1
|
Shaniv D, Allegaert K. Applied pharmacokinetics to improve pharmacotherapy in neonatal and paediatric intensive care units: focus on correct dose selection. Arch Dis Child Educ Pract Ed 2024; 109:184-190. [PMID: 38408792 DOI: 10.1136/archdischild-2023-326325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/13/2024] [Indexed: 02/28/2024]
Abstract
Drug dosing and exposure throughout childhood are constantly affected by maturational changes like weight, age or body surface area. In neonatal and paediatric intensive care units (NICU and PICU, respectively), drug dosing and exposure are further impacted by non-maturational changes. These changes are related to factors such as sepsis, cardiac failure, acute kidney injury, extracorporeal circuits or drug-drug interactions (DDIs) resulting from polypharmacy.This potentially complex situation may alter drug pharmacokinetics to result in greater-than-usual intrapatient and interpatient drug exposure variability. These effects may call for individual dosage adjustments. Dosage adjustments may apply to both loading doses or maintenance doses, which should be used as appropriate, depending on the specific characteristics of a given drug. Phenobarbital and vancomycin dosing are hereby used as illustrations.To optimise dose selection in NICU/PICU settings, we suggest to consider therapeutic drug monitoring integrated in model-informed precision dosing, and to familiarise oneself with existing paediatric drug formularies as well as DDI databases/search engines. Paediatric clinical pharmacologists and pharmacists can hereby guide clinicians with no prior experience on how to properly apply these data sources to day-to-day practice in individual patients or specific subpopulations of NICU or PICU patients.
Collapse
Affiliation(s)
- Dotan Shaniv
- Pharmacy Services, Kaplan Medical Center, Clalit Health Services, Rehovot, Israel
- Neonatal Intensive Care Unit, Kaplan Medical Center, Clarit Health Services, Rehovot, Israel
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, Netherlands
| |
Collapse
|
2
|
van der Heijden JEM, de Hoop-Sommen M, Hoevenaars N, Freriksen JJM, Joosten K, Greupink R, de Wildt SN. Getting the dose right using physiologically-based pharmacokinetic modeling: dexamethasone to prevent post-extubation stridor in children as proof of concept. Front Pediatr 2024; 12:1416440. [PMID: 39035463 PMCID: PMC11257885 DOI: 10.3389/fped.2024.1416440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 06/11/2024] [Indexed: 07/23/2024] Open
Abstract
Introduction Critically ill patients show large variability in drug disposition due to e.g., age, size, disease and treatment modalities. Physiologically-based pharmacokinetic (PBPK) models can be used to design individualized dosing regimens taking this into account. Dexamethasone, prescribed for the prevention post-extubation stridor (PES), is metabolized by the drug metabolizing enzyme CYP3A. As CYP3A4 undergoes major changes during childhood, we aimed to develop age-appropriate dosing recommendations for children of dexamethasone for PES, as proof of concept for PBPK modeling to individualize dosing for critically ill patients. Methods All simulations were conducted in Simcyp™ v21 (a population-based PBPK modeling platform), using an available dexamethasone compound model and pediatric population model in which CYP3A4 ontogeny is incorporated. Published pharmacokinetic (PK) data was used for model verification. Evidence for the dose to prevent post-extubation stridor was strongest for 2-6 year old children, hence simulated drug concentrations resulting from this dose from this age group were targeted when simulating age-appropriate doses for the whole pediatric age range. Results Dexamethasone plasma concentrations upon single and multiple intravenous administration were predicted adequately across the pediatric age range. Exposure-matched predictions of dexamethasone PK indicated that doses (in mg/kg) for the 2-6 years olds can be applied in 3 month-2 year old children, whereas lower doses are needed in children of other age groups (60% lower for 0-2 weeks, 40% lower for 2-4 weeks, 20% lower for 1-3 months, 20% lower for 6-12 year olds, 40% lower for 12-18 years olds). Discussion We show that PBPK modeling is a valuable tool that can be used to develop model-informed recommendations using dexamethasone to prevent PES in children. Based on exposure matching, the dose of dexamethasone should be reduced compared to commonly used doses, in infants <3 months and children ≥6 years, reflecting age-related variation in drug disposition. PBPK modeling is an promising tool to optimize dosing of critically ill patients.
