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Rohani R, Hoff B, Jain M, Philbrick A, Salama S, Cullina JF, Rhodes NJ. Defining the Importance of Age-Related Changes in Drug Clearance to Optimizing Aminoglycoside Dosing Regimens for Adult Patients with Cystic Fibrosis. Eur J Drug Metab Pharmacokinet 2021; 47:199-209. [PMID: 34882292 DOI: 10.1007/s13318-021-00734-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVE The number of adults living with cystic fibrosis (CF) has increased and will continue to do so with the approval of cystic fibrosis transmembrane conductance regulator (CFTR) modulators. Because systemic aminoglycosides are commonly administered for CF pulmonary exacerbations, we sought to define optimized dosing regimens using a population pharmacokinetic modeling and simulation approach. METHODS Adult CF patients admitted for pulmonary exacerbation, receiving at least 72 h of systemic gentamicin, tobramycin, or amikacin, with measured concentrations were included. Covariates [e.g., age, weight, creatinine clearance (CRCL)] were screened. Population modeling was completed using Monolix, and simulations were conducted in R. Simulated exposures were calculated using noncompartmental analysis. Once-daily fixed (10 mg/kg) and exposure-matched dosing (i.e., 15, 10, 7.5, 6 mg/kg for ages 20, 30, 40, and 50 years, respectively) strategies were compared. First-24 h exposures were evaluated for each strategy according to the probability of target attainment (PTA) (ratio of peak plasma concentrations relative to the minimum inhibitory concentration [Cmax/MIC] or ratio of the area under the concentration-time curve to MIC [AUC/MIC]) and the probability of toxic exposure (PTE) (trough concentration, Ctrough > 2 mg/l). RESULTS Forty-eight adult patients (55% female) were included. A one-compartment model best fit the data. Estimates for volume of distribution (V) and clearance (CL) were 22 l and 5.57 l/h, respectively. Weight significantly modified CL and V. Age significantly modified CL and was more influential than CRCL. PTA was > 90% at MICs ≤ 1 mg/l for fixed doses of 10 mg/kg and for exposure-matched doses at MIC ≤ 1 mg/l. Exposure-matched dosing reduced PTE roughly 50% in patients aged 40 and 50 years vs. fixed dosing. CONCLUSIONS Exposure-matching maintained PTA at MICs ≤ 1 mg/l while reducing toxicity risk in older patients compared to fixed dosing. Confirmatory studies are needed.
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Affiliation(s)
- Roxane Rohani
- Midwestern University College of Pharmacy Downers Grove Campus, 555 31st Street, Downers Grove, IL, 60515, USA.,Midwestern University College of Pharmacy Downers Grove Campus, Pharmacometrics Center of Excellence, Downers Grove, IL, USA.,Department of Pharmacy, Northwestern Medicine, Chicago, IL, USA
| | - Brian Hoff
- Department of Pharmacy, Northwestern Medicine, Chicago, IL, USA
| | - Manu Jain
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Sara Salama
- Midwestern University College of Pharmacy Downers Grove Campus, 555 31st Street, Downers Grove, IL, 60515, USA
| | | | - Nathaniel J Rhodes
- Midwestern University College of Pharmacy Downers Grove Campus, 555 31st Street, Downers Grove, IL, 60515, USA. .,Midwestern University College of Pharmacy Downers Grove Campus, Pharmacometrics Center of Excellence, Downers Grove, IL, USA. .,Department of Pharmacy, Northwestern Medicine, Chicago, IL, USA.
