1
|
Simeoli R, Lava SAG, Di Deo A, Roversi M, Cairoli S, Tambucci R, Rea F, Malamisura M, Angelino G, Biondi I, Simonetti A, De Angelis P, Dionisi Vici C, Rossi P, Pontrelli G, Della Pasqua O, Goffredo BM. Pharmacokinetic Evaluation of Oral Viscous Budesonide in Paediatric Patients with Eosinophilic Oesophagitis in Repaired Oesophageal Atresia. Pharmaceutics 2024; 16:872. [PMID: 39065569 PMCID: PMC11280286 DOI: 10.3390/pharmaceutics16070872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/24/2024] [Accepted: 06/27/2024] [Indexed: 07/28/2024] Open
Abstract
Eosinophilic oesophagitis is a long-term complication of oesophageal atresia (EA), an uncommon condition that affects approximately 1 in 3500 infants. An exploratory, open-label phase 2 clinical trial was conducted in paediatric eosinophilic oesophagitis after oesophageal atresia (EoE-EA) to assess the safety, pharmacokinetics, and efficacy of oral viscous budesonide (OVB). In total, eight patients were enrolled in the study and assigned to a twice-daily dosing regimen of either 0.8 or 1 mg OVB, depending on age and height, administered for 12 weeks. OVB was safe and effective in the treatment of EoE-EA. The current investigation focuses on the pharmacokinetics of budesonide and the impact of an oral viscous formulation on its absorption and bioavailability. Using a non-linear mixed effects approach, two distinct absorption profiles were identified, despite marked interindividual variability in drug concentrations. Budesonide exposure was higher than previously reported in children following oral inhalation. Even though no significant effect has been observed on serum cortisol levels, future studies should consider exploring different doses, schedules, and/or treatment durations, as there may be an opportunity to reduce the risk of cortisol suppression.
Collapse
Affiliation(s)
- Raffaele Simeoli
- Division of Metabolic Diseases, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.S.); (S.C.); (C.D.V.)
| | - Sebastiano A. G. Lava
- Clinical Pharmacology & Therapeutics Group, University College London, London WC1N 3JH, UK; (S.A.G.L.); (A.D.D.); (O.D.P.)
| | - Alessandro Di Deo
- Clinical Pharmacology & Therapeutics Group, University College London, London WC1N 3JH, UK; (S.A.G.L.); (A.D.D.); (O.D.P.)
| | - Marco Roversi
- PhD Program in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Sara Cairoli
- Division of Metabolic Diseases, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.S.); (S.C.); (C.D.V.)
| | - Renato Tambucci
- Digestive Endoscopy Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.T.); (F.R.); (M.M.); (G.A.); (P.D.A.)
| | - Francesca Rea
- Digestive Endoscopy Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.T.); (F.R.); (M.M.); (G.A.); (P.D.A.)
| | - Monica Malamisura
- Digestive Endoscopy Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.T.); (F.R.); (M.M.); (G.A.); (P.D.A.)
| | - Giulia Angelino
- Digestive Endoscopy Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.T.); (F.R.); (M.M.); (G.A.); (P.D.A.)
| | - Isabella Biondi
- Centre of Excellence for the Development and Implementation of Medicines, Vaccines, and Medical Devices for Pediatric Use, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (I.B.); (A.S.); (P.R.); (G.P.)
| | - Alessandra Simonetti
- Centre of Excellence for the Development and Implementation of Medicines, Vaccines, and Medical Devices for Pediatric Use, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (I.B.); (A.S.); (P.R.); (G.P.)
| | - Paola De Angelis
- Digestive Endoscopy Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.T.); (F.R.); (M.M.); (G.A.); (P.D.A.)
| | - Carlo Dionisi Vici
- Division of Metabolic Diseases, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.S.); (S.C.); (C.D.V.)
| | - Paolo Rossi
- Centre of Excellence for the Development and Implementation of Medicines, Vaccines, and Medical Devices for Pediatric Use, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (I.B.); (A.S.); (P.R.); (G.P.)
| | - Giuseppe Pontrelli
- Centre of Excellence for the Development and Implementation of Medicines, Vaccines, and Medical Devices for Pediatric Use, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (I.B.); (A.S.); (P.R.); (G.P.)
| | - Oscar Della Pasqua
- Clinical Pharmacology & Therapeutics Group, University College London, London WC1N 3JH, UK; (S.A.G.L.); (A.D.D.); (O.D.P.)
| | - Bianca Maria Goffredo
- Division of Metabolic Diseases, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (R.S.); (S.C.); (C.D.V.)
| |
Collapse
|
2
|
D'Agate S, Ruiz Gabarre D, Della Pasqua O. Population pharmacokinetics and dose rationale for aciclovir in term and pre-term neonates with herpes. Pharmacol Res Perspect 2024; 12:e1193. [PMID: 38775304 PMCID: PMC11110484 DOI: 10.1002/prp2.1193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/23/2024] [Indexed: 05/25/2024] Open
Abstract
Aciclovir is considered the first-line treatment against Herpes simplex virus (HSV) infections in new-borns and infants. As renal excretion is the major route of elimination, in renally-impaired patients, aciclovir doses are adjusted according to the degree of impairment. However, limited attention has been given to the implications of immature renal function or dysfunction due to the viral disease itself. The aim of this investigation was to characterize the pharmacokinetics of aciclovir taking into account maturation and disease processes in the neonatal population. Pharmacokinetic data obtained from 2 previously published clinical trials (n = 28) were analyzed using a nonlinear mixed effects modeling approach. Post-menstrual age (PMA) and creatinine clearance (CLCR) were assessed as descriptors of maturation and renal function. Simulation scenarios were also implemented to illustrate the use of pharmacokinetic data to extrapolate efficacy from adults. Aciclovir pharmacokinetics was described by a one-compartment model with first-order elimination. Body weight and diagnosis (systemic infection) were statistically significant covariates on the volume of distribution, whereas body weight, CLCR and PMA had a significant effect on clearance. Median clearance varied from 0.2 to 1.0 L/h in subjects with PMA <34 or ≥34 weeks, respectively. Population estimate for volume of distribution was 1.93 L with systemic infection increasing this value by almost 3-fold (2.67 times higher). A suitable model parameterization was identified, which discriminates the effects of developmental growth, maturation, and organ function. Exposure to aciclovir was found to increase with decreasing PMA and renal function (CLCR), suggesting different dosing requirement for pre-term neonates.
Collapse
Affiliation(s)
- S. D'Agate
- Clinical Pharmacology & Therapeutics GroupUniversity College LondonLondonUK
| | - D. Ruiz Gabarre
- Clinical Pharmacology & Therapeutics GroupUniversity College LondonLondonUK
- Present address:
Institute for Regeneration and RepairUniversity of EdinburghEdinburghUK
| | - O. Della Pasqua
- Clinical Pharmacology & Therapeutics GroupUniversity College LondonLondonUK
| |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
Wilkins CA, Hamman H, Hamman JH, Steenekamp JH. Fixed-Dose Combination Formulations in Solid Oral Drug Therapy: Advantages, Limitations, and Design Features. Pharmaceutics 2024; 16:178. [PMID: 38399239 PMCID: PMC10892518 DOI: 10.3390/pharmaceutics16020178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/14/2024] [Accepted: 01/17/2024] [Indexed: 02/25/2024] Open
Abstract
Whilst monotherapy is traditionally the preferred treatment starting point for chronic conditions such as hypertension and diabetes, other diseases require the use of multiple drugs (polytherapy) from the onset of treatment (e.g., human immunodeficiency virus acquired immunodeficiency syndrome, tuberculosis, and malaria). Successful treatment of these chronic conditions is sometimes hampered by patient non-adherence to polytherapy. The options available for polytherapy are either the sequential addition of individual drug products to deliver an effective multi-drug regimen or the use of a single fixed-dose combination (FDC) therapy product. This article intends to critically review the use of FDC drug therapy and provide an insight into FDC products which are already commercially available. Shortcomings of FDC formulations are discussed from multiple perspectives and research gaps are identified. Moreover, an overview of fundamental formulation considerations is provided to aid formulation scientists in the design and development of new FDC products.
Collapse
Affiliation(s)
| | | | | | - Jan H. Steenekamp
- Centre of Excellence for Pharmaceutical Sciences (Pharmacen™), Faculty of Health Sciences, North-West University, Private Bag X6001, Potchefstroom 2520, South Africa; (C.A.W.); (H.H.); (J.H.H.)
| |
Collapse
|
5
|
Zhang W, Zhang Q, Cao Z, Zheng L, Hu W. Physiologically Based Pharmacokinetic Modeling in Neonates: Current Status and Future Perspectives. Pharmaceutics 2023; 15:2765. [PMID: 38140105 PMCID: PMC10747965 DOI: 10.3390/pharmaceutics15122765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/07/2023] [Accepted: 12/09/2023] [Indexed: 12/24/2023] Open
Abstract
Rational drug use in special populations is a clinical problem that doctors and pharma-cists must consider seriously. Neonates are the most physiologically immature and vulnerable to drug dosing. There is a pronounced difference in the anatomical and physiological profiles be-tween neonates and older people, affecting the absorption, distribution, metabolism, and excretion of drugs in vivo, ultimately leading to changes in drug concentration. Thus, dose adjustments in neonates are necessary to achieve adequate therapeutic concentrations and avoid drug toxicity. Over the past few decades, modeling and simulation techniques, especially physiologically based pharmacokinetic (PBPK) modeling, have been increasingly used in pediatric drug development and clinical therapy. This rigorously designed and verified model can effectively compensate for the deficiencies of clinical trials in neonates, provide a valuable reference for clinical research design, and even replace some clinical trials to predict drug plasma concentrations in newborns. This review introduces previous findings regarding age-dependent physiological changes and pathological factors affecting neonatal pharmacokinetics, along with their research means. The application of PBPK modeling in neonatal pharmacokinetic studies of various medications is also reviewed. Based on this, we propose future perspectives on neonatal PBPK modeling and hope for its broader application.
Collapse
Affiliation(s)
| | | | | | - Liang Zheng
- Department of Clinical Pharmacology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China; (W.Z.); (Q.Z.); (Z.C.)
| | - Wei Hu
- Department of Clinical Pharmacology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China; (W.Z.); (Q.Z.); (Z.C.)
| |
Collapse
|
6
|
Healy P, Verrest L, Felisi M, Ceci A, Della Pasqua O. Dose rationale for gabapentin and tramadol in pediatric patients with chronic pain. Pharmacol Res Perspect 2023; 11:e01138. [PMID: 37803937 PMCID: PMC10558965 DOI: 10.1002/prp2.1138] [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: 07/04/2023] [Accepted: 07/14/2023] [Indexed: 10/08/2023] Open
Abstract
Despite off-label use, the efficacy and safety of gabapentin and tramadol in pediatric patients (3 months to <18 years old) diagnosed with chronic pain has not been characterized. However, generating evidence based on randomized clinical trials in this population has been extremely challenging. The current investigation illustrates the use of clinical trial simulations (CTSs) as a tool for optimizing doses and protocol design for a prospective investigation in pediatric patients with chronic pain. Pharmacokinetic (PK) modeling and CTSs were used to describe the PKs of gabapentin and tramadol in the target population. In the absence of biomarkers of analgesia, systemic exposure (AUC, Css) was used to guide dose selection under the assumption of a comparable exposure-response (PKPD) relationship for either compound between adults and children. Two weight bands were identified for gabapentin, with doses titrated from 5 to 63 mg/kg. This yields gabapentin exposures (AUC0-8 ) of approximately 35 mg/L*h (1200 mg/day adult dose equivalent). For tramadol, median steady state concentrations between 200 and 300 ng/mL were achieved after doses of 2-5 mg/kg, but concentrations showed high interindividual variability. Simulation scenarios showed that titration steps are required to explore therapeutically relevant dose ranges taking into account the safety profile of both drugs. Gabapentin can be used t.i.d. at doses between 7-63 and 5-45 mg/kg for patients receiving gabapentin weighing <15 and ≥15 kg, respectively, whereas a t.i.d. regimen with doses between 1 and 5 mg/kg can be used for tramadol in patients who are not fast metabolisers.