Collapse
Affiliation(s)
- Joyce E. M. van der Heijden
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marika de Hoop-Sommen
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Noa Hoevenaars
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jolien J. M. Freriksen
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Koen Joosten
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Rick Greupink
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Saskia N. de Wildt
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children’s Hospital, Rotterdam, Netherlands
| |
Collapse
|
3
|
Johnson TN, Batchelor HK, Goelen J, Horniblow RD, Dinh J. Combining data on the bioavailability of midazolam and physiologically-based pharmacokinetic modeling to investigate intestinal CYP3A4 ontogeny. CPT Pharmacometrics Syst Pharmacol 2024. [PMID: 38923249 DOI: 10.1002/psp4.13192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 06/06/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
Pediatric physiologically-based modeling in drug development has grown in the past decade and optimizing the underlying systems parameters is important in relation to overall performance. In this study, variation of clinical oral bioavailability of midazolam as a function of age is used to assess the underlying ontogeny models for intestinal CYP3A4. Data on midazolam bioavailability in adults and children and different ontogeny patterns for intestinal CYP3A4 were first collected from the literature. A pediatric PBPK model was then used to assess six different ontogeny models in predicting bioavailability from preterm neonates to adults. The average fold error ranged from 0.7 to 1.38, with the rank order of least to most biased model being No Ontogeny < Upreti = Johnson < Goelen < Chen < Kiss. The absolute average fold error ranged from 1.17 to 1.64 with the rank order of most to least precise being Johnson > Upreti > No Ontogeny > Goelen > Kiss > Chen. The optimal ontogeny model is difficult to discern when considering the possible influence of CYP3A5 and other population variability; however, this study suggests that from term neonates and older a faster onset Johnson model with a lower fraction at birth may be close to this. For inclusion in other PBPK models, independent verification will be needed to confirm these results. Further research is needed in this area both in terms of age-related changes in midazolam and similar drug bioavailability and intestinal CYP3A4 ontogeny.
Collapse
Affiliation(s)
| | - Hannah K Batchelor
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Jan Goelen
- Centre for Neonatal and Paediatric Infection, Antimicrobial Resistance Research Group, St George's, University of London, London, UK
| | - Richard D Horniblow
- School of Biomedical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | |
Collapse
|
4
|
Qu R, Dai Y, Zhu Z, Lu X, Zhou R, Qu X, Chen X. Therapeutic Drug Monitoring of Perampanel in Children With Refractory Epilepsy: Focus on Influencing Factors on the Free-Perampanel Concentration. Ther Drug Monit 2023; 45:660-667. [PMID: 37185798 DOI: 10.1097/ftd.0000000000001101] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/24/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND This study aimed to assess the effect of perampanel dose, age, sex, and antiseizure medication cotherapy on steady-state free-perampanel concentration in children with refractory epilepsy, as well as the relationship between inflammation and the pharmacokinetics of perampanel. METHODS This prospective study in China included 87 children with refractory epilepsy treated with adjunctive perampanel therapy. Free and total perampanel concentrations in plasma were determined using liquid chromatography-tandem mass spectrometry. Free-perampanel concentration was compared among patients with various potential influencing factors. RESULTS A total of 87 pediatric patients (44 female children) aged 2-14 years were enrolled. The mean free-perampanel concentration and free concentration-to-dose (CD) ratio in plasma were 5.7 ± 2.7 ng/mL (16.3 ± 7.7 nmol/L) and 45.3 ± 21.0 (ng/mL)/(mg/kg) [129.6 ± 60.1 (nmol/L)/(mg/kg)], respectively. The protein binding of perampanel in plasma was 97.98%. A linear relationship was observed between perampanel dose and free concentration in plasma, and a positive relationship was found between the total and free-perampanel concentrations. Concomitant use of oxcarbazepine reduced the free CD ratio by 37%. Concomitant use of valproic acid increased the free CD ratio by 52%. Five patients had a plasma high-sensitivity C-reactive protein (Hs-CRP) level of >5.0 mg/L (Hs-CRP positive). The total and free CD ratios of perampanel were increased in patients with inflammation. Two patients with inflammation developed adverse events, which disappeared as the Hs-CRP level returned to normal, and neither required perampanel dose reduction. Age and sex did not influence the free-perampanel concentration. CONCLUSIONS This study found complex drug interactions between perampanel and other concomitant antiseizure medications, providing valuable information to enable clinicians to apply perampanel in the future reasonably. In addition, it may be important to quantify both the total and free concentrations of perampanel to assess complex pharmacokinetic interactions.