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Ernest JP, Sarathy J, Wang N, Kaya F, Zimmerman MD, Strydom N, Wang H, Xie M, Gengenbacher M, Via LE, Barry CE, Carter CL, Savic RM, Dartois V. Lesion Penetration and Activity Limit the Utility of Second-Line Injectable Agents in Pulmonary Tuberculosis. Antimicrob Agents Chemother 2021; 65:e0050621. [PMID: 34252307 PMCID: PMC8448094 DOI: 10.1128/aac.00506-21] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 07/08/2021] [Indexed: 11/20/2022] Open
Abstract
Amikacin and kanamycin are second-line injectables used in the treatment of multidrug-resistant tuberculosis (MDR-TB) based on the clinical utility of streptomycin, another aminoglycoside and first-line anti-TB drug. While streptomycin was tested as a single agent in the first controlled TB clinical trial, introduction of amikacin and kanamycin into MDR-TB regimens was not preceded by randomized controlled trials. A recent large retrospective meta-analysis revealed that compared with regimens without any injectable drug, amikacin provided modest benefits, and kanamycin was associated with worse outcomes. Although their long-term use can cause irreversible ototoxicity, they remain part of MDR-TB regimens because they have a role in preventing emergence of resistance to other drugs. To quantify the contribution of amikacin and kanamycin to second-line regimens, we applied two-dimensional matrix-assisted laser desorption ionization (MALDI) mass spectrometry imaging in large lung lesions, quantified drug exposure in lung and in lesions of rabbits with active TB, and measured the concentrations required to kill or inhibit growth of the resident bacterial populations. Using these metrics, we applied site-of-action pharmacokinetic and pharmacodynamic (PK-PD) concepts and simulated drug coverage in patients' lung lesions. The results provide a pharmacological explanation for the limited clinical utility of both agents and reveal better PK-PD lesion coverage for amikacin than kanamycin, consistent with retrospective data of contribution to treatment success. Together with recent mechanistic studies dissecting antibacterial activity from aminoglycoside ototoxicity, the limited but rapid penetration of streptomycin, amikacin, and kanamycin to the sites of TB disease supports the development of analogs with improved efficacy and tolerability.
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Affiliation(s)
- Jacqueline P. Ernest
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Jansy Sarathy
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Ning Wang
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Firat Kaya
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Matthew D. Zimmerman
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Natasha Strydom
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Han Wang
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Min Xie
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Martin Gengenbacher
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
- Hackensack School of Medicine, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Laura E. Via
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda, Maryland, USA
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
| | - Clifton E. Barry
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda, Maryland, USA
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
| | - Claire L. Carter
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Radojka M. Savic
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Véronique Dartois
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
- Hackensack School of Medicine, Hackensack Meridian Health, Nutley, New Jersey, USA
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3
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Woillard JB, Bouchet S, Fayon M, Marquet P, Monchaud C, Bui S. A Population Pharmacokinetic Modeling Approach to Determine the Efficacy of Intravenous Amikacin in Children with Cystic Fibrosis. Ther Drug Monit 2021; 43:499-504. [PMID: 33346630 DOI: 10.1097/ftd.0000000000000855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/25/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND In children with cystic fibrosis (CF), the currently recommended amikacin dose ranges between 30 and 35 mg/kg/d; however, data supporting this dosing efficacy are lacking. In this article, the objectives were to develop a nonparametric pharmacokinetic population model for amikacin in children with CF and investigate the efficacy and toxicity at different dose rates for distinct minimum inhibitory concentration (MIC) clinical breakpoints using Monte Carlo simulations. METHODS Data from 94 children with CF (613 serum concentrations) from the Bordeaux University Hospital's CF-centre were analyzed. After determination of nonparametric pharmacokinetic population model parameters and associated influent covariates in Pmetrics, 1000 Monte Carlo simulations were performed for 7 different dose rates between 30 and 60 mg/kg/d, to predict the probability of obtaining peak serum amikacin ≥10 × MIC and trough level ≤2.5 mg/L, for MIC values between 1 and 16 mg/L. RESULTS The median (min-max) age and weight were 10 (0.3-17) years and 29 (6-71) kg, respectively, with only 2 children younger than 1 year of age. Body weight and creatinine clearance significantly impacted the amikacin volume of distribution and clearance. The mean relative bias/root mean squared error between observed and individual predicted concentrations was -0.68%/8.1%. Monte Carlo simulations showed that for sensitive bacteria with MICs ≤ 4, 30 mg/kg/d was most appropriate for a 100% success rate; for bacteria with MICs ≥ 8 [eg, Pseudomonas aeruginosa (MICamikacin = 8)], a dose of at least 40 mg/kg/d allowed a high success probability (90%), with a trough level below 2.5 mg/L. CONCLUSIONS For intermediate pathogens, a dose of at least 40 mg/kg/d can improve efficacy, with an acceptable calculated residual trough level in cases of normal or hyperfiltration. Because amikacin undergoes renal clearance, which is immature until 1 year of age, dosing recommendations for this age group may be markedly high, warranting cautious interpretation.