Collapse
Affiliation(s)
- Paul Healy
- Clinical Pharmacology & Therapeutics Group, School of PharmacyUniversity College LondonLondonUK
| | - Luka Verrest
- Clinical Pharmacology & Therapeutics Group, School of PharmacyUniversity College LondonLondonUK
| | | | - Adriana Ceci
- Fondazione per la Ricerca Farmacologica Gianni Benzi onlusValenzanoItaly
| | - Oscar Della Pasqua
- Clinical Pharmacology & Therapeutics Group, School of PharmacyUniversity College LondonLondonUK
| |
Collapse
|
7
|
Tran HN, Nguyen TNT, Tran NTK, Nguyen LT, Vu HD, Nguyen AH, Trinh NTH. Preventability of Adverse Drug Reactions Related to Antibiotics: An Assessment Based on Spontaneous Reporting System. Ther Innov Regul Sci 2023:10.1007/s43441-023-00552-y. [PMID: 37389792 DOI: 10.1007/s43441-023-00552-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/13/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Antibiotics are commonly used in both outpatient and inpatient settings and are responsible for the majority of adverse drug reaction (ADR) reports. We aimed to characterize spontaneously reported ADRs associated with antibiotics and assessing the preventability of these ADRs in a Vietnamese setting. MATERIALS AND METHODS We conducted a retrospective descriptive study based on ADRs related to antibiotics spontaneously reported by healthcare workers to the National Pharmacovigilance Database of Vietnam (NPDV) between June 2018 and May 2019. The characteristics of included reports were descriptively analyzed. The preventability of reported ADRs was assessed using a standardized preventability scale. We identified the leading causes and described the characteristics associated with preventable ADRs (pADRs). RESULTS We included 6385 antibiotic-related reports from a total of 12,056 reports submitted to the NPDV during the study period. Beta-lactam antibiotics, mostly broad-spectrum with parenteral route, were suspected in the majority cases. The most commonly reported pADRs were allergic reactions, mostly classified under skin and subcutaneous tissue disorders. Of all included cases, 537 cases (8.4%) were deemed as associated with pADRs. Major causes of pADRs include potentially inappropriate prescribing (352/537, 65.5%) and re-administration of antibiotics causing prior allergy/allergies (99/537, 18.4%). The majority of pADRs involved the use of beta-lactam antibiotics with inappropriate indications. CONCLUSION ADRs related to antibiotic use represent more than half of ADRs spontaneously reported in Vietnam. Approximately one in every ten reported cases is associated with pADRs. The majority pADRs can be prevented through simple improvement in antibiotic prescribing practices.
Collapse
Affiliation(s)
- Ha N Tran
- National Drug Information and Adverse Drug Reaction Monitoring Centre, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - Tien N T Nguyen
- National Drug Information and Adverse Drug Reaction Monitoring Centre, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - Ngan T K Tran
- National Drug Information and Adverse Drug Reaction Monitoring Centre, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - Ly T Nguyen
- National Drug Information and Adverse Drug Reaction Monitoring Centre, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - Hoa D Vu
- National Drug Information and Adverse Drug Reaction Monitoring Centre, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - Anh H Nguyen
- National Drug Information and Adverse Drug Reaction Monitoring Centre, Hanoi University of Pharmacy, Hanoi, Vietnam.
| | - Nhung T H Trinh
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, and, PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| |
Collapse
|
8
|
Treatment with topiramate in rats during childhood causes testicular structural impairment at adulthood. J Dev Orig Health Dis 2023; 14:279-285. [PMID: 36325941 DOI: 10.1017/s2040174422000587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Topiramate (TOP) is a psychotropic drug prescribed for the treatment of epilepsy in children older than 2 years of age and for migraine prophylaxis in adolescents. There is evidence that TOP promotes negative effects on the reproductive system of male rats. This study aimed to evaluate the immediate and late treatment effects of TOP during childhood and adolescence on the male rat reproductive system. Two experimental groups received 41 mg/kg of TOP daily, by gavage, from postnatal day (PND) 16 to 28 (TOPc group) or from PND 28 to 50 (TOPa group). Control groups (CTRc group or CTRa group) received water daily. Half of the anim-als were evaluated 24 h after the end of treatment (PND 29 and PND 51, respectively) and the remainder were evaluated in adulthood (PND120). The following parameters were determined: anogenital distance, sperm evaluation, testis' histomorphometry and plasma testosterone concentration. At PND 120, the volume (CTRc:62.58 ± 2.13; TOPc: 54.54 ± 2.10*%, p = 0.018) and total length (CTRc: 25.48 ± 1.61; TOPc: 18.94 ± 2.41*, p = 0.035) of seminiferous tubules were decreased and the volume of interstitial tissue (CTRc:37.41 ± 2.13; TOPc: 45.45 ± 2.09*%, p = 0.018) and number of Leydig cells/testis (CTRc: 277.00 ± 36.70; TOPc: 400.20 ± 13.23*, p = 0.013) were increased in the TOPc group. The other parameters remained similar between the groups. Therefore, the present study contributes to our understanding that childhood treatment with TOP has an impact on the rat reproductive system in adulthood, suggesting that this period is more sensitive to TOP exposure than adolescence.
Collapse
|
9
|
Zempsky W, Bell J, Mossali VM, Kachroo P, Siddiqui K. Common Selfcare Indications of Pain Medications in Children. Paediatr Drugs 2023; 25:321-341. [PMID: 36928608 PMCID: PMC10019440 DOI: 10.1007/s40272-023-00562-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2023] [Indexed: 03/17/2023]
Abstract
Pain has a multifaceted impact on individuals worldwide, affecting their physical functioning, emotional well-being, and quality of life. Children (age < 18 years) have a high prevalence of conditions associated with pain, such as toothache, headache, earache, sore throat, and respiratory tract infections, many of which may be accompanied by fever. Globally, the pharmacologic treatment of pain in pediatric patients is limited largely to nonopioid analgesics, and dosing must account for differences in age, weight, metabolism, and risk of adverse effects. This narrative review summarizes the findings of a literature search on the pediatric indications, dosing approaches, dosing guidelines, and pharmacokinetics of paracetamol and ibuprofen, which are common pain medications available globally for self-care use in children. The review also discusses the risks and benefits associated with these agents. The current roles of paracetamol and ibuprofen in the symptomatic management of coronavirus disease 2019 (COVID-19) infection and in the management of post-COVID-19 immunization symptoms in children are also discussed. Therefore, while a very large amount of data over several decades is available for paracetamol and ibuprofen, an urgent need exists for well-designed studies of these medications for the management of pain and fever in pediatric patients with COVID-19 to ensure optimal relief with minimal toxicity.
Collapse
Affiliation(s)
- William Zempsky
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, 06106, USA. .,University of Connecticut School of Medicine, Farmington, CT, USA.
| | - John Bell
- Graduate School of Health, University of Technology Sydney, Sydney, Australia
| | | | | | | |
Collapse
|
10
|
Stašek J, Keller F, Kočí V, Klučka J, Klabusayová E, Wiewiorka O, Strašilová Z, Beňovská M, Škardová M, Maláska J. Update on Therapeutic Drug Monitoring of Beta-Lactam Antibiotics in Critically Ill Patients—A Narrative Review. Antibiotics (Basel) 2023; 12:antibiotics12030568. [PMID: 36978435 PMCID: PMC10044408 DOI: 10.3390/antibiotics12030568] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/22/2023] [Accepted: 03/07/2023] [Indexed: 03/17/2023] Open
Abstract
Beta-lactam antibiotics remain one of the most preferred groups of antibiotics in critical care due to their excellent safety profiles and their activity against a wide spectrum of pathogens. The cornerstone of appropriate therapy with beta-lactams is to achieve an adequate plasmatic concentration of a given antibiotic, which is derived primarily from the minimum inhibitory concentration (MIC) of the specific pathogen. In a critically ill patient, the plasmatic levels of drugs could be affected by many significant changes in the patient’s physiology, such as hypoalbuminemia, endothelial dysfunction with the leakage of intravascular fluid into interstitial space and acute kidney injury. Predicting antibiotic concentration from models based on non-critically ill populations may be misleading. Therapeutic drug monitoring (TDM) has been shown to be effective in achieving adequate concentrations of many drugs, including beta-lactam antibiotics. Reliable methods, such as high-performance liquid chromatography, provide the accurate testing of a wide range of beta-lactam antibiotics. Long turnaround times remain the main drawback limiting their widespread use, although progress has been made recently in the implementation of different novel methods of antibiotic testing. However, whether the TDM approach can effectively improve clinically relevant patient outcomes must be proved in future clinical trials.
Collapse
Affiliation(s)
- Jan Stašek
- Department of Internal Medicine and Cardiology, Faculty of Medicine, University Hospital Brno, Masaryk University, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Filip Keller
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 625 00 Brno, Czech Republic
| | - Veronika Kočí
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 625 00 Brno, Czech Republic
| | - Jozef Klučka
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 662 63 Brno, Czech Republic
| | - Eva Klabusayová
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 662 63 Brno, Czech Republic
| | - Ondřej Wiewiorka
- Department of Laboratory Medicine, Division of Clinical Biochemistry, University Hospital Brno, 625 00 Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Zuzana Strašilová
- Department of Laboratory Medicine, Division of Clinical Biochemistry, University Hospital Brno, 625 00 Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Pharmacology, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Miroslava Beňovská
- Department of Laboratory Medicine, Division of Clinical Biochemistry, University Hospital Brno, 625 00 Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Markéta Škardová
- Department of Clinical Pharmacy, Hospital Pharmacy, University Hospital Brno, 625 00 Brno, Czech Republic
| | - Jan Maláska
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 662 63 Brno, Czech Republic
- 2nd Department of Anaesthesiology University Hospital Brno, 620 00 Brno, Czech Republic
- Correspondence:
| |
Collapse
|
11
|
Muacevic A, Adler JR. A Comparison of Innovative App-Based Prescriptions With Conventional Prescriptions for Children by General Dentists: A Mixed Methods Study. Cureus 2023; 15:e33583. [PMID: 36788825 PMCID: PMC9910809 DOI: 10.7759/cureus.33583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 01/11/2023] Open
Abstract
Introduction Writing drug prescriptions for children with accurate drug dosages and clear instructions is a must for general dentists. A digital tool in the form of a software application (app) to write, save and share prescriptions can potentially overcome the possible limitations of handwritten prescriptions such as handwriting illegibility, errors in calculations, and incomplete descriptions. However, it is also important to assess the satisfaction of dentists with making prescriptions using a digital tool such as an android application. A mixed methods study comparing an innovative "app-based" and handwritten prescriptions in dental settings is presented. Methodology An indigenously developed and piloted app "PREscribing children made EASY (PREASY)" was used in this study. Based on the preliminary study, a sample size of 20 was found to be adequate. Twenty-two dentists participated in the study. The conventional handwritten and an Android app PREASY-based prescriptions were compared in terms of the time taken, precision of writing, and satisfaction of the dentists. Qualitative feedback regarding the PREASY app was obtained in Google Forms (Google, Inc., Mountain View, CA, USA). Results A study sample of 20 subjects was calculated based on a pilot study, and 22 dentists were recruited. The mean time taken in seconds for handwritten prescriptions (199.14 (+ 59.18)) was almost four times higher than that for app-based prescriptions (52.05 (+ 23.89)) (t-test, P < 0.00001). The accuracy of handwritten prescriptions versus app-based prescriptions was compared by two examiners independently using analysis of variance (ANOVA) in three domains: dosage accuracy, legible handwriting, and completeness of instructions, the differences (Domain 1 mean + SD: 1.04 + 0.89, Domain 2 mean + SD: 1.38 + 0.40, Domain 3 mean + SD: 0.88 + 0.58) being statistically significant (P < 0.05). The differences in the percentages of the three domains (dosage accuracy: 40.9%, legibility of handwriting: 63.6%, completeness of instructions: 18.1%) were found to be statistically significant (P < 0.05; chi-squared statistic, 9.4017). Of the participants, 59% were very satisfied, 36.3% were satisfied, and 4.5% were neutral (chi-squared test, P < 0.00001). Participants' feedback/comments were categorized under technical suggestions, dosage suggestions, criticism, and positive remarks and were thematically analyzed. Conclusion App-based prescriptions proved to be more instantaneous and detailed than handwritten ones with the majority of dentists satisfied. Valuable feedback pertaining to the limitations of the tool was obtained for improving the app. PREASY-based prescriptions could be recommended for prescribing to pediatric dental patients.
Collapse
|
12
|
Rampedi PN, Ogunrombi MO, Wesley-Smith J, Adeleke OA. A Micro-Configured Multiparticulate Reconstitutable Suspension Powder of Fixed Dose Rifampicin and Pyrazinamide: Optimal Fabrication and In Vitro Quality Evaluation. Pharmaceutics 2022; 15:pharmaceutics15010064. [PMID: 36678693 PMCID: PMC9861895 DOI: 10.3390/pharmaceutics15010064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/28/2022] Open
Abstract
The scarcity of age-appropriate pharmaceutical formulations is one of the major challenges impeding successful management of tuberculosis (TB) prevalence in minors. To this end, we designed and assessed the quality of a multiparticulate reconstitutable suspension powder containing fixed dose rifampicin and pyrazinamide (150 mg/300 mg per 5 mL) which was prepared employing solid−liquid direct dispersion coupled with timed dehydration, and mechanical pulverization. The optimized formulation had a high production yield (96.000 ± 3.270%), displayed noteworthy powder flow quality (9.670 ± 1.150°), upon reconstitution the suspension flow property was non-Newtonian and was easily redispersible with gentle manual agitation (1.720 ± 0.011 strokes/second). Effective drug loading was attained for both pyrazinamide (97.230 ± 2.570%w/w) and rifampicin (97.610 ± 0.020%w/w) and drug release followed a zero-order kinetic model (R2 = 0.990) for both drugs. Microscopic examinations confirmed drug encapsulation efficiency and showed that the particulates were micro-dimensional in nature (n < 700.000 µm). The formulation was physicochemically stable with no chemically irreversible drug-excipient interactions based on the results of characterization experiments performed. Findings from organoleptic evaluations generated an overall rating of 4.000 ± 0.000 for its attractive appearance and colour 5.000 ± 0.000 confirming its excellent taste and extremely pleasant smell. Preliminary cytotoxicity studies showed a cell viability above 70.000% which indicates that the FDC formulation was biocompatible. The optimized formulation was environmentally stable either as a dry powder or reconstituted suspension. Accordingly, a stable and palatable FDC antimycobacterial reconstitutable oral suspension powder, intended for flexible dosing in children and adolescents, was optimally fabricated.