Collapse
Affiliation(s)
- Rui Qu
- Department of Neurology, Children's Hospital of Soochow University, Suzhou Industrial Park, Jiangsu Province, China
- Department of Pediatric Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Yuanyuan Dai
- Department of Pediatric Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Zengyan Zhu
- Department of Pharmacy, Children's Hospital of Soochow University, Suzhou Industrial Park, Jiangsu Province, China; and
| | - Xiaoyun Lu
- Department of Neurology, Children's Hospital of Soochow University, Suzhou Industrial Park, Jiangsu Province, China
| | - Rui Zhou
- Department of Neurology, Children's Hospital of Soochow University, Suzhou Industrial Park, Jiangsu Province, China
| | - Xiangju Qu
- Department of Mechanical and Electronic Engineering, Xuzhou University of Technology, Xuzhou, Jiangsu Province, China
| | - Xuqin Chen
- Department of Neurology, Children's Hospital of Soochow University, Suzhou Industrial Park, Jiangsu Province, China
| |
Collapse
|
5
|
Zeng B, Liu Y, Xu J, Niu L, Wu Y, Zhang D, Tang X, Zhu Z, Chen Y, Hu L, Yu S, Yu P, Zhang J, Wang W. Future Directions in Optimizing Anesthesia to Reduce Perioperative Acute Kidney Injury. Am J Nephrol 2023; 54:434-450. [PMID: 37742618 DOI: 10.1159/000533534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/01/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Perioperative acute kidney injury (AKI) is common in surgical patients and is associated with high morbidity and mortality. There are currently few options for AKI prevention and treatment. Due to its complex pathophysiology, there is no efficient medication therapy to stop the onset of the injury or repair the damage already done. Certain anesthetics, however, have been demonstrated to affect the risk of perioperative AKI in some studies. The impact of anesthetics on renal function is particularly important as it is closely related to the prognosis of patients. Some anesthetics can induce anti-inflammatory, anti-necrotic, and anti-apoptotic effects. Propofol, sevoflurane, and dexmedetomidine are a few examples of anesthetics that have protective association with AKI in the perioperative period. SUMMARY In this study, we reviewed the clinical characteristics, risk factors, and pathogenesis of AKI. Subsequently, the protective effects of various anesthetic agents against perioperative AKI and the latest research are introduced. KEY MESSAGE This work demonstrates that a thorough understanding of the reciprocal effects of anesthetic drugs and AKI is crucial for safe perioperative care and prognosis of patients. However, more complete mechanisms and pathophysiological processes still need to be further studied.
Collapse
Affiliation(s)
- Bin Zeng
- Department of Gastroenterology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Yinuo Liu
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China,
- The Second Clinical Medical College of Nanchang University, Nanchang, China,
| | - Jiawei Xu
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Liyan Niu
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Second Clinical Medical College of Nanchang University, Nanchang, China
- Huan Kui College, Nanchang University, Nanchang, China
| | - Yuting Wu
- Huan Kui College, Nanchang University, Nanchang, China
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Deju Zhang
- Huan Kui College, Nanchang University, Nanchang, China
- Food and Nutritional Sciences, School of Biological Sciences, The University of Hong Kong, Hong Kong, Hong Kong, China
| | - Xiaoyi Tang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zicheng Zhu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yixuan Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Leilei Hu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shuchun Yu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Peng Yu
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jing Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wenting Wang
- Department of Anesthesiology, The Second Affiliated Hospital of Hainan Medical University, Haikou, China
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
6
|
Ketharanathan N, Lili A, de Vries JMP, Wildschut ED, de Hoog M, Koch BCP, de Winter BCM. A Population Pharmacokinetic Model of Pentobarbital for Children with Status Epilepticus and Severe Traumatic Brain Injury. Clin Pharmacokinet 2023; 62:1011-1022. [PMID: 37247187 PMCID: PMC10338388 DOI: 10.1007/s40262-023-01249-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Pentobarbital pharmacokinetics (PK) remain elusive and the therapeutic windows narrow. Administration is frequent in critically ill children with refractory status epilepticus (SE) and severe traumatic brain injury (sTBI). OBJECTIVES To investigate pentobarbital PK in SE and sTBI patients admitted to the paediatric intensive care unit (PICU) with population-based PK (PopPK) modelling and dosing simulations. METHODS Develop a PopPK model with non-linear mixed-effects modelling (NONMEM®) with retrospective data (n = 36; median age 1.3 years; median weight 10 kg; 178 blood samples) treated with continuous intravenous pentobarbital. An independent dataset was used for external validation (n = 9). Dosing simulations with the validated model evaluated dosing regimens. RESULTS A one-compartment PK model with allometrically scaled weight on clearance (CL; 0.75) and volume of distribution (Vd; 1) captured data well. Typical CL and Vd values were 3.59 L/70 kg/h and 142 L/70 kg, respectively. Elevated creatinine and C-reactive protein (CRP) levels significantly correlated to decreased CL, explaining 84% of inter-patient variability, and were incorporated in the final model. External validation using stratified visual predictive checks showed good results. Simulations demonstrated patients with elevated serum creatinine and CRP failed to achieve steady state yet progressed to toxic levels with current dosing regimens. CONCLUSIONS The one-compartment PK model of intravenous pentobarbital described data well whereby serum creatinine and CRP significantly correlated with pentobarbital CL. Dosing simulations formulated adjusted dosing advice in patients with elevated creatinine and/or CRP. Prospective PK studies with pharmacodynamic endpoints, are imperative to optimise pentobarbital dosing in terms of safety and clinical efficacy in critically ill children.