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Affiliation(s)
- Jean-Baptiste Woillard
- Department of Pharmacology and Toxicology, CHU Limoges
- IPPRITT, Université de Limoges
- INSERM, IPPRITT, U1248, Limoges
| | - Stéphane Bouchet
- CHU de Bordeaux, Hôpital Pellegrin, Service de Pharmacologie et Toxicologie
| | - Michael Fayon
- CHU de Bordeaux, Hôpital Pellegrin-Enfants, CRCM Pédiatrique and
- Université de Bordeaux, INSERM, Centre de Recherche Cardio-thoracique de Bordeaux (U1045), Centre d'Investigation Clinique (CIC1401), Bordeaux, France
| | - Pierre Marquet
- Department of Pharmacology and Toxicology, CHU Limoges
- IPPRITT, Université de Limoges
- INSERM, IPPRITT, U1248, Limoges
| | - Caroline Monchaud
- Department of Pharmacology and Toxicology, CHU Limoges
- IPPRITT, Université de Limoges
- INSERM, IPPRITT, U1248, Limoges
| | - Stéphanie Bui
- CHU de Bordeaux, Hôpital Pellegrin-Enfants, CRCM Pédiatrique and
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Pérez-Blanco JS, Sáez Fernández EM, Calvo MV, Lanao JM, Martín-Suárez A. Amikacin initial dosage in patients with hypoalbuminaemia: an interactive tool based on a population pharmacokinetic approach. J Antimicrob Chemother 2021; 75:2222-2231. [PMID: 32363405 DOI: 10.1093/jac/dkaa158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/25/2020] [Accepted: 03/29/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To characterize amikacin population pharmacokinetics in patients with hypoalbuminaemia and to develop a model-based interactive application for amikacin initial dosage. METHODS A population pharmacokinetic model was developed using a non-linear mixed-effects modelling approach (NONMEM) with amikacin concentration-time data collected from clinical practice (75% hypoalbuminaemic patients). Goodness-of-fit plots, minimum objective function value, prediction-corrected visual predictive check, bootstrapping, precision and bias of parameter estimates were used for model evaluation. An interactive model-based simulation tool was developed in R (Shiny and R Markdown). Cmax/MIC ratio, time above MIC and AUC/MIC were used for optimizing amikacin initial dose recommendation. Probabilities of reaching targets were calculated for the dosage proposed. RESULTS A one-compartment model with first-order linear elimination best described the 873 amikacin plasma concentrations available from 294 subjects (model development and external validation groups). Estimated amikacin population pharmacokinetic parameters were CL (L/h) = 0.525 + 4.78 × (CKD-EPI/98) × (0.77 × vancomycin) and V (L) = 26.3 × (albumin/2.9)-0.51 × [1 + 0.006 × (weight - 70)], where CKD-EPI is calculated with the Chronic Kidney Disease Epidemiology Collaboration equation. AMKdose is a useful interactive model-based application for a priori optimization of amikacin dosage, using individual patient and microbiological information together with predefined pharmacokinetic/pharmacodynamic (PKPD) targets. CONCLUSIONS Serum albumin, total bodyweight, estimated glomerular filtration rate (using the CKD-EPI equation) and co-medication with vancomycin showed a significant impact on amikacin pharmacokinetics. A powerful interactive initial dose-finding tool has been developed and is freely available online. AMKdose could be useful for guiding initial amikacin dose selection before any individual pharmacokinetic information is available.
