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Rong Y, Wichart J, Hamiwka L, Kiang TKL. Significant Effects of Renal Function on Mycophenolic Acid Total Clearance in Pediatric Kidney Transplant Recipients with Population Pharmacokinetic Modeling. Clin Pharmacokinet 2023; 62:1289-1303. [PMID: 37493886 DOI: 10.1007/s40262-023-01280-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Mycophenolic acid (MPA) is an immunosuppressant commonly prescribed in pediatric kidney transplantation to prevent graft rejection. Large variabilities in MPA plasma exposures have been observed in this population, which could result in severe adverse effects. The majority of the MPA pharmacokinetic data have been reported in adult populations, whereas information in pediatric patients is still very limited. The objective of this study was to establish a novel, nonlinear mixed-effects model for MPA and investigate the clinical variables affecting MPA population pharmacokinetics in pediatric kidney transplant recipients. METHODS Data were collected retrospectively from pediatric kidney transplant patients (≤ 18 years when MPA concentrations were initially collected; on oral administration of mycophenolate mofetil) in Calgary, Alberta, Canada. Nonlinear mixed-effect modeling was conducted using stochastic approximation expectation-maximization in Monolix 2021R2 (Lixoft SAS, France) to determine population pharmacokinetic estimates, interindividual variabilities, and interoccasional variabilities. Covariate models were constructed using the Model Proposal function in Monolix in conjunction with a systematic stepwise inclusion/elimination protocol. The best model was selected based on objective function values, relative standard errors, goodness-of-fit plots, prediction-corrected visual predictive checks, and numerical predictive checks. RESULTS A total of 50 pediatric kidney transplant patients (25 female) with 219 MPA plasma concentration-time profiles were included. The average age (± standard deviation) and posttransplant time for the sample population were 12.8 ± 4.8 years and 762 ± 1160 days, respectively. The majority of study subjects (i.e., > 85% based on all occasions) were co-administered tacrolimus. A two-compartment, first-order absorption with lag time and linear elimination structural model with lognormal distributed proportional residual errors best described the MPA concentration-time data. The absorption rate constant (2.52 h-1 or 0.042 min-1), lag time (0.166 h or 9.96 min), volumes of distributions of the central (22.8 L) and peripheral (216 L) compartments, and intercompartment clearance (17.6 L h-1 or 0.293 L min-1) were consistent with literature values; whereas total MPA clearance (0.72 L h-1 or 0.012 L min-1) was relatively reduced, likely due to the general lack of cyclosporine interactions and the stabilized graft functions from significantly longer posttransplant time in our sample population. Of the clinical variables tested, only estimated glomerular filtration rate (eGFR) was identified a significant covariate affecting total MPA clearance with a positive, exponential relationship. The final population pharmacokinetic model was successfully evaluated/validated using a variety of complementary methods. CONCLUSION We have successfully constructed and validated a novel population pharmacokinetic model of MPA in pediatric kidney transplant patients. A positive, nonlinear relationship between eGFR and total MPA clearance identified in our model is likely attributed to multiple concurrent mechanisms, which warrant further systematic investigations.
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Affiliation(s)
- Yan Rong
- Faculty of Pharmacy and Pharmaceutical Sciences, Katz Group Centre for Pharmacy and Health Research, University of Alberta, Room 3-142D, 11361-87 Avenue, Edmonton, AB, T6G 2E1, Canada
| | - Jenny Wichart
- Alberta Health Services, Pharmacy Services, Calgary, AB, Canada
| | - Lorraine Hamiwka
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tony K L Kiang
- Faculty of Pharmacy and Pharmaceutical Sciences, Katz Group Centre for Pharmacy and Health Research, University of Alberta, Room 3-142D, 11361-87 Avenue, Edmonton, AB, T6G 2E1, Canada.