Collapse
Affiliation(s)
- Naomi Ketharanathan
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Room Sp-3435, Wytemaweg 80, 3015GD, Rotterdam, The Netherlands.
| | - Anastasia Lili
- Rotterdam Clinical Pharmacometrics Group, Erasmus MC, Rotterdam, The Netherlands
| | | | - Enno D Wildschut
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Room Sp-3435, Wytemaweg 80, 3015GD, Rotterdam, The Netherlands
| | - Matthijs de Hoog
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Room Sp-3435, Wytemaweg 80, 3015GD, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Rotterdam Clinical Pharmacometrics Group, Erasmus MC, Rotterdam, The Netherlands
| | - Brenda C M de Winter
- Rotterdam Clinical Pharmacometrics Group, Erasmus MC, Rotterdam, The Netherlands
| |
Collapse
|
7
|
Goulooze SC, Vis PW, Krekels EHJ, Knibbe CAJ. Advances in pharmacokinetic-pharmacodynamic modelling for pediatric drug development: extrapolations and exposure-response analyses. Expert Rev Clin Pharmacol 2023; 16:1201-1209. [PMID: 38069812 DOI: 10.1080/17512433.2023.2288171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023]
Abstract
INTRODUCTION Pharmacokinetic (PK)-Pharmacodynamic (PD) and exposure-response (E-R) modeling are critical parts of pediatric drug development. By integrating available knowledge and supportive data to support the design of future studies and pediatric dose selection, these techniques increase the efficiency of pediatric drug development and lowers the risk of exposing pediatric study participants to suboptimal or unsafe dose regimens. AREAS COVERED The role of PK, PK-PD and E-R modeling within pediatric drug development and pediatric dose selection is discussed. These models allow investigation of the impact of age and bodyweight on PK and PD in children, despite the often sparse data on the pediatric population. Also discussed is how E-R analyses strengthen the evidence basis to support (full or partial) extrapolation of drug efficacy from adults to children, and between different pediatric age groups. EXPERT OPINION Accelerated pediatric drug development and optimized pediatric dosing guidelines are expected from three future developments: (1) Increased focus on E-R modeling of currently approved drugs in children resulting in (novel) E-R modeling techniques and best practices, (2) increased use of real-world data for E-R (3) increased implementation of available population PK and E-R information in pediatric drug dosing guidelines.
Collapse
Affiliation(s)
| | - Peter W Vis
- LAP&P Consultants BV, Leiden, The Netherlands
| | - Elke H J Krekels
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Catherijne A J Knibbe
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
| |
Collapse
|
8
|
Ooi QX, Kristoffersson A, Korell J, Flack M, L. Plan E, Weber B. Bounded integer model-based analysis of psoriasis area and severity index in patients with moderate-to-severe plaque psoriasis receiving BI 730357. CPT Pharmacometrics Syst Pharmacol 2023; 12:758-769. [PMID: 36919398 PMCID: PMC10272300 DOI: 10.1002/psp4.12948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/14/2023] [Accepted: 02/20/2023] [Indexed: 03/16/2023] Open
Abstract
BI 730357 is investigated as an oral treatment of plaque psoriasis. We analyzed the impact of three dosage regimens on the Psoriasis Area and Severity Index (PASI) response with modeling based on phase I and II data from 109 healthy subjects and 274 patients with moderate-to-severe plaque psoriasis. The pharmacokinetics (PK) was characterized by a two-compartment model with dual absorption paths and a first-order elimination. Higher baseline C-reactive protein was associated with lower clearance and patients generally had lower clearance compared with healthy subjects. A bounded integer PK/pharmacodynamic model characterized the effect on the observed PASI. The maximum drug effect was largest for patients with no prior biologic use, smaller for patients with prior use of non-interleukin-17 inhibitors, and smallest for patients with prior interleukin-17 inhibitor use. The models allowed robust simulation of large patient populations, predicting a plateau in PASI outcomes for BI 730357 exposure above 2000 nmol/L.
