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Yang S, Wei J, Pan X, Li Z, Zhang X, Li Z, Dong X, Hua Z, Li X. Development and validation of individualized tacrolimus dosing software for Chinese pediatric liver transplantation patients: a population pharmacokinetic approach. Eur J Clin Pharmacol 2024:10.1007/s00228-024-03717-2. [PMID: 38904798 DOI: 10.1007/s00228-024-03717-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 06/14/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE We aim to describe the population pharmacokinetics (PPK) of tacrolimus in Chinese pediatric patients under 4 years old after liver transplantation and to develop individualized tacrolimus dosing software. METHODS A total of 663 blood concentrations from 85 patients aged 4.57 months to 3.97 years were collected in this study. PPK analysis was performed using a nonlinear mixed effects modeling approach with the software, Phoenix. Using C#, an individualized tacrolimus dosing software was created. The software was then used to predict the concentrations of another ten pediatric liver transplantation patients to verify the accuracy of said software. The predictive error (PE) and the absolute predictive error (APE) for each predicted time point were computed. RESULTS A one-compartment model with first-order elimination best fitted the data. The apparent volume of distribution (V/F) and apparent clearance (CL/F) were 198.65 L and 2.41 L/h. Postoperative days (POD), total bilirubin (TBIL), and the use of voriconazole significantly influenced tacrolimus apparent clearance. The incorporation of an increasing number of actual blood drug concentrations into the prediction resulted in a decrease in both PE (72%, 17%, 7%) and APE (87%, 53%, 26%). CONCLUSIONS A qualified PPK model of tacrolimus was developed in Chinese pediatric patients. The individualized tacrolimus dosing software could be used as a suitable tool for the personalization of tacrolimus dosing for pediatric patients after liver transplantation.
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Affiliation(s)
- Siyu Yang
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, 95 Yong An Road, Xi Cheng District, Beijing, 100050, China
| | - Jian Wei
- Department of Interventional Radiography, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Xueqiang Pan
- Pharmacy Department of Beijing Health Vocational College, No. 128, Jiukeshu East Road, Tongzhou District, Beijing, 101101, China
| | - Ze Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, 95 Yong An Road, Xi Cheng District, Beijing, 100050, China
| | - Xuanling Zhang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhe Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, 95 Yong An Road, Xi Cheng District, Beijing, 100050, China
| | - Xianzhe Dong
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China
| | - Zixin Hua
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, 95 Yong An Road, Xi Cheng District, Beijing, 100050, China
| | - Xingang Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, 95 Yong An Road, Xi Cheng District, Beijing, 100050, China.
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He S, Zhao J, Bian J, Zhao Y, Li Y, Guo N, Hu L, Liu B, Shao Q, He H, Huang L, Jiang Q. Population Pharmacokinetics and Pharmacogenetics Analyses of Dasatinib in Chinese Patients with Chronic Myeloid Leukemia. Pharm Res 2023; 40:2413-2422. [PMID: 37726405 DOI: 10.1007/s11095-023-03603-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/04/2023] [Indexed: 09/21/2023]
Abstract
AIMS Dasatinib, a second-generation tyrosine kinase inhibitor of BCR-ABL 1, used for first-line treatment of Philadelphia chromosome-positive chronic myeloid leukemia (CML), exhibits high pharmacokinetic (PK) variability. However, its PK data in Chinese patients with CML remains rarely reported to date. Thus, we developed a population pharmacokinetic (PPK) model of dasatinib in Chinese patients and identified the covariate that could explain the individual variability of PK for optimal individual administration. METHODS PPK modeling for dasatinib was performed based on 754 plasma concentrations obtained from 140 CML patients and analysis of various genetic and physicochemical parameters. Modeling was performed with nonlinear mixed-effects (NLME) using Phoenix NLME. The finally developed model was evaluated using internal and external validation. Monte Carlo simulations were used to predict drug exposures at a steady state for various dosages. RESULTS The PK of dasatinib were well described by a two-compartment with a log-additive residual error model. Patients in the current study had a relatively low estimate of CL/F (126 L/h). A significant association was found between the covariate of age and CL/F of dasatinib, which was incorporated into the final model. None of the genetic factors was confirmed as a significant covariate for dasatinib. The results of external validation with 140 samples from 36 patients were acceptable. Simulation results showed significantly higher exposures in elderly patients. CONCLUSIONS This study's findings suggested that low-dose dasatinib would be better suited for Chinese patients, and the dosage can be appropriately reduced according to the increase of age, especially for the elderly.
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Affiliation(s)
- Shiyu He
- Department of Pharmacy, Peking University People's Hospital, No. 11 Xizhimen South StreetXicheng District, Beijing, 100044, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Jinxia Zhao
- Department of Pharmacy, Peking University People's Hospital, No. 11 Xizhimen South StreetXicheng District, Beijing, 100044, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Jialu Bian
- Department of Pharmacy, Peking University People's Hospital, No. 11 Xizhimen South StreetXicheng District, Beijing, 100044, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Yinyu Zhao
- Department of Pharmacy, Peking University People's Hospital, No. 11 Xizhimen South StreetXicheng District, Beijing, 100044, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Yuanyuan Li
- Department of Pharmacy, Peking University People's Hospital, No. 11 Xizhimen South StreetXicheng District, Beijing, 100044, China
| | - Nan Guo
- Department of Pharmacy, Peking University People's Hospital, No. 11 Xizhimen South StreetXicheng District, Beijing, 100044, China
| | - Lei Hu
- Department of Pharmacy, Peking University People's Hospital, No. 11 Xizhimen South StreetXicheng District, Beijing, 100044, China
| | - Boyu Liu
- Department of Pharmacy, Peking University People's Hospital, No. 11 Xizhimen South StreetXicheng District, Beijing, 100044, China
| | - Qianhang Shao
- Department of Pharmacy, Peking University People's Hospital, No. 11 Xizhimen South StreetXicheng District, Beijing, 100044, China
| | - Huan He
- Department of Pharmacy, Beijing Children's Hospital of Capital Medical University, Beijing, China
| | - Lin Huang
- Department of Pharmacy, Peking University People's Hospital, No. 11 Xizhimen South StreetXicheng District, Beijing, 100044, China.
| | - Qian Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, No. 11 Xizhimen South StreetXicheng District, Beijing, 100044, China.
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Jin J, Zhong XB. Epigenetic Mechanisms Contribute to Intraindividual Variations of Drug Metabolism Mediated by Cytochrome P450 Enzymes. Drug Metab Dispos 2023; 51:672-684. [PMID: 36973001 PMCID: PMC10197210 DOI: 10.1124/dmd.122.001007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 02/24/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
Significant interindividual and intraindividual variations on cytochrome P450 (CYP)-mediated drug metabolism exist in the general population globally. Genetic polymorphisms are one of the major contribution factors for interindividual variations, but epigenetic mechanisms mainly contribute to intraindividual variations, including DNA methylation, histone modifications, microRNAs, and long non-coding RNAs. The current review provides analysis of advanced knowledge in the last decade on contributions of epigenetic mechanisms to intraindividual variations on CYP-mediated drug metabolism in several situations, including (1) ontogeny, the developmental changes of CYP expression in individuals from neonates to adults; (2) increased activities of CYP enzymes induced by drug treatment; (3) increased activities of CYP enzymes in adult ages induced by drug treatment at neonate ages; and (4) decreased activities of CYP enzymes in individuals with drug-induced liver injury (DILI). Furthermore, current challenges, knowledge gaps, and future perspective of the epigenetic mechanisms in development of CYP pharmacoepigenetics are discussed. In conclusion, epigenetic mechanisms have been proven to contribute to intraindividual variations of drug metabolism mediated by CYP enzymes in age development, drug induction, and DILI conditions. The knowledge has helped understanding how intraindividual variation are generated. Future studies are needed to develop CYP-based pharmacoepigenetics to guide clinical applications for precision medicine with improved therapeutic efficacy and reduced risk of adverse drug reactions and toxicity. SIGNIFICANCE STATEMENT: Understanding epigenetic mechanisms in contribution to intraindividual variations of CYP-mediated drug metabolism may help to develop CYP-based pharmacoepigenetics for precision medicine to improve therapeutic efficacy and reduce adverse drug reactions and toxicity for drugs metabolized by CYP enzymes.
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Affiliation(s)
- Jing Jin
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, Connecticut
| | - Xiao-Bo Zhong
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, Connecticut
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Jasper EA, Holley SE, Jones SH, Liu M, Israel T, Van Driest SL, Velez Edwards DR. Tutorial: Using Community Engagement Studios to Enhance Pharmacogenetic Study Design for Maximizing Enrollment of Diverse Children and Pregnant People. Clin Pharmacol Ther 2023; 113:607-614. [PMID: 36366911 PMCID: PMC9957793 DOI: 10.1002/cpt.2792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/01/2022] [Indexed: 11/13/2022]
Abstract
Most pharmacogenetic research is conducted in adult, non-pregnant populations of European ancestry. Study of more diverse and special populations is necessary to validate findings and improve health equity. However, there are significant barriers to recruitment of diverse populations for genetic studies, such as mistrust of researchers due to a history of unethical research and ongoing social inequities. Engaging communities and understanding community members' perspectives may help to overcome these barriers and improve research quality. Here, we highlight one method for engaging communities, the Community Engagement Studio (CES), a consultative session that allows researchers to obtain guidance and feedback based on community members' lived experiences. We also provide an example of its use in pharmacogenetic studies. In designing a survey study of knowledge and attitudes around pharmacogenetic testing among children with chronic conditions and pregnant individuals, we sought input from diverse community stakeholders through CESs at Vanderbilt University Medical Center. We participated in two CESs with community stakeholders representing study target populations. Our goals were to learn specific concerns about pharmacogenetic testing and preferred recruitment strategies for these communities. Concerns were expressed about how genetic information would be used beyond the immediate study. Participants emphasized the importance of clarity and transparency in communication to overcome participation hesitancy and mistrust of the study team. Recruitment strategy recommendations ranged from informal notices posted in healthcare settings to provider referrals. The CES enabled us to modify our recruitment methods and research materials to better communicate with populations currently under-represented in pharmacogenetics research.