Collapse
Affiliation(s)
- Penelope N. Rampedi
- Division of Pharmaceutical Sciences, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria 0208, South Africa
| | - Modupe O. Ogunrombi
- Department of Clinical Pharmacology and Therapeutics, School of Medicine, Sefako Makgatho Health Sciences University, Pretoria 0208, South Africa
| | - James Wesley-Smith
- Electron Microscope Unit, Sefako Makgatho Health Sciences University, Pretoria 0208, South Africa
| | - Oluwatoyin A. Adeleke
- Division of Pharmaceutical Sciences, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria 0208, South Africa
- Faculty of Health, College of Pharmacy, Dalhousie University, Halifax, NS B3H 4R2, Canada
- Correspondence: or
| |
Collapse
|
13
|
Kato H, Hagihara M, Matsuda H, Iwamoto T. Gentamicin Pharmacokinetics and Optimal Dosage in Infant Patients: A Case Report and Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15360. [PMID: 36430078 PMCID: PMC9691146 DOI: 10.3390/ijerph192215360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/08/2022] [Accepted: 11/18/2022] [Indexed: 06/16/2023]
Abstract
Gentamicin is an aminoglycoside antibiotic that is mostly used for the pediatric population. While the pediatric population is classified into neonates, infants, children, and adolescents based on developmental or maturational changes, infants are often overlooked in research. Three infant cases receiving gentamicin are presented to illustrate the pharmacokinetics and optimum dosage of gentamicin. Three infant patients received gentamicin (5.6-7.5 mg/kg/day) for urinary tract infections (UTIs) or bacteremia caused by Enterobacter aerogenes. The trough (Cmin) and peak (Cpeak) concentrations of gentamicin were 0.2-1.8 and 8.9 mg/L, respectively. The Cmin of a patient receiving gentamicin at 9.0 mg/kg/day was 3.3 mg/L, and the patient showed a decrease in urinary volume. The other two patients fully recovered from the infection and did not experience any adverse events. Additionally, we reviewed three studies regarding infant patients receiving gentamicin. The studies used gentamicin therapy for Gram-negative pathogen infections and UTIs caused by Escherichia coli and Enterococcus faecalis. The Cmin and Cpeak of patients receiving gentamicin at 2.2-7.5 mg/kg/day were 0.58-2.15 mg/kg and 4.67-8.88 mg/L, respectively. All patients were cured without any adverse events. Gentamicin dosages below 7.5 mg/kg/day may be effective and safe for use in infant patients. However, the optimal dosing regimen of gentamicin in infant patients is controversial, and limited data are available.
Collapse
Affiliation(s)
- Hideo Kato
- Department of Pharmacy, Mie University Hospital, Tsu 514-8507, Japan
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Tsu 514-8507, Japan
| | - Mao Hagihara
- Department of Molecular Epidemiology and Biomedical Sciences, Aichi Medical University Hospital, Nagakute 480-1195, Japan
| | - Hiroko Matsuda
- Department of Pharmacy, Mie University Hospital, Tsu 514-8507, Japan
| | - Takuya Iwamoto
- Department of Pharmacy, Mie University Hospital, Tsu 514-8507, Japan
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Tsu 514-8507, Japan
| |
Collapse
|
14
|
Nijstad AL, de Vos-Kerkhof E, Enters-Weijnen CF, van de Wetering MD, Tissing WJE, Tibben MM, Rosing H, Lalmohamed A, Huitema ADR, Zwaan CM. Overestimation of the effect of (fos)aprepitant on intravenous dexamethasone pharmacokinetics requires adaptation of the guidelines for children with chemotherapy-induced nausea and vomiting. Support Care Cancer 2022; 30:9991-9999. [PMID: 36287279 PMCID: PMC9607815 DOI: 10.1007/s00520-022-07423-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 10/15/2022] [Indexed: 11/28/2022]
Abstract
Purpose Chemotherapy-induced nausea and vomiting (CINV) are common side effects in pediatric oncology treatment. Besides 5-HT3-antagonists, both dexamethasone and aprepitant are cornerstone drugs in controlling these side effects. Based on results of adult studies, the dexamethasone dose is reduced by 50% when combined with aprepitant, because of a drug-drug interaction, even though data on the interaction in children is lacking. The current study was developed to investigate the effect of aprepitant on dexamethasone clearance (CL) in children, in order to assess if dexamethasone dose reduction for concomitant use of aprepitant is appropriate in the current antiemetic regimen. Methods In total, 65 children (0.6–17.9 years), receiving intravenous or oral antiemetic therapy (dexamethasone ± aprepitant) as standard of care, were included. 305 dexamethasone plasma concentrations were determined using LC–MS/MS. An integrated dexamethasone and aprepitant pharmacokinetic model was developed using non-linear mixed effects modelling in order to investigate the effect of aprepitant administration on dexamethasone CL. Results In this population, dexamethasone CL in patients with concomitant administration of aprepitant was reduced by approximately 30% of the uninhibited CL (23.3 L/h (95% confidence interval 20.4–26.0)). This result is not consistent with the results of adult studies (50% reduction). This difference was not age dependent, but might be related to the route of administration of dexamethasone. Future studies are needed to assess the difference in oral/intravenous dexamethasone. Conclusion When dexamethasone is given intravenously as a component of triple therapy to prevent CINV in children, we advise to reduce the dexamethasone dose by 30% instead of 50%. Supplementary Information The online version contains supplementary material available at 10.1007/s00520-022-07423-6.
Collapse
Affiliation(s)
- A Laura Nijstad
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Evelien de Vos-Kerkhof
- Princess Máxima Center for Pediatric Oncology, Postbus 113, 3720 AC, Bilthoven, Utrecht, The Netherlands
| | - Catherine F Enters-Weijnen
- Princess Máxima Center for Pediatric Oncology, Postbus 113, 3720 AC, Bilthoven, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marianne D van de Wetering
- Princess Máxima Center for Pediatric Oncology, Postbus 113, 3720 AC, Bilthoven, Utrecht, The Netherlands
| | - Wim J E Tissing
- Princess Máxima Center for Pediatric Oncology, Postbus 113, 3720 AC, Bilthoven, Utrecht, The Netherlands.,Department of Pediatric Oncology and Hematology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Matthijs M Tibben
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hilde Rosing
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Arief Lalmohamed
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands.,Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - C Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, Postbus 113, 3720 AC, Bilthoven, Utrecht, The Netherlands. .,Department of Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.
| |
Collapse
|
15
|
Gaeta F, Conti V, Pepe A, Vajro P, Filippelli A, Mandato C. Drug dosing in children with obesity: a narrative updated review. Ital J Pediatr 2022; 48:168. [PMID: 36076248 PMCID: PMC9454408 DOI: 10.1186/s13052-022-01361-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/30/2022] [Indexed: 11/16/2022] Open
Abstract
Childhood obesity and its associated comorbidities are highly prevalent diseases that may add to any other possible health problem commonly affecting the pediatric age. Uncertainties may arise concerning drug dosing when children with obesity need pharmacologic therapies. In general, in pediatric practice, there is a tendency to adapt drug doses to a child’s total body weight. However, this method does not consider the pharmacological impact that a specific drug can have under a two-fold point of view, that is, across various age and size groups as well. Moreover, there is a need for a therapeutic approach, as much as possible tailored considering relevant interacting aspects, such as modification in metabolomic profile, drug pharmacokinetics and pharmacodynamics. Taking into account the peculiar differences between children with overweight/obesity and those who are normal weight, the drug dosage in the case of obesity, cannot be empirically determined solely by the per kg criterion. In this narrative review, we examine the pros and cons of several drug dosing methods used when dealing with children who are affected also by obesity, focusing on specific aspects of some of the drugs most frequently prescribed in real-world practice by general pediatricians and pediatric subspecialists.
Collapse
Affiliation(s)
- Francesca Gaeta
- Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Valeria Conti
- Pharmacology Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Angela Pepe
- Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Pietro Vajro
- Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Amelia Filippelli
- Pharmacology Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Claudia Mandato
- Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy.
| |
Collapse
|
16
|
Singu BS, Akpabio P, Verbeeck RK. Performance of the allometric power model in scaling from adult to paediatric antiretroviral dose in children at a Referral Hospital in Windhoek, Namibia. Afr Health Sci 2022; 22:436-441. [PMID: 36910388 PMCID: PMC9993295 DOI: 10.4314/ahs.v22i3.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background World Health Organization (WHO) advocates use of weight bands in antiretroviral therapy (ART) guidelines. Allometric scaling could be a more reliable method because it uses a non-linear approach in relating dose to body weight. This study evaluates performance of the allometric ¾ power model in comparison to WHO weight band method in children receiving ART. Methods Records of children receiving (ABC/3TC) + DTG were reviewed. Paediatric ABC/3TC dose was calculated from the adult dose using the allometric ¾ power model and compared to WHO weight band dose. Results WHO weight band strategy grouped 50.6% of the children in the 25 kg category and therefore received the adult dose of ABC/3TC (600 mg/300 mg); only 1.1% received this dose with allometric scaling. Mean dose (3.8 tablets) for the WHO weight band dosing method was found to be significantly higher (p<0.0001) than for allometric scaling (1.5 tablets). Conclusions WHO weight bands may result in the 25 kg weight category receiving a much higher dose leading to ADRs. Using allometric scaling, we recommend a weight band strategy that could improve paediatric ABC/3TC dosing.
Collapse
Affiliation(s)
- Bonifasius S Singu
- School of Pharmacy, Faculty of Health Sciences & Veterinary Medicine, University of Namibia
| | - Prisca Akpabio
- School of Pharmacy, Faculty of Health Sciences & Veterinary Medicine, University of Namibia
| | - Roger K Verbeeck
- School of Pharmacy, Faculty of Health Sciences & Veterinary Medicine, University of Namibia
| |
Collapse
|
17
|
Kato H, Hamada Y. Amikacin Therapy in Japanese Pediatric Patients: Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19041972. [PMID: 35206156 PMCID: PMC8871704 DOI: 10.3390/ijerph19041972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/06/2022] [Accepted: 02/07/2022] [Indexed: 11/16/2022]
Abstract
Children show a very wide range of physical development processes. These changes impact pharmacokinetic (PK) variability in pediatric patients. Most PK studies have been conducted on the Caucasian population. Therefore, whether current evidence of how developmental change affects PK and exposure-response relationships applies to Japanese pediatric patients remains unclear. This narrative review focuses on amikacin therapy in Japanese pediatric patients and shows the relationship between amikacin concentrations and efficacy/toxicity. Ten relevant articles were identified. Of these, nine articles were published in the 1980s. All studies reported a maximum concentration (Cmax) and minimum concentration (Cmin) of amikacin. Overall, articles reporting PK/pharmacodynamic (PD) indices and minimum inhibitory concentration (MIC) of isolated bacteria in Japanese pediatric patients is lacking, whereas all patients recovered from an infection state and showed negative cultures. Five of the included studies reported the association between Cmin and toxicity. The Cmin in three of four patients who developed toxicity was above 10 mg/L. This narrative review shows that further PK study of amikacin in Japanese pediatric patients is necessary. In particular, the pursuit of knowledge of Cmax/MIC ratio is vital. On the other hand, this review demonstrates that the optimal Cmin for Japanese pediatric patients is below 10 mg/L as a candidate concentration. However, it is noted that the number of patients who developed toxicity is very small.
Collapse
Affiliation(s)
- Hideo Kato
- Department of Pharmacy, Mie University Hospital, Tsu 514-8507, Japan
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Tsu 514-8507, Japan
- Correspondence: or ; Tel.: +81-059-232-1111
| | - Yukihiro Hamada
- Department of Pharmacy, Tokyo Women’s Medical University Hospital, Tokyo 162-8666, Japan;
| |
Collapse
|
18
|
van Rongen A, Krekels EH, Calvier EA, de Wildt SN, Vermeulen A, Knibbe CA. An update on the use of allometric and other scaling methods to scale drug clearance in children: towards decision tables. Expert Opin Drug Metab Toxicol 2022; 18:99-113. [PMID: 35018879 DOI: 10.1080/17425255.2021.2027907] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION When pediatric data are not available for a drug, allometric and other methods are applied to scale drug clearance across the pediatric age-range from adult values. This is applied when designing first-in-child studies, but also for off-label drug prescription. AREAS COVERED This review provides an overview of the systematic accuracy of allometric and other pediatric clearance scaling methods compared to gold-standard PBPK predictions. The findings are summarized in decision tables to provide a priori guidance on the selection of appropriate pediatric clearance scaling methods for both novel drugs for which no pediatric data are available and existing drugs in clinical practice. EXPERT OPINION While allometric scaling principles are commonly used to scale pediatric clearance, there is no universal allometric exponent (i.e., 1, 0.75 or 0.67) that can accurately scale clearance for all drugs from adults to children of all ages. Therefore, pediatric scaling decision tables based on age, drug elimination route, binding plasma protein, fraction unbound, extraction ratio, and/or isoenzyme maturation are proposed to a priori select the appropriate (allometric) clearance scaling method, thereby reducing the need for full PBPK-based clearance predictions. Guidance on allometric scaling when estimating pediatric clearance values is provided as well.