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Siebert A, Deptuła M, Cichorek M, Ronowska A, Cholewiński G, Rachon J. Anticancer Properties of Amino Acid and Peptide Derivatives of Mycophenolic Acid. Anticancer Agents Med Chem 2021; 21:462-467. [PMID: 32416705 DOI: 10.2174/1871520620666200516151456] [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: 01/28/2020] [Revised: 03/26/2020] [Accepted: 04/13/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although Mycophenolic Acid (MPA) is applied as prodrugs in clinic as an immunosuppressant, it also possesses anticancer activity. MPA acts as Inosine-5'-Monophosphate Dehydrogenase (IMPDH) inhibitor, where the carboxylic group at the end of the side chain interacts with Ser 276 of the enzyme via hydrogen bonds. Therefore, MPA derivatives with other polar groups indicated high inhibition too. On the other hand, potent anticancer agents like dacarbazine and cisplatin give numerous side-effects. OBJECTIVE Based on the literature data, MPA derivatives should be explored towards anticancer properties. Conversion of the carboxylic group of MPA to amide could maintain antiproliferative activity. Therefore, we decided to investigate several amino acid and peptide derivatives of MPA against chosen cancer cell lines in vitro. METHODS Amides of MPA hold threonine and arginine amino acid unit. These amino acid derivatives were tested as L and D enantiomers and both in free acid and methyl esters forms. Additionally, MPA was modified with tuftsin or retro-tuftsin as biologically active peptides, which could act as a drug carrier. RESULTS Amino acid and peptide derivatives of MPA were investigated in vitro as potential anticancer agents on cell lines: Ab melanoma, A375 melanoma and SHSY5Y neuroblastoma. The activity of the tested compounds was compared to parent MPA and known chemotherapeutics: dacarbazine and cisplatin. CONCLUSION Amino acid moiety and the sequence of amino acids in the peptide part influenced observed activity. The most active amino acid MPA analogues occurred to be D and L-threonine derivatives as methyl esters, probably due to better cell membrane penetration.
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Affiliation(s)
- Agnieszka Siebert
- Department of Organic Chemistry, Gdansk University of Technology, G. Narutowicza 11/12, 80-233 Gdansk, Poland
| | - Milena Deptuła
- Department of Embryology, Medical University of Gdansk, Debinki 1, 80-211, Gdansk, Poland
| | - Mirosława Cichorek
- Department of Embryology, Medical University of Gdansk, Debinki 1, 80-211, Gdansk, Poland
| | - Anna Ronowska
- Department of Laboratory Medicine, Medical University of Gdansk, Debinki 1, 80-211, Gdansk, Poland
| | - Grzegorz Cholewiński
- Department of Organic Chemistry, Gdansk University of Technology, G. Narutowicza 11/12, 80-233 Gdansk, Poland
| | - Janusz Rachon
- Department of Organic Chemistry, Gdansk University of Technology, G. Narutowicza 11/12, 80-233 Gdansk, Poland
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Siebert A, Wysocka M, Krawczyk B, Cholewiński G, Rachoń J. Synthesis and antimicrobial activity of amino acid and peptide derivatives of mycophenolic acid. Eur J Med Chem 2018; 143:646-655. [PMID: 29216563 PMCID: PMC7173178 DOI: 10.1016/j.ejmech.2017.11.094] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 11/10/2017] [Accepted: 11/28/2017] [Indexed: 11/01/2022]
Abstract
The series of 16 novel amino acid and peptide mycophenolic acid (MPA) derivatives was obtained as potential antibacterial agents. Coupling of MPA with respective amines was optimized with condensing reagents such as EDCI/DMAP and T3P/TEA. Amino acid analogs were received both as methyl esters and also with the free carboxylic group. The biological activity of the products was tested on five references bacterial strains: Klebsiella pneumoniae ATCC 700603 (ESBL), Escherichia coli ATCC 8739, Pseudomonas aeruginosa ATCC 27853, Staphylococcus aureus MRSA ATCC 43300, Staphylococcus aureus MSSA ATCC 25923. Peptide derivatives proved to be the most versatile ones, their MIC values relative to most strains was lower than MPA alone. It has been noted that the activity of amino acid derivatives depends on the configuration at the chiral center in the amino acid unit and methyl esters indicated better antimicrobial activity than analogs with free carboxylic group.