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Affiliation(s)
- Elizabeth A Jasper
- Division of Quantitative Sciences, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sabrina E Holley
- Center for Pediatric Precision Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah H Jones
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michelle Liu
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tiffany Israel
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Center for Pediatric Precision Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Departments of Pediatrics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Digna R Velez Edwards
- Division of Quantitative Sciences, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Genetics Institute, Vanderbilt University, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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5
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Xu T, Kabir M, Sakamuru S, Shah P, Padilha E, Ngan DK, Xia M, Xu X, Simeonov A, Huang R. Predictive Models for Human Cytochrome P450 3A7 Selective Inhibitors and Substrates. J Chem Inf Model 2023; 63:846-855. [PMID: 36719788 PMCID: PMC10664139 DOI: 10.1021/acs.jcim.2c01516] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Inappropriate use of prescription drugs is potentially more harmful in fetuses/neonates than in adults. Cytochrome P450 (CYP) 3A subfamily undergoes developmental changes in expression, such as a transition from CYP3A7 to CYP3A4 shortly after birth, which provides a potential way to distinguish medication effects on fetuses/neonates and adults. The purpose of this study was to build first-in-class predictive models for both inhibitors and substrates of CYP3A7/CYP3A4 using chemical structure analysis. Three metrics were used to evaluate model performance: area under the receiver operating characteristic curve (AUC-ROC), balanced accuracy (BA), and Matthews correlation coefficient (MCC). The performance varied for each CYP3A7/CYP3A4 inhibitor/substrate model depending on the data set type, model type, rebalancing method, and specific feature set. For the active inhibitor/substrate data set, the optimal models achieved AUC-ROC values ranging from 0.77 ± 0.01 to 0.84 ± 0.01. For the selective inhibitor/substrate data set, the optimal models achieved AUC-ROC values ranging from 0.72 ± 0.02 to 0.79 ± 0.04. The predictive power of the optimal models was validated by compounds with known potencies as CYP3A7/CYP3A4 inhibitors or substrates. In addition, we identified structural features significant for CYP3A7/CYP3A4 selective or common inhibitors and substrates. In summary, the top performing models can be further applied as a tool to rapidly evaluate the safety and efficacy of new drugs separately for fetuses/neonates and adults. The significant structural features could guide the design of new therapeutic drugs as well as aid in the optimization of existing medicine for fetuses/neonates.
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Affiliation(s)
- Tuan Xu
- Division of Pre-clinical Innovation, National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, Maryland 20850, United States
| | - Md Kabir
- Division of Pre-clinical Innovation, National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, Maryland 20850, United States
- The Graduate School of Biomedical Sciences, Departments of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, New York 10029, United States
| | - Srilatha Sakamuru
- Division of Pre-clinical Innovation, National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, Maryland 20850, United States
| | - Pranav Shah
- Division of Pre-clinical Innovation, National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, Maryland 20850, United States
| | - Elias Padilha
- Division of Pre-clinical Innovation, National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, Maryland 20850, United States
| | - Deborah K. Ngan
- Division of Pre-clinical Innovation, National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, Maryland 20850, United States
| | - Menghang Xia
- Division of Pre-clinical Innovation, National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, Maryland 20850, United States
| | - Xin Xu
- Division of Pre-clinical Innovation, National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, Maryland 20850, United States
| | - Anton Simeonov
- Division of Pre-clinical Innovation, National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, Maryland 20850, United States
| | - Ruili Huang
- Division of Pre-clinical Innovation, National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, Maryland 20850, United States
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Pharmacogenetic Aspects of Drug Metabolizing Enzymes and Transporters in Pediatric Medicine: Study Progress, Clinical Practice and Future Perspectives. Paediatr Drugs 2023; 25:301-319. [PMID: 36707496 DOI: 10.1007/s40272-023-00560-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 01/28/2023]
Abstract
As the activity of certain drug metabolizing enzymes or transporter proteins can vary with age, the effect of ontogenetic and genetic variation on the activity of these enzymes is critical for the accurate prediction of treatment outcomes and toxicity in children. This makes pharmacogenetic research in pediatrics particularly important and urgently needed, but also challenging. This review summarizes pharmacogenetic studies on the effects of genetic polymorphisms on pharmacokinetic parameters and clinical outcomes in pediatric populations for certain drugs, which are commonly prescribed by clinicians across multiple therapeutic areas in a general hospital, organized from those with the most to the least pediatric evidence among each drug category. We also further discuss the research status of the gene-guided dosing regimens and clinical implementation of pediatric pharmacogenetics. More and more drug-gene interactions are demonstrated to have clinical validity for children, and pharmacogenomics in pediatrics have shown evidence-based benefits to enhance the efficacy and precision of existing drug dosing regimens in several therapeutic areas. However, the most important limitation to the implementation is the lack of high-quality, rigorous pediatric prospective clinical studies, so adequately powered interventional clinical trials that support incorporation of pharmacogenetics into the care of children are still needed.
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Rodieux F, Daali Y, Rollason V, Samer CF, Ing Lorenzini K. Practice of CYP450 genotyping and phenotyping in children in a real-life setting. Front Pharmacol 2023; 14:1130100. [PMID: 36937881 PMCID: PMC10022732 DOI: 10.3389/fphar.2023.1130100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/14/2023] [Indexed: 03/02/2023] Open
Abstract
Pharmacokinetics varies widely between children. Many factors play an important role in this variability, such as ontogeny, pharmacogenetics, gender, comorbidities, and drug-drug interactions. Significant work has already been done in adults to understand the impact of genetic polymorphisms on drug-metabolizing enzyme activity and drug response. Data remain poor in children due to ontogeny that impacts genotyping-phenotyping correlation and the difficulty enrolling children in prospective studies. Our study aimed to describe the use of cytochromes P450 (CYP) phenotyping and/or genotyping tests in children in a real-life setting and assess the correlation between the genotype and the phenotype. We reviewed the results of tests performed between January 2005 and December 2020. Fifty-two children were genotyped and/or phenotyped. Four patients were excluded from the present analysis as they only underwent ABCB1 genotyping, without CYP testing. Of the remainder, 18 underwent simultaneous CYP genotyping and phenotyping, while 17 underwent CYP genotyping only, and 13 underwent CYP phenotyping only. In all cases, investigations were performed after the following situations: insufficient clinical response to treatment, low plasma concentrations, and adverse drug reactions (ADR). The vast majority of cases were related to immunosuppressive or antipsychotic therapy. Genotyping and/or phenotyping explained or contributed to the aforementioned clinical events in 56% of cases. The correlation between the genotype and the phenotype showed variability depending on the assessed cytochrome. In several cases, the phenotype did not correspond to the genotype because of comedications. In conclusion, there is clearly value in guiding drug based on CYP activity in children.
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Affiliation(s)
- Frédérique Rodieux
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive care, Geneva University Hospitals, Geneva, Switzerland
- *Correspondence: Frédérique Rodieux,
| | - Youssef Daali
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive care, Geneva University Hospitals, Geneva, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Victoria Rollason
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive care, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Caroline F. Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive care, Geneva University Hospitals, Geneva, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Kuntheavy Ing Lorenzini
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive care, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Green EA, Metz D, Galinsky R, Atkinson R, Skuza EM, Clark M, Gunn AJ, Kirkpatrick CM, Hunt RW, Berger PJ, Nold-Petry CA, Nold MF. Anakinra Pilot - a clinical trial to demonstrate safety, feasibility and pharmacokinetics of interleukin 1 receptor antagonist in preterm infants. Front Immunol 2022; 13:1022104. [PMID: 36389766 PMCID: PMC9647081 DOI: 10.3389/fimmu.2022.1022104] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/10/2022] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD), its complication pulmonary hypertension (BPD-PH) and preterm brain and gut injury lead to significant morbidity and mortality in infants born extremely prematurely. There is extensive evidence that the pro-inflammatory cytokine interleukin 1 (IL-1) plays a key role in the pathophysiology of these illnesses. Two decades of clinical use in paediatric and adult medicine have established an excellent safety and efficacy record for IL-1 blockade with IL-1 receptor antagonist (IL-1Ra, medication name anakinra). Building on robust pre-clinical evidence, the Anakinra Pilot trial aims to demonstrate safety and feasibility of administering anakinra to preterm infants, and to establish pharmacokinetics in this population. Its ultimate goal is to facilitate large studies that will test whether anakinra can ameliorate early-life inflammation, thus alleviating multiple complications of prematurity. METHODS AND ANALYSIS Anakinra Pilot is an investigator-initiated, single arm, safety and feasibility dose-escalation trial in extremely preterm infants born between 24 weeks 0 days (240) and 276 weeks of gestational age (GA). Enrolled infants will receive anakinra intravenously over the first 21 days after birth, starting in the first 24 h after birth. In the first phase, dosing is 1 mg/kg every 48 h, and dosage will increase to 1.5 mg/kg every 24 h in the second phase. Initial anakinra dosing was determined through population pharmacokinetic model simulations. During the study, there will be a interim analysis to confirm predictions before undertaking dose assessment. Anakinra therapy will be considered safe if the frequency of adverse outcomes/events does not exceed that expected in infants born at 240-276 weeks GA. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/, identifier NCT05280340.
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Affiliation(s)
- Elys A. Green
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, VIC, Australia
| | - David Metz
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- Monash Children’s Hospital, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Rebecka Atkinson
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, VIC, Australia
| | - Elizbeth M. Skuza
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Megan Clark
- Monash Newborn, Monash Children’s Hospital, Melbourne, VIC, Australia
- Faculty of Pharmacy and Pharmaceutical Science, Monash University, Melbourne, VIC, Australia
| | - Alistair J Gunn
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Carl M. Kirkpatrick
- Monash Institute for Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Rod W. Hunt
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, VIC, Australia
| | - Philip J. Berger
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Claudia A. Nold-Petry
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Marcel F. Nold
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, VIC, Australia
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9
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Wojciechowski J, Malhotra BK, Wang X, Fostvedt L, Valdez H, Nicholas T. Population Pharmacokinetics of Abrocitinib in Healthy Individuals and Patients with Psoriasis or Atopic Dermatitis. Clin Pharmacokinet 2022; 61:709-723. [PMID: 35061234 PMCID: PMC9095539 DOI: 10.1007/s40262-021-01104-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVE Abrocitinib is a Janus kinase 1 inhibitor in development for the treatment of atopic dermatitis (AD). This work characterized orally administered abrocitinib population pharmacokinetics in healthy individuals, patients with psoriasis, and patients with AD and the effects of covariates on abrocitinib exposure. METHODS Abrocitinib concentration measurements (n = 6206) from 995 individuals from 11 clinical trials (seven phase I, two phase II, and two phase III) were analyzed, and a non-linear mixed-effects model was developed. Simulations of abrocitinib dose proportionality and steady-state accumulation of maximal plasma drug concentration (Cmax) and area under the curve (AUC) were conducted using the final model. RESULTS A two-compartment model with parallel zero- and first-order absorption, time-dependent bioavailability, and time- and dose-dependent clearance best described abrocitinib pharmacokinetics. Abrocitinib coadministration with rifampin resulted in lower exposure, whereas Asian/other race coadministration with fluconazole and fluvoxamine, inflammatory skin conditions (psoriasis/AD), and hepatic impairment resulted in higher exposure. After differences in body weight are accounted for, Asian participants demonstrated a 1.43- and 1.48-fold increase in Cmax and AUC, respectively. The overall distribution of exposures (Cmax and AUC) was similar in adolescents and adults after accounting for differences in total body weight. CONCLUSIONS A population pharmacokinetics model was developed for abrocitinib that can be used to predict abrocitinib steady-state exposure in the presence of drug-drug interaction effects or intrinsic patient factors. Key covariates in the study population accounting for variability in abrocitinib exposures are Asian race and adolescent age, although these factors are not clinically meaningful. CLINICAL TRIAL NUMBERS NCT01835197, NCT02163161, NCT02201524, NCT02780167, NCT03349060, NCT03575871, NCT03634345, NCT03637790, NCT03626415, NCT03386279, NCT03937258.
