twenty-two patients were enrolled into the study. Median (IQR) postnatal age was 157 (112-238) days. The median (IQR) volume of distribution and clearance for vancomycin were 0.50 (0.39-0.94) L/kg and 0.112 (0.095-0.133) L/h/kg, respectively. Vancomycin clearance was associated with actual body weight, height, body surface area, gestational age, postnatal age, postmenstrual age and estimate glomerular filtration rate. Actual body weight was the best predictive variable for vancomycin clearance. Daily maintenance dose (mg) calculated as 76.28 × actual body weight (kg) - 41.57 most closely approximated optimal dosing based on individual pharmacokinetics. This relationship was used to construct a dosing nomogram. CONCLUSIONS We developed an easy-to-use dosing nomogram for maintaining a vancomycin average steady-state concentration of 22.5 mg/L based on actual body weight.
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Affiliation(s)
- Pavla Pokorná
- a Institute of Pharmacology, First Faculty of Medicine , Charles University and General University Hospital in Prague , Prague , Czech Republic.,b Department of Pediatrics and Adolescent Medicine (PICU/NICU), First Faculty of Medicine , Charles University and General University Hospital in Prague , Prague , Czech Republic.,c Intensive Care and Department of Pediatric Surgery , Erasmus MC - Sophia Childrens Hospital , Rotterdam , the Netherlands
| | - Martin Šíma
- a Institute of Pharmacology, First Faculty of Medicine , Charles University and General University Hospital in Prague , Prague , Czech Republic
| | - Olga Černá
- b Department of Pediatrics and Adolescent Medicine (PICU/NICU), First Faculty of Medicine , Charles University and General University Hospital in Prague , Prague , Czech Republic
| | - Ondřej Slanař
- a Institute of Pharmacology, First Faculty of Medicine , Charles University and General University Hospital in Prague , Prague , Czech Republic
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Moffett BS, Resendiz K, Morris J, Akcan-Arikan A, Checchia PA. Population Pharmacokinetics of Vancomycin in the Pediatric Cardiac Surgical Population. J Pediatr Pharmacol Ther 2019; 24:107-116. [PMID: 31019403 DOI: 10.5863/1551-6776-24.2.107] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Vancomycin is often used in the pediatric cardiac surgical population, but few pharmacokinetic data are available to guide dosing. METHODS A retrospective, population pharmacokinetic study was performed for patients <19 years of age initiated on vancomycin after cardiac surgery in the cardiac intensive care unit from 2011-2016 in our institution. Patient data were summarized by using descriptive statistical methods, and population pharmacokinetic analysis was performed by using NONMEM. Simulation was performed to determine a dosing strategy that most frequently obtained an AUC0-24:MIC (minimum inhibitory concentration) ratio of >400. RESULTS A total of 261 patients (281 cardiac surgical procedures, cardiopulmonary bypass 82.3%) met inclusion criteria (60.1% male, median age 0.31 [IQR, 0.07-0.77] years). Vancomycin (14.5 ± 1.7 mg/kg/dose) was administered at median postoperative day 9 (IQR, 4-14), with a mean serum concentration of 11.5 ± 5.5 mg/L at 8.9 ± 3.8 hours after a dose. Population pharmacokinetic analysis demonstrated that a 1-compartment proportional error model with allometrically scaled weight best fit the data, with creatinine clearance and postmenstrual age as significant covariates. Simulation identified that a dosing regimen of 20 mg/kg/dose every 8 hours was most likely to achieve an AUC0-24:MIC ratio > 400 at a mean trough serum concentration of 12.9 ± 3.2 mg/L. CONCLUSIONS Vancomycin dosing in the postoperative pediatric cardiac surgical population should incorporate postmenstrual age and creatinine clearance. A vancomycin dose of 20 mg/kg every 8 hours is a reasonable empiric strategy.
