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Ghasemiyeh P, Vazin A, Mohammadi-Samani S. A Brief Review of Pharmacokinetic Assessments of Vancomycin in Special Groups of Patients with Altered Pharmacokinetic Parameters. Curr Drug Saf 2023; 18:425-439. [PMID: 35927907 DOI: 10.2174/1574886317666220801124718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/22/2022] [Accepted: 05/26/2022] [Indexed: 11/22/2022]
Abstract
Vancomycin is considered the drug of choice against many Gram-positive bacterial infections. Therapeutic drug monitoring (TDM) is essential to achieve an optimum clinical response and avoid vancomycin-induced adverse reactions including nephrotoxicity. Although different studies are available on vancomycin TDM, still there are controversies regarding the selection among different pharmacokinetic parameters including trough concentration, the area under the curve to minimum inhibitory concentration ratio (AUC24h/MIC), AUC of intervals, elimination constant, and vancomycin clearance. In this review, different pharmacokinetic parameters for vancomycin TDM have been discussed along with corresponding advantages and disadvantages. Also, vancomycin pharmacokinetic assessments are discussed in patients with altered pharmacokinetic parameters including those with renal and/or hepatic failure, critically ill patients, patients with burn injuries, intravenous drug users, obese and morbidly obese patients, those with cancer, patients undergoing organ transplantation, and vancomycin administration during pregnancy and lactation. An individualized dosing regimen is required to guarantee the optimum therapeutic responses and minimize adverse reactions including acute kidney injury in these special groups of patients. According to the pharmacoeconomic data on vancomycin TDM, pharmacokinetic assessments would be cost-effective in patients with altered pharmacokinetics and are associated with shorter hospitalization period, faster clinical stability status, and shorter courses of inpatient vancomycin administration.
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Affiliation(s)
- Parisa Ghasemiyeh
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
- Pharmaceutical Sciences Research Center, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Afsaneh Vazin
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Soliman Mohammadi-Samani
- Pharmaceutical Sciences Research Center, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmaceutics, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
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2
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Erstad BL, Matthias KR, Nix DE. Vancomycin dosing in patients with obesity. Am J Health Syst Pharm 2022; 79:2058-2069. [PMID: 35981345 DOI: 10.1093/ajhp/zxac229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Kathryn R Matthias
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - David E Nix
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
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3
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Wong S, Reuter SE, Jones GR, Stocker SL. Review and evaluation of vancomycin dosing guidelines for obese individuals. Expert Opin Drug Metab Toxicol 2022; 18:323-335. [PMID: 35815356 DOI: 10.1080/17425255.2022.2098106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Vancomycin dosing decisions are informed by factors such as body weight and renal function. It is important to understand the impact of obesity on vancomycin pharmacokinetics and how this may influence dosing decisions. Vancomycin dosing guidelines use varied descriptors of body weight and renal function. There is uncertainty whether current dosing guidelines result in attainment of therapeutic targets in obese individuals. AREAS COVERED Literature was explored using PubMed, Embase and Google Scholar for articles from January 1980 to July 2021 regarding obesity-driven physiological changes, their influence on vancomycin pharmacokinetics and body size descriptors and renal function calculations in vancomycin dosing. Pharmacokinetic simulations reflective of international vancomycin dosing guidelines were conducted to evaluate the ability of using total, ideal and adjusted body weight, as well as Cockcroft-Gault and CKD-EPI equations to attain an area-under-the-curve to minimum inhibitory concentration ratio (AUC24/MIC) target (400-650) in obese individuals. EXPERT OPINION Vancomycin pharmacokinetics in obese individuals remains debated. Guidelines that determine loading doses using total body weight, and maintenance doses adjusted based on renal function and adjusted body weight, may be most appropriate for obese individuals. Use of ideal body weight leads to subtherapeutic vancomycin exposure and underestimation of renal function.
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Affiliation(s)
- Sherilyn Wong
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Stephanie E Reuter
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Graham Rd Jones
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia.,Department of Chemical Pathology and Clinical Pharmacology, SydPath, St Vincent's Hospital, Darlinghurst, Australia
| | - Sophie L Stocker
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia.,Sydney School of Pharmacy, The University of Sydney, Sydney, Australia.,Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Darlinghurst, Australia
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4
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Silveira ALO, Alves GCDS, Xie J, Roberts JA, Sanches C. Vancomycin population pharmacokinetic modeling in children using Bayesian estimation and a Non Parametric Approach. BRAZ J PHARM SCI 2022. [DOI: 10.1590/s2175-97902020000x2e19313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | - Jiao Xie
- The University of Queensland, Australia
| | - Jason A Roberts
- The University of Queensland, Australia; Royal Brisbane and Women’s Hospital, Australia; Royal Brisbane and Women’s Hospital, Australia; The University of Queensland, Australia
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5
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Tøstesen SK, Hanberg P, Bue M, Thillemann TM, Falstie-Jensen T, Tøttrup M, Knudsen MB, Schmedes AV, Stilling M. Weight-based cefuroxime dosing provides comparable orthopedic target tissue concentrations between weight groups - a microdialysis porcine study. APMIS 2021; 130:111-118. [PMID: 34862642 DOI: 10.1111/apm.13198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/25/2021] [Indexed: 11/29/2022]
Abstract
Antibiotic prophylaxis is a key element in prevention of surgical site infections. For the majority of orthopedic procedures, antibiotic administration follows fixed dosing regimens irrespective of weight. However, this may result in insufficient antibiotic target tissue concentrations and higher risk of surgical site infections in obese individuals. The aim of this study was to investigate the effect of weight-based cefuroxime dosing on plasma and target tissue concentrations. Eighteen female pigs were allocated into three groups differentiated by weight: 53-57 kg, 73-77 kg, and 93-97 kg. Microdialysis catheters were placed for continuous sampling in bone, muscle, and subcutaneous tissue during an 8h sampling interval. Blood samples were collected as reference. Cefuroxime was administered intravenously as a bolus according to weight (20 mg/kg). The primary endpoint was the time above the cefuroxime minimal inhibitory concentration for Staphylococcus aureus (T > MIC (4 μg/mL)). Comparable target tissue T > MICs (4 μg/mL) were found between weight groups. Mean T > MIC ranged between 116-137 min for plasma, 118-154 min for bone, 109-146 min for the skeletal muscle, and 117-165 min for subcutaneous tissue across the groups. Weight-based cefuroxime (20 mg/kg) dosing approach provides comparable perioperative plasma and target tissue T > MIC (4 μg/mL) in animals between 50-100 kg body weight, and thus a comparable prophylaxis of surgical site infections.
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Affiliation(s)
- Sara Kousgaard Tøstesen
- Aarhus Microdialysis Research Group, Orthopedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Pelle Hanberg
- Aarhus Microdialysis Research Group, Orthopedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark
| | - Mats Bue
- Aarhus Microdialysis Research Group, Orthopedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Theis Muncholm Thillemann
- Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Mikkel Tøttrup
- Department of Orthopedic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | | | | | - Maiken Stilling
- Aarhus Microdialysis Research Group, Orthopedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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6
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Alzahrani AM, Naeem A, Alwadie AF, Albogami K, Alzhrani RM, Basudan SS, Alzahrani YA. Causes of vancomycin dosing error; problem detection and practical solutions; a retrospective, single-center, cross-sectional study. Saudi Pharm J 2021; 29:616-624. [PMID: 34194269 PMCID: PMC8233537 DOI: 10.1016/j.jsps.2021.04.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/18/2021] [Indexed: 11/27/2022] Open
Abstract
Vancomycindosing error and inappropriate monitoring is a common problem in hospital daily practice. In King Abdulaziz Medical City (KAMC) in Jeddah, a high percentage of abnormal vancomycin trough levels is still detected despite using the recommended dose. Therefore, the current research objective is to study the major causes of vancomycin dosing errors. This retrospective, single-center, cross-sectional study was carried out at KAMC hospital in Jeddah from January 1st until December 31st 2019. All adult patients (≥15 years) who received vancomycin and had an initial abnormal trough level at the measured steady-state were included in this study. 472 patients have met the study inclusion criteria. The current study evaluated the factors that play a role in causing vancomycin trough level abnormalities such as sampling time, vancomycin dosing, and patient’s pharmacokinetic and pharmacodynamic variations. In this study, we found that pharmacokinetic and pharmacodynamic variability was attributed to 65% of vancomycin's abnormal trough level. Also, the result showed a significantly increased odds of the low trough in the non-elderly group (OR 6, 95% CI 2.48 – 14.9, P < 0.001) and febrile neutropenic patients (OR 2.21, 95% CI 1.119 – 4.365, P < 0.05). However, the odds of high trough levels were significantly elevated among patients who have CrCl < 50 ml/min (OR 5, 95% CI 1.262–20.539, P < 0.05). In addition, the present investigation revealed that the occurrence of abnormal vancomycin levels was not affected by daily duty time or working days (p > 0.05). The current study indicated that vancomycin dosing errors were common in KAMC patients; thus, there is an unmet need to evaluate the causes of vancomycin abnormal trough level and optimize a strategy that would enhance the therapeutic effectiveness and minimize the potential toxicity.