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Affiliation(s)
| | - Bimal K. Malhotra
- Department of Global Product Development, Pfizer Inc., New York, NY USA
| | - Xiaoxing Wang
- Department of Global Product Development, Pfizer Inc., Groton, CT USA
| | - Luke Fostvedt
- Department of Global Product Development, Pfizer Inc., Cambridge, MA USA
| | - Hernan Valdez
- Department of Global Product Development, Pfizer Inc., New York, NY USA
| | - Timothy Nicholas
- Department of Global Product Development, Pfizer Inc., Groton, CT USA
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Berrios C, Sadaro SK, Sandritter T, Wagner JA, Soden S, Black B, Abdel-Rahman S. Parental understanding and attitudes following pharmacogenomic testing for pediatric neuropsychiatric patients. Pharmacogenomics 2022; 23:345-354. [DOI: 10.2217/pgs-2022-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This study explores parental understanding and attitudes around pharmacogenomic results in their child(ren). Patients and methods: In-depth interviews with parents whose child(ren) had received a pharmacogenomic testing panel for management of neuropsychiatric medications were completed. Interviews were analyzed for themes and accuracy of understanding of results. Results: In 18 parents interviewed, 49/63 (78%) of statements made regarding results were accurate. Differences in understanding were seen by clinic, number of medications and result type. Parents expected results to guide prescribing and perceived the greatest utility in results that could impact current care. Results predicting normal drug metabolism may create mixed feelings. Conclusion: Parents perceive utility in pharmacogenomic testing for their children. Challenges exist in understanding probabilistic and multifactorial information about pharmacogenomic results.
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Affiliation(s)
- Courtney Berrios
- Genomic Medicine Center, Children's Mercy, Kansas City, MO 64108, USA
- School of Medicine, University of Missouri Kansas City, Kansas City, MO 64108, USA
| | - Sophia K Sadaro
- Genomic Medicine Center, Children's Mercy, Kansas City, MO 64108, USA
| | - Tracy Sandritter
- Clinical Pharmacology, Toxicology, & Therapeutic Innovation, Children's Mercy, Kansas City, MO 64108, USA
- School of Pharmacy, University of Missouri Kansas City, Kansas City, MO 64108, USA
| | - Jennifer A Wagner
- School of Medicine, University of Missouri Kansas City, Kansas City, MO 64108, USA
- Clinical Pharmacology, Toxicology, & Therapeutic Innovation, Children's Mercy, Kansas City, MO 64108, USA
| | - Sarah Soden
- School of Medicine, University of Missouri Kansas City, Kansas City, MO 64108, USA
- Developmental & Behavioral Sciences, Children's Mercy, Kansas City, MO 64108, USA
| | - Benjamin Black
- The Thompson Center for Autism & Neurodevelopmental Disorders, University of Missouri, Columbia, MO 65201, USA
| | - Susan Abdel-Rahman
- Clinical Pharmacology, Toxicology, & Therapeutic Innovation, Children's Mercy, Kansas City, MO 64108, USA
- School of Pharmacy, University of Missouri Kansas City, Kansas City, MO 64108, USA
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11
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Higi L, Käser K, Wälti M, Grotzer M, Vonbach P. Description of a clinical decision support tool with integrated dose calculator for paediatrics. Eur J Pediatr 2022; 181:679-689. [PMID: 34524516 PMCID: PMC8821055 DOI: 10.1007/s00431-021-04261-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/02/2021] [Accepted: 09/05/2021] [Indexed: 12/02/2022]
Abstract
Medication errors, especially dosing errors are a leading cause of preventable harm in paediatric patients. The paediatric patient population is particularly vulnerable to dosing errors due to immaturity of metabolising organs and developmental changes. Moreover, the lack of clinical trial data or suitable drug forms, and the need for weight-based dosing, does not simplify drug dosing in paediatric or neonatal patients. Consequently, paediatric pharmacotherapy often requires unlicensed and off-label use including manipulation of adult dosage forms. In practice, this results in the need to calculate individual dosages which in turn increases the likelihood of dosing errors. In the age of digitalisation, clinical decision support (CDS) tools can support healthcare professionals in their daily work. CDS tools are currently amongst the gold standards in reducing preventable errors. In this publication, we describe the development and core functionalities of the CDS tool PEDeDose, a Class IIa medical device software certified according to the European Medical Device Regulation. The CDS tool provides a drug dosing formulary with an integrated calculator to determine individual dosages for paediatric, neonatal, and preterm patients. Even a technical interface is part of the CDS tool to facilitate integration into primary systems. This enables the support of the paediatrician directly during the prescribing process without changing the user interface.Conclusion: PEDeDose is a state-of-the-art CDS tool for individualised paediatric drug dosing that includes a certified calculator. What is Known: • Dosing errors are the most common type of medication errors in paediatric patients. • Clinical decision support tools can reduce medication errors effectively. Integration into the practitioner's workflow improves usability and user acceptance. What is New: • A clinical decision support tool with a certified integrated dosing calculator for paediatric drug dosing. • The tool was designed to facilitate integration into clinical information systems to directly support the prescribing process. Any clinical information system available can interoperate with the PEDeDose web service.
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Affiliation(s)
- Lukas Higi
- PEDeus Ltd, Zurich, Switzerland. .,Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland.
| | | | | | - Michael Grotzer
- PEDeus Ltd, Zurich, Switzerland ,University Children’s Hospital of Zurich, Zurich, Switzerland
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12
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Jovanović M, Vučićević K. Pediatric pharmacokinetic considerations and implications for drug dosing. ARHIV ZA FARMACIJU 2022. [DOI: 10.5937/arhfarm72-37605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Optimizing the dosing of medicines for pediatric patients in routine clinical practice and determining the dose for clinical trials is still a challenging task. Children differ from adults in their response to drugs due to inherent differences in pharmacokinetics and/or pharmacodynamics, and responses may also vary among pediatric patients of different ages. However, the greatest disparities compared to adult pharmacokinetic profiles are observed in children below 2 years of age. The maturation of the liver and the kidneys, as well as the variation in body composition, are considered to be the main sources of pharmacokinetic variability. Hence, besides specific pharmacodynamic features, understanding age-related changes in drug absorption, distribution, and elimination is fundamental for optimizing drug efficacy and avoiding toxicity. This paper summarizes the pharmacokinetic changes throughout the childhood, along with the effect of developmental changes on drug dosage calculation. In clinical practice, age and body weight-based dosing regimens are usually used. In spite of dosing recommendations based on age and/or body weight, variabilities in pharmacokinetics and pharmacodynamic response remain, implying a need to monitor patients and optimize the dosing regimen according to physiological characteristics, disease characteristics and therapy.
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13
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CYP3A-status is associated with blood concentration and dose-requirement of tacrolimus in heart transplant recipients. Sci Rep 2021; 11:21389. [PMID: 34725418 PMCID: PMC8560807 DOI: 10.1038/s41598-021-00942-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/20/2021] [Indexed: 01/08/2023] Open
Abstract
High inter-individual variability in tacrolimus clearance is attributed to genetic polymorphisms of CYP3A enzymes. However, due to CYP3A phenoconversion induced by non-genetic factors, continuous changes in tacrolimus-metabolizing capacity entail frequent dose-refinement for optimal immunosuppression. In heart transplant recipients, the contribution of patients' CYP3A-status (CYP3A5 genotype and CYP3A4 expression) to tacrolimus blood concentration and dose-requirement was evaluated in the early and late post-operative period. In low CYP3A4 expressers carrying CYP3A5*3/*3, the dose-corrected tacrolimus level was significantly higher than in normal CYP3A4 expressers or in those with CYP3A5*1. Modification of the initial tacrolimus dose was required for all patients: dose reduction by 20% for low CYP3A4 expressers, a 40% increase for normal expressers and a 2.4-fold increase for CYP3A5*1 carriers. The perioperative high-dose corticosteroid therapy was assumed to ameliorate the low initial tacrolimus-metabolizing capacity during the first month. The fluctuation of CYP3A4 expression and tacrolimus blood concentration (C0/D) was found to be associated with tapering and cessation of corticosteroid in CYP3A5 non-expressers, but not in those carrying CYP3A5*1. Although monitoring of tacrolimus blood concentration cannot be omitted, assaying recipients' CYP3A-status can guide optimization of the initial tacrolimus dose, and can facilitate personalized tacrolimus therapy during steroid withdrawal in the late post-operative period.
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14
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Li Q, Wu YE, Wang K, Shi HY, Zhou Y, Zheng Y, Hao GX, Yang YL, Su LQ, Wang WQ, Yang XM, Zhao W. Developmental Pharmacogenetics of CYP2D6 in Chinese Children: Loratadine as a Substrate Drug. Front Pharmacol 2021; 12:657287. [PMID: 34295246 PMCID: PMC8292113 DOI: 10.3389/fphar.2021.657287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/20/2021] [Indexed: 11/28/2022] Open
Abstract
Objective: The elucidation of CYP2D6 developmental pharmacogenetics in children has improved, however, these findings have been largely limited to studies of Caucasian children. Given the clear differences in CYP2D6 pharmacogenetic profiles in people of different ancestries, there remains an unmet need to better understand the developmental pharmacogenetics in populations of different ancestries. We sought to use loratadine as a substrate drug to evaluate the effects of ontogeny and pharmacogenetics on the developmental pattern of CYP2D6 in Chinese pediatric patients. Methods: Chinese children receiving loratadine treatment were enrolled in the present study. The metabolite-to-parent ratio (M/P ratio), defined as the molar ratio of desloratadine to loratadine of trough concentrations samples at steady-state condition, was used as a surrogate of CYP2D6 activity. Loratadine and desloratadine were determined by LC/MS/MS method. Variants of CYP2D6 were genotyped by polymerase chain reaction for CYP2D6 *4, *10, *41 and long polymerase chain reaction for CYP2D6 *5. Results: A total of 40 patients were available for final analysis. The mean age was 4.50 (range 0.50–9.00) years and the mean weight was 19.64 (range 7.00–42.00) kg. The M/P ratio was significantly lower in intermediate metabolizers (IMs) compared to normal metabolizers (NMs) (10.18 ± 7.97 vs. 18.80 ± 15.83, p = 0.03). Weight was also found to be significantly associated with M/P ratio (p = 0.03). Conclusion: The developmental pharmacogenetics of CYP2D6 in Chinese children was evaluated using loratadine as a substrate drug. This study emphasizes the importance of evaluating the developmental pharmacogenetics in populations of different ancestries.