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Reilly AM, Ding MX, Rower JE, Kiser TH. The Effectiveness of a Vancomycin Dosing Guideline in the Neonatal Intensive Care Unit for Achieving Goal Therapeutic Trough Concentrations. J Clin Pharmacol 2019; 59:997-1005. [PMID: 30776089 DOI: 10.1002/jcph.1392] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 01/28/2019] [Indexed: 11/06/2022]
Abstract
Concern for bacterial resistance and treatment failure with vancomycin trough concentrations < 10 μg/mL have led guidelines to increase goal concentrations. There is a paucity of data evaluating vancomycin dosage necessary to achieve goals in the neonatal intensive care unit (NICU). We aimed to evaluate the implementation of a new vancomycin dosing guideline in improving trough target attainment. This retrospective study evaluated neonates in the NICU treated with vancomycin between January 2009 and December 2015. Therapeutic trough concentration attainment (10-20 μg/mL) was compared between neonates receiving vancomycin per old versus new dosing guidelines. Vancomycin trough concentrations, modeled pharmacodynamic target attainment, and nephrotoxicity were compared between groups. A total of 212 vancomycin trough concentrations (n = 91 old and n = 121 new guideline) were evaluated in 182 unique neonates. The mean ± standard deviation trough concentration achieved was 18.0 ± 7.3 μg/mL vs 8.9 ± 4.8 μg/mL in the new and old guidelines, respectively (P < .01). The new guideline resulted in a higher percentage of neonates achieving trough concentrations of 10 to 20 μg/mL (62% vs 29%; P < .01) and decreased the percentage of neonates with subtherapeutic trough concentrations (9% vs 69%; P < .01). Pharmacokinetic modeling identified postmenstrual age, days of life, and urine output as predictors of vancomycin clearance and resultant trough and area under the curve values (P < .01 for all). Trough concentrations >10 μg/mL ensured area under the curve /minimum inhibitory concentration >400 in >90% of neonates when bacteria minimum inhibitory concentration was ≤ 1 μg/mL. Nephrotoxicity was similar between groups (8.3% vs 7.7%; P = .99). In conclusion, a vancomycin nomogram designed to achieve trough concentration of 10 to 20 μg/mL improves pharmacodynamic target attainment in neonates in the NICU.
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Affiliation(s)
- Ashley M Reilly
- Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
| | - Michelle X Ding
- Department of Pharmacy, Kaiser Permanente, Los Angeles, CA, USA
| | - Joseph E Rower
- Department of Pharmacology and Toxicology, University of Utah Skaggs College of Pharmacy, Salt Lake City, UT, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Vancomycin Pharmacokinetics Throughout Life: Results from a Pooled Population Analysis and Evaluation of Current Dosing Recommendations. Clin Pharmacokinet 2019; 58:767-780. [DOI: 10.1007/s40262-018-0727-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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38
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Population pharmacokinetics of oxcarbazepine active metabolite in Chinese paediatric epilepsy patients and its application in individualised dosage regimens. Eur J Clin Pharmacol 2018; 75:381-392. [DOI: 10.1007/s00228-018-2600-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 11/07/2018] [Indexed: 12/24/2022]
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39
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Population Pharmacokinetics of the Antimalarial Amodiaquine: a Pooled Analysis To Optimize Dosing. Antimicrob Agents Chemother 2018; 62:AAC.02193-17. [PMID: 30038039 PMCID: PMC6153844 DOI: 10.1128/aac.02193-17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 06/22/2018] [Indexed: 01/16/2023] Open
Abstract
Amodiaquine plus artesunate is the recommended antimalarial treatment in many countries where malaria is endemic. However, pediatric doses are largely based on a linear extrapolation from adult doses. Amodiaquine plus artesunate is the recommended antimalarial treatment in many countries where malaria is endemic. However, pediatric doses are largely based on a linear extrapolation from adult doses. We pooled data from previously published studies on the pharmacokinetics of amodiaquine, to optimize the dose across all age groups. Adults and children with uncomplicated malaria received daily weight-based doses of amodiaquine or artesunate-amodiaquine over 3 days. Plasma concentration-time profiles for both the parent drug and the metabolite were characterized using nonlinear mixed-effects modeling. Amodiaquine pharmacokinetics were adequately described by a two-compartment disposition model, with first-order elimination leading to the formation of desethylamodiaquine, which was best described by a three-compartment disposition model. Body size and age were the main covariates affecting amodiaquine clearance. After adjusting for the effect of weight, clearance rates for amodiaquine and desethylamodiaquine reached 50% of adult maturation at 2.8 months (95% confidence interval [CI], 1.5 to 3.7 months) and 3.9 months (95% CI, 2.6 to 5.3 months) after birth, assuming that the baby was born at term. Bioavailability was 22.4% (95% CI, 15.6 to 31.9%) lower at the start of treatment than during convalescence, which suggests a malaria disease effect. Neither the drug formulation nor the hemoglobin concentration had an effect on any pharmacokinetic parameters. Results from simulations showed that current manufacturer dosing recommendations resulted in low desethylamodiaquine exposure in patients weighing 8 kg, 15 to 17 kg, 33 to 35 kg, and >62 kg compared to that in a typical 50-kg patient. We propose possible optimized dosing regimens to achieve similar drug exposures among all age groups, which require further validation.
