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Zhao D, Huang P, Yu L, He Y. Pharmacokinetics-Pharmacodynamics Modeling for Evaluating Drug-Drug Interactions in Polypharmacy: Development and Challenges. Clin Pharmacokinet 2024; 63:919-944. [PMID: 38888813 DOI: 10.1007/s40262-024-01391-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 06/20/2024]
Abstract
Polypharmacy is commonly employed in clinical settings. The potential risks of drug-drug interactions (DDIs) can compromise efficacy and pose serious health hazards. Integrating pharmacokinetics (PK) and pharmacodynamics (PD) models into DDIs research provides a reliable method for evaluating and optimizing drug regimens. With advancements in our comprehension of both individual drug mechanisms and DDIs, conventional models have begun to evolve towards more detailed and precise directions, especially in terms of the simulation and analysis of physiological mechanisms. Selecting appropriate models is crucial for an accurate assessment of DDIs. This review details the theoretical frameworks and quantitative benchmarks of PK and PD modeling in DDI evaluation, highlighting the establishment of PK/PD modeling against a backdrop of complex DDIs and physiological conditions, and further showcases the potential of quantitative systems pharmacology (QSP) in this field. Furthermore, it explores the current advancements and challenges in DDI evaluation based on models, emphasizing the role of emerging in vitro detection systems, high-throughput screening technologies, and advanced computational resources in improving prediction accuracy.
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Affiliation(s)
- Di Zhao
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310000, China
- Henan University of Chinese Medicine, Zhengzhou, China
| | - Ping Huang
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310000, China
| | - Li Yu
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yu He
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310000, China.
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Bardol M, Pan S, Walker SM, Standing JF, Dawes JM. Pharmacokinetic pharmacodynamic modeling of analgesics and sedatives in children. Paediatr Anaesth 2023; 33:781-792. [PMID: 37341161 PMCID: PMC10947261 DOI: 10.1111/pan.14712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/18/2023] [Accepted: 05/21/2023] [Indexed: 06/22/2023]
Abstract
Pharmacokinetic pharmacodynamic modeling is an important tool which uses statistical methodology to provide a better understanding of the relationship between concentration and effect of drugs such as analgesics and sedatives. Pharmacokinetic pharmacodynamic models also describe between-subject variability that allows identification of subgroups and dose adjustment for optimal pain management in individual patients. This approach is particularly useful in the pediatric population, where most drugs have received limited evaluation and dosing is extrapolated from adult practice. In children, the covariates of weight and age are used to describe size- and maturation-related changes in pharmacokinetics. It is important to consider both size and maturation in order to develop an accurate model and determine the optimal dose for different age groups. An adequate assessment of analgesic and sedative effect using pain scales or brain activity measures is essential to build reliable pharmacokinetic pharmacodynamic models. This is often challenging in children due to the multidimensional nature of pain and the limited sensitivity and specificity of some measurement tools. This review provides a summary of the pharmacokinetic and pharmacodynamic methodology used to describe the dose-concentration-effect relationship of analgesics and sedation in children, with a focus on the different pharmacodynamic endpoints and the challenges of pharmacodynamic modeling.