Collapse
Affiliation(s)
- Anne van Rongen
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Elke Hj Krekels
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Elisa Am Calvier
- Sanofi Pharmacokinetics-Dynamics and Metabolism (PKDM), Translational Medicine and Early Development, Sanofi R&D, Montpellier, France
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands.,Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - An Vermeulen
- Laboratory of Medical Biochemistry and Clinical Analysis, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium.,Janssen R&D, a division of Janssen Pharmaceutica NV, Beerse, Belgium
| | - Catherijne Aj Knibbe
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.,Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| |
Collapse
|
19
|
Clinical pharmacology of cytotoxic drugs in neonates and infants: Providing evidence-based dosing guidance. Eur J Cancer 2021; 164:137-154. [PMID: 34865945 PMCID: PMC8914347 DOI: 10.1016/j.ejca.2021.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/11/2021] [Accepted: 11/01/2021] [Indexed: 01/29/2023]
Abstract
Cancer in neonates and infants is a rare but challenging entity. Treatment is complicated by marked physiological changes during the first year of life, excess rates of toxicity, mortality, and late effects. Dose optimisation of chemotherapeutics may be an important step to improving outcomes. Body size–based dosing is used for most anticancer drugs used in infants. However, dose regimens are generally not evidence based, and dosing strategies are frequently inconsistent between tumour types and treatment protocols. In this review, we collate available pharmacological evidence supporting dosing regimens in infants for a wide range of cytotoxic drugs. A systematic review was conducted, and available data ranked by a level of evidence (1–5) and a grade of recommendation (A–D) provided on a consensus basis, with recommended dosing approaches indicated as appropriate. For 9 of 29 drugs (busulfan, carboplatin, cyclophosphamide, daunorubicin, etoposide, fludarabine, isotretinoin, melphalan and vincristine), grade A was scored, indicating sufficient pharmacological evidence to recommend a dosing algorithm for infants. For busulfan and carboplatin, sufficient data were available to recommend therapeutic drug monitoring in infants. For eight drugs (actinomycin D, blinatumomab, dinutuximab, doxorubicin, mercaptopurine, pegaspargase, thioguanine and topotecan), some pharmacological evidence was available to guide dosing (graded as B). For the remaining drugs, including commonly used agents such as cisplatin, cytarabine, ifosfamide, and methotrexate, pharmacological evidence for dosing in infants was limited or non-existent: grades C and D were scored for 10 and 2 drugs, respectively. The review provides clinically relevant evidence-based dosing guidance for cytotoxic drugs in neonates and infants. Treating cancer in neonates and infants is challenging. Dose optimisation of cytotoxic drugs is an important step to improving outcomes. Clinical pharmacological evidence supporting dosing regimens in infants was collated. All available pharmacological evidence was ranked by a level of evidence. A grade of recommendation was derived and a recommended dose per agent provided.
Collapse
|
20
|
Lim GY, Chen CL, Chan Wei Shih D. Utility and Safety of Perampanel in Pediatric FIRES and Other Drug-Resistant Epilepsies. Child Neurol Open 2021; 8:2329048X211055335. [PMID: 34820471 PMCID: PMC8606971 DOI: 10.1177/2329048x211055335] [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: 07/09/2021] [Revised: 09/17/2021] [Accepted: 10/01/2021] [Indexed: 11/15/2022] Open
Abstract
Perampanel is a novel antiepileptic drug, which antagonises AMPA (alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) glutamate receptor. We describe perampanel as an adjunctive treatment for FIRES (febrile infection-related epilepsy syndrome) and other drug-resistant epilepsies. A single-centre, observational, retrospective study involving 20 pediatric patients was conducted. Perampanel was started for three patients with FIRES, achieving seizure cessation in two patients within a day and on days 19 and 32 of illness. Doses used ranged from 4 to 12 mg/day, without any adverse effects reported or discontinuation of therapy. Responder-rate for other drug-resistant epilepsies is 25%. Median time to achieve ≥50% seizure reduction was 80 days (range: 26-326 days). Adverse effect reported in 47% of the patients includes central nervous system-related, and thrombocytopenia. Eight patients discontinued perampanel, because of ineffectiveness or adverse effects. The median time on perampanel before discontinuation was 179 days (range: 94-345 days). Perampanel may be of benefit in pediatrics FIRES and is of utility in other drug-resistant epilepsies.
Collapse
Affiliation(s)
- Guo Yong Lim
- Department of Pharmacy, KK Women's and Children's Hospital, Singapore, Singapore
| | - Chun Liang Chen
- Department of Pharmacy, KK Women's and Children's Hospital, Singapore, Singapore
| | - Derrick Chan Wei Shih
- Department of Pediatric Medicine, Neurology Service, KK Women's and Children's Hospital, Singapore
| |
Collapse
|
21
|
Balevic SJ, Sagcal-Gironella ACP. Precision Medicine: Towards Individualized Dosing in Pediatric Rheumatology. Rheum Dis Clin North Am 2021; 48:305-330. [PMID: 34798954 DOI: 10.1016/j.rdc.2021.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Despite an increase in the number of available therapeutics, many children with rheumatic disease continue to experience active inflammatory disease and treatment failure. One reason for treatment failure is the lack of dosing paradigms to account for the wide between-patient variability in drug pharmacokinetics because of developmental changes or genetic polymorphisms that effect drug absorption, distribution, metabolism, and elimination. This review highlights several strategies to optimize dosing for biologic and nonbiologic disease-modifying antirheumatic drugs, including therapeutic drug monitoring, pharmacogenomics, and the use of pharmacokinetic/pharmacodynamic modeling.
Collapse
Affiliation(s)
- Stephen J Balevic
- Department of Pediatrics, Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
| | - Anna Carmela P Sagcal-Gironella
- Department of Pediatrics, Hackensack Meridian School of Medicine, Nutley, NJ, USA; Division of Pediatric Rheumatology, Joseph M. Sanzari Children's Hospital, 30 Prospect Avenue, WFAN 3rd Floor, Hackensack, NJ 07601, USA; K. HovnanianChildren's Hospital, Neptune, NJ, USA
| |
Collapse
|
22
|
Balevic SJ, Becker ML, Gonzalez D, Funk RS. Low Etanercept Concentrations in Children With Obesity and Juvenile Idiopathic Arthritis. J Pediatr Pharmacol Ther 2021; 26:809-814. [PMID: 34790070 DOI: 10.5863/1551-6776-26.8.809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/14/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the impact of obesity on etanercept (ETN) drug exposure in children with juvenile idiopathic arthritis (JIA). METHODS We conducted a pilot, cross-sectional, observational study in a real-world cohort of children with JIA receiving ETN as standard of care from a single center. We analyzed the relationship between body size and ETN plasma concentrations, adjusting for dosage. Body size was analyzed as a continuous measure using weight and body mass index (BMI) percentiles and categorically using BMI percentile classifications according to the CDC guidelines. RESULTS We enrolled a total of 29 children. Each child provided one plasma sample for ETN concentration measurement, and all participants were receiving subcutaneous ETN dosed weekly. We observed that the ETN concentration normalized for dose decreased significantly as a function of weight (p = 0.004) and BMI percentile (p = 0.04). Similarly, we observed a progressive decline in mean and median dose-normalized concentrations across higher body size categories. Because of reaching maximum ETN dosage (50 mg), 7 of 8 children (87.5%) with obesity received a weight-based dosage < 0.8 mg/kg/dose. CONCLUSIONS We found that higher body weight and BMI percentile are significantly and negatively associated with ETN drug serum concentration, accounting for differences in dosing. Our data suggest that children who are obese may be routinely under-dosed using current dosing strategies. Inadequate dosing may increase the risk for therapeutic failure and long-term morbidity in a developing child. As a result, characterizing adequate drug exposure in children of all sizes is an important step toward precision dosing.
Collapse
|
23
|
Goers R, Coman Schmid D, Jäggi VF, Paioni P, Okoniewski MJ, Parker A, Bangerter B, Georgakopoulou S, Sengstag T, Bielicki J, Tilen R, Vermeul S, Krämer SD, Berger C, Rinn B, Meyer Zu Schwabedissen HE. SwissPK cdw - A clinical data warehouse for the optimization of pediatric dosing regimens. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2021; 10:1578-1587. [PMID: 34729953 PMCID: PMC8673996 DOI: 10.1002/psp4.12723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/01/2021] [Accepted: 09/17/2021] [Indexed: 11/10/2022]
Abstract
Clinical trials have been performed mainly in adults and accordingly the necessary information is lacking for pediatric patients, especially regarding dosage recommendation for approved drugs. This gap in information could be filled with results from pharmacokinetic (PK) modeling, based on data collected in daily clinical routine. In order to make this data accessible and usable for research, the Swiss Pharmacokinetics Clinical Data Warehouse (SwissPKcdw) project has been set up, including a clinical data warehouse (CDW) and the regulatory framework for data transfer and use within. Embedded into the secure BioMedIT network, the CDW can connect to various data providers and researchers in order to collaborate on the data securely. Due to its modularity, partially containerized deployment and open‐source software, each of the components can be extended, modified, and re‐used for similar projects that require integrated data management, data analysis, and web tools in a secure scientific data and information technology (IT) environment. Here, we describe a collaborative and interprofessional effort to implement the aforementioned infrastructure between several partners from medical health care and academia. Furthermore, we describe a real‐world use case where blood samples from pediatric patients were analyzed for the presence of genetic polymorphisms and the results were aggregated and further analyzed together with the health‐related patient data in the SwissPKcdw.
Collapse
Affiliation(s)
- Roland Goers
- Biopharmacy, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | | | - Vera F Jäggi
- Division of Infectious Diseases and Hospital Epidemiology, University Children's Hospital Zürich, Zürich, Switzerland
| | - Paolo Paioni
- Division of Infectious Diseases and Hospital Epidemiology, University Children's Hospital Zürich, Zürich, Switzerland
| | | | - Althea Parker
- Scientific IT Services, ETH Zürich, Zürich, Switzerland
| | - Beat Bangerter
- Division of Infectious Diseases and Hospital Epidemiology, University Children's Hospital Zürich, Zürich, Switzerland
| | | | - Thierry Sengstag
- Center for Scientific Computing, University of Basel, Basel, Switzerland.,Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Julia Bielicki
- Pediatric Pharmacology and Pharmacometrics Research, University Children's Hospital Basel, Basel, Switzerland
| | - Romy Tilen
- Biopharmacy, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland.,Division of Infectious Diseases and Hospital Epidemiology, University Children's Hospital Zürich, Zürich, Switzerland
| | - Swen Vermeul
- Scientific IT Services, ETH Zürich, Zürich, Switzerland
| | - Stefanie D Krämer
- Biopharmacy, Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zürich, Zürich, Switzerland
| | - Christoph Berger
- Division of Infectious Diseases and Hospital Epidemiology, University Children's Hospital Zürich, Zürich, Switzerland
| | - Bernd Rinn
- Scientific IT Services, ETH Zürich, Zürich, Switzerland.,Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | | |
Collapse
|
24
|
Denti P, Wasmann RE, Francis J, McIlleron H, Sugandhi N, Cressey TR, Mirochnick M, Capparelli EV, Penazzato M. One dose does not fit all: revising the WHO paediatric dosing tool to include the non-linear effect of body size and maturation. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 6:9-10. [PMID: 34678142 DOI: 10.1016/s2352-4642(21)00302-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/08/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa.