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Affiliation(s)
- Agnieszka Siebert
- Department of Organic Chemistry, Gdansk University of Technology, ul. G. Narutowicza 11/12, 80-233 Gdansk, Poland
| | - Magdalena Wysocka
- Department of Molecular Biotechnology and Microbiology, Gdansk University of Technology, ul. G. Narutowicza 11/12, 80-233 Gdansk, Poland
| | - Beata Krawczyk
- Department of Molecular Biotechnology and Microbiology, Gdansk University of Technology, ul. G. Narutowicza 11/12, 80-233 Gdansk, Poland
| | - Grzegorz Cholewiński
- Department of Organic Chemistry, Gdansk University of Technology, ul. G. Narutowicza 11/12, 80-233 Gdansk, Poland.
| | - Janusz Rachoń
- Department of Organic Chemistry, Gdansk University of Technology, ul. G. Narutowicza 11/12, 80-233 Gdansk, Poland
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Tellier S, Dallocchio A, Guigonis V, Saint-Marcoux F, Llanas B, Ichay L, Bandin F, Godron A, Morin D, Brochard K, Gandia P, Bouchet S, Marquet P, Decramer S, Harambat J. Mycophenolic Acid Pharmacokinetics and Relapse in Children with Steroid-Dependent Idiopathic Nephrotic Syndrome. Clin J Am Soc Nephrol 2016; 11:1777-1782. [PMID: 27445161 PMCID: PMC5053778 DOI: 10.2215/cjn.00320116] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 06/06/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Therapeutic drug monitoring of mycophenolic acid can improve clinical outcome in organ transplantation and lupus, but data are scarce in idiopathic nephrotic syndrome. The aim of our study was to investigate whether mycophenolic acid pharmacokinetics are associated with disease control in children receiving mycophenolate mofetil for the treatment of steroid-dependent nephrotic syndrome. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This was a retrospective multicenter study including 95 children with steroid-dependent nephrotic syndrome treated with mycophenolate mofetil with or without steroids. Area under the concentration-time curve of mycophenolic acid was determined in all children on the basis of sampling times at 20, 60, and 180 minutes postdose, using Bayesian estimation. The association between a threshold value of the area under the concentration-time curve of mycophenolic acid and the relapse rate was assessed using a negative binomial model. RESULTS In total, 140 areas under the concentration-time curve of mycophenolic acid were analyzed. The findings indicate individual dose adaptation in 53 patients (38%) to achieve an area under the concentration-time curve target of 30-60 mg·h/L. In a multivariable negative binomial model including sex, age at disease onset, time to start of mycophenolate mofetil, previous immunomodulatory treatment, and concomitant prednisone dose, a level of area under the concentration-time curve of mycophenolic acid >45 mg·h/L was significantly associated with a lower relapse rate (rate ratio, 0.65; 95% confidence interval, 0.46 to 0.89; P=0.01). CONCLUSIONS Therapeutic drug monitoring leading to individualized dosing may improve the efficacy of mycophenolate mofetil in steroid-dependent nephrotic syndrome. Additional prospective studies are warranted to determine the optimal target for area under the concentration-time curve of mycophenolic acid in this population.
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Affiliation(s)
- Stéphanie Tellier
- Service de Pédiatrie, Centre de référence Maladies Rénales Rares du Sud Ouest and
| | - Aymeric Dallocchio
- Service de Pédiatrie, Centre de référence Maladies Rénales Rares du Sud Ouest and
| | - Vincent Guigonis
- Service de Pédiatrie, Centre de référence Maladies Rénales Rares du Sud Ouest and
| | - Frank Saint-Marcoux
- Service de Pharmacologie et Toxicologie, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Brigitte Llanas
- Service de Pédiatrie, Centre de référence Maladies Rénales Rares du Sud Ouest et Centre d'Investigation Clinique, Centre d'Investigation Clinique 1401, INSERM, and
| | - Lydia Ichay
- Service de Pédiatrie, Centre de référence Maladies Rénales Rares du Sud Ouest, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Flavio Bandin
- Service de Pédiatrie, Centre de référence Maladies Rénales Rares du Sud Ouest and
| | - Astrid Godron
- Service de Pédiatrie, Centre de référence Maladies Rénales Rares du Sud Ouest et Centre d'Investigation Clinique, Centre d'Investigation Clinique 1401, INSERM, and
| | - Denis Morin
- Service de Pédiatrie, Centre de référence Maladies Rénales Rares du Sud Ouest, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Karine Brochard
- Service de Pédiatrie, Centre de référence Maladies Rénales Rares du Sud Ouest and
| | - Peggy Gandia