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Affiliation(s)
- Jonás Samuel Pérez-Blanco
- Department of Pharmaceutical Sciences, University of Salamanca, Pharmacy Faculty, Campus Miguel de Unamuno, 37007 Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Hospital Virgen de la Vega, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Eva María Sáez Fernández
- Department of Pharmaceutical Sciences, University of Salamanca, Pharmacy Faculty, Campus Miguel de Unamuno, 37007 Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Hospital Virgen de la Vega, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain.,Pharmacy Service, University Hospital of Salamanca, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - M Victoria Calvo
- Department of Pharmaceutical Sciences, University of Salamanca, Pharmacy Faculty, Campus Miguel de Unamuno, 37007 Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Hospital Virgen de la Vega, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain.,Pharmacy Service, University Hospital of Salamanca, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - José M Lanao
- Department of Pharmaceutical Sciences, University of Salamanca, Pharmacy Faculty, Campus Miguel de Unamuno, 37007 Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Hospital Virgen de la Vega, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Ana Martín-Suárez
- Department of Pharmaceutical Sciences, University of Salamanca, Pharmacy Faculty, Campus Miguel de Unamuno, 37007 Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Hospital Virgen de la Vega, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
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5
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Burke A, Smith D, Coulter C, Bell SC, Thomson R, Roberts JA. Clinical Pharmacokinetic and Pharmacodynamic Considerations in the Drug Treatment of Non-Tuberculous Mycobacteria in Cystic Fibrosis. Clin Pharmacokinet 2021; 60:1081-1102. [PMID: 33982266 DOI: 10.1007/s40262-021-01010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2021] [Indexed: 10/21/2022]
Abstract
Non-tuberculous mycobacteria (NTM) are an emerging group of pulmonary infectious pathogens of increasing importance to the management of patients with cystic fibrosis (CF). NTM include slow-growing mycobacteria such as Mycobacterium avium complex (MAC) and rapidly growing mycobacteria such as Mycobacterium abscessus. The incidence of NTM in the CF population is increasing and infection contributes to significant morbidity to the patient and costs to the health system. Treating M. abscessus requires the combination of multiple costly antibiotics for months, with potentially significant toxicity associated with treatment. Although international guidelines for the treatment of NTM infection in CF are available, there are a lack of robust pharmacokinetic studies in CF patients to inform dosing and drug choice. This paper aims to outline the pharmacokinetic and pharmacodynamic factors informing the optimal treatment of NTM infections in CF.
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Affiliation(s)
- Andrew Burke
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia
| | - Daniel Smith
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia
| | - Chris Coulter
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia
| | - Scott C Bell
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia.,QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Rachel Thomson
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia.,Immunology Department, Gallipoli Medical Research Institute, Brisbane, QLD, Australia
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia. .,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia. .,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia. .,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
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Population Pharmacokinetics Analysis of Amikacin Initial Dosing Regimen in Elderly Patients. Antibiotics (Basel) 2021; 10:antibiotics10020100. [PMID: 33498481 PMCID: PMC7909551 DOI: 10.3390/antibiotics10020100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/14/2021] [Accepted: 01/19/2021] [Indexed: 11/16/2022] Open
Abstract
There are limited data of amikacin pharmacokinetics (PK) in the elderly population. Hence, we aimed to describe the population PK of amikacin in elderly patients (>70 years old) and to establish optimized initial dosing regimens. We simulated individual maximum concentrations in plasma (Cmax) and minimal concentrations (Cmin) for several dosing regimens (200–2000 mg every 24, 48, and 72 h) for patients with creatinine clearance (CCr) of 10–90 mL/min and analyzed efficacy (Cmax/minimal inhibitory concentration (MIC) ≥ 8) for MICs of 4, 8, and 16 mg/L and safety (Cmin < 4 mg/L). A one-compartment model best described the data. CCr was the only covariate associated with amikacin clearance. The population PK parameter estimates were 2.25 L/h for clearance and 18.0 L for volume of distribution. Dosing simulations recommended the dosing regimens (1800 mg) with dosing intervals ranging 48–72 h for patients with CCr of 40–90 mL/min based on achievement of both efficacy for the MIC of 8 mg/L and safety. None of the dosing regimens achieved the targets for an MIC of 16 mg/L. We recommend the initial dosing regimen using a nomogram based on CCr for an MIC of ≤8 mg/L in elderly patients with CCr of 40–90 mL/min.