| | - Roeland E Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa
| | - Jose Francis
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Tim R Cressey
- PHPT/Institut de recherche pour le développement (IRD), MIVEGEC (Maladies Infectieuses et Vecteurs: Ecologie, Génétique, Evolution et Contrôle) Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | | | - Edmund V Capparelli
- University of California, San Diego Schools of Medicine and Skaggs School of Pharmacy, La Jolla, CA, USA
| | | |
Collapse
|
25
|
Barnett S, Hellmann F, Parke E, Makin G, Tweddle DA, Osborne C, Hempel G, Veal GJ. Vincristine dosing, drug exposure and therapeutic drug monitoring in neonate and infant cancer patients. Eur J Cancer 2021; 164:127-136. [PMID: 34657763 PMCID: PMC8914346 DOI: 10.1016/j.ejca.2021.09.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/02/2021] [Accepted: 09/16/2021] [Indexed: 01/12/2023]
Abstract
Background The anticancer drug vincristine is associated with potentially dose-limiting side-effects, including neurotoxicity and myelosuppression. However, there currently exists a lack of published clinical pharmacology data relating to its use in neonate and infant patients. We report a study investigating vincristine dosing and drug exposure, alongside the feasibility and impact of a therapeutic drug monitoring treatment approach, in this challenging patient population. Patients and methods Vincristine pharmacokinetic data from a total of 57 childhood cancer patients, including 26 neonates and infants, were used to characterise a population pharmacokinetic model. Vincristine was administered at doses of 0.02–0.05 mg/kg or 0.75–1.5 mg/m2 in neonates and infants aged <1 year or ≤12 kg and doses of 1.5 mg/m2 in older children. Results A two-compartment model provided the best fit for the population analysis. There was no significant difference in vincristine clearance normalised for body surface area between neonates/infants and older children. Lower doses administered to neonates and infants resulted in significantly lower drug exposures (area under the curve [AUC]), compared with older children (p = 0.047). Vincristine doses of <0.05 mg/kg in neonates and infants resulted in significantly lower AUC values than observed in those receiving doses of ≥0.05 mg/kg (p ≤ 0.0001). Therapeutic drug monitoring was shown to be feasible, effective and well tolerated in neonates and infants experiencing suboptimal drug exposures. Conclusion Doses of <0.05 mg/kg should not be used in neonate and infant patients because of a high risk of patients experiencing potentially suboptimal drug exposures. Therapeutic drug monitoring approaches in neonates and infants are supported by the data generated, with a proposed target therapeutic window of 50–100 μg/l∗h. Vincristine dosing and drug exposure was investigated in neonates and infants. Vincristine concentrations were quantified in 210 plasma samples from 57 children. Lower drug exposures were observed in infants and neonates compared with older children. Therapeutic drug monitoring can be used to avoid suboptimal vincristine drug exposures. Vincristine dosing guidance is provided for treatment of neonate and infant patients.
Collapse
Affiliation(s)
- Shelby Barnett
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
| | - Farina Hellmann
- Department of Pharmaceutical and Medical Chemistry, University of Münster, Münster, Germany
| | - Elizabeth Parke
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
| | - Guy Makin
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Royal Manchester Children's Hospital, Manchester, UK
| | - Deborah A Tweddle
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK; Great North Children's Hospital, Newcastle, UK
| | - Caroline Osborne
- Pharmacy Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, University of Münster, Münster, Germany
| | - Gareth J Veal
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK.
| |
Collapse
|
26
|
Suk JW, Soltis-Vaughan B, Mahato K, Hwang S. Practical and Ethical Issues in Pediatric Psychopharmacology: Introductory Considerations. Psychiatr Ann 2021. [DOI: 10.3928/00485713-20210913-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
27
|
Pharmacokinetics of Antibiotics in Pediatric Intensive Care: Fostering Variability to Attain Precision Medicine. Antibiotics (Basel) 2021; 10:antibiotics10101182. [PMID: 34680763 PMCID: PMC8532953 DOI: 10.3390/antibiotics10101182] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 12/16/2022] Open
Abstract
Children show important developmental and maturational changes, which may contribute greatly to pharmacokinetic (PK) variability observed in pediatric patients. These PK alterations are further enhanced by disease-related, non-maturational factors. Specific to the intensive care setting, such factors include critical illness, inflammatory status, augmented renal clearance (ARC), as well as therapeutic interventions (e.g., extracorporeal organ support systems or whole-body hypothermia [WBH]). This narrative review illustrates the relevance of both maturational and non-maturational changes in absorption, distribution, metabolism, and excretion (ADME) applied to antibiotics. It hereby provides a focused assessment of the available literature on the impact of critical illness—in general, and in specific subpopulations (ARC, extracorporeal organ support systems, WBH)—on PK and potential underexposure in children and neonates. Overall, literature discussing antibiotic PK alterations in pediatric intensive care is scarce. Most studies describe antibiotics commonly monitored in clinical practice such as vancomycin and aminoglycosides. Because of the large PK variability, therapeutic drug monitoring, further extended to other antibiotics, and integration of model-informed precision dosing in clinical practice are suggested to optimise antibiotic dose and exposure in each newborn, infant, or child during intensive care.
Collapse
|
28
|
Webb EL, Edielu A, Wu HW, Kabatereine NB, Tukahebwa EM, Mubangizi A, Adriko M, Elliott AM, Hope WW, Mawa PA, Friedman JF, Bustinduy AL. The praziquantel in preschoolers (PIP) trial: study protocol for a phase II PK/PD-driven randomised controlled trial of praziquantel in children under 4 years of age. Trials 2021; 22:601. [PMID: 34488846 PMCID: PMC8419815 DOI: 10.1186/s13063-021-05558-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/19/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Over 200 million individuals worldwide are infected with Schistosoma species, with over half of infections occurring in children. Many children experience first infections early in life and this impacts their growth and development; however praziquantel (PZQ), the drug used worldwide for the treatment of schistosomiasis, only has regulatory approval among adults and children over the age of four, although it is frequently used "off label" in endemic settings. Furthermore, pharmacokinetic/pharmacodynamics (PK/PD) evidence suggests the standard PZQ dose of 40 mg/kg is insufficient in preschool-aged children (PSAC). Our goal is to understand the best approaches to optimising the treatment of PSAC with intestinal schistosomiasis. METHODS We will conduct a randomised, controlled phase II trial in a Schistosoma mansoni endemic region of Uganda and a Schistosoma japonicum endemic region of the Philippines. Six hundred children, 300 in each setting, aged 12-47 months with Schistosoma infection will be randomised in a 1:1:1:1 ratio to receive either (1) 40 mg/kg PZQ at baseline and placebo at 6 months, (2) 40 mg/kg PZQ at baseline and 40 mg/kg PZQ at 6 months, (3) 80 mg/kg PZQ at baseline and placebo at 6 months, or (4) 80 mg/kg PZQ at baseline and 80 mg/kg PZQ at 6 months. Following baseline treatment, children will be followed up for 12 months. The co-primary outcomes will be cure rate and egg reduction rate at 4 weeks. Secondary outcomes include drug efficacy assessed by novel antigenic endpoints at 4 weeks, actively collected adverse events and toxicity for 12 h post-treatment, morbidity and nutritional outcomes at 6 and 12 months, biomarkers of inflammation and environmental enteropathy and PZQ PK/PD parameters. DISCUSSION The trial will provide valuable information on the safety and efficacy of the 80 mg/kg PZQ dose in PSAC, and on the impact of six-monthly versus annual treatment, in this vulnerable age group. TRIAL REGISTRATION ClinicalTrials.gov NCT03640377 . Registered on 21 Aug 2018.
Collapse
Affiliation(s)
- Emily L Webb
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK.
| | - Andrew Edielu
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Hannah W Wu
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA.,Center for International Health Research, Lifespan Hospital, Providence, RI, USA
| | | | | | | | - Moses Adriko
- Vector Control Division, Ministry of Health, Kampala, Uganda
| | - Alison M Elliott
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - William W Hope
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool, UK.,Royal Liverpool, Broadgreen University Hospital Trust, Liverpool Health Partners, Liverpool, UK
| | - Patrice A Mawa
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda.,Department of Immunology, Uganda Virus Research Institute, Entebbe, Uganda.,Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
| | - Jennifer F Friedman
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA.,Center for International Health Research, Lifespan Hospital, Providence, RI, USA
| | - Amaya L Bustinduy
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
29
|
Chabala C, Turkova A, Hesseling AC, Zimba KM, van der Zalm M, Kapasa M, Palmer M, Chirehwa M, Wiesner L, Wobudeya E, Kinikar A, Mave V, Hissar S, Choo L, LeBeau K, Mulenga V, Aarnoutse R, Gibb D, McIlleron H. Pharmacokinetics of first-line drugs in children with tuberculosis using WHO-recommended weight band doses and formulations. Clin Infect Dis 2021; 74:1767-1775. [PMID: 34420049 PMCID: PMC9155615 DOI: 10.1093/cid/ciab725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Indexed: 11/15/2022] Open
Abstract
Background Dispersible pediatric fixed-dose combination (FDC) tablets delivering higher doses of first-line antituberculosis drugs in World Health Organization–recommended weight bands were introduced in 2015. We report the first pharmacokinetic data for these FDC tablets in Zambian and South African children in the treatment-shortening SHINE trial. Methods Children weighing 4.0–7.9, 8.0–11.9, 12.0–15.9, or 16.0–24.9 kg received 1, 2, 3, or 4 tablets daily, respectively (rifampicin/isoniazid/pyrazinamide [75/50/150 mg], with or without 100 mg ethambutol, or rifampicin/isoniazid [75/50 mg]). Children 25.0–36.9 kg received doses recommended for adults <37 kg (300, 150, 800, and 550 mg/d, respectively, for rifampicin, isoniazid, pyrazinamide, and ethambutol). Pharmacokinetics were evaluated after at least 2 weeks of treatment. Results In the 77 children evaluated, the median age (interquartile range) was 3.7 (1.4–6.6) years; 40 (52%) were male and 20 (26%) were human immunodeficiency virus positive. The median area under the concentration-time curve from 0 to 24 hours for rifampicin, isoniazid, pyrazinamide, and ethambutol was 32.5 (interquartile range, 20.1–45.1), 16.7 (9.2–25.9), 317 (263–399), and 9.5 (7.5–11.5) mg⋅h/L, respectively, and lower in children than in adults for rifampicin in the 4.0–7.9-, 8–11.9-, and ≥25-kg weight bands, isoniazid in the 4.0–7.9-kg and ≥25-kg weight bands, and ethambutol in all 5 weight bands. Pyrazinamide exposures were similar to those in adults. Conclusions Recommended weight band–based FDC doses result in lower drug exposures in children in lower weight bands and in those ≥25 kg (receiving adult doses). Further adjustments to current doses are needed to match current target exposures in adults. The use of ethambutol at the current World Health Organization–recommended doses requires further evaluation.
Collapse
Affiliation(s)
- Chishala Chabala
- University of Zambia, School of Medicine, Department of Paediatrics, Lusaka, Zambia.,University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa.,University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Anna Turkova
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Anneke C Hesseling
- University of Stellenbosch, Desmond Tutu Tuberculosis Centre, Cape Town, South Africa
| | - Kevin M Zimba
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Marieke van der Zalm
- University of Stellenbosch, Desmond Tutu Tuberculosis Centre, Cape Town, South Africa
| | - Monica Kapasa
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Megan Palmer
- University of Stellenbosch, Desmond Tutu Tuberculosis Centre, Cape Town, South Africa
| | - Maxwell Chirehwa
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Lubbe Wiesner
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Eric Wobudeya
- Makerere University-John Hopkins University Care Ltd, Kampala, Uganda
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Syed Hissar
- India Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Louise Choo
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Kristen LeBeau
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Veronica Mulenga
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Robb Aarnoutse
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Diana Gibb
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Helen McIlleron
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
30
|
Kim C, Park K, McMahon AW, Green FG, Green DJ, Burckart GJ. Drug Safety in Labeling for Pediatric Drug Development and Dose Selection in Submissions to the US Food and Drug Administration. J Clin Pharmacol 2021; 61 Suppl 1:S133-S140. [PMID: 34185899 DOI: 10.1002/jcph.1864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/26/2021] [Indexed: 11/12/2022]
Abstract
Pediatric safety evaluations are an essential part of a pediatric drug development program. Communication of the results of these safety evaluations is primarily accomplished by labeling of the drug either during the initial pediatric drug development program, or during the postmarketing period after drug approval for pediatric patients. During drug development, the dose-adverse drug event (ADE) relationship is an important part of the evaluation, but a consideration for pediatric ADEs that are unrelated to drug dosage must be maintained. Examples of dose-related and non-dose-related ADEs are presented. The failure to label a product for pediatric use has been safety related for a number of development programs. The US Food and Drug Administration's Pediatric Advisory Committee is a primary source of the pediatric postmarketing safety review and has been associated with a number of labeling changes through its ongoing review process. Pediatric drug safety remains a critical part of the assessment of dose-effect relationship in the pediatric patient population during the drug development and postmarketing surveillance process.