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Affiliation(s)
- Qian Li
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Yue-E Wu
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Kai Wang
- Department of Pediatrics, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Jinan, China
| | - Hai-Yan Shi
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Yue Zhou
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yi Zheng
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yi-Lei Yang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Le-Qun Su
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Wen-Qi Wang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Xin-Mei Yang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China.,Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
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15
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Hoshitsuki K, Fernandez CA, Yang JJ. Pharmacogenomics for Drug Dosing in Children: Current Use, Knowledge, and Gaps. J Clin Pharmacol 2021; 61 Suppl 1:S188-S192. [PMID: 34185912 DOI: 10.1002/jcph.1891] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/29/2021] [Indexed: 11/08/2022]
Abstract
Pharmacogenomics research ranges from the discovery of genetic factors to explain interpatient variability in drug exposure and response to clinical implementation of this knowledge to improve pharmacotherapy. Medications with actionable pharmacogenomic associations are frequently used in children, and therefore pharmacogenomics-guided precision medicine is readily applicable to the pediatric population. Although heritable genetics are considered immutable, the impact of genetic variation in pharmacogenes is modified by other factors such as age-dependent changes in gene expression. Early evidence has emerged indicating that the interaction between ontogeny and pharmacogenomics determines whether or how genetics-based dosing algorithms should be adjusted in children versus adults. However, there is still a paucity of data describing pharmacogenomic associations in patient populations across the life span. Future research is much needed to evaluate the impact of pharmacogenomics on drug dosing specific to the pediatric population, along with consideration of other developmental and physiological factors uniquely related to drug disposition in this population.
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Affiliation(s)
- Keito Hoshitsuki
- Center for Pharmacogenetics and Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA.,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christian A Fernandez
- Center for Pharmacogenetics and Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Jun J Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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16
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Implementing Pharmacogenomics Testing: Single Center Experience at Arkansas Children's Hospital. J Pers Med 2021; 11:jpm11050394. [PMID: 34064668 PMCID: PMC8150685 DOI: 10.3390/jpm11050394] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/03/2021] [Accepted: 05/06/2021] [Indexed: 02/07/2023] Open
Abstract
Pharmacogenomics (PGx) is a growing field within precision medicine. Testing can help predict adverse events and sub-therapeutic response risks of certain medications. To date, the US FDA lists over 280 drugs which provide biomarker-based dosing guidance for adults and children. At Arkansas Children’s Hospital (ACH), a clinical PGx laboratory-based test was developed and implemented to provide guidance on 66 pediatric medications for genotype-guided dosing. This PGx test consists of 174 single nucleotide polymorphisms (SNPs) targeting 23 clinically actionable PGx genes or gene variants. Individual genotypes are processed to provide per-gene discrete results in star-allele and phenotype format. These results are then integrated into EPIC- EHR. Genomic indicators built into EPIC-EHR provide the source for clinical decision support (CDS) for clinicians, providing genotype-guided dosing.
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17
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Posobiec LM, Laffan SB. Dose range finding approach for rodent preweaning juvenile animal studies. Birth Defects Res 2020; 113:409-426. [PMID: 33314670 DOI: 10.1002/bdr2.1856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/12/2020] [Accepted: 12/01/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Strategies for conducting juvenile dose ranging studies before definitive toxicity juvenile animal studies (JAS) have evolved, but the aim of demonstrating study design robustness and efficient animal use remains the same. The objective of dose selection is to identify a strategy to achieve consistent systemic exposure for the duration of the JAS while maintaining exposure separation between dose groups. For preweaning rodents this can prove challenging, as these studies typically treat animals over a broad period of considerable organ development. MATERIALS AND METHODS In our experience, over 45 rodent juvenile studies (dose range, definitive or investigative) were conducted over 20 years to support pediatric medicine development. In most cases (86%, 12/14), preweaning rodents required decreased doses of test articles than adult rodents; the majority (83%, 10/12) were due to increased systemic exposures in immature animals at the same doses. Thus, extrapolating tolerability and exposure data from adults is not ideal and should not take the place of well-designed juvenile dose range studies. RESULTS/DISCUSSION/CONCLUSION We propose a phased dose-range-finding approach by first conducting a tolerability phase with a few animals at a starting age corresponding to the youngest clinical starting age, spanning a wide range of doses, then a dose range phase with larger group sizes and fewer doses; both phases incorporate toxicokinetics. Often, exposure was higher in preweaning animals and decreased as animals matured postweaning (postnatal day, PND 21 and older), supporting an age-based dose adjustment strategy. Case studies demonstrate dose adjustment approaches incorporating dose increases or decreases or changes in dose frequency.
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Affiliation(s)
- Lorraine M Posobiec
- In Vivo/In Vitro Translation, Nonclinical Safety, GlaxoSmithKline, Collegeville, Pennsylvania, USA
| | - Susan B Laffan
- In Vivo/In Vitro Translation, Nonclinical Safety, GlaxoSmithKline, Collegeville, Pennsylvania, USA
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18
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Gregornik D, Salyakina D, Brown M, Roiko S, Ramos K. Pediatric pharmacogenomics: challenges and opportunities: on behalf of the Sanford Children's Genomic Medicine Consortium. THE PHARMACOGENOMICS JOURNAL 2020; 21:8-19. [PMID: 32843689 DOI: 10.1038/s41397-020-00181-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 06/15/2020] [Accepted: 08/12/2020] [Indexed: 01/13/2023]
Abstract
The advent of digital, electronic, and molecular technologies has allowed the study of complete genomes. Integrating this information into drug development has opened the door for pharmacogenomic (PGx) interventions in direct patient care. PGx allows clinicians to better identify drug of choice and optimize dosing regimens based on an individual's genetic characteristics. Integrating PGx into pediatric care is a priority for the Sanford Children's Genomic Medicine Consortium, a partnership of ten children's hospitals across the US committed to the innovation and advancement of genomics in pediatric care. In this white paper, we review the current state of PGx research and its clinical utility in pediatrics, a largely understudied population, and make recommendations for advancing cutting-edge practice in pediatrics.
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Affiliation(s)
- David Gregornik
- Pharmacogenomics Program, Children's Minnesota, Minneapolis, MN, USA.
| | - Daria Salyakina
- Research Institute and Personalized Medicine Initiative, Nicklaus Children's Hospital, Miami, FL, USA
| | - Marilyn Brown
- Research Institute and Personalized Medicine Initiative, Nicklaus Children's Hospital, Miami, FL, USA
| | - Samuel Roiko
- Children's Research Institute, Minnesota, Minneapolis, MN, USA
| | - Kenneth Ramos
- Texas A&M University System, College Station, TX, USA.
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19
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Badée J, Fowler S, de Wildt SN, Collier AC, Schmidt S, Parrott N. The Ontogeny of UDP-glucuronosyltransferase Enzymes, Recommendations for Future Profiling Studies and Application Through Physiologically Based Pharmacokinetic Modelling. Clin Pharmacokinet 2020; 58:189-211. [PMID: 29862468 DOI: 10.1007/s40262-018-0681-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Limited understanding of drug pharmacokinetics in children is one of the major challenges in paediatric drug development. This is most critical in neonates and infants owing to rapid changes in physiological functions, especially in the activity of drug-metabolising enzymes. Paediatric physiologically based pharmacokinetic models that integrate ontogeny functions for cytochrome P450 enzymes have aided our understanding of drug exposure in children, including those under the age of 2 years. Paediatric physiologically based pharmacokinetic models have consequently been recognised by the European Medicines Agency and the US Food and Drug Administration as innovative tools in paediatric drug development and regulatory decision making. However, little is currently known about age-related changes in UDP-glucuronosyltransferase-mediated metabolism, which represents the most important conjugation reaction for xenobiotics. Therefore, the objective of the review was to conduct a thorough literature survey to summarise our current understanding of age-related changes in UDP-glucuronosyltransferases as well as associated clinical and experimental sources of variance. Our findings indicate that there are distinct differences in UDP-glucuronosyltransferase expression and activity between isoforms for different age groups. In addition, there is substantial variability between individuals and laboratories reported for human liver microsomes, which results in part from a lack of standardised experimental conditions. Therefore, we provide a number of best practice recommendations for experimental conditions, which ultimately may help improve the quality of data used for quantitative clinical pharmacology approaches, and thus for safe and effective pharmacotherapy in children.
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Affiliation(s)
- Justine Badée
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, University of Florida at Lake Nona, Orlando, FL, USA
| | - Stephen Fowler
- Pharmaceutical Sciences, Roche Pharma Research and Early Development, Roche Innovation Centre Basel, Grenzacherstrasse 124, 4070, Basel, Switzerland
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud University, Nijmegen, The Netherlands.,Intensive Care and Department of Paediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Abby C Collier
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
| | - Stephan Schmidt
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, University of Florida at Lake Nona, Orlando, FL, USA
| | - Neil Parrott
- Pharmaceutical Sciences, Roche Pharma Research and Early Development, Roche Innovation Centre Basel, Grenzacherstrasse 124, 4070, Basel, Switzerland.
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20
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Rieder M. Adverse Drug Reactions Across the Age Continuum: Epidemiology, Diagnostic Challenges, Prevention, and Treatments. J Clin Pharmacol 2019; 58 Suppl 10:S36-S47. [PMID: 30248196 DOI: 10.1002/jcph.1115] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 02/11/2018] [Indexed: 12/15/2022]
Abstract
Adverse drug reactions (ADRs) are common and important complications of drug therapy for children. The risk for ADRs changes over childhood, as do the nature and types of ADRs. Importantly, the risk and nature of ADRs in children are markedly different from those of adults, and adult data cannot be relied on to guide safe drug therapy in children. There are groups of children, notably those with complex and chronic diseases, who are at substantial risk for ADRs. The evaluation of an undesired effect during therapy is ideally accomplished by an organized approach that is a skill that clinicians who care for children-especially those children at high risk for ADRs must have. Additionally, clinicians as well as drug regulatory agencies and industry need to be both vigilant and astute as well as aware that ADRs in children are often different in nature and frequency from those in adults. The increasing use of pharmacogenomics to guide drug dosing and the increasing number of biological agents will provide new sets of challenges to clinicians over the next decade.