- Service de Pharmacologie Clinique, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Stéphane Bouchet
- Service de Pharmacologie Clinique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; and
| | - Pierre Marquet
- Service de Pharmacologie et Toxicologie, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Stéphane Decramer
- Service de Pédiatrie, Centre de référence Maladies Rénales Rares du Sud Ouest and
| | - Jérôme Harambat
- Service de Pédiatrie, Centre de référence Maladies Rénales Rares du Sud Ouest et Centre d'Investigation Clinique, Centre d'Investigation Clinique 1401, INSERM, and
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Martial LC, Jacobs BAW, Cornelissen EAM, de Haan AFJ, Koch BCP, Burger DM, Aarnoutse RE, Schreuder MF, Brüggemann RJM. Pharmacokinetics and target attainment of mycophenolate in pediatric renal transplant patients. Pediatr Transplant 2016; 20:492-9. [PMID: 26923724 DOI: 10.1111/petr.12695] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2016] [Indexed: 01/23/2023]
Abstract
MPA is an immunosuppressive agent used to prevent graft rejection after renal transplantation. MPA shows considerable inter- and intraindividual variability in exposure in children and has a defined therapeutic window, and TDM is applied to individualize therapy. We aimed to study the exposure to MPA measured as the AUC in pediatric renal transplant patients, to identify factors influencing exposure and to assess target attainment. Children transplanted between 1998 and 2014 in a single center were included. Two groups were identified: Group 1 (AUC <3 wk post-transplantation) and Group 2 (AUC >18 months post-transplantation). Therapeutic targets were set at: AUC0-12h of 30-60 mg h/L. A total of 39 children were included in Group 1 (median age 13.3 yr) vs. 14 in Group 2 (median age 13.4 yr). AUC0-12h was 29.7 mg h/L in Group 1 and 56.6 mg h/L in Group 2, despite a lower dosage in Group 2 (584 and 426 mg/m(2) , respectively). About 46% of patients reached the target AUC0-12h in Group 1. Time since transplantation and serum creatinine were significantly associated with MPA exposure (p < 0.001), explaining 36% of the variability. Individualization of the mycophenolate dose by more intense and more early TDM could improve target attainment.
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Affiliation(s)
- Lisa C Martial
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Radboud University, Nijmegen, The Netherlands
| | - Bart A W Jacobs
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Anton F J de Haan
- Radboud Institute for Health Sciences, Radboud University, Nijmegen, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Radboud University, Nijmegen, The Netherlands
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Radboud University, Nijmegen, The Netherlands
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roger J M Brüggemann
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Radboud University, Nijmegen, The Netherlands
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Todorova EK, Huang SHS, Kobrzynski MC, Filler G. What is the intrapatient variability of mycophenolic acid trough levels? Pediatr Transplant 2015. [PMID: 26201386 DOI: 10.1111/petr.12559] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
TDM of MPA, the active compound of MMF, is rarely used despite its substantial intra- and interpatient variability. Little is known about the utility of long-term MPA TDM. Data are expressed as mean (one standard deviation). All available data from 27 renal transplant recipients (mean age at transplantation: 7.7 [5.0] yr) with an average follow-up of 9.3 (4.6) yr were analyzed. MPA levels were measured using the EMIT. GFR was measured using cystatin C and eGFR was calculated using the Filler formula. Intrapatient CV of the trough level was calculated as the ratio of the mean divided by one standard deviation. Mean cystatin C eGFR was 56.9 (24.4) mL/min/1.73 m(2) . There was a weak but significant correlation between the MPA trough level and the AUC (Spearman r = 0.6592, p < 0.0001). A total of 1964 MPA trough levels (73 [45]/patient) were measured, as compared to 3462 Tac trough levels (144 [71]/patient). The average MPA trough level was 3.01 (1.26) mg/L and the average trough Tac level was 7.3 (1.8) ng/mL. Intrapatient CV was statistically higher (p = 0.00093) for MPA at 0.68 (0.29) when compared to Tac with a CV of 0.46 (0.12). CV did not correlate with eGFR. Intrapatient MPA trough level CV is significantly higher than for Tac, while CV for both MPA and Tac was high. MPA trough level monitoring may be a feasible monitoring option to improve patient exposure and possibly outcomes.