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Xu S, Chen Y, Zhao M, Guo Y, Wang Z, Zhao L. Population pharmacokinetics of valproic acid in epileptic children: Effects of clinical and genetic factors. Eur J Pharm Sci 2018; 122:170-178. [PMID: 29981400 DOI: 10.1016/j.ejps.2018.06.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/12/2018] [Accepted: 06/29/2018] [Indexed: 01/25/2023]
Abstract
Valproic acid (VPA) is a first-line anti-epileptic drug that is used in the treatment of generalized and partial seizures. Gene variants had been proved to influence the pharmacokinetics (PK) of VPA and contribute to its inter-individual variability (IIV). The aim of this study was to systematically investigate the effects of candidate gene variants (CYPs, UGTs, ABC transporters, and nuclear receptors) on VPA PK in Chinese children with epilepsy. A total of 1065 VPA serum trough concentrations at steady state were collected from 264 epileptic pediatric patients aged 3 months to 16 years. The population pharmacokinetic (PPK) model was developed using a nonlinear mixed effects modelling (NONMEM) approach. For the final PPK model, the oral clearance (CL/F) of VPA was estimated to be 0.259 L/h with IIV of 13.3%. The estimates generated by NONMEM indicated that the VPA CL/F was significantly influenced by patient body weight (increased by an exponent of 0.662), co-administration with carbamazepine (increased CL/F by 22%), and daily dose of VPA (increased by an exponent of 0.22). CL/F in patients with the LEPR rs1137101 variant (668 AG and GG genotypes) was much lower than in patients with the AA genotype (17.8% and 22.6% lower, respectively). However, none of the CYPs or UGTs gene variants was found to influence the PK of VPA in this study. Evaluation by bootstrap and normalized prediction distribution error (NPDE) showed that the final model was stable. The predictive performance was evaluated by goodness-of-fit (GOF) plots and visual predictive checks (VPC), and the results indicated satisfactory precision. Our model suggests a correlation between VPA CL/F and LEPR rs1137101 variants, which might be beneficial in the context of individual dose optimization.
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Affiliation(s)
- Shansen Xu
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Yanan Chen
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Mingming Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Yingjie Guo
- School of Life Sciences, Jilin University, Changchun 130012, China
| | - Zhanyou Wang
- Institute of Health Sciences, Key Laboratory of Medical Cell Biology of Ministry of Education, China Medical University, Shenyang 110122, China
| | - Limei Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang 110004, China.