Collapse
Affiliation(s)
- Clara Kim
- University of Southern California School of Pharmacy, Los Angeles, California, USA
| | - Kyunghun Park
- Office of Clinical Pharmacology, US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, Maryland, USA
| | - Ann W McMahon
- Office of the Commissioner, US Food and Drug Administration, Office of Pediatric Therapeutics, Silver Spring, Maryland, USA
| | - Francis G Green
- Office of Clinical Pharmacology, US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, Maryland, USA
| | - Dionna J Green
- Office of the Commissioner, US Food and Drug Administration, Office of Pediatric Therapeutics, Silver Spring, Maryland, USA
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, Maryland, USA
| |
Collapse
|
31
|
Oosterholt SP, Della Pasqua O. Extrapolation and dosing recommendations for raxibacumab in children from birth to age <18 years. Br J Clin Pharmacol 2021; 87:4709-4717. [PMID: 33974281 DOI: 10.1111/bcp.14893] [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: 12/11/2020] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 11/27/2022] Open
Abstract
AIMS The US Food and Drug Administration's Animal Rule allows for the approval of drugs when human efficacy studies are not ethical. While the therapeutic doses of raxibacumab, a monoclonal antibody for the prophylaxis and treatment of inhalational anthrax, have been based on pharmacokinetic data from adult subjects, its disposition in children has not been investigated in clinical trials. Here we evaluate the effect of demographic covariates and maturation processes on the pharmacokinetics of raxibacumab and explore opportunities for the optimisation of paediatric doses. METHODS A population pharmacokinetic model was used as basis for the extrapolation of raxibacumab disposition from adults to children. Different extrapolation scenarios, including weight-banded dosing regimens, were considered to assess the effect of growth and maturation on the pharmacokinetic parameters of interest. Area under the concentration-time curve, maximum plasma concentration and the time of serum raxibacumab concentrations greater than or equimolar to the highest serum protective antigen concentrations observed for at least 28 days in any monkey challenged with Bacillus anthracis that died were derived and compared with the currently approved US doses. RESULTS Based on practical considerations, a weight-banded dosing regimen consisting of 4 dose levels (75 mg/kg for individuals ≤1.5 kg, 55 mg/kg for individuals <10 kg, 45 mg/kg for individuals <50 kg, 40 mg/kg for all individuals >50 kg) was required to optimise target exposure across the paediatric population. CONCLUSIONS Age-related maturation processes may affect raxibacumab clearance in very young patients. The proposed dosing regimens take into account effects of body weight and maturation processes on the elimination of raxibacumab.
Collapse
Affiliation(s)
- Sean P Oosterholt
- Clinical Pharmacology & Therapeutics Group, University College London, UK
| | - Oscar Della Pasqua
- Clinical Pharmacology & Therapeutics Group, University College London, UK.,Clinical Pharmacology Modelling and Simulation, GlaxoSmithKline, Brentford, UK
| |
Collapse
|
32
|
Orito Y, Kakara M, Okada A, Nagai N. Model-based approach to sampling optimization in studies of antibacterial drugs for infants and young children. Clin Transl Sci 2021; 14:1543-1553. [PMID: 33742784 PMCID: PMC8301546 DOI: 10.1111/cts.13018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 02/02/2021] [Accepted: 02/17/2021] [Indexed: 11/28/2022] Open
Abstract
Clinical trials for pediatric indications and new pediatric drugs face challenges, including the limited blood volume due to the patients’ small bodies. In Japan, the Evaluation Committee on Unapproved or Off‐labeled Drugs with High Medical Needs has discussed the necessity of pediatric indications against the background of a lack of Japanese pediatric data. The limited treatment options regarding antibiotics for pediatric patients are associated with the emergence of antibiotic‐resistant bacteria. Regulatory guidelines promote the use of model‐based drug development to reduce practical and ethical constraints for pediatric patients. Sampling optimization is one of the key study designs for pediatric drug development. In this simulation study, we evaluated the precision of the empirical Bayes estimates of pharmacokinetic (PK) parameters based on the sampling times optimized by published pediatric population PK models. We selected three previous PK studies of cefepime and ciprofloxacin in infants and young children as paradigms. The number of sampling times was reduced from original full sampling times to two to four sampling times based on the Fisher information matrix. We observed that the precision of empirical Bayes estimates of the key PK parameters and the predicted efficacy based on the reduced sampling times were generally comparable to those based on the original full sampling times. The model‐based approach to sampling optimization provided a maximization of PK information with a minimum burden on infants and young children for the future development of pediatric drugs.
Collapse
|
33
|
D'Agate S, Musuamba FT, Jacqz-Aigrain E, Della Pasqua O. Simplified Dosing Regimens for Gentamicin in Neonatal Sepsis. Front Pharmacol 2021; 12:624662. [PMID: 33762945 PMCID: PMC7982486 DOI: 10.3389/fphar.2021.624662] [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: 10/31/2020] [Accepted: 01/04/2021] [Indexed: 11/30/2022] Open
Abstract
Background: The effectiveness of antibiotics for the treatment of severe bacterial infections in newborns in resource-limited settings has been determined by empirical evidence. However, such an approach does not warrant optimal exposure to antibiotic agents, which are known to show different disposition characteristics in this population. Here we evaluate the rationale for a simplified regimen of gentamicin taking into account the effect of body size and organ maturation on pharmacokinetics. The analysis is supported by efficacy data from a series of clinical trials in this population. Methods: A previously published pharmacokinetic model was used to simulate gentamicin concentration vs. time profiles in a virtual cohort of neonates. Model predictive performance was assessed by supplementary external validation procedures using therapeutic drug monitoring data collected in neonates and young infants with or without sepsis. Subsequently, clinical trial simulations were performed to characterize the exposure to intra-muscular gentamicin after a q.d. regimen. The selection of a simplified regimen was based on peak and trough drug levels during the course of treatment. Results: In contrast to current World Health Organization guidelines, which recommend gentamicin doses between 5 and 7.5 mg/kg, our analysis shows that gentamicin can be used as a fixed dose regimen according to three weight-bands: 10 mg for patients with body weight <2.5 kg, 16 mg for patients with body weight between 2.5 and 4 kg, and 30 mg for those with body weight >4 kg. Conclusion: The choice of the dose of an antibiotic must be supported by a strong scientific rationale, taking into account the differences in drug disposition in the target patient population. Our analysis reveals that a simplified regimen is feasible and could be used in resource-limited settings for the treatment of sepsis in neonates and young infants with sepsis aged 0–59 days.
Collapse
Affiliation(s)
- S D'Agate
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
| | - F Tshinanu Musuamba
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
| | - E Jacqz-Aigrain
- Department of Paediatric Pharmacology and Pharmacogenetics, Centre Hospitalier Universitaire, Hôpital Robert Debré, Paris, France
| | - O Della Pasqua
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
| |
Collapse
|
34
|
Can filaments be stored as a shelf-item for on-demand manufacturing of oral 3D printed tablets? An initial stability assessment. Int J Pharm 2021; 600:120442. [PMID: 33675925 DOI: 10.1016/j.ijpharm.2021.120442] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 12/13/2022]
Abstract
3D printing of oral solid dosage forms is a recently introduced approach for dose personalisation. Fused deposition modelling (FDM) is one of the promising and heavily researched 3D printing techniques in the pharmaceutical field. However, the successful application of this technique relies greatly on the mass manufacturing of physically and chemically stable filaments, that can be readily available as a shelf item to be 3D printed on-demand. In this work, the stability of methacrylate polymers (Eudragit EPO, RL, L100-55 and S100), hydroxypropyl cellulose (HPC SSL) and polyvinyl pyrrolidone (PVP)-based filaments over 6 months were investigated. Filaments manufactured by hot melt extrusion (HME) were stored at either 5 °C or 30 °C + 65 %RH with/without vacuuming. The effects of storage on their dimensions, visual appearance, thermal properties, and 'printability' were analysed. Theophylline content, as well as in vitro release from the 3D printed tablets were also investigated. The filaments were analysed before storage, then after 1, 3 and 6 months from the manufacturing date. Storing the filaments at these conditions had a significant effect on their physical properties, such as shape, dimensions, flexibility and hence compatibility with FDM 3D printing. In general, the methacrylate-based filaments were more physically stable and compatible with FDM 3D printing following storage. Owing to their hygroscopic nature, cellulose- and PVP-based filaments demonstrated a reduction in their glass transition temperature upon storage, leading to increased flexibility and incompatibility with FDM 3D printer. Theophylline contents was not significantly changed during the storage. This work provides preliminary data for the impact of polymer species on the long-term stability of filaments. In general, storage and packaging conditions have a major impact on the potential of on-demand manufacturing of 3D printed tablets using hot melt extruded filaments.
Collapse
|
35
|
Min JY, Lee JR, Kang YS, Ho JH, Byon HJ. Pediatric characteristics and the dose of propofol for sedation during radiological examinations: a retrospective analysis. J Int Med Res 2021; 49:300060521990992. [PMID: 33641471 PMCID: PMC7923994 DOI: 10.1177/0300060521990992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE The present study aimed to investigate patients' characteristics that can affect the dose of propofol required to sedate children undergoing imaging. METHODS In this retrospective, observational study, we reviewed medical records of children aged 0 to 18 years who were classified as having American Society of Anesthesiologists status 1 or 2 and they underwent imaging under propofol sedation between January 2011 and August 2016. Collected data included patients' demographics, propofol doses, duration of sedation, and complications. Regression analysis was performed to determine patients' characteristics that may affect the dose of propofol required to induce sedation. RESULTS A total of 925 patients were included. Simple linear regression showed that the dose of propofol was correlated with age, height, weight, and body surface area. Using the results of multiple linear regression, the following formula was used to estimate the dose of propofol (mg) for sedation: 0.75 + 0.14 × age (months) + 45.82 × body surface area (m2). CONCLUSION A child's age, height, and body surface area should be considered when deciding the induction dose of propofol. Additionally, the formula that we have proposed can be used to estimate the dose of propofol required to induce sedation in children undergoing imaging.
Collapse
Affiliation(s)
- Ji Young Min
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Rim Lee
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yhen Seoung Kang
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, National Insurance Service Ilsan Hospital, Ilsan, Republic of Korea
| | - Jung Hwan Ho
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, National Insurance Service Ilsan Hospital, Ilsan, Republic of Korea
| | - Hyo Jin Byon
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| |
Collapse
|
36
|
Abdulla A, Edwina EE, Flint RB, Allegaert K, Wildschut ED, Koch BCP, de Hoog M. Model-Informed Precision Dosing of Antibiotics in Pediatric Patients: A Narrative Review. Front Pediatr 2021; 9:624639. [PMID: 33708753 PMCID: PMC7940353 DOI: 10.3389/fped.2021.624639] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 02/03/2021] [Indexed: 12/17/2022] Open
Abstract
Optimal pharmacotherapy in pediatric patients with suspected infections requires understanding and integration of relevant data on the antibiotic, bacterial pathogen, and patient characteristics. Because of age-related physiological maturation and non-maturational covariates (e.g., disease state, inflammation, organ failure, co-morbidity, co-medication and extracorporeal systems), antibiotic pharmacokinetics is highly variable in pediatric patients and difficult to predict without using population pharmacokinetics models. The intra- and inter-individual variability can result in under- or overexposure in a significant proportion of patients. Therapeutic drug monitoring typically covers assessment of pharmacokinetics and pharmacodynamics, and concurrent dose adaptation after initial standard dosing and drug concentration analysis. Model-informed precision dosing (MIPD) captures drug, disease, and patient characteristics in modeling approaches and can be used to perform Bayesian forecasting and dose optimization. Incorporating MIPD in the electronic patient record system brings pharmacometrics to the bedside of the patient, with the aim of a consisted and optimal drug exposure. In this narrative review, we evaluated studies assessing optimization of antibiotic pharmacotherapy using MIPD in pediatric populations. Four eligible studies involving amikacin and vancomycin were identified from 418 records. Key articles, independent of year of publication, were also selected to highlight important attributes of MIPD. Although very little research has been conducted until this moment, the available data on vancomycin indicate that MIPD is superior compared to conventional dosing strategies with respect to target attainment. The utility of MIPD in pediatrics needs to be further confirmed in frequently used antibiotic classes, particularly aminoglycosides and beta-lactams.
Collapse
Affiliation(s)
- Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Elma E Edwina
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Robert B Flint
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands.,Division of Neonatology, Department of Pediatrics, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Enno D Wildschut
- Department of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Matthijs de Hoog
- Department of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| |
Collapse
|
37
|
Zempsky WT, Bhagat PK, Siddiqui K. Practical Challenges-Use of Paracetamol in Children and Youth Who are Overweight or Obese: A Narrative Review. Paediatr Drugs 2020; 22:525-534. [PMID: 32918268 PMCID: PMC7529628 DOI: 10.1007/s40272-020-00417-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Worldwide, > 380 million children and adolescents are overweight or obese, including 41 million children aged < 5 years. Obesity can change the pharmacokinetic properties of drugs by altering their distribution, metabolism, and elimination. Thus, children who are overweight or obese are at increased risk for receiving inappropriate doses of commonly used drugs, which can result in treatment failure, adverse events, and/or drug toxicity. This review analyzes available data on paracetamol dosing for pain and fever in children and adolescents who are overweight or obese to identify gaps and challenges in optimal dosing strategies. Literature searches using Medline, Embase, and ClinicalTrials.gov were conducted to identify English-language articles reporting paracetamol pharmacokinetics, dosing practices, and guidelines in children and adolescents who are overweight or obese. Of 24 relevant studies identified, 20 were specific to overweight/obese individuals and 15 were specific to children and/or adolescents. Data on paracetamol pharmacokinetics in children and adolescents who are overweight or obese are lacking, and there is no high-quality evidence to guide paracetamol prescribing practices in these patients. Adult data have been extrapolated to pediatric populations; however, extrapolation does not address differences in paracetamol metabolism in adults versus children; the efficacy and safety effects of such differences are unknown. Given the growing worldwide prevalence of obesity in children and adolescents and the likelihood that paracetamol use in this population will increase accordingly, obesity-specific pediatric dosing guidelines for paracetamol are urgently needed. High-quality research is necessary to inform such guidelines.