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Affiliation(s)
- Michael Rieder
- Department of Paediatrics, University of Western Ontario, London, Ontario, Canada
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21
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Matlock MK, Tambe A, Elliott-Higgins J, Hines RN, Miller GP, Swamidass SJ. A Time-Embedding Network Models the Ontogeny of 23 Hepatic Drug Metabolizing Enzymes. Chem Res Toxicol 2019; 32:1707-1721. [PMID: 31304741 PMCID: PMC6933754 DOI: 10.1021/acs.chemrestox.9b00223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pediatric patients are at elevated risk of adverse drug reactions, and there is insufficient information on drug safety in children. Complicating risk assessment in children, there are numerous age-dependent changes in the absorption, distribution, metabolism, and elimination of drugs. A key contributor to age-dependent drug toxicity risk is the ontogeny of drug metabolism enzymes, the changes in both abundance and type throughout development from the fetal period through adulthood. Critically, these changes affect not only the overall clearance of drugs but also exposure to individual metabolites. In this study, we introduce time-embedding neural networks in order to model population-level variation in metabolism enzyme expression as a function of age. We use a time-embedding network to model the ontogeny of 23 drug metabolism enzymes. The time-embedding network recapitulates known demographic factors impacting 3A5 expression. The time-embedding network also effectively models the nonlinear dynamics of 2D6 expression, enabling a better fit to clinical data than prior work. In contrast, a standard neural network fails to model these features of 3A5 and 2D6 expression. Finally, we combine the time-embedding model of ontogeny with additional information to estimate age-dependent changes in reactive metabolite exposure. This simple approach identifies age-dependent changes in exposure to valproic acid and dextromethorphan metabolites and suggests potential mechanisms of valproic acid toxicity. This approach may help researchers evaluate the risk of drug toxicity in pediatric populations.
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Affiliation(s)
- Matthew K Matlock
- Department of Pathology and Immunology , Washington University in St. Louis , Saint Louis , Missouri 63110 , United States
| | - Abhik Tambe
- Department of Pathology and Immunology , Washington University in St. Louis , Saint Louis , Missouri 63110 , United States
| | - Jack Elliott-Higgins
- Department of Pathology and Immunology , Washington University in St. Louis , Saint Louis , Missouri 63110 , United States
| | - Ronald N Hines
- National Health and Environmental Effects Research Laboratory , United States Environmental Protection Agency , Research Triangle Park , North Carolina 27709 , United States
| | - Grover P Miller
- Department of Biochemistry and Molecular Biology , University of Arkansas for Medical Sciences , Little Rock , Arkansas 72205 , United States
| | - S Joshua Swamidass
- Institute for Informatics , Washington University in St. Louis , Saint Louis , Missouri 63110 , United States
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22
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Rödle W, Wimmer S, Zahn J, Prokosch HU, Hinkes B, Neubert A, Rascher W, Kraus S, Toddenroth D, Sedlmayr B. User-Centered Development of an Online Platform for Drug Dosing Recommendations in Pediatrics. Appl Clin Inform 2019; 10:570-579. [PMID: 31390668 PMCID: PMC6685729 DOI: 10.1055/s-0039-1693714] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Drug therapy in pediatric patients is a complex process. Children are subject to continuous growth and variation in drug-metabolizing enzyme activity, requiring continuous adaption of dosages. In Germany, currently no publicly available database exists that provides evidence-based information on drug dosages in pediatrics. For local drug dosing support, a prototype database has been developed within the Children's Hospital, Erlangen. A user-centered development process was initiated to establish an online platform for evidence-based dosing recommendations, as well as pharmacological and pharmaceutical drug information in pediatrics. OBJECTIVES The objectives of the study were to survey the demand for such a platform and to assess the usability of the different versions of the developed system. METHODS The developed prototype was evaluated in a pluralistic walkthrough with prospective end users. After a redesign, the second prototype of the online platform underwent an online usability testing based on a tailored questionnaire and the System Usability Scale (SUS) (n = 12). RESULTS Eleven of 12 participants expressed a demand for an online platform for pediatric dosing recommendations. The majority of the participants requested the integration of extended features, such as drug-drug interaction alerts, or information on adverse effects, pharmacokinetics, and pharmacodynamics. Particularly noteworthy is the demand for an online calculator; 5 of a total of 15 participants explicitly requested a calculator for dosages (based on age, weight, body surface) and glomerular filtration rate. The usability of the second prototype was rated "good to excellent" with a median SUS of 81.25. CONCLUSION Local domain experts demand an online platform for pediatric dosing recommendations. The application of the user-centered design approach enabled the development of a prototype suitable for practical use. Multiple additional required functionalities have been identified, whereby the importance of an online calculator for patient-individual dosing recommendations was particularly emphasized.
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Affiliation(s)
- Wolfgang Rödle
- Department of Medical Informatics, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Stefan Wimmer
- Department of Paediatrics and Adolescent Medicine, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Julia Zahn
- Department of Paediatrics and Adolescent Medicine, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Hans-Ulrich Prokosch
- Department of Medical Informatics, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | | | - Antje Neubert
- Department of Paediatrics and Adolescent Medicine, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Wolfgang Rascher
- Department of Paediatrics and Adolescent Medicine, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Stefan Kraus
- Department of Medical Informatics, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Dennis Toddenroth
- Department of Medical Informatics, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Brita Sedlmayr
- Center for Evidence-Based Healthcare, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
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Howard M, Barber J, Alizai N, Rostami-Hodjegan A. Dose adjustment in orphan disease populations: the quest to fulfill the requirements of physiologically based pharmacokinetics. Expert Opin Drug Metab Toxicol 2018; 14:1315-1330. [PMID: 30465453 DOI: 10.1080/17425255.2018.1546288] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION While the media is engaged and fascinated by the idea of 'Precision Medicine', the nuances related to 'Precision Dosing' seem to be largely ignored. Assuming the 'right drug' is selected, clinicians still need to decide on the 'right dose' for individuals. Ideally, optimal dosing should be studied in clinical trials; however, many drugs on the market lack evidence-based dosing recommendations, and small groups of patients (orphan disease populations) are dependent on local guidance and clinician experience to determine drug dosage adjustments. Areas Covered: This report explores the current understanding of dosing adjustment in special populations and examines the requirements for developing 'in silico' models for pediatric, elderly and pregnant patients. The report also highlights current use of modeling to provide evidence-based recommendations for drug labeling in the absence of complete clinical trials in orphan disease populations. Expert Opinion: Physiologically based pharmacokinetics (PBPK) is an attractive prospect for determining the best drug dosage adjustments in special populations. However, it is not sufficient for individualized, or even stratified dosing, unless the systems (drug-independent) data required to build robust PBPK models are obtained. Such models are not a substitute for clinical trials, but they are an alternative to undocumented and inconsistent guesswork.
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Affiliation(s)
- Martyn Howard
- a Centre for Applied Pharmacokinetic Research , University of Manchester , Manchester , UK
| | - Jill Barber
- a Centre for Applied Pharmacokinetic Research , University of Manchester , Manchester , UK
| | - Naved Alizai
- b Leeds General Infirmary , Leeds Children's Hospital , Leeds , UK
| | - Amin Rostami-Hodjegan
- a Centre for Applied Pharmacokinetic Research , University of Manchester , Manchester , UK
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[Medication safety in children : What role do dosing and formulations play?]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:1139-1145. [PMID: 30014190 DOI: 10.1007/s00103-018-2792-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Medication errors are more common in children compared to adults due to often missing efficacy evidence and limited or missing regulatory approvals for paediatric drugs.Roots of errors are located at different levels. They result, for example, from missing clinical studies that particularly investigate efficacy and correct dosing in younger age groups, the lack of age-appropriate dosage forms, the use of harmful ingredients, as well as the complicated and high-risk prescribing process.Electronic systems may improve the quality of drug prescriptions and reduce medication errors. The basic assumption is valid, evidence-based data behind such a system. In contrast to other countries, such a database is not yet available in Germany. The Plan of Action for the improvement of medication safety in Germany 2016-2019 (Aktionsplan) contains an action point "Creation of a database for dosing of paediatric medicines". Initial funding for 2 years has been granted for its implementation.Through systematic literature searches and the availability and provision of up-to-date knowledge on paediatric medicines, medication safety for children and adolescents can be improved. A database with relevant information to support more correct prescriptions within the paediatric population appears productive. The Aktionsplan has paved the way for the dissemination of evidence-based drug information for the country's paediatric population.
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Ockleford C, Adriaanse P, Hougaard Bennekou S, Berny P, Brock T, Duquesne S, Grilli S, Hernandez-Jerez AF, Klein M, Kuhl T, Laskowski R, Machera K, Pelkonen O, Pieper S, Smith R, Stemmer M, Sundh I, Teodorovic I, Tiktak A, Topping CJ, Gundert-Remy U, Kersting M, Waalkens-Berendsen I, Chiusolo A, Court Marques D, Dujardin B, Kass GEN, Mohimont L, Nougadère A, Reich H, Wolterink G. Scientific opinion on pesticides in foods for infants and young children. EFSA J 2018; 16:e05286. [PMID: 32625927 PMCID: PMC7009577 DOI: 10.2903/j.efsa.2018.5286] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Following a request from the European Commission, the EFSA Panel on Plant Protection Products and their Residues (PPR Panel) prepared a scientific opinion to provide a comprehensive evaluation of pesticide residues in foods for infants and young children. In its approach to develop this scientific opinion, the EFSA PPR Panel took into account, among the others, (i) the relevant opinions of the Scientific Committee for Food setting a default maximum residue level (MRL) of 0.01 mg/kg for pesticide residues in foods for infants and young children; (ii) the recommendations provided by EFSA Scientific Committee in a guidance on risk assessment of substances present in food intended for infants below 16 weeks of age; (iii) the knowledge on organ/system development in infants and young children. For infants below 16 weeks of age, the EFSA PPR Panel concluded that pesticide residues at the default MRL of 0.01 mg/kg for food for infants and young children are not likely to result in an unacceptable exposure for active substances for which a health-based guidance value (HBGV) of 0.0026 mg/kg body weight (bw) per day or higher applies. Lower MRLs are recommended for active substances with HBGVs below this value. For infants above 16 weeks of age and young children, the established approach for setting HBGVs is considered appropriate. For infants below 16 weeks of age the approach may not be appropriate and the application of the EFSA guidance on risk assessment of substances present in food intended for infants below 16 weeks of age is recommended. The contribution of conventional food to the total exposure to pesticide residues is much higher than that from foods intended for infants and young children. Because of the increased intake of conventional food by young children, these have the highest exposure to pesticide residues, whereas infants 3-6 months of age generally have lower exposure. The impact of cumulative exposure to pesticide residues on infants and young children is not different from the general population and the EFSA cumulative risk assessment methodology is also applicable to these age groups. Residue definitions established under Regulation (EC) No 396/2005 are in general considered appropriate also for foods for infants and young children. However, based on a tier 1 analysis of the hydrolysis potential of pesticides simulating processing, the particular appropriateness of existing residue definitions for monitoring to cover processed food, both intended for infants and young children as well as conventional food, is questionable.