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Li ZL, Liu YX, Jiao Z, Qiu G, Huang JQ, Xiao YB, Wu SJ, Wang CY, Hu WJ, Sun HJ. Population Pharmacokinetics of Vancomycin in Chinese ICU Neonates: Initial Dosage Recommendations. Front Pharmacol 2018; 9:603. [PMID: 29997498 PMCID: PMC6029141 DOI: 10.3389/fphar.2018.00603] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/21/2018] [Indexed: 01/21/2023] Open
Abstract
The main goal of our study was to characterize the population pharmacokinetics of vancomycin in critically ill Chinese neonates to develop a pharmacokinetic model and investigate factors that have significant influences on the pharmacokinetics of vancomycin in this population. The study population consisted of 80 neonates in the neonatal intensive care unit (ICU) from which 165 trough and peak concentrations of vancomycin were obtained. Nonlinear mixed effect modeling was used to develop a population pharmacokinetic model for vancomycin. The stability and predictive ability of the final model were evaluated based on diagnostic plots, normalized prediction distribution errors and the bootstrap method. Serum creatinine (Scr) and body weight were significant covariates on the clearance of vancomycin. The average clearance was 0.309 L/h for a neonate with Scr of 23.3 μmol/L and body weight of 2.9 kg. No obvious ethnic differences in the clearance of vancomycin were found relative to the earlier studies of Caucasian neonates. Moreover, the established model indicated that in patients with a greater renal clearance status, especially Scr < 15 μmol/L, current guideline recommendations would likely not achieve therapeutic area under the concentration-time curve over 24 h/minimum inhibitory concentration (AUC24h/MIC) ≥ 400. The exceptions to this are British National Formulary (2016-2017), Blue Book (2016) and Neofax (2017). Recommended dose regimens for neonates with different Scr levels and postmenstrual ages were estimated based on Monte Carlo simulations and the established model. These findings will be valuable for developing individualized dosage regimens in the neonatal ICU setting.
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Affiliation(s)
- Zhi-ling Li
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yi-xi Liu
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Zheng Jiao
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Gang Qiu
- Department of Neonatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jian-quan Huang
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yu-bo Xiao
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
- Department of Pharmacy, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shu-jin Wu
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
- Department of Pharmacy, Gansu Provincial Hospital, Lanzhou, China
| | - Chen-yu Wang
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Wen-juan Hu
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Hua-jun Sun
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Factors impacting unbound vancomycin concentrations in neonates and young infants. Eur J Clin Microbiol Infect Dis 2018; 37:1503-1510. [DOI: 10.1007/s10096-018-3277-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/09/2018] [Indexed: 01/19/2023]
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Chen Y, Wu D, Dong M, Zhu Y, Lu J, Li X, Chen C, Li Z. Population pharmacokinetics of vancomycin and AUC-guided dosing in Chinese neonates and young infants. Eur J Clin Pharmacol 2018; 74:921-930. [PMID: 29602981 DOI: 10.1007/s00228-018-2454-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 03/19/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To develop a population pharmacokinetic (PK) model for vancomycin in Chinese neonates and infants less than 2 months of age (young infants) with a wide gestational age range, in order to determine the appropriate dosing regimen for this population. METHODS We performed a retrospective chart review of patients from the neonatal intensive care unit (NICU) at Children's Hospital of Fudan University to identify neonates and young infants treated with vancomycin from May 2014 to May 2017. Vancomycin concentrations and covariates were utilized to develop a one-compartment model with first-order elimination. The predictive performance of the final model was assessed by both internal and external evaluation, and the relationship between trough concentration and AUC0-24 was investigated. Monte Carlo simulations were performed to design an initial dosing schedule targeting an AUC0-24 ≥ 400. RESULTS The analysis included a total of 330 concentration-time data points from 213 neonates and young infants with gestational age (GA) and body weight of 25-42 weeks and 0.88-5.1 kg, respectively. Body weight, postmenstrual age (PMA) and serum creatinine level were found to be important factors explaining the between-subject variability in vancomycin PK parameters for this population. Both internal and external evaluation supported the prediction of the final vancomycin PK model. The typical population parameter estimates of clearance and distribution volume for an infant weighing 2.73 kg with a PMA of 39.8 weeks and serum creatinine of 0.28 mg/dL were 0.103 L/h/kg and 0.58 L/kg, respectively. Although vancomycin serum trough concentrations were predictive of the AUC, considerable variability was observed in the achievement of an AUC0-24/MIC of ≥400. For MIC values of ≤0.5 mg/L, AUC0-24/MIC ≥400 was achieved for 95% of the newborn infants with vancomycin troughs of 5-10 mg/L. When the MIC increased to 1 mg/L, only 15% of the patients with troughs of 5-10 mg/L achieved AUC0-24/MIC ≥400. For MIC values of 2 mg/L, no infants achieved the target. Simulations predicted that a dose of at least 14 and 15 mg/kg every 12 h was required to attain the target AUC0-24 ≥ 400 in 90% of infants with a PMA of 30-32 and 32-34 weeks, respectively. This target was also achieved in 93% of simulated infants in the oldest PMA groups (36-38 and 38-40 weeks, respectively) when the dosing interval was extended to 8 h. For infants with a PMA ≥44 weeks, a dose increase to 18 mg/kg every 8 h was needed. The trough concentrations of 5-15 mg/L were highly predictive of an AUC0-24 of ≥400 when treating invasive MRSA infections with an MIC of ≤1 mg/L. CONCLUSIONS The PK parameters for vancomycin in Chinese infants younger than 2 months of age were estimated using the model developed herein. This model has been used to predict individualized dosing regimens in this vulnerable population in our hospital. A large external evaluation of our model will be conducted in future studies.