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Affiliation(s)
- Abdullah M Alzahrani
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.,Pharmaceutical Care Department, Ministry of National Guard - Health Affairs, Jeddah, Saudi Arabia
| | - Anjum Naeem
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.,Pharmaceutical Care Department, Ministry of National Guard - Health Affairs, Jeddah, Saudi Arabia
| | - Ali F Alwadie
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.,Pharmaceutical Care Department, Ministry of National Guard - Health Affairs, Jeddah, Saudi Arabia
| | - Khalid Albogami
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.,Pharmaceutical Care Department, Ministry of National Guard - Health Affairs, Jeddah, Saudi Arabia
| | - Rami M Alzhrani
- Department of Pharmaceutics and Industrial Pharmacy, College of Pharmacy, Taif University, P.O. Box 11099, Taif 21944, Saudi Arabia
| | - Samah S Basudan
- Department of Pharmacy, King Abdullah Medical Complex, Ministry of Health, Jeddah, Saudi Arabia
| | - Yahya A Alzahrani
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.,Department of Pharmacy, East Jeddah Hospital, Ministry of Health, Jeddah, Saudi Arabia
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Rybak MJ, Le J, Lodise TP, Levine DP, Bradley JS, Liu C, Mueller BA, Pai MP, Wong-Beringer A, Rotschafer JC, Rodvold KA, Maples HD, Lomaestro BM. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2021; 77:835-864. [PMID: 32191793 DOI: 10.1093/ajhp/zxaa036] [Citation(s) in RCA: 581] [Impact Index Per Article: 193.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI, School of Medicine, Wayne State University, Detroit, MI, and Detroit Receiving Hospital, Detroit, MI
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Albany, NY, and Stratton VA Medical Center, Albany, NY
| | - Donald P Levine
- School of Medicine, Wayne State University, Detroit, MI, and Detroit Receiving Hospital, Detroit, MI
| | - John S Bradley
- Department of Pediatrics, Division of Infectious Diseases, University of California at San Diego, La Jolla, CA, and Rady Children's Hospital San Diego, San Diego, CA
| | - Catherine Liu
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, and Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | | | | | | | | | - Holly D Maples
- University of Arkansas for Medical Sciences College of Pharmacy & Arkansas Children's Hospital, Little Rock, AR
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8
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Ameer B, Weintraub MA. Dosing Common Medications in Hospitalized Pediatric Patients with Obesity: A Review. Obesity (Silver Spring) 2020; 28:1013-1022. [PMID: 32441477 DOI: 10.1002/oby.22739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 12/17/2019] [Indexed: 12/31/2022]
Abstract
Medication management in children and adolescents with obesity is challenging because both developmental and pathophysiological changes may impact drug disposition and response. Evidence to date indicates an effect of obesity on drug disposition for certain drugs used in this population. This work identified published studies evaluating drug dosing, pharmacokinetics (PK), and effect in pediatric patients with obesity, focusing on 70 common medications used in a pediatric network of 42 US medical centers. A PubMed search revealed 33 studies providing PK and/or effectiveness data for 23% (16 of 70) of medications, 44% of which have just one study and can be considered exploratory. This work appraising 4 decades of literature shows several promising approaches: greater use of PK models applied to prospective clinical studies, dosing recommendations derived from both PK and safety, and multiyear effectiveness data on drugs for chronic conditions (e.g., asthma). Most studies make dose recommendations but are weakened by retrospective study design, small study populations, and no controls or historic controls. Dosing decisions continue to rely on extrapolating knowledge, including targeting systemic drug exposure typically achieved in adults. Optimal weight-based dosing strategies vary by drug and warrant prospective, controlled studies incorporating PK and modeling and simulation to complement clinical assessment.
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Affiliation(s)
- Barbara Ameer
- Department of Medicine, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - Michael A Weintraub
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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9
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Smit C, Wasmann RE, Goulooze SC, Wiezer MJ, van Dongen EPA, Mouton JW, Brüggemann RJM, Knibbe CAJ. Population pharmacokinetics of vancomycin in obesity: Finding the optimal dose for (morbidly) obese individuals. Br J Clin Pharmacol 2020; 86:303-317. [PMID: 31661553 PMCID: PMC7015748 DOI: 10.1111/bcp.14144] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/19/2019] [Accepted: 09/24/2019] [Indexed: 12/11/2022] Open
Abstract
Aims For vancomycin treatment in obese patients, there is no consensus on the optimal dose that will lead to the pharmacodynamic target (area under the curve 400–700 mg h L−1). This prospective study quantifies vancomycin pharmacokinetics in morbidly obese and nonobese individuals, in order to guide vancomycin dosing in the obese. Methods Morbidly obese individuals (n = 20) undergoing bariatric surgery and nonobese healthy volunteers (n = 8; total body weight [TBW] 60.0–234.6 kg) received a single vancomycin dose (obese: 12.5 mg kg−1, maximum 2500 mg; nonobese: 1000 mg) with plasma concentrations measured over 48 h (11–13 samples per individual). Modelling, internal validation, external validation using previously published data and simulations (n = 10.000 individuals, TBW 60–230 kg) were performed using NONMEM. Results In a 3‐compartment model, peripheral volume of distribution and clearance increased with TBW (both p < 0.001), which was confirmed in the external validation. A dose of 35 mg kg−1 day−1 (maximum 5500 mg/day) resulted in a > 90% target attainment (area under the curve > 400 mg h L−1) in individuals up to 200 kg, with corresponding trough concentrations of 5.7–14.6 mg L−1 (twice daily dosing). For continuous infusion, a loading dose of 1500 mg is required for steady state on day 1. Conclusion In this prospective, rich sampling pharmacokinetic study, vancomycin clearance was well predicted using TBW. We recommend that in obese individuals without renal impairment, vancomycin should be dosed as 35 mg kg−1 day−1 (maximized at 5500 mg/day). When given over 2 daily doses, trough concentrations of 5.7–14.6 mg L−1 correspond to the target exposure in obese individuals.
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Affiliation(s)
- Cornelis Smit
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Roeland E Wasmann
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Sebastiaan C Goulooze
- Department of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Marinus J Wiezer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Eric P A van Dongen
- Department of Anesthesiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Roger J M Brüggemann
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
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10
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Zhang T, Cheng H, Pan Z, Mi J, Dong Y, Zhang Y, Sun D, Du Q, Cheng X, Dong Y. Desired vancomycin trough concentration to achieve an AUC 0-24 /MIC ≥400 in Chinese children with complicated infectious diseases. Basic Clin Pharmacol Toxicol 2020; 126:75-85. [PMID: 31403243 DOI: 10.1111/bcpt.13303] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/17/2019] [Indexed: 01/19/2023]
Abstract
A vancomycin steady-state trough concentration (Cmin ) of 15-20 mg/L is recommended for achieving a ratio of the 24-hour area under the curve to the minimum inhibitory concentration (AUC0-24 /MIC) of ≥400 in adults. Since few paediatric data are available, our objectives were to (a) measure the pharmacokinetic indices of vancomycin and (b) determine the correlation between Cmin and AUC0-24 /MIC in paediatric patients. Population-based pharmacokinetic modelling was performed for paediatric patients to estimate the individual parameters. The relationship between Cmin and the calculated AUC0-24 /MIC was explored using linear regression and a probabilistic framework. A sensitivity analysis was also conducted using Monte Carlo simulations. Body-weight significantly influenced the pharmacokinetics of vancomycin. Based on real data and simulations, Cmin ranges of 5.0-5.9 and 9.0-12.9 mg/L were associated with AUC0-24 /MIC ≥400 for MIC values of ≤0.5 and ≤1 mg/L, respectively. Vancomycin regimens of 10 and 15 mg/kg every 6 hours achieved a Cmin of 5.0-5.9 mg/L and AUC0-24 /MIC ≥400 in >90% of the children when MIC was ≤0.5 mg/L. At a MIC of ≤1 mg/L, vancomycin at 15 mg/kg every 6 hours achieved Cmin of 9.0-12.9 mg/L and AUC0-24 /MIC ≥400 in 2.0- and 1.6-fold as many children compared to a dose of 10 mg/kg every 6 hours, respectively. Vancomycin Cmin values of 5.0-12.9 mg/L were strongly predictive of achieving AUC0-24 /MIC ≥400, and rational dosing regimens of 10-15 mg/kg q6h were required in paediatric patients, depending on the pathogen.
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Affiliation(s)
- Tao Zhang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Hua Cheng
- Department of Pharmacy, The Affiliated Children Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhenyu Pan
- Department of Pharmacy, The Affiliated Children Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jie Mi
- Department of Pharmacy, The Affiliated Children Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yuzhu Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ying Zhang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Dan Sun
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Qian Du
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiaoliang Cheng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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11
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Dunn RD, Crass RL, Hong J, Pai MP, Krop LC. Vancomycin volume of distribution estimation in adults with class III obesity. Am J Health Syst Pharm 2019; 76:2013-2018. [PMID: 31630155 DOI: 10.1093/ajhp/zxz241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To compare methods of estimating vancomycin volume of distribution (V) in adults with class III obesity. METHODS A retrospective, multicenter pharmacokinetic analysis of adults treated with vancomycin and monitored through measurement of peak and trough concentrations was performed. Individual pharmacokinetic parameter estimates were obtained via maximum a posteriori Bayesian analysis. The relationship between V and body weight was assessed using linear regression. Mean bias and root-mean-square error (RMSE) were calculated to assess the precision of multiple methods of estimating V. RESULTS Of 241 patients included in the study sample, 159 (66.0%) had a body mass index (BMI) of 40.0-49.9 kg/m2, and 82 (34.0%) had a BMI of ≥50.0 kg/m2. The median (5th, 95th percentile) weight of patients was 136 (103, 204) kg, and baseline characteristics were similar between BMI groups. The mean ± S.D. V was lower in patients with a BMI of 40.0-49.9 kg/m2 than in those with a BMI of ≥50.0 kg/m2 (72.4 ± 19.6 L versus 79.3 ± 20.6 L, p = 0.009); however, body size poorly predicted V in regression analyses (R2 < 0.20). A fixed estimate of V (75 L) and use of a weight-based value (0.52 L/kg by total body weight [TBW]) yielded similar bias and error in this population. CONCLUSION Results of the largest analysis of vancomycin V in class III obesity to date indicated that use of a fixed V value (75 L) and use of a TBW-based estimate (0.52 L/kg) for estimation of vancomycin V in patients with a BMI of ≥40.0 kg/m2 have similar bias. Two postdistribution vancomycin concentrations are needed to accurately determine patient-specific pharmacokinetic parameters, estimate area under the curve, and improve the precision of vancomycin dosing in this patient population.