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Affiliation(s)
- Ekaterina K Todorova
- Department of Pediatrics, Schulich School of Medicine & Dentistry, London, ON, Canada
| | - Shih-Han S Huang
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Marta C Kobrzynski
- Department of Pediatrics, Schulich School of Medicine & Dentistry, London, ON, Canada
| | - Guido Filler
- Department of Pediatrics, Schulich School of Medicine & Dentistry, London, ON, Canada.,Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada.,Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
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Sobiak J, Resztak M, Ostalska-Nowicka D, Zachwieja J, Gąsiorowska K, Piechanowska W, Chrzanowska M. Monitoring of mycophenolate mofetil metabolites in children with nephrotic syndrome and the proposed novel target values of pharmacokinetic parameters. Eur J Pharm Sci 2015; 77:189-96. [PMID: 26102431 DOI: 10.1016/j.ejps.2015.06.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Revised: 05/22/2015] [Accepted: 06/19/2015] [Indexed: 11/30/2022]
Abstract
The aim of the study was to estimate target values of mycophenolate mofetil (MMF) pharmacokinetic parameters in children with proteinuric glomerulopathies by calculating the pharmacokinetic parameters of MMF metabolites (mycophenolic acid [MPA], free MPA [fMPA] and MPA glucuronide [MPAG]) and assessing their relation to proteinuria recurrence. One hundred and sixty-eight blood samples were collected from children, aged 3-18 years, diagnosed with nephrotic syndrome or lupus nephritis. MMF metabolites concentrations were examined before drug administration (Ctrough) and up to 12h afterward employing high-performance liquid chromatography. Dose-normalized MPA Ctrough and area under the concentration-time curve from 0 to 12h (AUC12) were within 0.29-6.47 μg/mL/600 mg/m(2) and 9.97-105.52 μg h/mL/600 mg/m(2), respectively. MPA Ctrough was twofold lower (p=0.024) in children with proteinuria recurrence. MPA, fMPA and MPAG concentrations correlated positively to respective AUC12. It may be suggested MMF metabolites monitoring in children with proteinuric glomerulopathies is justified by MPA Ctrough<2 μg/mL in patients at risk of the proteinuria recurrence. Such a recurrence is most probably caused by not sufficient MPA concentration during proteinuric glomerulopathies treatment. MPA Ctrough>3 μg/mL may be considered as an efficient one to avoid proteinuria recurrence. Finally, MPA target AUC12 should exceed 60 μg h/mL to ensure the safe and effective treatment in children with nephrotic syndrome, however, the upper limit is still to be established.
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Affiliation(s)
- Joanna Sobiak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Swiecickiego Street, 60-781 Poznan, Poland.
| | - Matylda Resztak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Swiecickiego Street, 60-781 Poznan, Poland
| | - Danuta Ostalska-Nowicka
- Department of Pediatric Cardiology and Nephrology, Poznan University of Medical Sciences, 27/33 Szpitalna Street, 60-572 Poznan, Poland
| | - Jacek Zachwieja
- Department of Pediatric Cardiology and Nephrology, Poznan University of Medical Sciences, 27/33 Szpitalna Street, 60-572 Poznan, Poland
| | - Karolina Gąsiorowska
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Swiecickiego Street, 60-781 Poznan, Poland
| | - Wiktoria Piechanowska
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Swiecickiego Street, 60-781 Poznan, Poland
| | - Maria Chrzanowska
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Swiecickiego Street, 60-781 Poznan, Poland
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Andrews LM, Riva N, de Winter BC, Hesselink DA, de Wildt SN, Cransberg K, van Gelder T. Dosing algorithms for initiation of immunosuppressive drugs in solid organ transplant recipients. Expert Opin Drug Metab Toxicol 2015; 11:921-36. [DOI: 10.1517/17425255.2015.1033397] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Li P, Shuker N, Hesselink DA, van Schaik RHN, Zhang X, van Gelder T. Do Asian renal transplant patients need another mycophenolate mofetil dose compared with Caucasian or African American patients? Transpl Int 2014; 27:994-1004. [PMID: 24963914 DOI: 10.1111/tri.12382] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 04/22/2014] [Accepted: 06/17/2014] [Indexed: 01/01/2023]