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Affiliation(s)
- Yewei Chen
- Department of Pharmacy, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Dan Wu
- Department of Pharmacy, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Min Dong
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Yiqing Zhu
- Department of Pharmacy, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Jinmiao Lu
- Department of Pharmacy, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Xiaoxia Li
- Department of Pharmacy, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Chao Chen
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Zhiping Li
- Department of Pharmacy, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China.
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Evaluating the Relationship between Vancomycin Trough Concentration and 24-Hour Area under the Concentration-Time Curve in Neonates. Antimicrob Agents Chemother 2018; 62:AAC.01647-17. [PMID: 29358290 DOI: 10.1128/aac.01647-17] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/09/2018] [Indexed: 12/25/2022] Open
Abstract
Bacterial sepsis is a major cause of morbidity and mortality in neonates, especially those involving methicillin-resistant Staphylococcus aureus (MRSA). Guidelines by the Infectious Diseases Society of America recommend the vancomycin 24-h area under the concentration-time curve to MIC ratio (AUC24/MIC) of >400 as the best predictor of successful treatment against MRSA infections when the MIC is ≤1 mg/liter. The relationship between steady-state vancomycin trough concentrations and AUC24 values (mg·h/liter) has not been studied in an Asian neonatal population. We conducted a retrospective chart review in Singapore hospitals and collected patient characteristics and therapeutic drug monitoring data from neonates on vancomycin therapy over a 5-year period. A one-compartment population pharmacokinetic model was built from the collected data, internally validated, and then used to assess the relationship between steady-state trough concentrations and AUC24 A Monte Carlo simulation sensitivity analysis was also conducted. A total of 76 neonates with 429 vancomycin concentrations were included for analysis. Median (interquartile range) was 30 weeks (28 to 36 weeks) for postmenstrual age (PMA) and 1,043 g (811 to 1,919 g) for weight at the initiation of treatment. Vancomycin clearance was predicted by weight, PMA, and serum creatinine. For MRSA isolates with a vancomycin MIC of ≤1, our major finding was that the minimum steady-state trough concentration range predictive of achieving an AUC24/MIC of >400 was 8 to 8.9 mg/liter. Steady-state troughs within 15 to 20 mg/liter are unlikely to be necessary to achieve an AUC24/MIC of >400, whereas troughs within 10 to 14.9 mg/liter may be more appropriate.