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Affiliation(s)
- Ryan D Dunn
- Department of Pharmacy, Morton Plant Hospital, BayCare Health System, Clearwater, FL
| | - Ryan L Crass
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI
| | - Joseph Hong
- Department of Pharmacy, Morton Plant Hospital, BayCare Health System, Clearwater, FL
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI
| | - Lynne C Krop
- Department of Pharmacy, Morton Plant Hospital, BayCare Health System, Clearwater, FL
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12
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Rawson TM, Charani E, Moore LSP, Gilchrist M, Georgiou P, Hope W, Holmes AH. Exploring the Use of C-Reactive Protein to Estimate the Pharmacodynamics of Vancomycin. Ther Drug Monit 2018; 40:315-321. [PMID: 29561305 PMCID: PMC6485622 DOI: 10.1097/ftd.0000000000000507] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND C-reactive protein (CRP) pharmacodynamic (PD) models have the potential to provide adjunctive methods for predicting the individual exposure response to antimicrobial therapy. We investigated CRP PD linked to a vancomycin pharmacokinetic (PK) model using routinely collected data from noncritical care adults in secondary care. METHODS Patients receiving intermittent intravenous vancomycin therapy in secondary care were identified. A 2-compartment vancomycin PK model was linked to a previously described PD model describing CRP response. PK and PD parameters were estimated using a Non-Parametric Adaptive Grid technique. Exposure-response relationships were explored with vancomycin area-under-the-concentration-time-curve (AUC) and EC50 (concentration of drug that causes a half maximal effect) using the index, AUC:EC50, fitted to CRP data using a sigmoidal Emax model. RESULTS Twenty-nine individuals were included. Median age was 62 (21-97) years. Fifteen (52%) patients were microbiology confirmed. PK and PD models were adequately fitted (r 0.83 and 0.82, respectively). There was a wide variation observed in individual Bayesian posterior EC50 estimates (6.95-48.55 mg/L), with mean (SD) AUC:EC50 of 31.46 (29.22). AUC:EC50 was fitted to terminal CRP with AUC:EC50 >19 associated with lower CRP value at 96-120 hours of therapy (100 mg/L versus 44 mg/L; P < 0.01). CONCLUSIONS The use of AUC:EC50 has the potential to provide in vivo organism and host response data as an adjunct for in vitro minimum inhibitory concentration data, which is currently used as the gold standard PD index for vancomycin therapy. This index can be estimated using routinely collected clinical data. Future work must investigate the role of AUC:EC50 in a prospective cohort and explore linkage with direct patient outcomes.
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Affiliation(s)
- Timothy M Rawson
- National Institute for Health Research Health Protection Research
Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial
College London, Hammersmith Campus, Du Cane Road, London. W12 0NN. United
Kingdom
| | - Esmita Charani
- National Institute for Health Research Health Protection Research
Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial
College London, Hammersmith Campus, Du Cane Road, London. W12 0NN. United
Kingdom
| | - Luke SP Moore
- National Institute for Health Research Health Protection Research
Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial
College London, Hammersmith Campus, Du Cane Road, London. W12 0NN. United
Kingdom
- Imperial College Healthcare NHS Trust, Du Cane Road, London.W12 0HS.
United Kingdom
| | - Mark Gilchrist
- Imperial College Healthcare NHS Trust, Du Cane Road, London.W12 0HS.
United Kingdom
| | - Pantelis Georgiou
- Department of Electrical and Electronic Engineering, Imperial
College London, South Kensington Campus, London, SW7 2AZ, United Kingdom
| | - William Hope
- Department of Molecular and Clinical Pharmacology, University of
Liverpool, Liverpool, L69 3GE, United Kingdom
| | - Alison H Holmes
- National Institute for Health Research Health Protection Research
Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial
College London, Hammersmith Campus, Du Cane Road, London. W12 0NN. United
Kingdom
- Imperial College Healthcare NHS Trust, Du Cane Road, London.W12 0HS.
United Kingdom
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13
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Vancomycin Dosing in Haemodialysis Patients and Bayesian Estimate of Individual Pharmacokinetic Parameters. Int J Artif Organs 2018. [DOI: 10.1177/039139889401700104] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A dose reduction of vancomycin to 1000 mg once a week usually is recommended for haemodialysis patients. Our modified dosing schedule consists of a loading dose of 1000 mg and a maintenance dose of 500 mg administered 3 times a week after haemodialysis. Different vancomycin regimens were retrospectively evaluated by therapeutic drug monitoring and bayesian parameter estimates in 39 dialysis patients. The mean (± SD) trough level in 7 patients receiving only the conventional dosage regimen was significantly lower than in 17 patients strictly treated by the modified schedule (7 ± 4 versus 17 ± 8 mg/L; p = 0.001). The corresponding peaks were low in both groups and no different (23 ± 10 versus 27 ± 12 mg/L). The one week average vancomycin clearance was significantly lower in the conventional dosage group compared to the modified dosage group (6 ± 3 versus 10 ± 3 ml/min; p = 0.001). High-flux dialysers were not used in the conventional dosage group but for 30 percent of the procedures in the modified dosage group, where the vancomycin one week average elimination half-life was 66 hours (± 18) and the volume of distribution 50 litres (± 5). As compared to the bayesian programme, NONMEM calculated comparable pharmacokinetic parameters but could be applied only in 5 cases with a sufficient number of concentration measurements. Ototoxicity occurred in 1 patient, whereas vancomycin treatment was judged as ineffective against infection in 5 of the 39 patients. Their troughs were below 15 mg/L. The apparent tendency toward underdosage can be avoided by giving haemodialysis patients the modified vancomycin schedule (3 × 500 mg/week) with the higher trough levels considered therapeutic (10 - 20 mg/L).
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Durand C, Bylo M, Howard B, Belliveau P. Vancomycin Dosing in Obese Patients: Special Considerations and Novel Dosing Strategies. Ann Pharmacother 2017; 52:580-590. [PMID: 29262697 DOI: 10.1177/1060028017750084] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To review the literature regarding vancomycin pharmacokinetics in obese patients and strategies used to improve dosing in this population. DATA SOURCES PubMed, EMBASE (1974 to November 2017), and Google Scholar searches were conducted using the search terms vancomycin, obese, obesity, pharmacokinetics, strategy, and dosing. Additional articles were selected from reference lists of selected studies. STUDY SELECTION AND DATA EXTRACTION Included articles were those published in English with a primary focus on vancomycin pharmacokinetic parameters in obese patients and practical vancomycin dosing strategies, clinical experiences, or challenges of dosing vancomycin in this population. DATA SYNTHESIS Volume of distribution and clearance are the pharmacokinetic parameters that most often affect vancomycin dosing in obese patients; both are increased in this population. Challenges with dosing in obese patients include inconsistent and inadequate dosing, observations that the obese population may not be homogeneous, and reports of an increased likelihood of supratherapeutic trough concentrations. Investigators have revised and developed dosing and monitoring protocols to address these challenges. These approaches improved target trough attainment to varying degrees. CONCLUSIONS Some of the vancomycin dosing approaches provided promising results in obese patients, but there were notable differences in methods used to develop these approaches, and sample sizes were small. Although some approaches can be considered for validation in individual institutions, further research is warranted. This may include validating approaches in larger populations with narrower obesity severity ranges, investigating target attainment in indication-specific target ranges, and evaluating the impact of different dosing weights and methods of creatinine clearance calculation.