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26
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Kaguelidou F, Sommet A, Lapeyre-Mestre M. Use of French healthcare insurance databases in pediatric pharmacoepidemiology. Therapie 2018; 73:127-133. [DOI: 10.1016/j.therap.2017.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 11/15/2017] [Indexed: 01/24/2023]
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27
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Zhao W, Leroux S, Biran V, Jacqz-Aigrain E. Developmental pharmacogenetics of CYP2C19 in neonates and young infants: omeprazole as a probe drug. Br J Clin Pharmacol 2018; 84:997-1005. [PMID: 29377228 DOI: 10.1111/bcp.13526] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 12/13/2017] [Accepted: 12/22/2017] [Indexed: 12/13/2022] Open
Abstract
AIMS Although substantial progress has been made in understanding of ontogeny of drug metabolism, there is still a gap of knowledge in developmental pharmacogenetics in neonates. We hypothesized that both age and pharmacogenetics might explain the developmental pattern of CYP2C19. We conducted a population pharmacokinetic-pharmacogenetic study to quantify the developmental pharmacogenetics of CYP2C19 in neonates and young infants using omeprazole as a probe drug. METHODS Pharmacokinetic samples were collected from 51 Caucasian neonates and young infants, who were receiving omeprazole treatment. Population pharmacokinetic-pharmacogenetic analysis of omeprazole and its metabolites was performed using NONMEM. RESULTS Data fitted a one-compartment parent and metabolite model with first-order absorption and elimination. CYP2C19 and CYP3A4 are predominantly involved in the metabolism of omeprazole despite their relatively low activities compared to adults. The clearance of omeprazole converted to 5-hydroxy-omeprazole (CLOMZ-M1 ) increases with postnatal age. In CYP2C19 poor and intermediate metabolizers, model-predicted CLOMZ-M1 are 12.5% (5-95% percentile: 3-14.9%) and 44.9% (5-95% percentile: 29.9-72.6%) of the value in extensive/ultrarapid metabolizer, respectively. Model-predicted absorption rate constant of omeprazole is 6.93 (5-95% percentile: 3.01-14.61) times higher in ABCB1 homozygous mutant patients, 1.86 (5-95% percentile: 0.86-3.47) times higher in ABCB1 heterozygous patients than that in ABCB1 homozygous wild-type patients. CONCLUSIONS Developmental pharmacogenetics of CYP2C19 was quantitatively described in neonates and young infants using omeprazole as a probe drug. Our findings emphasize the importance of semiphysiological developmental pharmacokinetic modelling approach when evaluating developmental pharmacogenetics of drugs with multiple routes of biotransformation.
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Affiliation(s)
- Wei Zhao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China.,Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,Department of Paediatric Pharmacology and Pharmacogenetics, Robert Debré University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Stéphanie Leroux
- Department of Paediatric Pharmacology and Pharmacogenetics, Robert Debré University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,Department of Neonatology, Rennes University Hospital, Rennes, France
| | - Valérie Biran
- Department of Neonatology, Robert Debré University Hospital, Assistance Publiqqiue - Hôpitaux de Paris, Paris, France
| | - Evelyne Jacqz-Aigrain
- Department of Paediatric Pharmacology and Pharmacogenetics, Robert Debré University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,Clinical Investigation Center CIC1426, INSERM, Paris, France.,EA7323, University Paris Diderot - Sorbonne Paris Cité, Paris, France
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Kornø KT, Aagaard L. Off-Label Prescribing of Antipsychotics in a Danish Child and Adolescent Mental Health Center: A Register-Based Study. J Res Pharm Pract 2018; 7:205-209. [PMID: 30622989 PMCID: PMC6298142 DOI: 10.4103/jrpp.jrpp_18_42] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Objective We analyzed prescribing patterns of antipsychotics for children and adolescent affiliated with a Danish Child and Adolescent Mental Health Center) with respect to age, sex, medicine, diagnoses, off-label status, and time. Methods We included all patients below 19 years of age prescribed antipsychotics during 2007-2008 and as of November 1, 2014. Prescription data included all antipsychotic prescriptions and prescriptions of concomitant psychotropic medications. We defined an antipsychotic user as a patient receiving at least one prescription during the study period, irrespective of any previous history of antipsychotic use. We defined off-label prescribing as prescriptions outside the licensed age group and approved indication. Findings We analyzed 404 antipsychotic prescriptions that were located for 150 patients. The patients were between 7 and 18 years of age. Two-thirds of the prescriptions were for girls and two-thirds of prescriptions for olanzapine and quetiapine. Totally, 92% of all prescribed antipsychotics were used off-label. For typical antipsychotics, this share was 96% and for atypical antipsychotics 90%. As of November 1, 2014, the total share of off-label antipsychotic prescriptions was 96%, and 63% of these were for medications prescribed outside the approved age group, and 26% for nonlicensed indication(s). Conclusion This study demonstrated a high level of off-label prescribing over time with respect to age and indication. The prescribing patterns underpin the need for further economic incentives for pharmaceutical companies to register pediatric indications, particular for off-patent products.
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Affiliation(s)
- Kristine Tøfting Kornø
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lise Aagaard
- Havemann Law Firm, Frederiksberggade, Copenhagen, Denmark
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29
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Daly AK. Pharmacogenetics: a general review on progress to date. Br Med Bull 2017; 124:65-79. [PMID: 29040422 DOI: 10.1093/bmb/ldx035] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 09/20/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pharmacogenetics is not a new subject area but its relevance to drug prescribing has become clearer in recent years due to developments in gene cloning and DNA genotyping and sequencing. SOURCES OF DATA There is a very extensive published literature concerned with a variety of different genes and drugs. AREAS OF AGREEMENT There is general agreement that pharmacogenetic testing is essential for the safe use of drugs such as the thiopurines and abacavir. AREAS OF CONTROVERSY Whether pharmacogenetic testing should be applied more widely including to the prescription of certain drugs such as warfarin and clopidogrel where the overall benefit is less clear remains controversial. GROWING POINTS Personal genotype information is increasingly being made available directly to the consumer. This is likely to increase demand for personalized prescription and mean that prescribers need to take pharmacogenetic information into account. Projects such as 100 000 genomes are providing complete genome sequences that can form part of a patient medical record. This information will be of great value in personalized prescribing. AREAS TIMELY FOR DEVELOPING RESEARCH Development of new drugs targeting particular genetic risk factors for disease. These could be prescribed to those with an at risk genotype.
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Affiliation(s)
- Ann K Daly
- Institute of Cellular Medicine, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4HH, UK
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30
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Hardy A, Benford D, Halldorsson T, Jeger MJ, Knutsen HK, More S, Naegeli H, Noteborn H, Ockleford C, Ricci A, Rychen G, Schlatter JR, Silano V, Solecki R, Turck D, Bresson JL, Dusemund B, Gundert-Remy U, Kersting M, Lambré C, Penninks A, Tritscher A, Waalkens-Berendsen I, Woutersen R, Arcella D, Court Marques D, Dorne JL, Kass GE, Mortensen A. Guidance on the risk assessment of substances present in food intended for infants below 16 weeks of age. EFSA J 2017; 15:e04849. [PMID: 32625502 PMCID: PMC7010120 DOI: 10.2903/j.efsa.2017.4849] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Following a request from the European Commission to EFSA, the EFSA Scientific Committee (SC) prepared a guidance for the risk assessment of substances present in food intended for infants below 16 weeks of age. In its approach to develop this guidance, the EFSA SC took into account, among others, (i) an exposure assessment based on infant formula as the only source of nutrition; (ii) knowledge of organ development in human infants, including the development of the gut, metabolic and excretory capacities, the brain and brain barriers, the immune system, the endocrine and reproductive systems; (iii) the overall toxicological profile of the substance identified through the standard toxicological tests, including critical effects; (iv) the relevance for the human infant of the neonatal experimental animal models used. The EFSA SC notes that during the period from birth up to 16 weeks, infants are expected to be exclusively fed on breast milk and/or infant formula. The EFSA SC views this period as the time where health-based guidance values for the general population do not apply without further considerations. High infant formula consumption per body weight is derived from 95th percentile consumption. The first weeks of life is the time of the highest relative consumption on a body weight basis. Therefore, when performing an exposure assessment, the EFSA SC proposes to use the high consumption value of 260 mL/kg bw per day. A decision tree approach is proposed that enables a risk assessment of substances present in food intended for infants below 16 weeks of age. The additional information needed when testing substances present in food for infants below 16 weeks of age and the approach to be taken for the risk assessment are on a case-by-case basis, depending on whether the substance is added intentionally to food and is systemically available.
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Desselas E, Pansieri C, Leroux S, Bonati M, Jacqz-Aigrain E. Drug versus placebo randomized controlled trials in neonates: A review of ClinicalTrials.gov registry. PLoS One 2017; 12:e0171760. [PMID: 28192509 PMCID: PMC5305102 DOI: 10.1371/journal.pone.0171760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 01/25/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Despite specific initiatives and identified needs, most neonatal drugs are still used off-label, with variable dosage administrations and schedules. In high risk preterm and term neonates, drug evaluation is challenging and randomized controlled trials (RCT) are difficult to conduct and even more is the use of a placebo, required in the absence of a reference validated drug to be used as comparator. METHODS We analyzed the complete ClinicalTrials.gov registry 1) to describe neonatal RCT involving a placebo, 2) to report on the medical context and ethical aspects of placebo use. RESULTS Placebo versus drug RCT (n = 146), either prevention trials (n = 57, 39%) or therapeutic interventions (n = 89, 61%), represent more than a third of neonatal trials registered in the National Institute of Health clinical trial database (USA) since 1999. They mainly concerned preterm infants, evaluating complications of prematurity. Most trials were conducted in the USA, were single centered, and funded by non-profit organizations. For the three top drug trials evaluating steroids (n = 13, 9.6%), erythropoietin (EPO, n = 10, 6.8%) and nitric oxide (NO, n = 9, 6.2%), the objectives of the trial and follow-up were analyzed in more details. CONCLUSION Although a matter of debate, the use of placebo should be promoted in neonates to evaluate a potential new treatment, in the absence of reference drug. Analysis of the trials evaluating steroids showed that long-term follow-up of exposed patients, although required by international guidelines, is frequently missing and should be planned to collect additional information and optimize drug evaluation in these high-risk patients.