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Antibiotics in Adult Cystic Fibrosis Patients: A Review of Population Pharmacokinetic Analyses. Clin Pharmacokinet 2021; 60:447-470. [PMID: 33447944 DOI: 10.1007/s40262-020-00970-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Lower respiratory tract infections are common in adult patients with cystic fibrosis (CF) and are frequently caused by Pseudomonas aeruginosa, resulting in chronic lung inflammation and fibrosis. The progression of multidrug-resistant strains of P. aeruginosa and alterations in the pharmacokinetics of many antibiotics in CF make optimal antimicrobial therapy a challenge, as reflected by high between- and inter-individual variability (IIV). OBJECTIVES This review provides a synthesis of population pharmacokinetic models for various antibiotics prescribed in adult CF patients, and aims at identifying the most reported structural models, covariates and sources of variability influencing the dose-concentration relationship. METHODS A literature search was conducted using the PubMed database, from inception to August 2020, and articles were retained if they met the inclusion/exclusion criteria. RESULTS A total of 19 articles were included in this review. One-, two- and three-compartment models were reported to best describe the pharmacokinetics of various antibiotics. The most common covariates were lean body mass and creatinine clearance. After covariate inclusion, the IIV (range) in total body clearance was 27.2% (10.40-59.7%) and 25.9% (18.0-33.9%) for β-lactams and aminoglycosides, respectively. IIV in total body clearance was estimated at 36.3% for linezolid and 22.4% for telavancin. The IIV (range) in volume of distribution was 29.4% (8.8-45.9%) and 15.2 (11.6-18.0%) for β-lactams and aminoglycosides, respectively, and 26.9% for telavancin. The median (range) of residual variability for all studies, using a combined (proportional and additive) model, was 12.7% (0.384-30.80%) and 0.126 mg/L (0.007-1.88 mg/L), respectively. CONCLUSION This is the first review that highlights key aspects of different population pharmacokinetic models of antibiotics prescribed in adult CF patients, effectively proposing relevant information for clinicians and researchers to optimize antibiotic therapy in CF.
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8
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Jin X, Oh J, Cho JY, Lee S, Rhee SJ. Population Pharmacokinetic Analysis of Amikacin for Optimal Pharmacotherapy in Korean Patients with Nontuberculous Mycobacterial Pulmonary Disease. Antibiotics (Basel) 2020; 9:antibiotics9110784. [PMID: 33172135 PMCID: PMC7694782 DOI: 10.3390/antibiotics9110784] [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: 10/06/2020] [Revised: 11/05/2020] [Accepted: 11/05/2020] [Indexed: 11/26/2022] Open
Abstract
Amikacin is used as a therapy for patients with nontuberculous mycobacterial pulmonary disease (NTM-PD) who are resistant to macrolide antibiotics or have severe symptoms. This study aimed to characterize the pharmacokinetic properties of amikacin in patients with NTM-PD by developing a population pharmacokinetic model and to explore the optimal pharmacotherapy in patients with NTM-PD. For this study, all data were retrospectively collected. The amikacin pharmacokinetic properties were best described by a two-compartment model with first-order elimination. The estimated glomerular filtration rate and body weight were identified as significant covariates for clearance and the volume of distribution, respectively. A model-based simulation was conducted to explore the probability of reaching the target therapeutic range when various dose regimens were administered according to the body weight and renal function. The simulation results indicated that the amikacin dosage should be determined based on the body weight, and for patients who weigh over 70 kg, it is necessary to adjust the dose according to renal function. In conclusion, the optimal pharmacotherapy of amikacin for patients with NTM-PD was recommended based on the population pharmacokinetic model, which is expected to enable the personalization of drug therapy and improve the clinical outcomes of amikacin therapy.
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Marsot A, Hraiech S, Cassir N, Daviet F, Parzy G, Blin O, Papazian L, Guilhaumou R. Aminoglycosides in critically ill patients: which dosing regimens for which pathogens? Int J Antimicrob Agents 2020; 56:106124. [PMID: 32739478 DOI: 10.1016/j.ijantimicag.2020.106124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 06/17/2020] [Accepted: 07/23/2020] [Indexed: 12/20/2022]
Abstract
Modifications of antibiotic pharmacokinetic parameters have been reported in critically ill patients, resulting in a risk of treatment failure. We aimed to determine optimised amikacin (AMK), gentamicin (GEN) and tobramycin (TOB) intravenous dosing regimens in this patient population. Patients admitted to the medical ICU and treated with AMK, GEN or TOB were included. Analyses were performed using a parametric population approach. Monte Carlo simulations were performed and the probability of target attainment (PTA) was calculated using Cmax/MIC ≥ 8 and trough concentrations as targets. A total of 117 critically ill hospitalised patients were studied. Median values (interindividual variability, ɷ2) of clearance were 3.51 (0.539), 3.53 (0.297), 2.70 (0.339) and 5.07 (0.339) L/h for AMK, GEN, TOB, and TOB in cystic fibrosis (CF), respectively. Median values (ɷ2) of central volume of distribution were 30.2 (0.215), 20.0 (0.109) and 25.6 (0.177) L for AMK, GEN and TOB, respectively. Simulations showed that doses should be adjusted to actual body weight and creatinine clearance (CLCR) for AMK and GEN, and according to CLCR and presence of CF for TOB. In conclusion, our recommendations for treating Pseudomonas aeruginosa infections in this population include using initial doses of 35 mg/kg for AMK or 10 mg/kg for TOB (CF and non-CF patients). GEN demonstrated the best rates of target attainment against Staphylococcus aureus infections with a dose of 5 mg/kg. As high aminoglycoside doses are required in this population, efficacy and safety targets are conflicting and therapeutic drug monitoring remains an important tool to manage this issue.