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Affiliation(s)
| | - Mary Bylo
- 1 MCPHS University, Manchester, NH, USA
| | - Brian Howard
- 1 MCPHS University, Manchester, NH, USA.,2 Pfizer, Groton, CT, USA
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15
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Meng L, Mui E, Holubar MK, Deresinski SC. Comprehensive Guidance for Antibiotic Dosing in Obese Adults. Pharmacotherapy 2017; 37:1415-1431. [DOI: 10.1002/phar.2023] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Lina Meng
- Department of Pharmacy; Stanford Health Care; Stanford California
- Stanford Antimicrobial Safety and Sustainability Program; Stanford Health Care; Stanford California
| | - Emily Mui
- Department of Pharmacy; Stanford Health Care; Stanford California
- Stanford Antimicrobial Safety and Sustainability Program; Stanford Health Care; Stanford California
| | - Marisa K. Holubar
- Stanford Antimicrobial Safety and Sustainability Program; Stanford Health Care; Stanford California
- Division of Infectious Diseases and Geographic Medicine; Stanford University School of Medicine; Stanford California
| | - Stan C. Deresinski
- Stanford Antimicrobial Safety and Sustainability Program; Stanford Health Care; Stanford California
- Division of Infectious Diseases and Geographic Medicine; Stanford University School of Medicine; Stanford California
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16
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Chu C, Lteif L, Young N. The Daniel K. Inouye College of Pharmacy Scripts: Obesity: The Drug Dose Debate. HAWAI'I JOURNAL OF MEDICINE & PUBLIC HEALTH : A JOURNAL OF ASIA PACIFIC MEDICINE & PUBLIC HEALTH 2017; 76:162-165. [PMID: 28607835 PMCID: PMC5458583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Cherie Chu
- Daniel K. Inouye College of Pharmacy, University of Hawai'i at Hilo, Hilo, HI
| | - Louis Lteif
- Daniel K. Inouye College of Pharmacy, University of Hawai'i at Hilo, Hilo, HI
| | - Nicole Young
- Daniel K. Inouye College of Pharmacy, University of Hawai'i at Hilo, Hilo, HI
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17
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Pilot Study of a Bayesian Approach To Estimate Vancomycin Exposure in Obese Patients with Limited Pharmacokinetic Sampling. Antimicrob Agents Chemother 2017; 61:AAC.02478-16. [PMID: 28289024 DOI: 10.1128/aac.02478-16] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 03/04/2017] [Indexed: 11/20/2022] Open
Abstract
This study evaluated the predictive performance of a Bayesian PK estimation method (ADAPT V) to estimate the 24-h vancomycin area under the curve (AUC) with limited pharmacokinetic (PK) sampling in adult obese patients receiving vancomycin for suspected or confirmed Gram-positive infections. This was an Albany Medical Center Institutional Review Board-approved prospective evaluation of 12 patients. Patients had a median (95% confidence interval) age of 61 years (39 to 71 years), a median creatinine clearance of 86 ml/min (75 to 120 ml/min), and a median body mass index of 45 kg/m2 (40 to 52 kg/m2). For each patient, five PK concentrations were measured, and four different vancomycin population PK models were used as Bayesian priors to estimate the vancomycin AUC (AUCFULL). Using each PK model as a prior, data-depleted PK subsets were used to estimate the 24-h AUC (i.e., peak and trough data [AUCPT], midpoint and trough data [AUCMT], and trough-only data [AUCT]). The 24-h AUC derived from the full data set (AUCFULL) was compared to the AUC derived from data-depleted subsets (AUCPT, AUCMT, and AUCT) for each model. For the four sets of analyses, AUCFULL estimates ranged from 437 to 489 mg·h/liter. The AUCPT provided the best approximation of the AUCFULL; AUCMT and AUCT tended to overestimate AUCFULL Further prospective studies are needed to evaluate the impact of AUC monitoring in clinical practice, but the findings from this study suggest that the vancomycin AUC can be estimated with good precision and accuracy with limited PK sampling using Bayesian PK estimation software.
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18
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Barber KE, Bell AM, Stover KR, Wagner JL. Intravenous Vancomycin Dosing in the Elderly: A Focus on Clinical Issues and Practical Application. Drugs Aging 2016; 33:845-854. [PMID: 27878526 PMCID: PMC5122618 DOI: 10.1007/s40266-016-0420-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The elderly population can be divided into three distinct age groups: 65-74 years (young-old), 75-84 years (middle-old), and 85+ years (old-old). Despite evidence of a shift in leading causes for mortality in the elderly from infectious diseases to chronic conditions, infections are still a serious cause of death in this population. These patients are at increased risk due to weakened immune systems, an increased prevalence of underlying comorbidities, and decreased physiologic reserves to fight infection. Additionally, elderly patients, especially adults in institutional settings, are at an increased risk of colonization and subsequent infection with methicillin-resistant Staphylococcus aureus at a rate that is five times higher than in younger individuals, causing an increase in empiric and definitive vancomycin use. Elderly patients have unique characteristics that make dosing vancomycin a challenge for clinicians, such as increased volume of distribution and decreased renal function. Using the best available evidence, it is recommended to initiate lower empiric maintenance doses and monitor vancomycin serum concentrations earlier than steady state to accurately calculate drug elimination and make appropriate dose adjustments.
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Affiliation(s)
- Katie E Barber
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, 2500 N. State Street, Jackson, MS, 39216, USA
| | - Allison M Bell
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, 2500 N. State Street, Jackson, MS, 39216, USA
| | - Kayla R Stover
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, 2500 N. State Street, Jackson, MS, 39216, USA
- Department of Medicine-Infectious Diseases, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS, 39216, USA
| | - Jamie L Wagner
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, 2500 N. State Street, Jackson, MS, 39216, USA.
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19
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Pai MP. Anti-infective Dosing for Obese Adult Patients: A Focus on Newer Drugs to Treat Methicillin-resistant Staphylococcus aureus Acute Bacterial Skin and Skin Structure Infections. Clin Ther 2016; 38:2032-44. [DOI: 10.1016/j.clinthera.2016.07.094] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/22/2016] [Accepted: 07/22/2016] [Indexed: 12/11/2022]
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20
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Rushing TA, Ambrose PJ. Clinical Application and Evaluation of Vancomycin Dosing in Adults. J Pharm Technol 2016. [DOI: 10.1177/875512250101700201] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To evaluate the accuracy of a vancomycin dosing method (study method) in estimating volume of distribution (Vd) and clearance of vancomycin (Clvanco) and the frequency with which it would provide serum vancomycin concentrations (SVCs) within a specified range compared with other published methods. Methods: One hundred and seven patients with 108 pairs of SVCs were used to calculate patient-specific Vd and Clvanco. Based on these patient-specific Vd and Clvanco values, the predictive ability of the estimated parameters from the study dosing method (Vd [L] = 0.17 [age] + 0.22 [actual body weight] + 15; Clvanco = creatinine clearance) was evaluated against three previously published pharmacokinetic dosing methods, using predictive performance analysis (precision and bias). Furthermore, the patient-specific pharmacokinetic parameters were used to simulate steady-state peak and trough SVCs, using first-order pharmacokinetic equations from doses derived from the study method, the three different pharmacokinetic methods, and two other published dosing schemes. The frequency with which each method would have achieved target peak and trough SVCs was determined. Results: The study method was found to be more precise and less biased (p < 0.05) than comparative methods in predicting vancomycin Vd and Clvanco. The study method also resulted in a higher frequency of steady-state peak and trough SVCs within the target range specified. Conclusions: The study method presented here provided a reliable estimation of vancomycin pharmacokinetic parameters that was easily applied to various patient populations to individualize vancomycin dosing, and frequently yielded SVCs within a predictable and desired range.
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Affiliation(s)
- Todd A Rushing
- TODD A RUSHING PharmD, Infectious Disease Pharmacist, Pharmacy Services, Long Beach Memorial Medical Center, Long Beach, CA
| | - Peter J Ambrose
- PETER J AMBROSE PharmD FASHP, Associate Clinical Professor, Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, CA
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21
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Crew P, Heintz SJ, Heintz BH. Vancomycin dosing and monitoring for patients with end-stage renal disease receiving intermittent hemodialysis. Am J Health Syst Pharm 2016; 72:1856-64. [PMID: 26490819 DOI: 10.2146/ajhp150051] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Vancomycin dosing and monitoring algorithms for patients with end-stage renal disease (ESRD) receiving intermittent hemodialysis are reviewed. SUMMARY Vancomycin is one of the most commonly administered antimicrobial agents in adult patients with ESRD receiving intermittent hemodialysis. However, despite the availability of many published studies, the single best method of vancomycin administration in this population remains unclear. Many studies evaluating vancomycin dosing in adult patients with ESRD receiving intermittent hemodialysis were limited by a small sample size, inappropriate therapeutic targets, older hemodialysis modalities (e.g., low-flux intermittent hemodialysis), and inconsistencies in the timing of dosing or therapeutic drug monitoring. Pharmacokinetic variables that must be accounted for include a prolonged distribution phase, a redistribution phase and rebound effect after completion of hemodialysis, patient weight, residual renal function, and nonrenal clearance. Optimal vancomycin dosing recommendations are needed, but clinicians should always consider patient-specific variables, the timing of vancomycin administration, the timing of serum vancomycin concentrations, and technical aspects of the dialysis procedure when creating a dosing regimen. CONCLUSION Individualized vancomycin dosing regimens and therapeutic drug monitoring are necessary for patients with ESRD receiving intermittent hemodialysis to ensure that goal serum vancomycin levels are reached to adequately treat an infection.