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Affiliation(s)
- Emilie Desselas
- Department of Pediatric Pharmacology and Pharmacogenetics, Hopital Robert Debré, Paris, France
- Clinical Investigation Center INSERM CIC1426, Hopital Robert Debré, Paris, France
| | - Claudia Pansieri
- Department of Public Health, Laboratory for Mother and Child Health, IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
| | - Stephanie Leroux
- Department of Pediatric Pharmacology and Pharmacogenetics, Hopital Robert Debré, Paris, France
- Clinical Investigation Center INSERM CIC1426, Hopital Robert Debré, Paris, France
| | - Maurizio Bonati
- Department of Public Health, Laboratory for Mother and Child Health, IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
| | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hopital Robert Debré, Paris, France
- Clinical Investigation Center INSERM CIC1426, Hopital Robert Debré, Paris, France
- Université Paris 7 Diderot, Paris, France
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Abstract
The majority of medications in children are administered in an unlicensed or off-label manner. Paediatricians are obliged to prescribe using the limited evidence available. The 2007 EU regulation on the use of paediatric drugs means pharmaceutical companies are now obliged to (and receive incentives for) contributing to paediatric drug data and carrying out paediatric clinical trials. This is important, as the efficacy and adverse effect profiles of medicines vary across childhood. Additionally, there are significant age-related changes in the pharmacodynamic and pharmacokinetic activity of many drugs. This may be related to physiological (differential expressions of cytochrome P450 enzymes or variable glomerular filtration rates at different ages for example) and psychological (increasing autonomy and risk perception in teenage years) changes. Increasing numbers of children are surviving life-threatening childhood conditions due to medical advances. This means there is an increasing population who are at risk of the consequences of the long-term, early exposure to nephrotoxic agents. The kidney is an organ that is particularly vulnerable to damage as a consequence of drugs. Drug-induced acute kidney injury (AKI) episodes in children and babies are principally due to non-steroidal anti-inflammatory drugs, antibiotics or chemotherapeutic agents. The renal tubules are vulnerable to injury because of their concentrating ability and high-energy hypoxic environment. This review focuses on drug-induced AKI and the methods to minimise its effect, including general management plus the role of child-specific pharmacokinetic data, the use of pharmacogenomics and early detection of AKI using urinary biomarkers and electronic triggers.
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Abstract
This study aimed to describe the frequency of off-label prescriptions of psychopharmacological drugs in a child and adolescent psychiatric setting. A cross-sectional study was conducted on November 1, 2014, including all inpatients and outpatients at the Mental Health Centre for Child and Adolescent Psychiatry, Capital Region of Denmark, aged 0 to 17 years receiving medical treatment with antidepressants, antipsychotic agents, benzodiazepines, melatonin and/or attention deficit hyperactivity disorder (ADHD) medication. We included a total of 5555 prescriptions representing 2932 patients. The main findings were that 32.3% of all prescriptions were off-label, and 41.6% of subjects received at least 1 off-label prescription. The most frequent off-label category was low age, 72.2%, meaning that the drug was not approved for the age group of the patient. The off-label rates for each drug class were as follows: melatonin, 100%; antipsychotic agents, 95.6%; benzodiazepines, 72.5%; antidepressants, 51.1%; and ADHD medication, 2.7%. Prescription of 2 or more psychopharmacological drugs per patient was common (31.5%). The group of subjects with 4 or more prescriptions (n = 36) was characterized by a higher frequency of inpatients, older age, and a different distribution of diagnoses. This study found a frequent use of off-label prescriptions when treating children and adolescents with psychopharmacological drugs other than ADHD medication. In addition, prescription of more than 1 psychotropic drug is common. These findings support the need for extending the evidence base for psychopharmacologic treatment in children and adolescents.
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Burris JF, Tortorici MA, Mandic M, Neely M, Reed MD. Dosage Adjustments Related to Young or Old Age and Organ Impairment. J Clin Pharmacol 2016; 56:1461-1473. [PMID: 27539787 DOI: 10.1002/jcph.816] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 08/16/2016] [Accepted: 08/16/2016] [Indexed: 11/11/2022]
Abstract
Differences in physiology related to young or old age and/or organ system impairment alter the absorption, distribution, metabolism, and excretion of many medications and consequently their effectiveness and toxicity. This module discusses common alterations in medication use and dosage that are required in the pediatric age group, in the elderly, and in patients with renal or hepatic disease.
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Affiliation(s)
- James F Burris
- Georgetown University School of Medicine, Washington, DC, USA
| | | | - Maja Mandic
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Neely
- Children's Hospital of Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael D Reed
- Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Cleveland, OH, USA
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35
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Drug trials: Kids are no little adults and not all kids are the same. J Clin Epidemiol 2016; 71:111-2. [DOI: 10.1016/j.jclinepi.2015.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 06/17/2015] [Indexed: 11/19/2022]
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Sammons HM, Choonara I. Learning Lessons from Adverse Drug Reactions in Children. CHILDREN (BASEL, SWITZERLAND) 2016; 3:E1. [PMID: 27417239 PMCID: PMC4934475 DOI: 10.3390/children3010001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 12/17/2015] [Accepted: 12/18/2015] [Indexed: 11/28/2022]
Abstract
Drug toxicity is, unfortunately, a significant problem in children both in the hospital and in the community. Drug toxicity in children is different to that seen in adults. At least one in 500 children will experience an adverse drug reaction each year. For children in hospital, the risk is far greater (one in ten). Additionally, different and sometimes unique adverse drug reactions are seen in the paediatric age groups. Some of the major cases of drug toxicity historically have occurred in neonates. It is important that we understand the mechanism of action of adverse drug reactions. Greater understanding alongside rational prescribing should hopefully reduce drug toxicity in children in the future.
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Affiliation(s)
- Helen M Sammons
- University of Nottingham, Division of Medical Sciences and Graduate Entry Medicine, Derbyshire Children's Hospital, Derby DE22 3DT, UK.
| | - Imti Choonara
- University of Nottingham, Division of Medical Sciences and Graduate Entry Medicine, Derbyshire Children's Hospital, Derby DE22 3DT, UK.
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Opportunities in low-level radiocarbon microtracing: applications and new technology. Future Sci OA 2015; 2:FSO74. [PMID: 28031933 PMCID: PMC5137946 DOI: 10.4155/fso.15.74] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 08/20/2015] [Indexed: 12/14/2022] Open
Abstract
14C-radiolabeled (radiocarbon) drug studies are central to defining the disposition of therapeutics in clinical development. Concerns over radiation, however, have dissuaded investigators from conducting these studies as often as their utility may merit. Accelerator mass spectrometry (AMS), originally designed for carbon dating and geochronology, has changed the outlook for in-human radiolabeled testing. The high sensitivity of AMS affords human clinical testing with vastly reduced radiative (microtracing) and chemical exposures (microdosing). Early iterations of AMS were unsuitable for routine biomedical use due to the instruments' large size and associated per sample costs. The situation is changing with advances in the core and peripheral instrumentation. We review the important milestones in applied AMS research and recent advances in the core technology platform. We also look ahead to an entirely new class of 14C detection systems that use lasers to measure carbon dioxide in small gas cells.
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Rodieux F, Wilbaux M, van den Anker JN, Pfister M. Effect of Kidney Function on Drug Kinetics and Dosing in Neonates, Infants, and Children. Clin Pharmacokinet 2015; 54:1183-204. [PMID: 26138291 PMCID: PMC4661214 DOI: 10.1007/s40262-015-0298-7] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Neonates, infants, and children differ from adults in many aspects, not just in age, weight, and body composition. Growth, maturation and environmental factors affect drug kinetics, response and dosing in pediatric patients. Almost 80% of drugs have not been studied in children, and dosing of these drugs is derived from adult doses by adjusting for body weight/size. As developmental and maturational changes are complex processes, such simplified methods may result in subtherapeutic effects or adverse events. Kidney function is impaired during the first 2 years of life as a result of normal growth and development. Reduced kidney function during childhood has an impact not only on renal clearance but also on absorption, distribution, metabolism and nonrenal clearance of drugs. 'Omics'-based technologies, such as proteomics and metabolomics, can be leveraged to uncover novel markers for kidney function during normal development, acute kidney injury, and chronic diseases. Pharmacometric modeling and simulation can be applied to simplify the design of pediatric investigations, characterize the effects of kidney function on drug exposure and response, and fine-tune dosing in pediatric patients, especially in those with impaired kidney function. One case study of amikacin dosing in neonates with reduced kidney function is presented. Collaborative efforts between clinicians and scientists in academia, industry, and regulatory agencies are required to evaluate new renal biomarkers, collect and share prospective pharmacokinetic, genetic and clinical data, build integrated pharmacometric models for key drugs, optimize and standardize dosing strategies, develop bedside decision tools, and enhance labels of drugs utilized in neonates, infants, and children.
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Affiliation(s)
- Frederique Rodieux
- Department of Pediatric Clinical Pharmacology, Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, CH-4056, Basel, Switzerland.
| | - Melanie Wilbaux
- Department of Pediatric Clinical Pharmacology, Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, CH-4056, Basel, Switzerland
| | - Johannes N van den Anker
- Department of Pediatric Clinical Pharmacology, Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, CH-4056, Basel, Switzerland.
- Division of Pediatric Clinical Pharmacology, Children's National Health System, Washington, DC, USA.
- Intensive Care, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Marc Pfister
- Department of Pediatric Clinical Pharmacology, Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, CH-4056, Basel, Switzerland
- Quantitative Solutions LP, Menlo Park, CA, USA
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Wimmer S, Neubert A, Rascher W. The Safety of Drug Therapy in Children. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:781-7. [PMID: 26806565 PMCID: PMC4671328 DOI: 10.3238/arztebl.2015.0781] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/16/2015] [Accepted: 07/16/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND 1.7% of children taking medication on an outpatient basis in Germany have at least one adverse drug reaction (ADR). The corresponding figure for hospitalized children is estimated at 10% . METHODS This review is based on pertinent literature retrieved by a selective search in PubMed. RESULTS According to reports submitted to the Drug Commission of the German Medical Association (Arzneimittelkommission der deutschen Ärzteschaft, AkdÄ), serious ADRs can arise, for example, after the administration of dimenhydrinate, α-adrenergic nose drops, enemas containing phosphate, ACE inhibitors, angiotensin-2-receptor antagonists (sartans), and methylphenidate. The causes of ADRs include overdoses, drug administration despite contraindications, and inadequate monitoring of long-term treatment. Errors can also be made in communication, labeling, and drug administration. The risk of ADRs is especially high in off-label use. Computerized physician order entry systems, individual packaging and labeling of single doses, and the use of bar codes for patient and drug identification can help prevent such errors. CONCLUSION The process of drug administration should be optimized through suitable interventions and electronic support, with due consideration of local circumstances. Clinical trials on children should be encouraged as a means of improving drug safety, and additional financial incentives should be created for trials concerning drugs that are off-patent. Physicians and pharmacists should take care to report adverse reactions as they are required to do by professional code, particularly in the case of new drugs, off-label use, or medication errors. A recognized national standard for dosing that can be implemented in computerized physician order entry systems is needed so that evidence-based pediatric dosages can be calculated.
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Affiliation(s)
- Stefan Wimmer
- Department of Paediatrics and Adolescent Medicine, Universitätsklinikum Erlangen
| | - Antje Neubert
- Department of Paediatrics and Adolescent Medicine, Universitätsklinikum Erlangen
| | - Wolfgang Rascher
- Department of Paediatrics and Adolescent Medicine, Universitätsklinikum Erlangen
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Allegaert K, van den Anker J. Neonatal drug therapy: The first frontier of therapeutics for children. Clin Pharmacol Ther 2015; 98:288-97. [PMID: 26095519 DOI: 10.1002/cpt.166] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 06/08/2015] [Indexed: 02/06/2023]
Abstract
Knowledge about the safe and effective use of medicines in neonates has increased substantially but has resulted in few label changes. Drugs developed for use in adults are reshaped and tailored to specific neonatal indications. However, the use of drugs in neonates should not only mirror adult pharmacotherapy, but should be driven by their own specific needs. Therefore, building collaborative networks may assist to develop a newborn-driven research agenda addressing their clinical needs and diseases.