Collapse
Affiliation(s)
| | | | - Julia Korell
- Boehringer Ingelheim Pharmaceuticals, Inc.RidgefieldConnecticutUSA
| | - Mary Flack
- Boehringer Ingelheim Pharmaceuticals, Inc.RidgefieldConnecticutUSA
| | | | - Benjamin Weber
- Boehringer Ingelheim Pharmaceuticals, Inc.RidgefieldConnecticutUSA
| |
Collapse
|
9
|
Abdallah YEH, Chahal S, Jamali F, Mahmoud SH. Drug-disease interaction: Clinical consequences of inflammation on drugs action and disposition. JOURNAL OF PHARMACY & PHARMACEUTICAL SCIENCES : A PUBLICATION OF THE CANADIAN SOCIETY FOR PHARMACEUTICAL SCIENCES, SOCIETE CANADIENNE DES SCIENCES PHARMACEUTIQUES 2023; 26:11137. [PMID: 36942294 PMCID: PMC9990632 DOI: 10.3389/jpps.2023.11137] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/23/2023] [Indexed: 02/07/2023]
Abstract
Inflammation is a culprit in many conditions affecting millions of people worldwide. A plethora of studies has revealed that inflammation and inflammatory mediators such as cytokines and chemokines are associated with altered expression and activity of various proteins such as those involved in drug metabolism, specifically cytochrome P450 enzymes (CYPs). Emphasis of most available reports is on the inflammation-induced downregulation of CYPs, subsequently an increase in their substrate concentrations, and the link between the condition and the inflammatory mediators such as interleukin-6 and tumor necrosis factor alpha. However, reports also suggest that inflammation influences expression and/or activity of other proteins such as those involved in the drug-receptor interaction. These multifaced involvements render the clinical consequence of the inflammation unexpected. Such changes are shown in many inflammatory conditions including rheumatoid arthritis, Crohn's disease, acute respiratory illnesses as well as natural processes such as aging, among others. For example, some commonly used cardiovascular drugs lose their efficacy when patients get afflicted with inflammatory conditions such as rheumatoid arthritis and Crohn's disease. Interestingly, this is despite increased concentration subsequent to reduced clearance. The observation is attributed to a simultaneous reduction in the expression of target receptor proteins such as the calcium and potassium channel and β-adrenergic receptor as well as the metabolic enzymes. This narrative review summarizes the current understanding and clinical implications of the inflammatory effects on both CYPs and drug-receptor target proteins.
Collapse
|
10
|
Smits A, Annaert P, Cavallaro G, De Cock PAJG, de Wildt SN, Kindblom JM, Lagler FB, Moreno C, Pokorna P, Schreuder MF, Standing JF, Turner MA, Vitiello B, Zhao W, Weingberg AM, Willmann R, van den Anker J, Allegaert K. Current knowledge, challenges and innovations in developmental pharmacology: A combined conect4children Expert Group and European Society for Developmental, Perinatal and Paediatric Pharmacology White Paper. Br J Clin Pharmacol 2022; 88:4965-4984. [PMID: 34180088 PMCID: PMC9787161 DOI: 10.1111/bcp.14958] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/22/2021] [Accepted: 05/30/2021] [Indexed: 12/30/2022] Open
Abstract
Developmental pharmacology describes the impact of maturation on drug disposition (pharmacokinetics, PK) and drug effects (pharmacodynamics, PD) throughout the paediatric age range. This paper, written by a multidisciplinary group of experts, summarizes current knowledge, and provides suggestions to pharmaceutical companies, regulatory agencies and academicians on how to incorporate the latest knowledge regarding developmental pharmacology and innovative techniques into neonatal and paediatric drug development. Biological aspects of drug absorption, distribution, metabolism and excretion throughout development are summarized. Although this area made enormous progress during the last two decades, remaining knowledge gaps were identified. Minimal risk and burden designs allow for optimally informative but minimally invasive PK sampling, while concomitant profiling of drug metabolites may provide additional insight in the unique PK behaviour in children. Furthermore, developmental PD needs to be considered during drug development, which is illustrated by disease- and/or target organ-specific examples. Identifying and testing PD targets and effects in special populations, and application of age- and/or population-specific assessment tools are discussed. Drug development plans also need to incorporate innovative techniques such as preclinical models to study therapeutic strategies, and shift from sequential enrolment of subgroups, to more rational designs. To stimulate appropriate research plans, illustrations of specific PK/PD-related as well as drug safety-related challenges during drug development are provided. The suggestions made in this joint paper of the Innovative Medicines Initiative conect4children Expert group on Developmental Pharmacology and the European Society for Developmental, Perinatal and Paediatric Pharmacology, should facilitate all those involved in drug development.