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Affiliation(s)
- Page Crew
- Page Crew, Pharm.D., M.P.H., is Postgraduate Year 1 Pharmacy Resident, Froedtert and the Medical College of Wisconsin, Milwaukee. Shannon J. Heintz, Pharm.D., BCPS, is Assistant Professor of Clinical Pharmacy, University of Iowa College of Pharmacy, Iowa City, and Pharmacy Specialist, Critical Care/Surgery, Department of Pharmaceutical Services, Iowa City Veterans Affairs Healthcare System, Iowa City. Brett H. Heintz, Pharm.D., BCPS (AQ-ID), AAHIVE, is Associate Professor of Clinical Pharmacy, University of Iowa College of Pharmacy, and Pharmacy Specialist, Internal Medicine and Infectious Diseases, Department of Pharmaceutical Services, Iowa City Veterans Affairs Healthcare System
| | - Shannon J Heintz
- Page Crew, Pharm.D., M.P.H., is Postgraduate Year 1 Pharmacy Resident, Froedtert and the Medical College of Wisconsin, Milwaukee. Shannon J. Heintz, Pharm.D., BCPS, is Assistant Professor of Clinical Pharmacy, University of Iowa College of Pharmacy, Iowa City, and Pharmacy Specialist, Critical Care/Surgery, Department of Pharmaceutical Services, Iowa City Veterans Affairs Healthcare System, Iowa City. Brett H. Heintz, Pharm.D., BCPS (AQ-ID), AAHIVE, is Associate Professor of Clinical Pharmacy, University of Iowa College of Pharmacy, and Pharmacy Specialist, Internal Medicine and Infectious Diseases, Department of Pharmaceutical Services, Iowa City Veterans Affairs Healthcare System
| | - Brett H Heintz
- Page Crew, Pharm.D., M.P.H., is Postgraduate Year 1 Pharmacy Resident, Froedtert and the Medical College of Wisconsin, Milwaukee. Shannon J. Heintz, Pharm.D., BCPS, is Assistant Professor of Clinical Pharmacy, University of Iowa College of Pharmacy, Iowa City, and Pharmacy Specialist, Critical Care/Surgery, Department of Pharmaceutical Services, Iowa City Veterans Affairs Healthcare System, Iowa City. Brett H. Heintz, Pharm.D., BCPS (AQ-ID), AAHIVE, is Associate Professor of Clinical Pharmacy, University of Iowa College of Pharmacy, and Pharmacy Specialist, Internal Medicine and Infectious Diseases, Department of Pharmaceutical Services, Iowa City Veterans Affairs Healthcare System.
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22
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Lin H, Yeh DD, Levine AR. Daily vancomycin dose requirements as a continuous infusion in obese versus non-obese SICU patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:205. [PMID: 27363312 PMCID: PMC4929768 DOI: 10.1186/s13054-016-1363-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 05/27/2016] [Indexed: 01/21/2023]
Abstract
Background Limited data are available assessing vancomycin concentrations in obese critically ill patients. Currently, there are no studies evaluating dosing requirements in this population who receive vancomycin administered as a continuous infusion (CI). The aim of this study was to assess whether there was a difference in the weight-based maintenance dose required to reach a therapeutic vancomycin concentration at 24 hours when given as a CI in obese versus non-obese critically ill patients. Methods A retrospective cohort study of adult obese patients admitted to the SICU between 2013 and 2015 receiving a vancomycin CI (CIV), and with 24-hour serum measurements were included. Obese patients (body mass index (BMI) ≥35 kg/m2) were matched with non-obese patients (BMI <30 kg/m2) based on renal function, age and acute physiology and chronic health evaluation (APACHE)-II score at admission. All patients in this study received a loading dose of 25 mg/kg then a maintenance dose based on renal function according to the protocol. The study was approved by the Institutional Review Board. The primary outcome was the weight-based total daily maintenance dose required to achieve a vancomycin level of 20 mg/L. The secondary endpoints included the achievement of a therapeutic level at 24 hours. Results Twenty-six matched pairs of patients met the inclusion criteria. Of these, 17 pairs had preserved renal function and 9 pairs required continuous venovenous hemofiltration. Mean BMI was 40.9 kg/m2 in obese and 24.8 kg/m2 in non-obese patients. To achieve a vancomycin concentration of 20 mg/L, the weight-based daily maintenance dose in obese patients was 25.6 mg/kg versus 43.8 mg/kg in non-obese patients (p <0.01). Therapeutic 24-hour levels were achieved in 24/26 obese versus 23/26 no-obese patients (p = 0.63). Mean 24-hour vancomycin level was 20.3 ± 3.81 mcg/ml in obese compared to 20.03 ± 3.79 mcg/ml in non-obese patients (p = 0.77). Mean daily maintenance doses required to achieve a level of 20 mcg/ml were 2961 ± 1670 mg in obese compared to 3189 ± 1600.69 mg in non-obese (p = 0.61). Conclusions The results of our study suggest that critically ill obese patients treated with CIV required a significantly lower maintenance dose per unit of body weight than non-obese patients to achieve the same target level.
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Affiliation(s)
- Hsin Lin
- Department of Pharmacy, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Daniel Dante Yeh
- Departments of Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Alexander R Levine
- Department of Pharmacy Practice and Administration, University of Saint Joseph School of Pharmacy, 229 Trumbull St, Hartford, CT, USA
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Kubiak DW, Alquwaizani M, Sansonetti D, Barra ME, Calderwood MS. An Evaluation of Systemic Vancomycin Dosing in Obese Patients. Open Forum Infect Dis 2015; 2:ofv176. [PMID: 26716105 PMCID: PMC4691676 DOI: 10.1093/ofid/ofv176] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 11/10/2015] [Indexed: 01/30/2023] Open
Abstract
We retrospectively identified 67 patients with severe or morbid obesity (body mass index ≥35 kg/m2) who had received intravenous vancomycin at our institution. We observed that an initial dose of 45 to 65 mg/kg vancomycin per day based upon ideal body weight rather than actual body weight was more predictive of initial trough concentrations between 15 and 20 mcg/mL.
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Affiliation(s)
| | | | | | - Megan E Barra
- Brigham and Women's Hospital , Boston, Massachusetts
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24
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Kosmisky DE, Griffiths CL, Templin MA, Norton J, Martin KE. Evaluation of a New Vancomycin Dosing Protocol in Morbidly Obese Patients. Hosp Pharm 2015; 50:789-97. [PMID: 26912920 DOI: 10.1310/hpj5009-789] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Optimal dosing of vancomycin in morbidly obese patients (>100 kg and at least 140% of their ideal body weight) has not been determined. Conventional dosing strategies have led to the observation of supratherapeutic trough concentrations (>20 mcg/mL). OBJECTIVE To evaluate the effectiveness of a new vancomycin dosing protocol in morbidly obese patients in achieving therapeutic trough concentrations between 10 and 20 mcg/mL and to determine patient-specific factors influencing the trough concentration attained. METHODOLOGY A single-center, retrospective chart review included morbidly obese adult patients with a pharmacy-to-dose vancomycin consult and at least 1 trough concentration obtained at steady state. Patients were excluded if they had a creatinine clearance (CrCl) less than 35 mL/min or unstable renal function, were not dosed according to the revised protocol, or received vancomycin prior to initiation of the protocol. RESULTS Of the 48 patients included, 17 (35.4%) achieved a therapeutic vancomycin trough concentration. Subtherapeutic concentrations (<10 mcg/mL) were observed in 27 patients (56.3%) and supratherapeutic concentrations were observed in 4 (8.3%) patients. Age less than 45 years and CrCl greater than 100 mL/min were associated with subtherapeutic trough concentrations. CONCLUSION This study demonstrates that the revised vancomycin dosing protocol led to the attainment of therapeutic trough concentrations in 35.4% of patients. The majority had subtherapeutic concentrations, which increases the risk of treatment failures and resistance. Further study is needed to determine the optimal dosing strategy in this patient population.
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Affiliation(s)
- Desiree E Kosmisky
- Critical Care Pharmacy Specialist, Carolinas Healthcare System , Charlotte, North Carolina
| | - Carrie L Griffiths
- Medical ICU Clinical Pharmacy Specialist, Carolinas Medical Center, Charlotte, North Carolina; Assistant Professor of Pharmacy, Wingate University School of Pharmacy, Wingate, North Carolina
| | - Megan A Templin
- Statistician, Dickson Advanced Analytics Group, Carolinas Healthcare System , Charlotte, North Carolina
| | - James Norton
- Director of Biostatistics, Carolinas Healthcare System, Charlotte , North Carolina
| | - Kelly E Martin
- Infectious Diseases and Antimicrobial Stewardship Clinical Pharmacy Specialist, Carolinas Medical Center, Charlotte , North Carolina
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Weight-based antibiotic dosing in a real-world European study of complicated skin and soft-tissue infections due to methicillin-resistant Staphylococcus aureus. Clin Microbiol Infect 2015. [DOI: 10.1016/j.cmi.2015.05.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Stockmann C, Roberts JK, Yu T, Constance JE, Knibbe CAJ, Spigarelli MG, Sherwin CMT. Vancomycin pharmacokinetic models: informing the clinical management of drug-resistant bacterial infections. Expert Rev Anti Infect Ther 2015; 12:1371-88. [PMID: 25301231 DOI: 10.1586/14787210.2014.966081] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This review aims to critically evaluate the pharmacokinetic literature describing the use of vancomycin in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections. Guidelines recommend that trough concentrations be used to guide vancomycin dosing for the treatment of MRSA infections; however, numerous in vitro, animal model and clinical studies have demonstrated that the therapeutic effectiveness of vancomycin is best described by the area under the concentration versus time curve (AUC) divided by the minimum inhibitory concentration (MIC) of the infecting organism (AUC/MIC). Among patients with lower respiratory tract infections, an AUC/MIC ≥400 was associated with a superior clinical and bacteriological response. Similarly, patients with MRSA bacteremia who achieved an Etest AUC/MIC ≥320 within 48 h were 50% less likely to experience treatment failure. For other patient populations and different clinical syndromes (e.g., children, the elderly, patients with osteomyelitis, etc.), pharmacokinetic/pharmacodynamic studies and prospective clinical trials are needed to establish appropriate therapeutic targets.