Affiliation(s)
- Pengmei Li
- Department of Hospital Pharmacy; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
- Department of Pharmacy; China-Japan Friendship Hospital; Beijing China
| | - Nauras Shuker
- Department of Hospital Pharmacy; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
- Department of Internal Medicine; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
| | - Dennis A. Hesselink
- Department of Internal Medicine; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
| | - Ron H. N. van Schaik
- Department of Clinical Chemistry; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
| | - Xianglin Zhang
- Department of Pharmacy; China-Japan Friendship Hospital; Beijing China
| | - Teun van Gelder
- Department of Hospital Pharmacy; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
- Department of Internal Medicine; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
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Pharmacology and toxicology of mycophenolate in organ transplant recipients: an update. Arch Toxicol 2014; 88:1351-89. [PMID: 24792322 DOI: 10.1007/s00204-014-1247-1] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 04/15/2014] [Indexed: 12/22/2022]
Abstract
This review aims to provide an update of the literature on the pharmacology and toxicology of mycophenolate in solid organ transplant recipients. Mycophenolate is now the antimetabolite of choice in immunosuppressant regimens in transplant recipients. The active drug moiety mycophenolic acid (MPA) is available as an ester pro-drug and an enteric-coated sodium salt. MPA is a competitive, selective and reversible inhibitor of inosine-5'-monophosphate dehydrogenase (IMPDH), an important rate-limiting enzyme in purine synthesis. MPA suppresses T and B lymphocyte proliferation; it also decreases expression of glycoproteins and adhesion molecules responsible for recruiting monocytes and lymphocytes to sites of inflammation and graft rejection; and may destroy activated lymphocytes by induction of a necrotic signal. Improved long-term allograft survival has been demonstrated for MPA and may be due to inhibition of monocyte chemoattractant protein 1 or fibroblast proliferation. Recent research also suggested a differential effect of mycophenolate on the regulatory T cell/helper T cell balance which could potentially encourage immune tolerance. Lower exposure to calcineurin inhibitors (renal sparing) appears to be possible with concomitant use of MPA in renal transplant recipients without undue risk of rejection. MPA displays large between- and within-subject pharmacokinetic variability. At least three studies have now reported that MPA exhibits nonlinear pharmacokinetics, with bioavailability decreasing significantly with increasing doses, perhaps due to saturable absorption processes or saturable enterohepatic recirculation. The role of therapeutic drug monitoring (TDM) is still controversial and the ability of routine MPA TDM to improve long-term graft survival and patient outcomes is largely unknown. MPA monitoring may be more important in high-immunological recipients, those on calcineurin-inhibitor-sparing regimens and in whom unexpected rejection or infections have occurred. The majority of pharmacodynamic data on MPA has been obtained in patients receiving MMF therapy in the first year after kidney transplantation. Low MPA area under the concentration time from 0 to 12 h post-dose (AUC0-12) is associated with increased incidence of biopsy-proven acute rejection although AUC0-12 optimal cut-off values vary across study populations. IMPDH monitoring to identify individuals at increased risk of rejection shows some promise but is still in the experimental stage. A relationship between MPA exposure and adverse events was identified in some but not all studies. Genetic variants within genes involved in MPA metabolism (UGT1A9, UGT1A8, UGT2B7), cellular transportation (SLCOB1, SLCO1B3, ABCC2) and targets (IMPDH) have been reported to effect MPA pharmacokinetics and/or response in some studies; however, larger studies across different ethnic groups that take into account genetic linkage and drug interactions that can alter a patient's phenotype are needed before any clinical recommendations based on patient genotype can be formulated. There is little data on the pharmacology and toxicology of MPA in older and paediatric transplant recipients.