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Affiliation(s)
- Maddlie Bardol
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - Shan Pan
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - Suellen M. Walker
- Department of Anaesthesia and Pain MedicineGreat Ormond St Hospital NHS Foundation TrustLondonUK
- Developmental Neurosciences Program, UCL Great Ormond St Institute of Child HealthUniversity College LondonLondonUK
| | - Joseph F. Standing
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- Department of PharmacyGreat Ormond St Hospital NHS Foundation TrustLondonUK
| | - Joy M. Dawes
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- Department of Anaesthesia and Pain MedicineGreat Ormond St Hospital NHS Foundation TrustLondonUK
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Hannam JA, Murto KT, Anderson BJ, Dembo G, Kharasch ED. Modeling adult COX-2 cerebrospinal fluid pharmacokinetics to inform pediatric investigation. Paediatr Anaesth 2023; 33:291-302. [PMID: 36318604 DOI: 10.1111/pan.14590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
AIM Hysteresis is reported between plasma concentration and analgesic effect from nonsteroidal anti-inflammatory drugs. It is possible that the temporal delay between plasma and CSF nonsteroidal anti-inflammatory drugs mirrors this hysteresis. The temporal relationship between plasma and CSF concentrations of COX-inhibitors (celecoxib, rofecoxib, valdecoxib) has been described. The purpose of this secondary data analysis was to develop a compartmental model for plasma and CSF disposition of these COX-2 inhibitors. METHODS Plasma and CSF concentration-time profiles and protein binding data in 10 adult volunteers given oral celecoxib 200 mg, valdecoxib 40 mg and rofecoxib 50 mg were available for study. Nonlinear mixed effects models with a single plasma compartment were used to link a single CSF compartment with a transfer factor and an equilibration rate constant (Keq). To enable predictive modeling in pediatrics, celecoxib pharmacokinetics were standardized using allometry. RESULTS Movement of all three unbound plasma COX-2 drugs into CSF was characterized by a common equilibration half-time (T1/2 keq) of 0.84 h. Influx was faster than efflux and a transfer scaling factor of 2.01 was required to describe conditions at steady-state. Estimated celecoxib clearance was 49 (95% CI 34-80) L/h/70 kg and the volume of distribution was 346 (95% CI 237-468) L/70 kg. The celecoxib absorption half-time was 0.35 h with a lag time of 0.62 h. Simulations predicted a 70-kg adult given oral celecoxib 200 mg with maintenance 100 mg twice daily would have a mean steady-state total (bound and unbound) plasma concentration of 174 μg L-1 and CSF concentration of 1.1 μg L-1 . A child (e.g., 25 kg, typically 7 years) given oral celecoxib 6 mg kg-1 with maintenance of 3 mg kg-1 twice daily would have 282 and 1.7 μg L-1 mean plasma and CSF concentrations, respectively. CONCLUSIONS Transfer of unbound COX-2 inhibitors from plasma to CSF compartment can be described with a delayed effect model using an equilibration rate constant to collapse observed hysteresis. An additional transfer factor was required to account for passage across the blood-brain barrier. Use of a target concentration strategy for dose and consequent plasma (total and unbound) and CSF concentration prediction could be used to inform pediatric clinical studies.
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Affiliation(s)
- Jacqueline A Hannam
- Department Pharmacology & Clinical Pharmacology, Faculty Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Kimmo T Murto
- Department Anesthesiology and Pain Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Brian J Anderson
- Department Anaesthesiology, Faculty Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Gregory Dembo
- Department of Anesthesiology, University of Washington, Seattle, Washington, USA
| | - Evan D Kharasch
- Department of Anesthesiology and Clinical Chemistry, Duke University School of Medicine, Durham, North Carolina, USA
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Anderson BJ, Cortinez LI. Perioperative Acetaminophen Dosing in Obese Children. CHILDREN 2023; 10:children10040625. [PMID: 37189874 DOI: 10.3390/children10040625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
Acetaminophen is a commonly used perioperative analgesic drug in children. The use of a preoperative loading dose achieves a target concentration of 10 mg/L associated with a target analgesic effect that is 2.6 pain units (visual analogue scale 1–10). Postoperative maintenance dosing is used to keep this effect at a steady-state concentration. The loading dose in children is commonly prescribed per kilogram. That dose is consistent with the linear relationship between the volume of distribution and total body weight. Total body weight is made up of both fat and fat-free mass. The fat mass has little influence on the volume of distribution of acetaminophen but fat mass should be considered for maintenance dosing that is determined by clearance. The relationship between the pharmacokinetic parameter, clearance, and size is not linear. A number of size metrics (e.g., fat-free and normal fat mass, ideal body weight and lean body weight) have been proposed to scale clearance and all consequent dosing schedules recognize curvilinear relationships between clearance and size. This relationship can be described using allometric theory. Fat mass also has an indirect influence on clearance that is independent of its effects due to increased body mass. Normal fat mass, used in conjunction with allometry, has proven a useful size metric for acetaminophen; it is calculated using fat-free mass and a fraction (Ffat) of the additional mass contributing to total body weight. However, the Ffat for acetaminophen is large (Ffat = 0.82), pharmacokinetic and pharmacodynamic parameter variability high, and the concentration–response slope gentle at the target concentration. Consequently, total body weight with allometry is acceptable for the calculation of maintenance dose. The dose of acetaminophen is tempered by concerns about adverse effects, notably hepatotoxicity associated with use after 2–3 days at doses greater than 90 mg/kg/day.