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Affiliation(s)
- Chris Stockmann
- Department of Pediatrics, Division of Clinical Pharmacology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, Utah 84108, USA
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Bayesian Estimation of Vancomycin Pharmacokinetics in Obese Children: Matched Case-Control Study. Clin Ther 2015; 37:1340-51. [PMID: 26031618 DOI: 10.1016/j.clinthera.2015.05.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 03/29/2015] [Accepted: 05/08/2015] [Indexed: 01/28/2023]
Abstract
PURPOSE The study objective was to compare different body size descriptors that best estimate vancomycin Vd and clearance (CL). METHODS Patients between 3 months and 21 years old who received vancomycin for ≥48 hours from 2003 to 2011 were evaluated in this matched case-control study. Cases had body mass index in the ≥85th percentile; controls were nonobese individuals who were matched by age and baseline serum creatinine (SCr). Using a 1-compartment model with first-order kinetics, Bayesian post hoc individual Vd and CL were estimated. FINDINGS Analysis included 87 matched pairs with 389 vancomycin serum concentrations. Median ages were 10.0 (interquartile range [IQR], 4.8-15.2) years for cases (overweight and obese children) and 10.2 (IQR, 4.5-14.8) years for controls (normal-weight children). Median weights were 44.0 (IQR, 23.4-78.1) kg for cases and 31.3 (IQR, 16.8-47.1) kg for controls. Mean (SD) for the baseline SCr values were also similar between the groups: 0.51 (0.22) (IQR, 0.34-0.67) mg/dL and 0.48 (0.20) (IQR, 0.30-0.60) mg/dL for the cases and controls, respectively. Actual weight and allometric weight (ie, weight(0.75)) were used in the final model to estimate Vd and CL, respectively. The mean Vd and CL, based on weight, for cases were lower than controls by 0.012 L/kg and 0.014 L/kg/h, respectively. IMPLICATIONS In obese children, actual weight and allometric weight are reasonable, convenient estimations of body fat to use for estimating vancomycin Vd and CL, respectively. However, these pharmacokinetic differences between obese children and those with normal weights are small and may not likely to be clinically relevant in dose variation.
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Mangin O, Urien S, Mainardi JL, Fagon JY, Faisy C. Vancomycin pharmacokinetic and pharmacodynamic models for critically ill patients with post-sternotomy mediastinitis. Clin Pharmacokinet 2015; 53:849-61. [PMID: 25117184 DOI: 10.1007/s40262-014-0164-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Vancomycin is commonly used to treat serious methicillin-resistant staphylococcal infections, especially post-sternotomy mediastinitis (PSM). However, information on pharmacokinetics and pharmacodynamics in intensive care unit (ICU) patients remains scarce. We conducted vancomycin pharmacokinetic-pharmacodynamic modeling for ICU patients with PSM. METHODS This cohort study included 30 consecutive patients who received multiple vancomycin doses during primary closed drainage of PSM with Redon catheters, targeting serum drug trough concentrations of 25-35 mg/L, and generating 359 serum vancomycin concentration-time values for analysis. Population pharmacodynamics served to describe the withdrawal of Redon catheters, i.e., the probability of in-ICU cure. RESULTS Vancomycin pharmacokinetics corresponded to a two-compartment open model with first-order elimination kinetics. Mean [between-subject variability] population estimates were 1.91 (men)/1.25 (women) [0.28] L/h for vancomycin elimination, with intercompartmental clearance of 5.71 [1.01] L/h, and respective central and peripheral distribution volumes of 21.9 and 68 [0.53] L. Vancomycin clearance increased with body weight and declined with severity at ICU admission and serum creatinine (SCr), thereby allowing the prediction of the vancomycin plateau. Intercompartmental clearance decreased with diabetes mellitus (-70 %). The probability of withdrawing all Redon catheters (patient cured) was dependent only on the area under the concentration-time curve to minimum inhibitory concentration (AUC/MIC) exposures ratio in plasma. Neither preoperative factors, antistaphylococcal co-treatments, nor the initial number of Redon catheters significantly influenced this probability. The AUC/MIC exposures ratio had no significant effect on SCr levels. CONCLUSION These modeling analysis results identified five clinically relevant covariates that influenced vancomycin pharmacokinetics and might achieve better individualization of vancomycin dosing for methicillin-resistant staphylococcal PSM in ICU patients.
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Affiliation(s)
- Olivier Mangin
- Medical Intensive Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes Sorbonne Paris Cité, 20 rue Leblanc, 75908, Paris Cedex 15, France
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The association of elevated trough serum vancomycin concentrations with obesity. J Infect Chemother 2015; 21:507-11. [PMID: 25851852 DOI: 10.1016/j.jiac.2015.03.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 02/10/2015] [Accepted: 03/13/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND Obese patients display differences in vancomycin drug disposition, which may complicate attainment of appropriate serum vancomycin concentrations (SVCs). This study was conducted to determine if obesity leads to trough SVCs above the therapeutic range. METHODS This retrospective cohort study sought to determine the rate and predictors of high (i.e. >20 mg/L) serum trough levels according to level of obesity. RESULTS Increasing BMI predicted SVCs > 20 mg/L after controlling for dose, age, and serum creatinine. Obese patients had significantly higher mean trough SVCs compared to non-obese patients (16.5 mg/L vs 12.1 mg/L, p = 0.004) and a significantly higher proportion of obese patients had trough SVCs > 20 mg/L (18.9% vs 4.2%, p = 0.03). CONCLUSION Increasing obesity predicted higher probabilities of SVCs > 20 mg/L. Development of alternative dosing and management strategies for vancomycin may be necessary to account for pharmacokinetic changes associated with obesity.
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Eiland LS, Sonawane KB. Vancomycin dosing in healthy-weight, overweight, and obese pediatric patients. J Pediatr Pharmacol Ther 2014; 19:182-8. [PMID: 25309148 DOI: 10.5863/1551-6776-19.3.182] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES With an increase in vancomycin resistance and the prevalence of obesity in children, alterations of vancomycin dosing regimens may be necessary to achieve target serum concentrations. The primary objective of this study was to describe initial vancomycin dosing with resulting serum concentrations in healthy-weight and overweight/obese children. Secondary objectives include comparing vancomycin dosing regimens of healthy-weight and overweight/obese patients that produced target trough serum concentrations and evaluating the likelihood of attaining target concentrations by patient characteristics. METHODS This retrospective review evaluated healthy-weight and overweight/obese patients, aged 2 to 18 years, who had vancomycin trough serum concentrations obtained between 2005 and 2010. Vancomycin dosing, initial trough serum concentrations, pharmacokinetic parameters, and patient demographics were collected for analysis. Target trough serum concentrations were defined as 10 to 20 mg/L. RESULTS The study included 98 patients (48 healthy weight, 50 overweight/obese) of which only 14 patients (14.2%, 6 healthy weight, 8 obese) reached a target trough serum concentration with empiric dosing. No difference was found between the mean daily dosing of vancomycin that produced target trough serum concentrations in healthy-weight or overweight/obese patients (53.63 mg/kg/day vs 51.6 mg/kg/day, respectively). Demographic or clinical characteristics were not found to be associated with the likelihood of target trough serum concentration attainment. CONCLUSIONS Vancomycin dosing in healthy-weight and overweight/obese pediatric patients did not reach target trough serum concentrations most of the time. In obtaining initial target serum concentrations, no dosing difference was identified for overweight/obese patients compared with healthy-weight patients. Alternate dosing strategies, therapeutic monitoring, and clinical outcomes should continue to be evaluated in this population.
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Affiliation(s)
- Lea S Eiland
- Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Huntsville, Alabama
| | - Kalyani B Sonawane
- Department of Health Outcomes and Research Policy, Auburn University Harrison School of Pharmacy, Auburn, Alabama
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31
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Polso AK, Lassiter JL, Nagel JL. Impact of hospital guideline for weight-based antimicrobial dosing in morbidly obese adults and comprehensive literature review. J Clin Pharm Ther 2014; 39:584-608. [PMID: 25203631 DOI: 10.1111/jcpt.12200] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 08/07/2014] [Indexed: 12/19/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Obesity is a significant burden on the healthcare system in the United States, and determining the appropriate antimicrobial dosing regimen in morbidly obese patients is challenging. Morbidly obese patients have documented differences in pharmacokinetic and pharmacodynamic properties compared to normal-weight patients, which impact antibiotic efficacy and toxicity. The Food and Drug Administration does not recognize obesity as a special population and does not require pharmaceutical companies to perform studies specific to obese patients. However, there are an increasing number of post-approval studies in obese patients, and this manuscript reviews available clinical and pharmacokinetic literature regarding weight-based antimicrobial agents. Additionally, we describe a single-centre approach to optimize dosing in morbidly obese patients. METHODS A comprehensive literature search was performed on 15 weight-based antimicrobials in the setting of obesity: acyclovir, aminoglycosides, amphotericin B, cidofovir, colistimethate, daptomycin, flucytosine, foscarnet, ganciclovir, quinupristin/dalfopristin, trimethoprim/sulfamethoxazole, vancomycin and voriconazole. A weight-based antimicrobial dosing guideline for morbidly obese patients was developed. An analysis of guideline compliance and cost analysis were performed following guideline implementation. RESULTS AND DISCUSSION This review describes the pharmacokinetic changes that occur in obese patients, including increased volume of distribution, altered hepatic metabolism, renal excretion and changes in protein binding. The majority of weight-based antimicrobials result in increased serum concentrations in morbidly obese patients compared to normal-weight patients when the calculated dose is based on actual body weight. WHAT IS NEW AND CONCLUSION This review demonstrates different antibiotic pharmacokinetic properties are altered in obese patients that could impact efficacy and toxicity. A single-centre guideline for weight-based antimicrobial dosing in obesity was developed and provides recommendations for using ideal body weight, adjusted body weight or actual body weight when calculating antimicrobial doses. However, more research is needed to better elucidate optimal dosing of weight-based antimicrobials in obesity, with particular focus on efficacy and toxicity.