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Huang HF, Yao X, Chen Y, Xie WQ, Shen-Tu JZ, Chen JH. Cyclosporine A and tacrolimus combined with enteric-coated mycophenolate sodium influence the plasma mycophenolic acid concentration - a randomised controlled trial in Chinese live related donor kidney transplant recipients. Int J Clin Pract 2014:4-9. [PMID: 24673713 DOI: 10.1111/ijcp.12400] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- H. F. Huang
- Center of Kidney Disease; The First Affiliated Hospital; College of Medicine; Zhejiang University; Zhejiang China
| | - X. Yao
- Center of Kidney Disease; The First Affiliated Hospital; College of Medicine; Zhejiang University; Zhejiang China
| | - Y. Chen
- Center of Kidney Disease; The First Affiliated Hospital; College of Medicine; Zhejiang University; Zhejiang China
| | - W. Q. Xie
- Center of Kidney Disease; The First Affiliated Hospital; College of Medicine; Zhejiang University; Zhejiang China
| | - J. Z. Shen-Tu
- Department of Clinical Pharmacology; The First Affiliated Hospital; College of Medicine; Zhejiang University; Zhejiang China
| | - J. H. Chen
- Center of Kidney Disease; The First Affiliated Hospital; College of Medicine; Zhejiang University; Zhejiang China
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Abd Rahman AN, Tett SE, Staatz CE. Clinical Pharmacokinetics and Pharmacodynamics of Mycophenolate in Patients with Autoimmune Disease. Clin Pharmacokinet 2013; 52:303-31. [DOI: 10.1007/s40262-013-0039-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Burckart GJ, Estes KE, Leong R, Mulugeta Y, Tandon V, Wang J, Abernethy DR, Jadhav PR. Methodological Issues in the Design of Paediatric Pharmacokinetic Studies. Pharmaceut Med 2012. [DOI: 10.1007/bf03256888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Baudouin V, Alberti C, Lapeyraque AL, Bensman A, André JL, Broux F, Cailliez M, Decramer S, Niaudet P, Deschênes G, Jacqz-Aigrain E, Loirat C. Mycophenolate mofetil for steroid-dependent nephrotic syndrome: a phase II Bayesian trial. Pediatr Nephrol 2012; 27:389-96. [PMID: 21947272 DOI: 10.1007/s00467-011-2006-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 08/30/2011] [Accepted: 08/31/2011] [Indexed: 10/17/2022]
Abstract
Mycophenolate mofetil (MMF) has emerged as a new therapeutic option in steroid-dependent nephrotic syndrome (SDNS). We conducted a phase II Bayesian trial of MMF in children with SDNS. Phase II trials, usually single-arm studies, investigate the effect of new treatments. Standard Fleming's procedure relies on observed results (relapse rate during the trial), whereas Bayesian approach combines observed results with prior information (expected relapse rate according to prior studies and clinical experience). All patients were required to have received prior alkylating-agent treatment. Sixty-seven percent of them had also received levamisole. Patients received MMF (1,200 mg/m(2)/day) and prednisone according to a defined schedule [reduction of alternate-day (e.o.d) dose to 50% of pre-MMF dose at 3 months, 25% at 6 months]. Twenty-four children (median age 6.0 years, 2.8-14.4) entered the study and 23 completed it. Bayesian analysis showed that adding four patients would not change significance of results, allowing stopping inclusions. Four patients relapsed during the first 6 months (estimated probability 17.6%, 95% credibility interval: 5.4-35.0%) and two at months 8 and 11.5. In the 19 patients free of relapse during the first 6 months, median (Q1-Q3) prednisone maintenance dose decreased from 25 (10-44) to 9 (7.5-11.2) mg/m(2) e.o.d (p < 0.001) and cumulative dose from 459 (382-689) to 264 (196-306) mg/m(2)/month (p < 0.001) before and on MMF respectively. Pre-MMF patient characteristics and MMF pharmacokinetics did not differ between patients with or without relapse. MMF reduces relapse rate and steroid dose in children with SDNS and should be proposed before cyclosporine and cyclophosphamide.