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Parri N, Silvagni D, Chiarugi A, Cortis E, D'Avino A, Lanari M, Marchisio PG, Vezzoli C, Zampogna S, Staiano A. Paracetamol and ibuprofen combination for the management of acute mild-to-moderate pain in children: expert consensus using the Nominal Group Technique (NGT). Ital J Pediatr 2023; 49:36. [PMID: 36945023 PMCID: PMC10031994 DOI: 10.1186/s13052-023-01445-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 03/14/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Acute pain is a common symptom in children of all ages, and is associated with a variety of conditions. Despite the availability of guidelines, pain often remains underestimated and undertreated. Paracetamol and ibuprofen are the most commonly used drugs for analgesia in Pediatrics. Multimodal pain management by using a combination of paracetamol and ibuprofen results in greater analgesia. METHODS An investigation using the Nominal Group Technique was carried out between May and August 2022. Two open (non-anonymous) questionnaires were consecutively sent to a Board of ten clinicians to understand their opinions on the use of the oral paracetamol and ibuprofen association. Answers were examined in a final meeting where conclusions were drawn. RESULTS The board achieved a final consensus on a better analgesic power of paracetamol and ibuprofen in fixed-dose combination as compared to monotherapy, without compromising safety. Strong consensus was reached on the opinion that the fixed-dose combination of paracetamol and ibuprofen may be a useful option in case of inefficacy of one or other drug as monotherapy, especially in case of headaches, odontalgia, earache, and musculoskeletal pain. The use of the fixed combination may be also considered suitable for postoperative pain management. CONCLUSIONS The use of the fixed-dose combination may represent advantage in terms of efficacy and safety, allowing a better control of the dose of both paracetamol and ibuprofen as monotherapy, thus minimizing the risk of incorrect dosage. However, the limited evidence available highlights the need for future well designed studies to better define the advantages of this formulation in the various therapeutic areas.
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Affiliation(s)
- Niccolò Parri
- Department of Emergency Medicine and Trauma Center, Meyer Children's Hospital IRCCS, Florence, Italy.
| | - Davide Silvagni
- Pediatric Emergency Unit, Department of Neonatal and Pediatric Critical Care, University Hospital of Verona, Verona, Italy
| | - Alberto Chiarugi
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | | | - Antonio D'Avino
- President of FIMP (Italian Federation of Primary Care Pediatricians), Naples, Italy
| | - Marcello Lanari
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliera Universitaria Di Bologna, Bologna, Italy
| | - Paola Giovanna Marchisio
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- University of Milan, Milan, Italy
| | - Cesare Vezzoli
- Pediatric Intensive Care Unit, Children's Hospital, ASST-Spedali Civili Brescia, Brescia, Italy
| | - Stefania Zampogna
- Department Pediatrics, Azienda Sanitaria Di Crotone President of SIMEUP (Italian Society of Pediatric Emergency Medicine Urgency), Crotone, Italy
| | - Annamaria Staiano
- Department of Translational Medical Sciences, Section of Pediatrics, University of Naples "Federico II", President of SIP (Italian Society of Pediatric), Naples, Italy