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Ji XW, Ji SM, He XR, Zhu X, Chen R, Lu W. Influences of renal function descriptors on population pharmacokinetic modeling of vancomycin in Chinese adult patients. Acta Pharmacol Sin 2018; 39:286-293. [PMID: 28836582 DOI: 10.1038/aps.2017.57] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 04/19/2017] [Indexed: 12/27/2022] Open
Abstract
Vancomycin, a glycopeptide antibiotic for the treatment of grampositive infections, is mainly eliminated via glomerular filtration. Thus, its therapeutic effects are affected predominantly by renal function. The aim of this study was to develop a population pharmacokinetic model of vancomycin for Chinese adult patients and to investigate the influence of different renal function descriptors on the predictability of the model. A retrospective analysis was performed based on the blood concentrations of vancomycin in 218 Chinese adult patients. Among these patients, the data from 160 were used to establish the population pharmacokinetic model, and the data from the remaining 58 patients were used for external model validation. A simulation was employed to determine the appropriate initial vancomycin dosage regimens in adult Chinese patients for reaching the target steady-state trough concentrations of 10-15 mg/L and 15-20 mg/L. We developed a one-compartment model with first-order absorption to characterize the concentration-time profile of vancomycin. There was a positive correlation between the body clearance of vancomycin and renal function; both creatinine clearance (CLCr) and age were the covariates that influenced the PK of vancomycin, and the excretion of vancomycin decreased as renal function diminishing with age. The typical clearance (CL) value was 2.829 L/h for 75-year-old patients with CLCr values of 80 mL/min, and the rate constant of CL with the CLCr changing at 1 mL/min was 0.00842. The influence coefficient of age on CL was 0.08143. The external validation results revealed that the current different descriptors of renal function behaved similarly to the predicted performance of the models. In conclusion, the developed model is appropriate for Bayesian dose predictions of vancomycin concentrations in the population of Chinese adult patients. Furthermore, the simulation provides a reference for clinical optimized antibacterial therapy with vancomycin.
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DosOpt: A Tool for Personalized Bayesian Dose Adjustment of Vancomycin in Neonates. Ther Drug Monit 2017; 39:604-613. [DOI: 10.1097/ftd.0000000000000456] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Semi-Mechanistic Model for Predicting the Dosing Rate in Children and Neonates for Drugs Mainly Eliminated by Cytochrome Metabolism. Clin Pharmacokinet 2017; 57:831-841. [DOI: 10.1007/s40262-017-0596-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Holford NHG, Anderson BJ. Why standards are useful for predicting doses. Br J Clin Pharmacol 2017; 83:685-687. [PMID: 28155239 PMCID: PMC6436183 DOI: 10.1111/bcp.13230] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 12/30/2016] [Indexed: 01/08/2023] Open
Abstract
Germovsek and colleagues have recently concluded that a standard approach to modelling pharmacokinetics is not wrong and appears to be at least as useful as other ad hoc methods for describing drug concentrations. There are other advantages of this approach including learning about biology, comparing different studies, detecting errors and rationalizing dose prediction. A standard approach to size and maturation is not a panacea but provides the framework for challenging new ideas and supports a consistent method of dosing in patients of all ages.
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Affiliation(s)
- Nick H. G. Holford
- Department of Pharmacology & Clinical PharmacologyUniversity of AucklandNew Zealand
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Muntau AC, Burlina A, Eyskens F, Freisinger P, De Laet C, Leuzzi V, Rutsch F, Sivri HS, Vijay S, Bal MO, Gramer G, Pazdírková R, Cleary M, Lotz-Havla AS, Munafo A, Mould DR, Moreau-Stucker F, Rogoff D. Efficacy, safety and population pharmacokinetics of sapropterin in PKU patients <4 years: results from the SPARK open-label, multicentre, randomized phase IIIb trial. Orphanet J Rare Dis 2017; 12:47. [PMID: 28274234 PMCID: PMC5343543 DOI: 10.1186/s13023-017-0600-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 02/23/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sapropterin dihydrochloride, a synthetic formulation of BH4, the cofactor for phenylalanine hydroxylase (PAH, EC 1.14.16.1), was initially approved in Europe only for patients ≥4 years with BH4-responsive phenylketonuria. The aim of the SPARK (Safety Paediatric efficAcy phaRmacokinetic with Kuvan®) trial was to assess the efficacy (improvement in daily phenylalanine tolerance, neuromotor development and growth parameters), safety and pharmacokinetics of sapropterin dihydrochloride in children <4 years. RESULTS In total, 109 male or female children <4 years with confirmed BH4-responsive phenylketonuria or mild hyperphenylalaninemia and good adherence to dietary treatment were screened. 