Collapse
Affiliation(s)
- William T Zempsky
- Department of Pediatrics, Connecticut Children's Medical Center, University of Connecticut, 282 Washington St, Hartford, CT, 06106, USA.
| | - Preeti K Bhagat
- Consumer Healthcare R & D, GlaxoSmithKline Consumer Healthcare, Singapore, Singapore
| | - Kamran Siddiqui
- Consumer Healthcare R & D, GlaxoSmithKline Consumer Healthcare, Singapore, Singapore
| |
Collapse
|
38
|
D'Agate S, Musuamba FT, Della Pasqua O. Dose Rationale for Amoxicillin in Neonatal Sepsis When Referral Is Not Possible. Front Pharmacol 2020; 11:521933. [PMID: 33117151 PMCID: PMC7549385 DOI: 10.3389/fphar.2020.521933] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 08/24/2020] [Indexed: 01/17/2023] Open
Abstract
Background Despite the widespread use of amoxicillin in young children, efforts to establish the feasibility of simplified dosing regimens in resource-limited settings have relied upon empirical evidence of efficacy. Given the antibacterial profile of beta-lactams, understanding of the determinants of pharmacokinetic variability may provide a more robust guidance for the selection of a suitable regimen. Here we propose a simplified dosing regimen based on pharmacokinetic-pharmacodynamic principles, taking into account the impact of growth, renal maturation and disease processes on the systemic exposure to amoxicillin. Materials and Methods A meta-analytical modeling approach was applied to allow the adaptation of an existing pharmacokinetic model for amoxicillin in critically ill adults. Model parameterization was based on allometric concepts, including a maturation function. Clinical trial simulations were then performed to characterize exposure, as defined by secondary pharmacokinetic parameters (AUC, Cmax, Cmin) and T>MIC. The maximization of the T>MIC was used as criterion for the purpose of this analysis and results compared to current WHO guidelines. Results A two-compartment model with first order absorption and elimination was found to best describe the pharmacokinetics of amoxicillin in the target population. In addition to the changes in clearance and volume distribution associated with demographic covariates, our results show that sepsis alters drug distribution, leading to lower amoxicillin levels and longer half-life as compared to non-systemic disease conditions. In contrast to the current WHO guidelines, our analysis reveals that amoxicillin can be used as a fixed dose regimen including two weight bands: 125 mg b.i.d. for patients with body weight < 4.0 kg and 250 mg b.i.d. for patients with body weight ≥ 4.0 kg. Conclusions In addition to the effect of developmental growth and renal maturation, sepsis also alters drug disposition. The use of a model-based approach enabled the integration of these factors when defining the dose rationale for amoxicillin. A simplified weight-banded dosing regimen should be considered for neonates and young infants with sepsis when referral is not possible.
Collapse
Affiliation(s)
- Salvatore D'Agate
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
| | - Flora Tshinanu Musuamba
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
| | - Oscar Della Pasqua
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
| |
Collapse
|
39
|
Crass RL, Pai MP. Optimizing Estimated Glomerular Filtration Rate to Support Adult to Pediatric Pharmacokinetic Bridging Studies in Patients with Cystic Fibrosis. Clin Pharmacokinet 2020; 58:1323-1332. [PMID: 30972695 DOI: 10.1007/s40262-019-00761-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The estimated glomerular filtration rate (eGFR) is often used to model drug clearance (CL) and scale doses across age and body size. Over their lifetime, patients with cystic fibrosis (CF) receive repeated courses of tobramycin, an antibiotic with eGFR-dependent CL, for the treatment of pulmonary exacerbations. Tobramycin population pharmacokinetic (PK) modeling can be used to decipher the best approach to define eGFR for pediatric bridging studies. METHODS Inpatients with CF who received intravenous tobramycin between 1 January 2006 and 30 May 2018 were eligible for inclusion. Encounters without tobramycin concentration measurement or missing covariate data were excluded. Population PK analysis was performed using NONMEM.Covariate models were built following identification of the base model, with specific emphasis on the effect of different methods of estimating renal function as a covariate of tobramycin CL. RESULTS A total of 296 CF patients contributed 1029 care encounters (420 pediatric, 609 adult) and 4352 tobramycin concentrations to this analysis. The median (minimum, maximum) age at encounter was 19 years (0.2, 60), with serum creatinine of 0.60 mg/dL (0.10, 3.41). A two-compartment model best described the observed data, with height and eGFR as significant covariates of tobramycin CL. eGFR was best modeled using a combination of the modified Schwartz and Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) equations expressed in absolute units. CONCLUSIONS The CKDEPI equation bridges PK data generated in adults to adolescents with CF better than the current regulatory standard. The eGFR should be expressed in absolute units (mL/min) for PK analyses.
Collapse
Affiliation(s)
- Ryan L Crass
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, MI, 48109, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, MI, 48109, USA.
| |
Collapse
|
40
|
Prediction of lisinopril pediatric dose from the reference adult dose by employing a physiologically based pharmacokinetic model. BMC Pharmacol Toxicol 2020; 21:56. [PMID: 32727574 PMCID: PMC7389632 DOI: 10.1186/s40360-020-00429-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 07/02/2020] [Indexed: 01/10/2023] Open
Abstract
Background This study aimed to assess the pediatric lisinopril doses using an adult physiological based pharmacokinetic (PBPK) model. As the empirical rules of dose calculation cannot calculate gender-specific pediatric doses and ignores the age-related physiological differences. Methods A PBPK model of lisinopril for the healthy adult population was developed for oral (fed and fasting) and IV administration using PK-Sim MoBI® and was scaled down to a virtual pediatric population for prediction of lisinopril doses in neonates to infants, infants to toddler, children at pre-school age, children at school age and the adolescents. The pharmacokinetic parameters were predicted for the above groups at decremental doses of 20 mg, 10 mg, 5 mg, 2.5 mg, and 1.5 mg in order to accomplish doses producing the pharmacokinetic parameters, similar (or comparable) to that of the adult population. The above simulated pediatric doses were compared to the doses computed using the conventional four methods, such as Young’s rule, Clark’s rule, and weight-based and body surface area-based equations and the dose reported in different studies. Results Though the doses predicted for all subpopulations of children were comparable to those calculated by Young’s rule, yet the conventional methods overestimated the pediatric doses when compared to the respective PBPK-predicted doses. The findings of previous real time pharmacokinetic studies in pediatric patients supported the present simulated dose. Conclusion Thus, PBPK seems to have predictability potential for pediatric dose since it takes into consideration the physiological changes related to age and gender.
Collapse
|
41
|
Physiologically-based pharmacokinetic models for children: Starting to reach maturation? Pharmacol Ther 2020; 211:107541. [DOI: 10.1016/j.pharmthera.2020.107541] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 03/19/2020] [Indexed: 12/13/2022]
|
42
|
Ye PP, Zheng Y, Du B, Liu XT, Tang BH, Kan M, Zhou Y, Hao GX, Huang X, Su LQ, Wang WQ, Yu F, Zhao W. First dose in neonates: pharmacokinetic bridging study from juvenile mice to neonates for drugs metabolized by CYP3A. Xenobiotica 2020; 50:1275-1284. [PMID: 32400275 DOI: 10.1080/00498254.2020.1768454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
First dose prediction is challenging in neonates. Our objective in this proof-of-concept study was to perform a pharmacokinetic (PK) bridging study from juvenile mice to neonates for drugs metabolized by CYP3A. We selected midazolam and clindamycin as model drugs. We developed juvenile mice population PK models using NONMEM. The PK parameters of these two drugs in juvenile mice were used to bridge PK parameters in neonates using different correction methods. The bridging results were evaluated by the fold-error of 0.5- to 1.5-fold. Simple allometry with and without a correction factor for maximum lifespan potential could be used for a bridging of clearance (CL) and volume of distribution (Vd), respectively, from juvenile mice to neonates. Simulation results demonstrated that for midazolam, 100% of clinical studies for which both the predictive CL and Vd were within 0.5- to 1.5-fold of the observed. For clindamycin, 75% and 100% of clinical studies for which the predictive CL and Vd were within 0.5- to 1.5-fold of the observed. A PK bridging of drugs metabolized by CYP3A is feasible from juvenile mice to neonates. It could be a complement to the ADE and PBPK models to support the first dose in neonates.
Collapse
Affiliation(s)
- Pan-Pan Ye
- Department of Clinical Pharmacy, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.,Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yi Zheng
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bin Du
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xi-Ting Liu
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bo-Hao Tang
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Min Kan
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yue Zhou
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xin Huang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Le-Qun Su
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Wen-Qi Wang
- Clinical Research Center, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Feng Yu
- Department of Clinical Pharmacy, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Wei Zhao
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University, Jinan, China.,Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.,Clinical Research Center, The First Affiliated Hospital of Shandong First Medical University, Jinan, China.,Department of Pediatrics, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| |
Collapse
|
43
|
Mintz M, Pina-Garza JE, Wolf SM, McGoldrick PE, Józwiak S, Grinnell T, Cantu D, Costa R, Moreira J, Li Y, Blum D. Safety and Tolerability of Adjunctive Eslicarbazepine Acetate in Pediatric Patients (Aged 4-17 Years) With Focal Seizures. J Child Neurol 2020; 35:265-273. [PMID: 31878820 PMCID: PMC7005936 DOI: 10.1177/0883073819890997] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the safety and tolerability of adjunctive eslicarbazepine acetate (ESL) in pediatric patients (aged 4-17 years) with refractory focal seizures. METHODS Pooled safety data from patients aged 4-17 years in Study 208 (NCT01527513) and Study 305 (NCT00988156) were analyzed. Both were randomized, double-blind, placebo-controlled studies of ESL as adjunctive treatment in pediatric patients with refractory focal seizures receiving 1 or 2 antiepileptic drugs. Incidences of treatment-emergent adverse events (TEAEs), serious adverse events (SAEs), TEAEs leading to discontinuation, and TEAEs of special interest were evaluated. RESULTS The safety population comprised 362 patients (placebo, n = 160; ESL, n = 202). The overall incidence of TEAEs was similar between the ESL (67.8%) and placebo groups (65.6%), with no clear dose-response relationship. The most frequently reported TEAEs with ESL were headache, somnolence, vomiting, and diplopia. Overall incidences of SAEs and TEAEs leading to discontinuation were higher with ESL versus placebo (9.9% vs 5.0% and 5.9% vs 2.5%, respectively). The majority of SAEs with ESL occurred in Study 305. Two deaths were reported, 1 with ESL (0.5%) due to cluster seizures (resulting in herniation of the cerebellar tonsils) and 1 with placebo (0.6%) due to asphyxia. TEAEs related to allergic reaction, hyponatremia, hypothyroidism, cytopenia, seizure exacerbation, cognitive dysfunction, psychiatric disorders, or suicide occurred infrequently (<9%). CONCLUSION Adjunctive ESL was generally well tolerated in children aged 4-17 years with focal seizures. The safety profile of ESL in children was comparable to that observed in adults.
Collapse
Affiliation(s)
- Mark Mintz
- The Center for Neurological and Neurodevelopmental Health (CNNH) and the Clinical Research Center of New Jersey (CRCNJ), Voorhees, NJ, USA
| | | | - Steven M. Wolf
- Department of Neurology, Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA
| | - Patricia E. McGoldrick
- Department of Neurology, Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA
| | - Sergiusz Józwiak
- Department of Pediatric Neurology, Medical University Warsaw, Warsaw, Poland,Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Todd Grinnell
- Sunovion Pharmaceuticals Inc, Marlborough, MA, USA,Todd Grinnell, AB, Sunovion Pharmaceuticals Inc, 84 Waterford Drive, Marlborough, MA, USA.
| | - David Cantu
- Sunovion Pharmaceuticals Inc, Marlborough, MA, USA
| | - Raquel Costa
- BIAL–Portela & Cª, SA, Coronado (São Romão e São Mamede), Portugal
| | - Joana Moreira
- BIAL–Portela & Cª, SA, Coronado (São Romão e São Mamede), Portugal
| | - Yan Li
- Sunovion Pharmaceuticals Inc, Marlborough, MA, USA
| | - David Blum
- Sunovion Pharmaceuticals Inc, Marlborough, MA, USA
| |
Collapse
|
44
|
Germovsek E, Barker CIS, Sharland M, Standing JF. Pharmacokinetic-Pharmacodynamic Modeling in Pediatric Drug Development, and the Importance of Standardized Scaling of Clearance. Clin Pharmacokinet 2020; 58:39-52. [PMID: 29675639 PMCID: PMC6325987 DOI: 10.1007/s40262-018-0659-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Pharmacokinetic/pharmacodynamic (PKPD) modeling is important in the design and conduct of clinical pharmacology research in children. During drug development, PKPD modeling and simulation should underpin rational trial design and facilitate extrapolation to investigate efficacy and safety. The application of PKPD modeling to optimize dosing recommendations and therapeutic drug monitoring is also increasing, and PKPD model-based dose individualization will become a core feature of personalized medicine. Following extensive progress on pediatric PK modeling, a greater emphasis now needs to be placed on PD modeling to understand age-related changes in drug effects. This paper discusses the principles of PKPD modeling in the context of pediatric drug development, summarizing how important PK parameters, such as clearance (CL), are scaled with size and age, and highlights a standardized method for CL scaling in children. One standard scaling method would facilitate comparison of PK parameters across multiple studies, thus increasing the utility of existing PK models and facilitating optimal design of new studies.