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Morse JD, Stanescu I, Atkinson HC, Anderson BJ. Population Pharmacokinetic Modelling of Acetaminophen and Ibuprofen: the Influence of Body Composition, Formulation and Feeding in Healthy Adult Volunteers. Eur J Drug Metab Pharmacokinet 2022; 47:497-507. [PMID: 35366213 PMCID: PMC9232434 DOI: 10.1007/s13318-022-00766-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVE Combined acetaminophen and ibuprofen are common antipyretic and analgesic drugs. Formulation and feeding affect drug absorption. Drug clearance has a nonlinear relationship with total body weight. The covariate effect of fat mass on acetaminophen and ibuprofen pharmacokinetics remains unexplored. This study sought to quantify acetaminophen and ibuprofen pharmacokinetics with intravenous, tablet, sachet and oral suspension formulations in fed and fasted states. METHODS Pooled time-concentration data for acetaminophen and ibuprofen were available from fasting and fed healthy adults. Data from intravenous, tablet, sachet and suspension formulations were analysed using nonlinear mixed-effects models. Body composition was considered as a covariate on clearances and volumes of distribution (Vd). Size metrics investigated were total body weight, fat and fat-free mass. Theory-based allometry was used to scale pharmacokinetic parameters to a 70 kg individual. A factor on absorption half-life and lag time quantified delays due to feeding for oral formulations. Pharmacokinetic-pharmacodynamic simulations were used to explore the time courses of pain response for acetaminophen and ibuprofen for each formulation. RESULTS Pooled data included 116 individuals (18-49 years, 49-116 kg) with 6095 acetaminophen and 6046 ibuprofen concentrations available for analysis. A two-compartment pharmacokinetic model with first-order elimination described disposition for both drugs. Normal fat mass was the best covariate to describe acetaminophen clearance (CL), with a factor for fat contribution (FFATCL) of 0.816. Acetaminophen volume of distribution was described using total body weight. Normal fat mass was the best covariate to describe ibuprofen clearance (FFATCL = 0.863) and volume of distribution: (FFATV = 0.718). Clearance and central volume of distribution were 24.0 L/h/70 kg and 43.5 L/h/70 kg for acetaminophen. Ibuprofen clearance and central volume of distribution were 3.79 L/h/70 kg and 10.5 L/h/70 kg. Bioavailability and absorption half-life were 86% and 12 min for acetaminophen and 94% and 27 min for ibuprofen. Absorption lag times were 5.3 min and 6.7 min for acetaminophen and ibuprofen, respectively. Feeding increased both absorption half-life and absorption lag time when compared to the tablet formulation under fasting conditions. Feeding had the most pronounced effect on the lag time associated with tablet formulation for both drugs. Time to a pain score reduction of 2 points (visual analogue score, 0-10) differed by only 5-10 min across all formulations for acetaminophen and ibuprofen. CONCLUSION Fat mass was an important covariate to describe acetaminophen and ibuprofen pharmacokinetics. The absorption half-lives of acetaminophen and ibuprofen were increased in fed states. The delay in absorption, quantified by a lag time, was protracted for both drugs.
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Affiliation(s)
- James D Morse
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Park Road, Auckland, 1023, New Zealand
| | | | | | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Park Road, Auckland, 1023, New Zealand. .,Department of Anaesthesia, Auckland Children's Hospital, Park Road, Private Bag 92024, Auckland, New Zealand.
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Eccleston C, Fisher E, Howard RF, Slater R, Forgeron P, Palermo TM, Birnie KA, Anderson BJ, Chambers CT, Crombez G, Ljungman G, Jordan I, Jordan Z, Roberts C, Schechter N, Sieberg CB, Tibboel D, Walker SM, Wilkinson D, Wood C. Delivering transformative action in paediatric pain: a Lancet Child & Adolescent Health Commission. THE LANCET. CHILD & ADOLESCENT HEALTH 2021; 5:47-87. [PMID: 33064998 DOI: 10.1016/s2352-4642(20)30277-7] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/30/2020] [Accepted: 08/06/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Christopher Eccleston
- Centre for Pain Research, University of Bath, Bath, UK; Cochrane Pain, Palliative, and Supportive Care Review Groups, Churchill Hospital, Oxford, UK; Department of Clinical-Experimental and Health Psychology, Ghent University, Ghent, Belgium.