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Affiliation(s)
- Véronique Baudouin
- Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Pediatric Nephrology Department, Université Paris 7, 48 Boulevard Sérurier, 75019, Paris, France
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Lampón N, Tutor-Crespo MJ, Romero R, Tutor JC. Diagnostic efficiency of truncated area under the curve from 0 to 2 h (AUC₀₋₂) of mycophenolic acid in kidney transplant recipients receiving mycophenolate mofetil and concomitant tacrolimus. Clin Chem Lab Med 2011; 49:1167-70. [PMID: 21574884 DOI: 10.1515/cclm.2011.191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Recently, the use of the truncated area under the curve from 0 to 2 h (AUC(0-2)) of mycophenolic acid (MPA) has been proposed for therapeutic monitoring in liver transplant recipients. The aim of our study was the evaluation of the clinical usefulness of truncated AUC(0-2) in kidney transplant patients. METHODS Plasma MPA was measured in samples taken before the morning dose of mycophenolate mofetil, and one-half and 2 h post-dose, completing 63 MPA concentration-time profiles from 40 adult kidney transplant recipients. The AUC from 0 to 12 h (AUC(0-12)) was calculated using the validated algorithm of Pawinski et al. The truncated AUC(0-2) was calculated using the linear trapezoidal rule, and extrapolated to 0-12 h (trapezoidal extrapolated AUC(0-12)) as previously described. RESULTS Algorithm calculated and trapezoidal extrapolated AUC(0-12) values showed high correlation (r=0.995) and acceptable dispersion (ma68=0.71 μg·h/mL), median prediction error (6.6%) and median absolute prediction error (12.6%). The truncated AUC(0-2) had acceptable diagnostic efficiency (87%) in the classification of subtherapeutic, therapeutic or supratherapeutic values with respect to AUC(0-12). However, due to the high inter-individual variation of the drug absorption-rate, the dispersion between both pharmacokinetic variables (ma68=6.9 μg·h/mL) was unacceptable. CONCLUSIONS The substantial dispersion between truncated AUC(0-2) and AUC(0-12) values may be a serious objection for the routine use of MPA AUC(0-2) in clinical practice.
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Affiliation(s)
- Natalia Lampón
- Unidad Monitorización Fármacos, Laboratorio Central, Hospital Clínico Universitario, Instituto de Investigación Sanitaria, Santiago de Compostela, Spain
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Capone D, Tarantino G, Kadilli I, Polichetti G, Basile V, Federico S, Sabbatini M. Evalutation of mycophenolic acid systemic exposure by limited sampling strategy in kidney transplant recipients receiving enteric-coated mycophenolate sodium (EC-MPS) and cyclosporine. Nephrol Dial Transplant 2011; 26:3019-25. [PMID: 21317409 DOI: 10.1093/ndt/gfq819] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Enteric-coated mycophenolate sodium (EC-MPS) and mycophenolate mofetil (MMF) are prodrugs of mycophenolic acid (MPA). Although many patients still receive MMF as an inosine monophosphate dehydrogenase inhibitor, EC-MPS could be considered a reliable alternative to MMF in the immunosuppressive protocols of kidney transplant recipients. MPA shows high pharmacokinetic variability and consequently a 12-h area under the curve (AUC(0-12)) should be used to guide the therapeutic dosage. However, patient compliance and economic costs make MPA AUC(0-12) an unpractical approach. Limited sampling strategies or predictive systemic drug exposure equation models based on limited sampling times are available only for MMF but lack for EC-MPS. METHODS The present study enrolled 26 kidney transplant recipients receiving EC-MPS as part of their immunosuppressive therapy. Twenty-six full MPA AUC(0-12) were performed. By using multiple stepwise regression analysis, we obtained several predictive equations of MPA systemic exposure in this group of patients. The value of the selected equations was tested in a subsequently enrolled group of 26 kidney transplant recipients. RESULTS The best equations obtained in the first group of patients were the following: 22.906 + 3.880·C(0) + 1.117·C(1) + 7.527·C(8) (r = 0.901) and 35.064 +3.784·C(0) + 1.002·C(1) + 1.192·C(2) (r = 0.846). These equation models showed an optimal agreement between the full AUCs and estimated AUCs by using the validation group of patients. CONCLUSIONS Limited sampling strategies are useful for MPA AUC(0-12) estimation in patients receiving EC-MPS and cyclosporine. The choice of one or the other equation model depends on the pharmacokinetic characteristics of the patients, in particular the potential presence of enterohepatic recirculation.
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Affiliation(s)
- Domenico Capone
- Department of Neurosciences, Unit of Clinical Pharmacology, School of Medicine, Federico II University, Naples, Italy.
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