Collapse
Affiliation(s)
- Eva Germovsek
- Infection, Inflammation and Rheumatology Section, UCL Great Ormond Street Institute of Child Heath, University College London, London, UK. .,Pharmacometrics Research Group, Department of Pharmaceutical Biosciences, Uppsala University, PO Box 591, 751 24, Uppsala, Sweden.
| | - Charlotte I S Barker
- Infection, Inflammation and Rheumatology Section, UCL Great Ormond Street Institute of Child Heath, University College London, London, UK.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Joseph F Standing
- Infection, Inflammation and Rheumatology Section, UCL Great Ormond Street Institute of Child Heath, University College London, London, UK.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| |
Collapse
|
45
|
Burckart GJ, Kim C. The Revolution in Pediatric Drug Development and Drug Use: Therapeutic Orphans No More. J Pediatr Pharmacol Ther 2020; 25:565-573. [PMID: 33041711 PMCID: PMC7541025 DOI: 10.5863/1551-6776-25.7.565] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2020] [Indexed: 01/04/2023]
Abstract
This lecture was given by Dr. Burckart in association with presentation of the 2014 Sumner J. Yaffe Lifetime Achievement Award in Pediatric Pharmacology and Therapeutics, which is selected by the Pediatric Pharmacy Association. Multiple factors make conducting drug studies in the pediatric population difficult, resulting in a historic lack of information surrounding safe and efficacious drug dosing in children. The paradigm in pediatric drug development has shifted from normal science being that children are therapeutic orphans in the drug development system, to a model drift caused by pediatric legislation, to a model crisis caused by failed pediatric drug development trials, to finally a model revolution that includes pediatric patients routinely in drug development. Major regulatory actions and the accumulation of scientific evidence has created an environment where clinicians can expect properly labeled drug usage information for the pediatric population.
Collapse
|
46
|
de Sena LWP, Mello AGNC, Ferreira MVD, de Ataide MA, Dias RM, Vieira JLF. Doses of chloroquine in the treatment of malaria by Plasmodium vivax in patients between 2 and 14 years of age from the Brazilian Amazon basin. Malar J 2019; 18:439. [PMID: 31864358 PMCID: PMC6925880 DOI: 10.1186/s12936-019-3072-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 12/13/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A total dose of chloroquine of 25 mg/kg is recommended by the World Health Organization (WHO) to treat malaria by Plasmodium vivax. In several endemic areas, including the Brazilian Amazon basin, anti-malarial drugs are dispensed in small plastic bags at a dosing regimen based on age. This practice can lead to suboptimal dosing of the drug, which can impact treatment outcomes. The aim of the present study was to estimate the extent of sub-dosing of chloroquine in children and adolescents with vivax malaria using an age-based dose regimen, in addition to investigating the influence of age on the plasma concentrations of chloroquine and desethylchloroquine. METHODS A study of cases was conducted with male patients with a confirmed infection by P. vivax, ages 2 to 14 years, using a combined regimen of chloroquine and primaquine. Height, weight and body surface area were determined at admission on the study. The total dose of chloroquine administered was estimated based on the weight and on the body surface area of the study patients. Chloroquine and desethylchloroquine were measured on Day 7 in each patient included in the study by a high-performance liquid chromatographic method with fluorescence detection. RESULTS A total of 81 patients were enrolled and completed the study. The median age was 9 years (2-14 years). All patients presented negative blood smears at 42 days follow-up. The total dose of chloroquine ranged from 13.1 to 38.1 mg/kg. The percentage of patients with a total dose of the drug below 25 mg/kg ranged from 29.4 to 63.6%. The total dose of chloroquine administered based on BSA ranged from 387 to 1079 mg/m2, increasing with age. Plasma chloroquine concentrations ranged from 107 to 420 ng/ml, increasing with age. For desethylchloroquine, the plasma concentrations ranged from 167 to 390 ng/ml, with similar values among age-groups. CONCLUSION The data demonstrated the widespread exposure of children and adolescents to suboptimal doses of chloroquine in the endemic area investigated.
Collapse
Affiliation(s)
- Luann Wendel Pereira de Sena
- Pharmacy Faculty, Para Federal University, Campus Universitario do Guama, Augusto Correa Street 01, Belem, Para, 66074740, Brazil
| | | | - Michelle Valéria Dias Ferreira
- Pharmacy Faculty, Para Federal University, Campus Universitario do Guama, Augusto Correa Street 01, Belem, Para, 66074740, Brazil
| | - Marcieni Andrade de Ataide
- Pharmacy Faculty, Para Federal University, Campus Universitario do Guama, Augusto Correa Street 01, Belem, Para, 66074740, Brazil
| | - Rosa Maria Dias
- Pharmacy Faculty, Para Federal University, Campus Universitario do Guama, Augusto Correa Street 01, Belem, Para, 66074740, Brazil
| | - José Luiz Fernandes Vieira
- Pharmacy Faculty, Para Federal University, Campus Universitario do Guama, Augusto Correa Street 01, Belem, Para, 66074740, Brazil.
| |
Collapse
|
47
|
Gade C, Sverrisdóttir E, Dalhoff K, Sonne J, Johansen MØ, Christensen HR, Burhenne J, Mikus G, Holm JC, Lund TM, Holst H. Midazolam Pharmacokinetics in Obese and Non-obese Children and Adolescents. Clin Pharmacokinet 2019; 59:643-654. [DOI: 10.1007/s40262-019-00838-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
48
|
Waalewijn H, Turkova A, Rakhmanina N, Cressey TR, Penazzato M, Colbers A, Burger DM. Optimizing Pediatric Dosing Recommendations and Treatment Management of Antiretroviral Drugs Using Therapeutic Drug Monitoring Data in Children Living With HIV. Ther Drug Monit 2019; 41:431-443. [PMID: 31008997 PMCID: PMC6636807 DOI: 10.1097/ftd.0000000000000637] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/03/2019] [Indexed: 12/27/2022]
Abstract
INTRODUCTION This review summarizes the current dosing recommendations for antiretroviral (ARV) drugs in the international pediatric guidelines of the World Health Organization (WHO), US Department of Health and Human Services (DHHS), and Pediatric European Network for Treatment of AIDS (PENTA), and evaluates the research that informed these approaches. We further explore the role of data generated through therapeutic drug monitoring in optimizing the dosing of ARVs in children. METHODS A PubMed search was conducted for the literature on ARV dosing published in English. In addition, the registration documentation of European Medicines Agency and the US Food and Drug Administration for currently used ARVs and studies referenced by the WHO, DHHS, and EMA guidelines were screened. Resulting publications were screened for papers containing data on the area under the concentration-time curve, trough concentration, and peak concentration. Studies with enrolled participants with a median or mean age of ≥18 years were excluded. No restriction on publishing date was applied. DISCUSSION AND CONCLUSION Pediatric ARV dosing is frequently based on data obtained from small studies and is often simplified to facilitate dosing in the context of a public health approach. Pharmacokinetic parameters of pediatric ARVs are subject to high interpatient variation and this leads to a potential risk of underdosing or overdosing when drugs are used in real life. To ensure optimal use of ARVs and validate dosing recommendations for children, it is essential to monitor ARV dosing more thoroughly with larger sample sizes and to include diverse subpopulations. Therapeutic drug monitoring data generated in children, where available and affordable, have the potential to enhance our understanding of the appropriateness of simplified pediatric dosing strategies recommended using a public health approach and to uncover suboptimal dosing or other unanticipated issues postmarketing, further facilitating the ultimate goal of optimizing pediatric ARV treatment.
Collapse
Affiliation(s)
- Hylke Waalewijn
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Anna Turkova
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Natella Rakhmanina
- Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University
- Division of Infectious Diseases, Children's National Medical Center
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia
| | - Tim R. Cressey
- PHPT/IRD UMI 174, Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Immunology and Infectious Diseases, Harvard T.H Chan School of Public Health, Boston, Massachusetts
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom; and
| | - Martina Penazzato
- Treatment and Care, Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - David M. Burger
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| |
Collapse
|
49
|
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.
Collapse
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.
| |
Collapse
|
50
|
Ahmad FS, Kallen MA, Schifferdecker KE, Carluzzo KL, Yount SE, Gelow JM, McCullough PA, Kimmel SE, Fisher ES, Cella D. Development and Initial Validation of the PROMIS®-Plus-HF Profile Measure. Circ Heart Fail 2019; 12:e005751. [PMID: 31163985 DOI: 10.1161/circheartfailure.118.005751] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Bringing together generic and heart failure (HF)-specific items in a publicly available, patient-reported outcome measure may facilitate routine health status assessment for improving clinical care and shared decision-making, assessing quality of care, evaluating new interventions, and comparing groups with different conditions. Methods and Results We performed a mixed-methods study to develop and validate the PROMIS®-Plus-HF (Patient-Reported Outcomes Measurement Information System®-Plus-Heart Failure) profile measure-a HF-specific instrument based on the generic PROMIS. We conducted 8 focus groups with 61 patients with HF and phone interviews with 10 HF clinicians. The measure was developed via an iterative process of reviewing existing PROMIS items and developing and testing new HF items. In a 600-patient sample, we estimated reliability (internal consistency; test-retest, with n=100 participants). We conducted validity analyses using Pearson r and Spearman ρ correlations with Kansas City Cardiomyopathy Questionnaire subscores. In a longitudinal sample, we performed responsiveness testing (paired t tests) with 75 patients with HF receiving interventions with expected health status improvement. The PROMIS-Plus-HF measure comprises 86 items (64 existing; 22 new) across 18 domains. Internal consistency reliability (Cronbach α) coefficients ranged from 0.52 to 0.96, with α≥0.70 in 12 of 17 domains. Test-retest intraclass correlation coefficients were ≥0.90. Correlations with Kansas City Cardiomyopathy Questionnaire subscores supported expected convergent ( r/ρ>0.60) and divergent validity ( r/ρ<0.30). In the longitudinal sample, 10 of 18 domains had improved ( P<0.05) scores from baseline to follow-up. Conclusions The PROMIS-Plus-HF profile measure-a complete assessment of physical, mental, and social health-exhibited good psychometric characteristics and may facilitate patient-centered care and research. Subsets of domains and items can be used depending on the clinical or research purpose.
Collapse
Affiliation(s)
- Faraz S Ahmad
- Division of Cardiology, Department of Medicine (F.S.A.), Northwestern University Feinberg School of Medicine, Chicago, IL.,Center for Health Information Partnerships, Institute of Public Health and Medicine (F.S.A.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael A Kallen
- Department of Medical Social Sciences (M.A.K., S.E.Y., D.C.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Karen E Schifferdecker
- Community and Family Medicine (K.E.S., E.S.F.), Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,Center for Program Design and Evaluation at Dartmouth (K.E.S., K.L.C.), Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,The Dartmouth Institute for Health Policy and Clinical Practice (K.E.S., K.L.C., E.S.F.), Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Kathleen L Carluzzo
- Center for Program Design and Evaluation at Dartmouth (K.E.S., K.L.C.), Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,The Dartmouth Institute for Health Policy and Clinical Practice (K.E.S., K.L.C., E.S.F.), Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Susan E Yount
- Department of Medical Social Sciences (M.A.K., S.E.Y., D.C.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jill M Gelow
- Oregon Health and Science University Knight Cardiovascular Institute, Portland (J.M.G.).,Providence Heart and Vascular Institute, Portland, Oregon (J.M.G.)
| | - Peter A McCullough
- Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX (P.A.M.)
| | - Stephen E Kimmel
- Departments of Medicine (S.E.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia.,Biostatistics, Epidemiology and Informatics (S.E.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Elliot S Fisher
- Community and Family Medicine (K.E.S., E.S.F.), Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,The Dartmouth Institute for Health Policy and Clinical Practice (K.E.S., K.L.C., E.S.F.), Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - David Cella
- Department of Medical Social Sciences (M.A.K., S.E.Y., D.C.), Northwestern University Feinberg School of Medicine, Chicago, IL.,Center for Patient Centered Outcomes, Institute of Public Health and Medicine (D.C.), Northwestern University Feinberg School of Medicine, Chicago, IL
| |
Collapse
|