| | - Emma Fisher
- Centre for Pain Research, University of Bath, Bath, UK; Cochrane Pain, Palliative, and Supportive Care Review Groups, Churchill Hospital, Oxford, UK
| | - Richard F Howard
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Clinical Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK; Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Paula Forgeron
- School of Nursing, Faculty of Health Sciences, University of Ottawa, ON, Canada
| | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA; Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Kathryn A Birnie
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, AB, Canada
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Christine T Chambers
- Department of Psychology and Neuroscience, and Department of Pediatrics, Dalhousie University, Halifax, NS, Canada; Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS, Canada
| | - Geert Crombez
- Department of Clinical-Experimental and Health Psychology, Ghent University, Ghent, Belgium
| | - Gustaf Ljungman
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | | | | | - Neil Schechter
- Division of Pain Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Anesthesiology, Harvard Medical School, Boston, MA, USA
| | - Christine B Sieberg
- Division of Pain Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Psychiatry, Boston Children's Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Suellen M Walker
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Clinical Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK; John Radcliffe Hospital, Oxford, UK; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Chantal Wood
- Department of Spine Surgery and Neuromodulation, Poitiers University Hospital, Poitiers, France
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Chandrakantan A, Mehta D, Adler AC. Pediatric obstructive sleep apnea revisited: Perioperative considerations for the pediatric Anesthesiologist. Int J Pediatr Otorhinolaryngol 2020; 139:110420. [PMID: 33035805 DOI: 10.1016/j.ijporl.2020.110420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 01/10/2023]
Abstract
Pediatric obstructive sleep apnea presents in up to 7% of children and represents a constellation from nasal turbulence to cessation in gas exchange. There are numerous end organ sequelae including neurocognitive morbidity associated with persistent OSA. Adenotonsillectomy (AT), the first line therapy for pediatric OSA, has not been demonstrated to reduce all end organ morbidity, specifically neurological and behavioral morbidity. Furthermore, certain at-risk populations are at higher risk from neurocognitive morbidity. Precise knowledge and perioperative planning is required to ensure optimal evidence-based practices in children with OSA. This comprehensive review covers the seminal perioperative implications of OSA, including preoperative polysomnography, pharmacotherapeutics, and postoperative risk stratification.
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Affiliation(s)
| | - Deepak Mehta
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Adam C Adler
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Tan L, Carachi P, Anderson BJ. The time course of pain after tonsillectomy. Paediatr Anaesth 2020; 30:1051-1053. [PMID: 32666587 DOI: 10.1111/pan.13970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/04/2020] [Accepted: 07/09/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Lena Tan
- Department of Anaesthesia, Starship Children's Hospital, Auckland, New Zealand
| | - Peter Carachi
- Department of Anaesthesia, Great Ormond Street Hospital for Children, London, UK
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
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Zalan J, Vaccani JP, Murto K. Paediatric adenotonsillectomy, part 2: considerations for anaesthesia. BJA Educ 2020; 20:193-200. [PMID: 33456950 PMCID: PMC7807924 DOI: 10.1016/j.bjae.2020.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2020] [Indexed: 12/11/2022] Open
Affiliation(s)
- J. Zalan
- Kingston Health Sciences Centre, Kingston, ON, Canada
| | - J-P. Vaccani
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - K.T. Murto
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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Anderson BJ, Morse JD, Hannam JA, Cortinez LI. Pharmacokinetic and pharmacodynamic considerations of general anesthesia in pediatric subjects. Expert Opin Drug Metab Toxicol 2020; 16:279-295. [PMID: 32148110 DOI: 10.1080/17425255.2020.1739648] [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] [Indexed: 01/06/2023]
Abstract
Introduction: The target concentration strategy uses PKPD information for dose determination. Models have also quantified exposure-response relationships, improved understanding of developmental pharmacokinetics, rationalized dose prescription, provided insight into the importance of covariate information, explained drug interactions and driven decision-making and learning during drug development.Areas covered: The prime PKPD consideration is parameter estimation and quantification of variability. The main sources of variability in children are age (maturation) and weight (size). Model use is mostly confined to pharmacokinetics, partly because anesthesia effect models in the young are imprecise. Exploration of PK and PD covariates and their variability hold potential to better individualize treatment.Expert opinion: The ability to model drugs using computer-based technology is hindered because covariate data required to individualize treatment using these programs remain lacking. Target concentration intervention strategies remain incomplete because covariate information that might better predict individualization of dose is absent. Pharmacogenomics appear a valuable area for investigation for pharmacodynamics and pharmacodynamics. Effect measures in the very young are imprecise. Assessment of the analgesic component of anesthesia is crude. While neuromuscular monitoring is satisfactory, depth of anaesthesia EEG interpretation is inadequate. Closed loop anesthesia is possible with better understanding of EEG changes.