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Affiliation(s)
- A Marsot
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.
| | - S Hraiech
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France; CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - N Cassir
- Aix-Marseille Université, IRD, APHM, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France
| | - F Daviet
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France; CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - G Parzy
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France; CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - O Blin
- IHU Méditerranée Infection, Marseille, France
| | - L Papazian
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France; CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - R Guilhaumou
- Aix-Marseille Univ., APHM, INSERM, CIC CPCET Service de Pharmacologie Clinique et Pharmacovigilance, INS Inst Neurosci Syst, Marseille, France
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10
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Thirion DJG, Pasche V, Matouk E, Marsot A. Amikacin nomogram for treatment of adult cystic fibrosis exacerbations based on an external evaluation of a population pharmacokinetic model. Pediatr Pulmonol 2020; 55:1154-1160. [PMID: 32119197 DOI: 10.1002/ppul.24689] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 02/04/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND In patients with cystic fibrosis (CF), amikacin is the alternative for the treatment of acute pulmonary exacerbations associated with pathogens resistant to tobramycin. Population pharmacokinetic (PK) models of amikacin in adult patients with CF have been previously published. However, current dosing recommendations remain disputed (Illamola et al. Clin Pharmacokinet. 2018;57(10):1217-1228). We perform here the first external evaluation of a published amikacin adult CF population PK model and propose a dosing nomogram for initial dosing. METHODS We retrospectively collected demographic, biological, and clinical data from the medical records of adult patients who had received intravenous amikacin. To assess the predictive performance of this model we applied visual comparison of predictions to observations, calculation of bias and inaccuracy, and simulation-based diagnostics. Monte Carlo simulations from the evaluated model were used to compare maximum concentration/minimum inhibitory concentration achieved with different dosing regimens. RESULTS A total of 91 concentrations from 19 adult patients with CF were collected for external evaluation. The model predicted amikacin concentrations with reasonable bias (7.2% [95% confidence interval, CI: -0.7% to 15.0%]) and inaccuracy (18.2% [95% CI: 12.0%-24.4%]). Our simulations with this model suggest that administered amikacin doses must be adjusted to creatinine clearance and also adjusted to body weight (doses from 20 to 45 mg/kg/d). According to these simulations, we developed the Montreal amikacin nomogram to optimize amikacin dosing regimens in patients with CF. CONCLUSION In conclusion, we developed the first nomogram to optimize initial amikacin dosing regimens in patients with CF based on this external evaluation of a recently published amikacin population PK model.