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Affiliation(s)
- A K Polso
- Department of Pharmacy, University of Michigan Hospitals and Health Centers, Ann Arbor, MI, USA
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Payne KD, Hall RG. Dosing of antibacterial agents in obese adults: does one size fit all? Expert Rev Anti Infect Ther 2014; 12:829-54. [DOI: 10.1586/14787210.2014.912942] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Kenna D Payne
- Texas Tech University Health Sciences Center,
1300 S. Coulter, Rm 323, Amarillo, TX 79106, USA
| | - Ronald G Hall
- Texas Tech University Health Sciences Center,
1300 S. Coulter, Rm 323, Amarillo, TX 79106, USA
- Dose Optimization and Outcomes Research (DOOR) Program,
5920 Forest Park Rd, Suite 400, Dallas, TX 75235, USA
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Catanzano A, Phillips M, Dubrovskaya Y, Hutzler L, Bosco J. The standard one gram dose of vancomycin is not adequate prophylaxis for MRSA. THE IOWA ORTHOPAEDIC JOURNAL 2014; 34:111-117. [PMID: 25328469 PMCID: PMC4127722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION The indications for vancomycin prophylaxis to prevent Methicillin-resistant Staphylococcus aureus (MRSA) surgical site infections are increasing. The recommended dose of vancomycin has traditionally been 1 gram intravenous. However, the increasing prevalence of obesity in our population coupled with increasing resistance of MRSA to vancomycin has resulted in recent recommendations for weight-based dosing of vancomycin at 15 mg/kg. We hypothesize that the standard one gram dose of vancomycin is inadequate to meet the recently recommended dosage of 15 mg/kg. METHODS We performed a retrospective chart review on 216 patients who were screened positive for MRSA prior to undergoing elective total joint or spine surgeries between January 2009 to January 2012. All patients were given 1 gram of vancomycin within an hour prior to surgical incision as prophylaxis. Using the revised dosing protocol of 15 mg/kg of body weight for vancomycin, proper dosage was calculated for each patient. These values were then compared to the 1 gram dose given to the patients at time of surgery. Patients were assessed as either underdosed (a calculated weight-based dose >1 gram) or overdosed (a calculated weight-based dose <1 gram). Additionally, we used actual case times and pharmacokinetic equations to determine the vancomycin (VAN) levels at the end of the procedures. RESULTS Out of 216 patients who tested positive for MRSA, 149 patients (69%) were determined to be underdosed and 22 patients (10%) patients were determined to be overdosed. The predicted VAN level at the end of procedure was <15 mg/L in 60% of patients with 1 gram dose compared to 12% (p=0.0005) with weight base dose. Six patients developed post-operative MRSA surgical site infections (SSI). Of these six patients; four had strains of MRSA with vancomycin minimum inhibitory concentration of >1.0 mg/L. Based on 1 g dosing, 5/6 patients with MRSA positive SSIs had wound closure levels of <15 mg/L and all six were <20 mg/L. CONCLUSION In settings such as hospitals, where the risk for resistant bacteria, especially MRSA, is high, it is becoming increasingly important to accurately dose patients who require vancomycin. In order to avoid incorrect dosing of vancomycin health care providers must use weight-based dosing.
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Deng C, Liu T, Wu K, Wang S, Li L, Lu H, Zhou T, Cheng D, Zhong X, Lu W. Predictive performance of reported population pharmacokinetic models of vancomycin in Chinese adult patients. J Clin Pharm Ther 2013; 38:480-9. [PMID: 24033587 DOI: 10.1111/jcpt.12092] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 07/25/2013] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE There are numerous studies on population pharmacokinetics of vancomycin in adult patients. However, there is no such research for Chinese adult patients. This study was conducted to evaluate the predictive performance of reported population pharmacokinetic models of vancomycin in Chinese adult patients and to identify some models appropriate for our population. METHODS A literature search was conducted in PubMed to obtain the population pharmacokinetic models of vancomycin published between December 2010 and September 2012. The models were assessed using concentration data collected from Chinese patients for external validation. Models with relatively poor predictability were excluded from further analysis. The performance of the remaining models was evaluated in patients with different levels of creatinine clearance, age, body weight and sex by Bayesian method. This method was also used to compare the predictive performance based on peak concentration and trough concentration and the predictability based on different number of observed concentrations. RESULTS One hundred and sixty-five blood concentrations from 72 Chinese adult patients were collected retrospectively to serve as the test data set. The evaluated models included all those reported in the seven publications reviewed by Marsot et al. and three other studies published after December 2010. Three models with poor performance on external validation were excluded from the next Bayesian analysis. The distribution of covariates in the model building data set had an important effect on prediction. The predictability based on peak/trough concentration was similar among the evaluated models, and no significant difference was found using our data set except for Roberts' model. As expected, an increased number of samples improved the performance of the Bayesian prediction. WHAT IS NEW AND CONCLUSION With our data set, the performance of the evaluated models varied. The characteristics of the patient population and distribution of covariates should be given more consideration when choosing a model to predict blood concentrations. The model developed by Purwonugroho et al. using a data set from patients similar to ours is appropriate for Bayesian dose predictions for vancomycin concentrations in our population of Chinese adult patients.
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Affiliation(s)
- C Deng
- State Key Laboratory of Natural and Biomimetic Drugs, School of Pharmaceutical Sciences, Peking University, Beijing, China
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Davis SL, Scheetz MH, Bosso JA, Goff DA, Rybak MJ. Adherence to the 2009 consensus guidelines for vancomycin dosing and monitoring practices: a cross-sectional survey of U.S. hospitals. Pharmacotherapy 2013; 33:1256-63. [PMID: 23897602 DOI: 10.1002/phar.1327] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
STUDY OBJECTIVES To describe the implementation of vancomycin dosing and monitoring practices recommended by the consensus guidelines in a diverse sample of hospitals, and to identify needs for quality improvement and research. DESIGN Cross-sectional study using an online survey instrument. SETTING Making a Difference in Infectious Diseases Pharmacotherapy (MAD-ID) Research Network. PARTICIPANTS A total of 163 respondents from MAD-ID who work in antimicrobial stewardship and represent unique hospitals. MEASUREMENTS AND MAIN RESULTS The survey population represented a wide range of patient populations (96% adult, 49% pediatric, and 23% long-term care) and settings (52% not-for-profit nonuniversity, 31% university based, and 11% for profit). Automatic consultation of pharmacy services for all vancomycin dosing was reported in 51% of the institutions. Among the dosing and monitoring practices endorsed by the consensus guidelines, participant institutions commonly followed these recommendations: use of trough concentrations without peak concentrations, maintenance of trough concentration higher than 10 mg/L, and target trough concentrations of 15-20 mg/L for complicated infections. In contrast, there was less consistent application of appropriate timing of trough concentrations, use of loading doses, and use of actual body weight. The remaining challenges and controversies surrounding vancomycin dosing are discussed. CONCLUSION Despite the availability of consensus guideline recommendations, practices for dosing and monitoring of vancomycin are not universally applied. The findings of this survey highlight many opportunities for future research and quality improvement strategies.
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Affiliation(s)
- Susan L Davis
- Anti-Infective Research Laboratory, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan; Henry Ford Hospital, Detroit, Michigan
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Madigan T, Sieve RM, Graner KK, Banerjee R. The effect of age and weight on vancomycin serum trough concentrations in pediatric patients. Pharmacotherapy 2013; 33:1264-72. [PMID: 23864541 DOI: 10.1002/phar.1331] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Vancomycin treatment failure has been associated with low serum vancomycin trough concentrations, prompting recommendations to increase the daily doses in adults and children. Despite more aggressive vancomycin dosing, there continues to be significant variability in vancomycin trough concentrations in pediatric patients. METHODS To determine if vancomycin trough concentrations in pediatric patients differ by age and weight, we reviewed records of hospitalized patients who received vancomycin between 2008 and 2012. Patients were divided into groups that received vancomycin 40 mg/kg/day (2008-2009) or 60 mg/kg/day (2010-2012). Vancomycin trough concentrations were compared between groups and within the 60 mg/kg/day group, stratified by patient age and weight. RESULTS After increasing the vancomycin dose from 40 to 60 mg/kg/day, initial trough concentrations increased significantly in patients younger than 2 and greater than 6 years of age, but not in patients between the ages of 2 and 5 years. In the 60 mg/kg/day group, only 16.7% of patients between 2 and 5 years of age had initial trough concentrations in the therapeutic range (10-20 μg/ml). Initial trough concentrations were therapeutic in a greater proportion of patients ages 6-12 years (38.7%) and 13-18 years (63.0%). Patients between the ages of 13 and 18 had the highest proportion of supratherapeutic initial vancomycin trough concentrations (14.8%). Patients weighing over 50 kg had significantly higher trough concentrations than patients 50 kg or less (17.1 μg/ml vs 9.3 μg/ml, p<0.001). CONCLUSION Although increasing the vancomycin dose from 40 to 60 mg/kg/day led to a significant increase in vancomycin trough concentrations, a large proportion of patients receiving 60 mg/kg/day of vancomycin had trough concentrations outside of the therapeutic range. Specifically, patients younger than 6 years tended to have low trough concentrations, whereas adolescents and children over 50 kg were more likely to have elevated trough concentrations. Vancomycin dosing strategies in pediatric patients should consider age and weight as well as renal function and indication.