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Affiliation(s)
- Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - James D Morse
- Department of Pharmacology & Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Jacqueline A Hannam
- Department of Pharmacology & Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - L Ignacio Cortinez
- División Anestesiología, Pontificia Universidad Católica De Chile, Santiago De Chile, Chile
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Anderson BJ, Hannam JA. A target concentration strategy to determine ibuprofen dosing in children. Paediatr Anaesth 2019; 29:1107-1113. [PMID: 31472084 DOI: 10.1111/pan.13731] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/14/2019] [Accepted: 08/21/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Ibuprofen is widely used for ductus arteriosus closure in premature neonates and for analgesia in children and adults. There are no maturation descriptors of clearance. This lack of maturation understanding limits dosing recommendations from premature neonates to adulthood. METHODS Published clearance estimates from different aged patients determined after administration from time-concentration profiles were used to construct a maturation model based on size and age. Curve fitting was performed using nonlinear mixed-effects models. A target concentration strategy was used to estimate maintenance dose at different ages. RESULTS There were three publications reporting an estimate of individual clearance estimates in premature neonates, three reporting population clearances in infants, 11 in children 2-15 years (1 with individual and 9 with population clearances), and 13 adult studies (1 with individual and 12 with population clearances). Clearance maturation, standardized to a 70 kg person was described using the Hill equation. Mature clearance was 3.81 (CV 15.5%, 95%CI 3.72, 3.92) L/h/70 kg. The maturation half-time was 36.8 (CV 9.2%, 95%CI 34.7, 40.9) weeks postmenstrual age and the Hill coefficient 11.5 (95%CI 8.1, 15). A target effect of four units (visual analogue scale 0-10) correlated with an effect site concentration of 6.3 mg/L: a concentration achieved at trough after 400 mg 8 hourly in adults. CONCLUSION Previously published pharmacokinetic parameters can be used to develop maturation models that address gaps in current knowledge regarding the influence of age on a drug's disposition. Maturation of ibuprofen clearance was rapid and was 90% of adult values by the first month of life in term neonates (ie, 44 weeks postmenstrual age) and 98% of standardized adult estimates by 3 months of age (53 weeks postmenstrual age). Clearance informed dosing predictions in all ages (premature neonate to adult) and matched those doses in common use in children older than 3 months.
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Affiliation(s)
- Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand.,Department of Pharmacology & Clinical Pharmacology, Auckland University, Auckland, New Zealand
| | - Jacqueline A Hannam
- Department of Pharmacology & Clinical Pharmacology, Auckland University, Auckland, New Zealand
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13
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Wright JA. An update of systemic analgesics in children. ANAESTHESIA AND INTENSIVE CARE MEDICINE 2019. [DOI: 10.1016/j.mpaic.2019.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pharmacokinetic–pharmacodynamic population modelling in paediatric anaesthesia and its clinical translation. Curr Opin Anaesthesiol 2019; 32:353-362. [DOI: 10.1097/aco.0000000000000725] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Rugytė D, Gudaitytė J. Intravenous Paracetamol in Adjunct to Intravenous Ketoprofen for Postoperative Pain in Children Undergoing General Surgery: A Double-Blinded Randomized Study. ACTA ACUST UNITED AC 2019; 55:medicina55040086. [PMID: 30939851 PMCID: PMC6524359 DOI: 10.3390/medicina55040086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/28/2019] [Accepted: 03/26/2019] [Indexed: 02/07/2023]
Abstract
Background and objectives: The combination of non-steroidal anti-inflammatory drugs and paracetamol is widely used for pediatric postoperative pain management, although the evidence of superiority of a combination over either drug alone is insufficient. We aimed to find out if intravenous (i.v.) paracetamol in a dose of 60 mg kg-1 24 h-¹, given in addition to i.v. ketoprofen (4.5 mg kg-1 24 h-¹), improves analgesia, physical recovery, and satisfaction with postoperative well-being in children and adolescents following moderate and major general surgery. Materials and Methods: Fifty-four patients were randomized to receive either i.v. paracetamol or normal saline as a placebo in adjunct to i.v. ketoprofen. For rescue analgesia in patients after moderate surgery, i.v. tramadol (2 mg kg-¹ up two doses in 24 h), and for children after major surgery, i.v. morphine-patient-controlled analgesia (PCA) were available. The main outcome measure was the amount of opioid consumed during the first 24 h after surgery. Pain level at 1 and over 24 h, time until the resumption of normal oral fluid intake, spontaneous urination after surgery, and satisfaction with postoperative well-being were also assessed. Results: Fifty-one patients (26 in the placebo group and 25 in the paracetamol group) were studied. There was no difference in required rescue tramadol doses (n = 11 in each group) or 24-h morphine consumption (mean difference (95% CI): 0.06 (⁻0.17; 0.29) or pain scores between placebo and paracetamol groups. In patients given morphine-PCA, time to normal fluid intake was faster in the paracetamol than the placebo subgroup: median difference (95% CI): 7.5 (1.3; 13.7) h, p = 0.02. Parental satisfaction score was higher in the paracetamol than the placebo group (mean difference: ⁻1.3 (⁻2.5; ⁻0.06), p = 0.04). Conclusions: There were no obvious benefits to opioid requirement or analgesia of adding regular intravenous paracetamol to intravenous ketoprofen in used doses. However, intravenous paracetamol may contribute to faster recovery of normal functions and higher satisfaction with postoperative well-being.