Collapse
Affiliation(s)
- Anne Smits
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Neonatal intensive Care unit, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Giacomo Cavallaro
- Neonatal intensive care unit, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milan, Italy
| | - Pieter A J G De Cock
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium.,Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | - Saskia N de Wildt
- Intensive Care and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Pharmacology and Toxicology, Radboud Institute Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jenny M Kindblom
- Pediatric Clinical Research Center, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Florian B Lagler
- Institute for Inherited Metabolic Diseases and Department of Pediatrics, Paracelsus Medical University, Clinical Research Center Salzburg, Salzburg, Austria
| | - Carmen Moreno
- Institute of Psychiatry and Mental Health, Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| | - Paula Pokorna
- Intensive Care and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.,Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.,Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Joseph F Standing
- UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Mark A Turner
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - Benedetto Vitiello
- Division of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Wei Zhao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, China.,Department of Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China.,Clinical Research Centre, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | | | | | - John van den Anker
- Intensive Care and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland.,Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Hospital Pharmacy, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| |
Collapse
|
11
|
Singla S, Block R. Effect Compartment Model for the Evaluation of Tolerance to Psychological Highness Following Smoking Marijuana. J Clin Pharmacol 2022; 62:1539-1547. [PMID: 35692186 PMCID: PMC9796419 DOI: 10.1002/jcph.2109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 06/09/2022] [Indexed: 01/01/2023]
Abstract
The purpose of this study is to evaluate the development of tolerance, using a population modeling approach, in recreational marijuana users after acute pulmonary administration of tetrahydrocannabinol (THC), a primary ingredient in marijuana. A total of 85 subjects in 3 separate studies smoked marijuana cigarettes (dose = 13-49 mg) under controlled conditions. Each study was designed as a randomized, crossover, double-blind, and placebo-controlled study. Up to 5 THC plasma samples and corresponding user-reported psychological highness were pooled for population modeling analyses. Age, sex, user status, and body mass index were evaluated as covariates. Population pharmacokinetic (PK) parameters were estimated in the 2-compartment PK model. PK parameters were fixed in the effect compartment model to describe the relationship between THC plasma concentration-psychological highness. The distribution rate constant in the effect compartment was estimated to be 0.988 (95%CI 0.964-1.010)/h. The population mean half-maximal effective concentration (EC50 ) was 23.8 (95%CI 22.7-24.9) ng/mL. Covariate analysis revealed that user status was a significant covariate, and that chronic users appear to need higher plasma concentrations compared with occasional users to achieve a similar degree of highness. The modeling results conclude that chronic users develop tolerance to euphoria, which is the primary central nervous system effect of smoking marijuana.