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Affiliation(s)
- Theresa Madigan
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
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37
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Population Pharmacokinetics of Intermittent Vancomycin in Children with Cystic Fibrosis. Pharmacotherapy 2013; 33:1288-96. [DOI: 10.1002/phar.1320] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Jones TE, Vasileff H, Hewton C. Should monitoring of vancomycin be delayed? A case of likely nephrotoxicity occasioned by morbid obesity and minimal monitoring. Br J Clin Pharmacol 2012; 74:1063-5. [DOI: 10.1111/j.1365-2125.2011.04006.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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40
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Reynolds DC, Waite LH, Alexander DP, DeRyke CA. Performance of a vancomycin dosage regimen developed for obese patients. Am J Health Syst Pharm 2012; 69:944-50. [DOI: 10.2146/ajhp110324] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- David C. Reynolds
- Moses H. Cone Memorial Hospital, Greensboro, NC; when this article was written, he was Clinical Staff Pharmacist, Department of Pharmacy, Orlando Health, Orlando, FL
| | | | - Donald P. Alexander
- Infectious Diseases, Department of Pharmacy, University of Utah Hospitals and Clinics, Salt Lake City
| | - C. Andrew DeRyke
- Optimer Pharmaceuticals, Altamonte Springs, FL; at the time of writing, he was Infectious Diseases Clinical Specialist, Department of Pharmacy, Division of Infectious Diseases, Orlando Health
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41
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Hall RG, Giuliano CA, Haase KK, Hazlewood KA, Frei CR, Forcade NA, Brouse SD, Bell T, Bedimo RJ, Alvarez CA. Empiric guideline-recommended weight-based vancomycin dosing and mortality in methicillin-resistant Staphylococcus aureus bacteremia: a retrospective cohort study. BMC Infect Dis 2012; 12:104. [PMID: 22540223 PMCID: PMC3532187 DOI: 10.1186/1471-2334-12-104] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 04/27/2012] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND No studies have evaluated the effect of guideline-recommended weight-based dosing on in-hospital mortality of patients with methicillin-resistant Staphylococcus aureus bacteremia. METHODS This was a multicenter, retrospective, cohort study of patients with methicillin-resistant Staphylococcus aureus bacteremia receiving at least 48 hours of empiric vancomycin therapy between 01/07/2002 and 30/06/2008. We compared in-hospital mortality for patients treated empirically with weight-based, guideline-recommended vancomycin doses (at least 15 mg/kg/dose) to those treated with less than 15 mg/kg/dose. We used a general linear mixed multivariable model analysis with variables identified a priori through a conceptual framework based on the literature. RESULTS A total of 337 patients who were admitted to the three hospitals were included in the cohort. One-third of patients received vancomycin empirically at the guideline-recommended dose. Guideline-recommended dosing was not associated with in-hospital mortality in the univariable (16% vs. 13%, OR 1.26 [95%CI 0.67-2.39]) or multivariable (OR 0.71, 95%CI 0.33-1.55) analysis. Independent predictors of in-hospital mortality were ICU admission, Pitt bacteremia score of 4 or greater, age 53 years or greater, and nephrotoxicity. CONCLUSIONS Empiric use of weight-based, guideline-recommended empiric vancomycin dosing was not associated with reduced mortality in this multicenter study.
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Affiliation(s)
- Ronald G Hall
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, School of Pharmacy, Dallas, TX, USA.
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Grace E. Altered vancomycin pharmacokinetics in obese and morbidly obese patients: what we have learned over the past 30 years. J Antimicrob Chemother 2012; 67:1305-10. [DOI: 10.1093/jac/dks066] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Croes S, Neef C, Stolk LM. Comment: Outcomes Associated with AUC 24/MIC Nomogram Dosing of Vancomycin. Ann Pharmacother 2011; 45:1313-4; author reply 1314-5. [DOI: 10.1345/aph.1p495b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Sander Croes
- Department of Clinical Pharmacy and Toxicology Maastricht University Medical Center Maastricht, Netherlands
| | - Cees Neef
- Clinical Pharmacologist Professor of Clinical Pharmacy Department of Clinical Pharmacy and Toxicology Maastricht University Medical Center
| | - Leo M Stolk
- Clinical Pharmacologist Toxicologist Department of Clinical Pharmacy and Toxicology Maastricht University Medical Center
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44
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Leong JVB, Boro MS, Winter ME. Vancomycin clearance in overweight and obese patients. Am J Health Syst Pharm 2011. [DOI: 10.2146/ajhp110286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Julie V. B. Leong
- San Francisco Veterans Affairs Medical Center 4150 Clement Street San Francisco, CA 94121
| | - Maureen S. Boro
- San Francisco Veterans Affairs Medical Center 4150 Clement Street San Francisco, CA 94121
| | - Michael E. Winter
- School of Pharmacy University of California at San Francisco San Francisco, CA
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Shah-Khan F, Scheetz MH, Ghossein C. Biopsy-Proven Acute Tubular Necrosis due to Vancomycin Toxicity. Int J Nephrol 2011; 2011:436856. [PMID: 21716699 PMCID: PMC3118644 DOI: 10.4061/2011/436856] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 04/26/2011] [Indexed: 11/28/2022] Open
Abstract
Vancomycin (VAN) has been associated with acute kidney injury (AKI) since it has been put into clinical use in the 1950's. Early reports of AKI were likely linked to the impurities of the VAN preparation. With the advent of the more purified forms of VAN, the incidence of AKI related to VAN were limited to acute interstitial nephritis (AIN) or as a potentiating agent to other nephrotoxins such as Aminoglycosides. VAN as the sole etiologic factor for nephrotoxic acute tubular necrosis (ATN) has not been described. Here, we report a case of biopsy-proven ATN resulting from VAN.
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Affiliation(s)
- Farheen Shah-Khan
- Division of Nephrology, Northwestern Memorial Hospital, Chicago, IL 60611, USA
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Jain R, Chung SM, Jain L, Khurana M, Lau SWJ, Lee JE, Vaidyanathan J, Zadezensky I, Choe S, Sahajwalla CG. Implications of obesity for drug therapy: limitations and challenges. Clin Pharmacol Ther 2011; 90:77-89. [PMID: 21633345 DOI: 10.1038/clpt.2011.104] [Citation(s) in RCA: 143] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Obesity has become a worldwide challenge with significant health and socioeconomic implications. One of the major implications is its impact on drug therapy. In order to gain a better understanding of this impact, we surveyed the regulatory guidances, the newly approved molecular entity drug products, and drug product labels in the Physician's Desk Reference. This review summarizes the findings of the survey along with the existing knowledge on pharmacokinetic and pharmacodynamic changes associated with obesity.
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Affiliation(s)
- R Jain
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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47
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Leong JVB, Boro MS, Winter ME. Determining vancomycin clearance in an overweight and obese population. Am J Health Syst Pharm 2011; 68:599-603. [DOI: 10.2146/ajhp100410] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Julie V. B. Leong
- San Francisco Veterans Affairs Medical Center (SFVAMC), San Francisco, CA; at the time of this study she was Pharmacy Resident, SFVAMC
| | - Maureen S. Boro
- School of Pharmacy, University of California at San Francisco (UCSF), San Francisco
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More VR, Slitt AL. Alteration of hepatic but not renal transporter expression in diet-induced obese mice. Drug Metab Dispos 2011; 39:992-9. [PMID: 21430232 DOI: 10.1124/dmd.110.037507] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Drug pharmacokinetics can be altered in obese and diabetic subjects. In consideration of the prevalence of obesity and diabetes, characterization of transporter expression in mouse models of diabetes and obesity may be a useful tool to aid in prediction of altered drug pharmacokinetics or adverse drug reactions. It has been reported that ob/ob mice, which display a severe obesity and diabetes phenotype, exhibit multiple changes in drug transporter expression in liver and kidney. In the present study, the mRNA and protein expression of major drug transporters was determined in livers and kidneys of diet-induced obese (DIO) C57BL/6J male mice. The mice were fed a high-fat diet (HFD) (60% fat) from 6 weeks of age and display obesity, fatty liver, and mild hyperglycemia. The HFD diet increased expression of multidrug resistance-associated proteins Abcc3 and 4 mRNA and protein in liver by 3.4- and 1.4-fold, respectively, compared with that detected in control mice fed a low-fat diet (LFD). In contrast, Abcc1 mRNA and protein decreased by 50% in livers of DIO mice compared with those in livers to lean mice. The HFD did not alter transporter expression in kidney compared with the LFD. In summary, unlike ob/ob and db/db mice, DIO mice exhibited a selective induction of efflux transporter expression in liver (i.e., Abcc3 and 4). In addition, diet-induced obesity affects transporter expression in liver but not kidney in the C57BL/6J mouse model. These data indicate that hepatic transporter expression is only slightly altered in a model of mild diabetes and nonalcoholic fatty liver disease and obesity.
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Affiliation(s)
- Vijay R More
- Department of Biomedical and Pharmaceutical Sciences, University of Rhode Island, Kingston, RI 02881, USA
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Jelassi ML, Benlmouden A, Lefeuvre S, Mainardi JL, Billaud EM. Niveau de preuve pour le suivi thérapeutique pharmacologique de la vancomycine. Therapie 2011; 66:29-37. [DOI: 10.2515/therapie/2011005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Accepted: 11/17/2010] [Indexed: 11/20/2022]
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