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MESH Headings
- Acetaminophen/administration & dosage
- Acetaminophen/adverse effects
- Administration, Intravenous
- Adolescent
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/adverse effects
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Child
- Child, Preschool
- Double-Blind Method
- Drug Therapy, Combination
- Female
- Follow-Up Studies
- Humans
- Infant
- Ketoprofen/administration & dosage
- Male
- Morphine/administration & dosage
- Morphine/therapeutic use
- Pain, Postoperative/drug therapy
- Patient Satisfaction
- Statistics, Nonparametric
- Tramadol/administration & dosage
- Tramadol/therapeutic use
- Treatment Outcome
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Affiliation(s)
- Danguolė Rugytė
- Department of Anesthesiology, Lithuanian University of Health Sciences, 44307Kaunas, Lithuania.
| | - Jūratė Gudaitytė
- Department of Anesthesiology, Lithuanian University of Health Sciences, 44307Kaunas, Lithuania.
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Playne R, Anderson BJ, Frampton C, Stanescu I, Atkinson HC. Analgesic effectiveness, pharmacokinetics, and safety of a paracetamol/ibuprofen fixed-dose combination in children undergoing adenotonsillectomy: A randomized, single-blind, parallel group trial. Paediatr Anaesth 2018; 28:1087-1095. [PMID: 30375109 DOI: 10.1111/pan.13517] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/13/2018] [Accepted: 09/21/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pain following tonsillectomy is often poorly managed in the home setting. Multimodal analgesia with acetaminophen (paracetamol) and nonsteroidal anti-inflammatory drugs offers superior analgesia over monotherapy but may be difficult for caregivers to manage. A fixed-dose combination oral suspension product containing paracetamol and ibuprofen has been developed to facilitate pediatric dosing. AIMS The aims of this study are to determine the analgesic effectiveness, pharmacokinetics, and safety of the fixed-dose combination at two doses in the pediatric population. METHODS In this prospective, multicenter, randomized, single-blind, parallel group trial, 251 children aged 2-12 years undergoing day-stay (adeno)tonsillectomy were randomized to two dose groups of the fixed-dose combination. A doubled loading dose was given preoperatively, followed by treatment for up to 11 days (Higher dose: paracetamol 15 mg/kg + ibuprofen 4.5 mg/kg, Lower dose: paracetamol 12 mg/kg + ibuprofen 3.6 mg/kg). Blood samples were collected for pharmacokinetic analysis for up to 6 hours after the loading dose. The analgesic effectiveness was examined on the first day after surgery using both Parents Postoperative Pain Measurement and modified Wong-Baker Faces pain scales. Rescue medication consumption was recorded throughout the study. RESULTS Differences in maximum plasma concentration (Cmax ) and total exposure (AUC0→t ) between the treatment groups for both analytes were consistent with a 25% increase in dose; there was no difference in time to peak concentration (Tmax ). On the first postoperative day, there was no difference in pain scores or rescue medication use between treatment groups (approximately 30% in both groups). The combination was well tolerated by both groups. The most common adverse events were vomiting and nausea. The incidence of postoperative bleeding was 4.4%. CONCLUSION The shallow dose-response relationship and good tolerability of the fixed-dose combination over an extended study period supports the utility of both doses of the fixed-dose combination in the home setting.
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Affiliation(s)
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Chris Frampton
- Department of Medicine, University of Otago, Christchurch, New Zealand
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