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Affiliation(s)
- K Allegaert
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU, Leuven, Belgium
| | - J van den Anker
- Division of Pediatric Clinical Pharmacology, Children's National Health System, Washington, DC, USA
- Departments of Pediatrics, Integrative Systems Biology, Pharmacology and Physiology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Intensive Care and Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, the Netherlands
- Department of Paediatric Pharmacology, University Children's Hospital Basel, Basel, Switzerland
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Tran TH, Smith C, Mangione RA. Theoretical pharmacokinetic drug alterations in pediatric celiac disease. Expert Opin Drug Metab Toxicol 2015; 11:1539-50. [PMID: 26155875 DOI: 10.1517/17425255.2015.1065813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION The incidence of pediatric celiac disease has risen and many of these children will receive medications at some time in their life. However, the absorption of drugs in pediatric patients with celiac disease has never been studied. The few studies that do exist have only been performed in adults and indicate that drug concentrations can be altered for some drugs. It is also noteworthy that few researchers have conducted studies to determine if the distribution, metabolism, and excretion of drugs are altered in celiac disease. AREAS COVERED The pharmacokinetics of drugs greatly differ between children and adults. Combined with the pathophysiological changes known to occur with celiac disease, there is compelling evidence to support that drug exposure in pediatric celiac disease may be altered. Relevant characteristics of celiac disease that may affect drug disposition include intestinal atrophy, hypoalbuminemia, reduced CYP3A enzymes, and thyroid dysfunction. EXPERT OPINION The safety and efficacy of drug dosing in children with celiac disease can be enhanced with additional pharmacokinetic studies of commonly prescribed drugs in this population. Ideally, these studies should include drugs that have high bioavailability, are highly protein bound, undergo extensive CYP3A enzyme metabolism, and/or have a narrow therapeutic range.
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Affiliation(s)
- Tran H Tran
- a 1 St. John's University, College of Pharmacy and Health Sciences , 8000 Utopia Parkway, St. Albert Hall, Room 114, Queens, NY 11439, USA +1 202 957 4306 ; +1 718 990 1986 ; .,b 2 Clinical Pharmacy Manager,NewYork-Presbyterian Hospital/Columbia University Medical Center , New York, NY, USA
| | - Candace Smith
- c 3 St. John's University College of Pharmacy and Health Sciences, Chair, Clinical Pharmacy Practice Department , Queens, NY 11439, USA
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Chung CP, Callahan ST, Cooper WO, Murray KT, Hall K, Dudley JA, Stein CM, Ray WA. Development of an algorithm to identify serious opioid toxicity in children. BMC Res Notes 2015; 8:293. [PMID: 26141980 PMCID: PMC4491206 DOI: 10.1186/s13104-015-1185-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 05/20/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of opioids is increasing in children; therefore, opioid toxicity could be a public health problem in this vulnerable population. However, we are not aware of a published algorithm to identify cases of opioid toxicity in children using administrative databases. We sought to develop an algorithm to identify them. After review of literature and de-identified computer profiles, a broad set of ICD-9 CM codes consistent with serious opioid toxicity was selected. Based on these codes, we identified 195 potential cases of opioid toxicity in children enrolled in Tennessee Medicaid. Medical records were independently reviewed by two physicians; episodes considered equivocal were reviewed by an adjudication committee. Cases were adjudicated as Group 1 (definite/probable), Group 2 (possible), or Group 3 (excluded). RESULTS Of the 195 potential cases, 168 (86.2%) had complete records for review and 85 were confirmed cases. The overall positive predictive value (PPV) for all codes was 50.6%. The PPV for codes indicating: unintentional opioid overdose (25/31) was 80.7%; intentional opioid overdose (15/30) was 50.0%, adverse events (33/58) was 56.9%, the presence of signs or symptoms compatible with opioid toxicity (12/47) was 25.5%, and no cases were confirmed in records from the two deaths. Of the confirmed cases, 65.8% were related to therapeutic opioid use. CONCLUSION For studies utilizing administrative claims to quantify incidence of opioid toxicity in children, our findings suggest that use of a broad set of screening codes coupled with medical record review is important to increase the completeness of case ascertainment.
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Affiliation(s)
- Cecilia P Chung
- Division of Rheumatology, Department of Medicine, Vanderbilt University School of Medicine, T-3113 MCN, 1161 21st Ave. S., Nashville, TN, 37232, USA.
| | - S Todd Callahan
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, 37232, USA.
| | - William O Cooper
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, 37232, USA. .,Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, 37232, USA.
| | - Katherine T Murray
- Division of Rheumatology, Department of Medicine, Vanderbilt University School of Medicine, T-3113 MCN, 1161 21st Ave. S., Nashville, TN, 37232, USA.
| | - Kathi Hall
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, 37232, USA.
| | - Judith A Dudley
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, 37232, USA.
| | - C Michael Stein
- Division of Rheumatology, Department of Medicine, Vanderbilt University School of Medicine, T-3113 MCN, 1161 21st Ave. S., Nashville, TN, 37232, USA.
| | - Wayne A Ray
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, 37232, USA.
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Oshikoya KA, Sammons H, Smith K, Choonara I. Lack of a significant change in caffeine metabolism in underweight children as determined by the caffeine breath test. Arch Dis Child 2015; 100:689-93. [PMID: 25897037 PMCID: PMC4483790 DOI: 10.1136/archdischild-2014-308017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 03/11/2015] [Accepted: 03/12/2015] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Limited data from pharmacokinetic studies in underweight and severely malnourished children have indicated an impaired activity of their hepatic enzymes. We used the caffeine breath test to assess the metabolising activity of cytochrome P450 1A2 (CYP1A2) enzyme in underweight children. METHODS Underweight children from the paediatric outpatient clinic, Lagos State University Teaching Hospital, Ikeja in Nigeria, were studied. After an overnight fast, 15 underweight children took 3 mg/kg labelled caffeine orally. Breath samples were collected in duplicate at -20, -10 and -1 min and at 15 min intervals for 2 h. The mean cumulative per cent dose recovered (CPDR) of labelled caffeine in the expired carbon dioxide was determined over the study period. This was repeated after 2-6 weeks of nutritional rehabilitation. RESULTS The mean areas under the enrichment-time curve before and after nutritional rehabilitation were 0.539±0.320 and 0.620±0.322 atom per cent excess minute, respectively. The difference between the two values was not statistically significant (p=0.528). The mean CPDR in the exhaled carbon dioxide of the underweight children over a period of 2 h was 7.56±4.01% and 7.95±3.68% before and after nutritional rehabilitation, respectively, and there was no significant difference in the mean values (p=0.603). CONCLUSIONS The metabolism of caffeine was not significantly affected in underweight children compared with after 2-6 weeks of nutritional rehabilitation. This suggests that hepatic CYP1A2-metabolising activity was not significantly impaired in underweight children.
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Affiliation(s)
- K A Oshikoya
- Academic Division of Child Health, Graduate Entry Medical School in Derby, University of Nottingham, Derby, UK Department of Pharmacology, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria
| | - H Sammons
- Academic Division of Child Health, Graduate Entry Medical School in Derby, University of Nottingham, Derby, UK
| | - K Smith
- Clinical Physiology Department Graduate Entry Medical School in Derby, University of Nottingham, Derby, UK
| | - I Choonara
- Academic Division of Child Health, Graduate Entry Medical School in Derby, University of Nottingham, Derby, UK
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Chirita-Emandi A, Socolov D, Haivas C, Calapiș A, Gheorghiu C, Puiu M. Vitamin D Status: A Different Story in the Very Young versus the Very Old Romanian Patients. PLoS One 2015; 10:e0128010. [PMID: 26024516 PMCID: PMC4449004 DOI: 10.1371/journal.pone.0128010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 04/21/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In Romania (latitude 48°15'N to 43°40'N), vitamin D supplementation is common practice mostly in infants 0-1 year old. No published information is available regarding epidemiological data on vitamin D status in the Romanian population for a wide age range and geographical territory. In this context, we aimed to evaluate the seasonal and age variation of vitamin D status in a large Romanian population. METHODS 6631 individuals from across Romania had performed 7544 vitamin D assessments (2012-2014) in a chain of private laboratories. Vitamin D (25-hydroxyvitamin D2 and 25-hydroxyvitamin D3) was measured using High Performance Liquid Chromatography. Vitamin D levels were classified as severe deficiency<10 ng/mL, deficiency 10-20 ng/mL, insufficiency 21-29 ng/mL, sufficiency ≥ 30 ng/mL and potentially harmful>100 ng/ml. RESULTS Male to female ratio was 1:2.9. Age ranged from 0 to 85 years. Mean vitamin D levels increased from April (26.3n g/ml) to September (35.6 ng/ml) and decreased from October (33.5 ng/ml) to March (24.4 ng/ml). Overall 40% had sufficient vitamin D, while the rest were insufficient 33%, deficient 22%, severely deficient 4% and 1% potentially harmful (of them 81% under 1 year old). Males compared to females showed higher percentages of sufficiency (47% vs. 38%). Children 0- 2 years presented the highest percentage of vitamin D sufficiency (77%). Lowest percentages (21%) of sufficiency were in people 80-84 years. CONCLUSION In Romania, suboptimal vitamin D levels are common (59%), especially in older age, wintertime and in women. Vitamin D supplementation would be most warranted from January to April in the Romanian population. 25-hydroxyvitamin D levels > 100 ng/ml were relatively prevalent in children 0-1 year old (17.3%). This was attributed to supplementation errors and the fact that high-risk individuals were more likely to visit for medical check-up. Nonetheless, it stresses the need to increase awareness of the importance of preventing Vitamin D supplementation administration errors in the young.
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Affiliation(s)
- Adela Chirita-Emandi
- Genetics Department, University of Medicine and Pharmacy “Victor Babeș”, Timișoara, Romania
- * E-mail:
| | - Demetra Socolov
- Ginecology Department, University of Medicine and Pharmacy “Gr. T. Popa”, Iași, Romania
| | - Carmen Haivas
- Anatomy Department, University of Medicine and Pharmacy “Victor Babeș”, Timișoara, Romania
| | - Anca Calapiș
- Bioclinica Laboratoarele, SA, Timișoara, Romania
| | - Cristina Gheorghiu
- Genetics Department, University of Medicine and Pharmacy “Victor Babeș”, Timișoara, Romania
| | - Maria Puiu
- Genetics Department, University of Medicine and Pharmacy “Victor Babeș”, Timișoara, Romania
- Genetics Department, Clinical Emergency Hospital for Children “Louis Țurcanu”, Timișoara, Romania
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