Collapse
Affiliation(s)
- Sumeet Singla
- Department of Pharmaceutical SciencesCollege of PharmacyUniversity of IowaIowa CityIowaUSA,Regeneron PharmaceuticalsTarrytownNew YorkUSA
| | - Robert Block
- Department of AnesthesiaRoy J. and Lucille A. Carver College of MedicineUniversity of IowaIowa CityIowaUSA
| |
Collapse
|
12
|
Neupane B, Pandya H, Pandya T, Austin R, Spooner N, Rudge J, Mulla H. Inflammation and cardiovascular status impact midazolam pharmacokinetics in critically ill children: An observational, prospective, controlled study. Pharmacol Res Perspect 2022; 10:e01004. [PMID: 36036654 PMCID: PMC9422629 DOI: 10.1002/prp2.1004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/12/2022] [Accepted: 07/26/2022] [Indexed: 12/02/2022] Open
Abstract
Altered physiology caused by critical illness may change midazolam pharmacokinetics and thereby result in adverse reactions and outcomes in this vulnerable patient population. This study set out to determine which critical illness-related factors impact midazolam pharmacokinetics in children using population modeling. This was an observational, prospective, controlled study of children receiving IV midazolam as part of routine care. Children recruited into the study were either critically-ill receiving continuous infusions of midazolam or otherwise well, admitted for elective day-case surgery (control) who received a single IV bolus dose of midazolam. The primary outcome was to determine the population pharmacokinetics and identify covariates that influence midazolam disposition during critical illness. Thirty-five patients were recruited into the critically ill arm of the study, and 54 children into the control arm. Blood samples for assessing midazolam and 1-OH-midazolam concentrations were collected opportunistically (critically ill arm) and in pre-set time windows (control arm). Pharmacokinetic modeling demonstrated a significant change in midazolam clearance with acute inflammation (measured using C-Reactive Protein), cardio-vascular status, and weight. Simulations predict that elevated C-Reactive Protein and compromised cardiovascular function in critically ill children result in midazolam concentrations up to 10-fold higher than in healthy children. The extremely high concentrations of midazolam observed in some critically-ill children indicate that the current therapeutic dosing regimen for midazolam can lead to over-dosing. Clinicians should be aware of this risk and intensify monitoring for oversedation in such patients.
Collapse
Affiliation(s)
- Bikalpa Neupane
- Department of Respiratory Sciences, College of Life SciencesUniversity of LeicesterLeicesterUK
- Jenny Lind Children's HospitalNorfolk and Norwich University Hospital NHS TrustNorwichUK
| | - Hitesh Pandya
- Department of Respiratory Sciences, College of Life SciencesUniversity of LeicesterLeicesterUK
| | - Tej Pandya
- Royal Bolton NHS Foundation TrustFarnworthUK
| | | | - Neil Spooner
- Spooner Bioanalytical Solutions LimitedHertfordUK
| | | | - Hussain Mulla
- Department of Respiratory Sciences, College of Life SciencesUniversity of LeicesterLeicesterUK
- Department of PharmacyUniversity Hospitals of Leicester NHS TrustLeicesterUK
| |
Collapse
|
13
|
Managing Cancer Drug Resistance from the Perspective of Inflammation. JOURNAL OF ONCOLOGY 2022; 2022:3426407. [PMID: 36245983 PMCID: PMC9553519 DOI: 10.1155/2022/3426407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/17/2022] [Indexed: 11/17/2022]
Abstract
The development of multidrug resistance in cancer chemotherapy is a major obstacle to the effective treatment of human malignant tumors. Several epidemiological studies have demonstrated that inflammation is closely related to cancer and plays a key role in the development of both solid and liquid tumors. Therefore, targeting inflammation and the molecules involved in the inflammatory process may be a good strategy for treating drug-resistant tumors. In this review, we discuss the molecular mechanisms underlying inflammation in regulating anticancer drug resistance by modulating drug action and drug-mediated cell death pathways. Inflammation alters the effectiveness of drugs through modulation of the expression of multidrug efflux transporters (e.g., ABCG2, ABCB1, and ABCC1) and drug-metabolizing enzymes (e.g., CYP1A2 and CYP3A4). In addition, inflammation can protect cancer cells from drug-mediated cell death by regulating DNA damage repair, downstream adaptive response (e.g., apoptosis, autophagy, and oncogenic bypass signaling), and tumor microenvironment. Intriguingly, manipulating inflammation may affect drug resistance through various molecular mechanisms validated by in vitro/in vivo models. In this review, we aim to summarize the underlying molecular mechanisms that inflammation participates in cancer drug resistance and discuss the potential clinical strategies targeting inflammation to overcome drug resistance.