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Affiliation(s)
- Daniel J G Thirion
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada.,Department of Pharmacy, McGill University Health Center, Montréal, Québec, Canada
| | - Valérian Pasche
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada.,Laboratoire de suivi thérapeutique pharmacologique et pharmacocinétique, Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada
| | - Elias Matouk
- Adult Cystic Fibrosis Clinic, Montreal Chest Institute, McGill University, Montréal, Québec, Canada.,McGill University Health Center Research Institute, Montréal, Québec, Canada.,Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Amélie Marsot
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada.,Laboratoire de suivi thérapeutique pharmacologique et pharmacocinétique, Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada
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11
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Thirion DJG, Pasche V, Marsot A. What is the recommended amikacin dosing for cystic fibrosis patients with acute pulmonary exacerbations? Pediatr Pulmonol 2019; 54:1652-1653. [PMID: 31313524 DOI: 10.1002/ppul.24453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 06/30/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Daniel J G Thirion
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada.,Pharmacy Department, McGill University Health Center, Montréal, Québec, Canada
| | - Valérian Pasche
- Laboratoire de suivi thérapeutique pharmacologique et pharmacocinétique, Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada
| | - Amélie Marsot
- Laboratoire de suivi thérapeutique pharmacologique et pharmacocinétique, Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada
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Caceres Guido P, Perez M, Halac A, Ferrari M, Ibarra M, Licciardone N, Castaños C, Gravina LP, Jimenez C, Garcia Bournissen F, Schaiquevich P. Population pharmacokinetics of amikacin in patients with pediatric cystic fibrosis. Pediatr Pulmonol 2019; 54:1801-1810. [PMID: 31402602 DOI: 10.1002/ppul.24468] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/21/2019] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Amikacin is commonly used in patients with pediatric cystic fibrosis (CF) for the treatment of pulmonary exacerbations. Amikacin efficacy is related to maximum plasma concentration/minimum inhibitory concentration (Cmax/MIC) ratio >8. Pharmacokinetic data in patients with pediatric CF are scarce. The aim of this study was to develop a population pharmacokinetic (PopPK) model describing amikacin disposition in patients with pediatric CF. METHODS CF patients under 18 years of age with pulmonary exacerbation who received amikacin were enrolled. Patients received different amikacin regimens (30 mg-1 kg-1 day-1 every 8, 12, or 24 hours) depending on the patient's status and hospital protocols. Amikacin serum levels were obtained for therapeutic drug monitoring. PopPK model was developed using MONOLIX Suite-2018R1 (Lixoft). RESULTS A total of 39 patients (114 amikacin concentrations) were included in this study. Population estimates for the elimination rate constant (k) and the volume of distribution (V) were 0.541 hours-1 and 0.451 L/kg, respectively. Between-subject and between-occasion variability were 53% and 16.5% for k and 31% and 22% for V, respectively. Bodyweight was a significant covariate associated with V. Based on simulations, almost 70% of the patients receiving 30 mg-1 kg-1 day-1 every 24 hours would achieve a Cmax/MIC ratio >8 which is an appropriate therapeutic goal while no patient in the other two groups (Q8 and Q12) would achieve that objective. CONCLUSIONS The regimen of 30 mg-1 kg-1 day-1 every 24 hours more adequately fulfilled the therapeutic target for amikacin. Although all our patients had good clinical results and a good adverse-events profile, further studies are necessary to redefine the optimal treatment strategy.
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Affiliation(s)
- Paulo Caceres Guido
- Clinical Pharmacokinetics Unit, Hospital de Pediatria JP Garrahan, Buenos Aires, Argentina
| | - Mariel Perez
- Pharmacy Area, Hospital de Pediatria JP Garrahan, Buenos Aires, Argentina
| | - Alicia Halac
- Intermediate and Moderate Care Ward, Hospital de Pediatria JP Garrahan, Buenos Aires, Argentina
| | - Mariela Ferrari
- Intermediate and Moderate Care Ward, Hospital de Pediatria JP Garrahan, Buenos Aires, Argentina
| | - Manuel Ibarra
- Pharmaceutical Sciences, Department of Chemistry, Universidad de la Republica, Uruguay, Uruguay
| | - Nieves Licciardone
- Laboratory Service, Hospital de Pediatria JP Garrahan, Buenos Aires, Argentina
| | - Claudio Castaños
- Department of Pulmonology, Hospital de Pediatria JP Garrahan, Buenos Aires, Argentina
| | - Luis P Gravina
- Molecular Biology - Genetics, Hospital de Pediatria JP Garrahan, Buenos Aires, Argentina
| | - Cristina Jimenez
- Intermediate and Moderate Care Ward, Hospital de Pediatria JP Garrahan, Buenos Aires, Argentina
| | - Facundo Garcia Bournissen
- Multidisciplinary Institute for Pediatric Pathology Research (IMIPP), Hospital General de Niños R, Gutierrez, Argentina
| | - Paula Schaiquevich
- Clinical Pharmacokinetics Unit, Hospital de Pediatria JP Garrahan, Buenos Aires, Argentina.,National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
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