56 patients were randomly assigned (1:1) to 10 mg/kg/day oral sapropterin plus a phenylalanine-restricted diet or to only a phenylalanine-restricted diet for 26 weeks (27 to the sapropterin and diet group and 29 to the diet-only group; intention-to-treat population). Of these, 52 patients with ≥1 pharmacokinetic sample were included in the pharmacokinetic analysis, and 54 patients were included in the safety analysis. At week 26 in the sapropterin plus diet group, mean phenylalanine tolerance was 30.5 (95% confidence interval 18.7-42.3) mg/kg/day higher than in the diet-only group (p < 0.001). The safety profile of sapropterin, measured monthly, was acceptable and consistent with that seen in studies of older children. Using non-linear mixed effect modelling, a one-compartment model with flip-flop pharmacokinetic behaviour, in which the effect of weight was substantial, best described the pharmacokinetic profile. Patients in both groups had normal neuromotor development and stable growth parameters. CONCLUSIONS The addition of sapropterin to a phenylalanine-restricted diet was well tolerated and led to a significant improvement in phenylalanine tolerance in children <4 years with BH4-responsive phenylketonuria or mild hyperphenylalaninemia. The pharmacokinetic model favours once per day dosing with adjustment for weight. Based on the SPARK trial results, sapropterin has received EU approval to treat patients <4 years with BH4-responsive phenylketonuria. TRIAL REGISTRATION ClinicalTrials.gov, NCT01376908 . Registered June 17, 2011.
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Affiliation(s)
- Ania C Muntau
- University Children's Hospital, University Medical Center Hamburg Eppendorf, Martinistrasse 52, D-20246, Hamburg, Germany.
| | | | | | | | - Corinne De Laet
- Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium
| | | | - Frank Rutsch
- Muenster University Children's Hospital, Muenster, Germany
| | - H Serap Sivri
- Hacettepe University School of Medicine, Ankara, Turkey
| | | | | | - Gwendolyn Gramer
- Centre for Paediatric and Adolescent Medicine, Division for Neuropaediatrics and Metabolic Medicine, University of Heidelberg, Heidelberg, Germany
| | | | | | | | - Alain Munafo
- Merck Institute for Pharmacometrics, Lausanne, Switzerland
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Coagulase negative staphylococcal sepsis in neonates: do we need to adapt vancomycin dose or target? BMC Pediatr 2016; 16:206. [PMID: 27931193 PMCID: PMC5146818 DOI: 10.1186/s12887-016-0753-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 12/03/2016] [Indexed: 11/15/2022] Open
Abstract
Background Despite differences in types of infection and causative organisms, pharmacokinetic-pharmacodynamic (PKPD) targets of vancomycin therapy derived from adult studies are suggested for neonates. We aimed to identify doses needed for the attainment of AUC/MIC > 400 and AUC/MIC > 300 in neonates with sepsis and correlate these targets with recommended doses and treatment outcome. Methods Neonates who had Vancomycin therapeutic drug monitoring (TDM) performed between January 1, 2010 and December 31, 2012 were studied. Clinical characteristics, episodes of Gram-positive sepsis with outcomes and all neonatal blood culture isolates in hospital were collected from medical records. To estimate probability of target attainment of AUC/MIC >400 and AUC/MIC >300 a 1000-subject Monte Carlo simulation was performed by calculating AUC using Anderson’s (Anderson et al. 2006) and TDM trough concentrations (Ctrough) based population PK models. Results Final dataset included 76 patients; 57 with confirmed Gram-positive sepsis. TDM was taken after the 1st to 44th dose. 84.1% of Ctrough were within the range 5–15 mg/L. Currently recommended doses achieved probability of the targets (PTA) of AUC/MIC >400 and AUC/MIC >300 in less than 25% and 40% of cases, respectively. Doses required for 80% PTA of AUC/MIC > 400 for MIC ≥2 mg/L resulted in Ctrough values ≥14 mg/L. Mean AUC/MIC values were similar in treatment failure and success groups. Conclusion With currently recommended vancomycin dosing the therapeutic target of AUC/MIC > 400 is achieved only by 25% of neonates. Appropriate PKPD targets and respective dosing regimens need to be defined in prospective clinical studies in this population.
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