Collapse
|
14
|
Ewoldt TMJ, Abdulla A, Hunfeld N, Li L, Smeets TJL, Gommers D, Koch BCP, Endeman H. The impact of sepsis on hepatic drug metabolism in critically ill patients: a narrative review. Expert Opin Drug Metab Toxicol 2022; 18:413-421. [PMID: 35912845 DOI: 10.1080/17425255.2022.2106215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Hepatic drug metabolism is important in improving drug dosing strategies in sepsis. Pharmacokinetics in the critically ill population are severely altered due to changes in absorption, distribution, excretion and metabolization. Hepatic drug metabolism might be altered due to changes in hepatic blood flow, drug metabolizing protein availability, and protein binding. The purpose of this review is to examine evidence on whether hepatic drug metabolism is significantly affected in septic patients, and to provide insights in the need for future research. AREAS COVERED This review describes the effect of sepsis on hepatic drug metabolism in humans. Clinical trials, pathophysiological background information and example drug groups are further discussed. The literature search has been conducted in Embase, Medline ALL Ovid, and Cochrane CENTRAL register of trials. EXPERT OPINION Limited research has been conducted on drug metabolism in the sepsis population, with some trials having researched healthy individuals using endotoxin injections. Notwithstanding this limitation, hepatic drug metabolism seems to be decreased for certain drugs in sepsis. More research on the pharmacokinetic behavior of hepatic metabolized drugs in sepsis is warranted, using inflammatory biomarkers, hemodynamic changes, mechanical ventilation, organ support, and catecholamine infusion as possible confounders.
Collapse
Affiliation(s)
- Tim M J Ewoldt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicole Hunfeld
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Letao Li
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tim J L Smeets
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
15
|
Hirai T, Kasai H, Takahashi M, Uchida S, Akai N, Hanada K, Itoh T, Iwamoto T. Population Pharmacokinetic Model of Amiodarone and N-Desethylamiodarone Focusing on Glucocorticoid and Inflammation. Biol Pharm Bull 2022; 45:948-954. [PMID: 35786602 DOI: 10.1248/bpb.b21-00940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Some population pharmacokinetic models for amiodarone (AMD) did not incorporate N-desethylamiodarone (DEA) concentration. Glucocorticoids activate CYP3A4 activity, metabolizing AMD. In contrast, CYP3A4 activity may decrease under inflammation conditions. However, direct evidence for the role of glucocorticoid or inflammation on the pharmacokinetics of AMD and DEA is lacking. The pilot study aimed to address this gap using a population pharmacokinetic analysis of AMD and DEA. A retrospective cohort observational study in adult patients who underwent AMD treatment with trough concentration measurement was conducted at Tokyo Women's Medical University, Medical Center East from June 2015 to March 2019. Both structural models of AMD and DEA applied 1-compartment models, which included significant covariates using a stepwise forward selection and backward elimination method. The eligible 81 patients (C-reactive protein level: 0.26 [interquartile range; 0.09-1.92] mg/dL) had a total of 408 trough concentrations for both AMD and DEA. The median trough concentrations were 0.49 [0.31-0.81] µg/mL for AMD and 0.43 [0.28-0.71] µg/mL for DEA during a median follow-up period of 446 [147-1059] d. Three patients received low-dose oral glucocorticoid. The final model identified that AMD clearance was 7.9 L/h, and the apparent DEA clearance was 10.3 L/h. Co-administered glucocorticoids lowered apparent DEA clearance by 35%. These results indicate that co-administered glucocorticoids may increase DEA concentrations in patients without severe inflammation.
Collapse
Affiliation(s)
- Toshinori Hirai
- Department of Pharmacy, Mie University Hospital, Faculty of Medicine, Mie University
| | | | | | - Satomi Uchida
- Department of Pharmacy, Tokyo Women's Medical University Medical Center East
| | - Naoko Akai
- Department of Pharmacy, Tokyo Women's Medical University Medical Center East
| | - Kazuhiko Hanada
- Department of Pharmacometrics and Pharmacokinetics, Meiji Pharmaceutical University
| | - Toshimasa Itoh
- Department of Pharmacy, Tokyo Women's Medical University Medical Center East
| | - Takuya Iwamoto
- Department of Pharmacy, Mie University Hospital, Faculty of Medicine, Mie University
| |
Collapse
|
16
|
Smeets TJL, Valkenburg AJ, van der Jagt M, Koch BCP, Endeman H, Gommers DAMPJ, Sassen SDT, Hunfeld NGM. Hyperinflammation Reduces Midazolam Metabolism in Critically Ill Adults with COVID-19. Clin Pharmacokinet 2022; 61:973-983. [PMID: 35397768 PMCID: PMC8994846 DOI: 10.1007/s40262-022-01122-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Many patients treated for COVID-19 related acute respiratory distress syndrome in the intensive care unit are sedated with the benzodiazepine midazolam. Midazolam undergoes extensive metabolism by CYP3A enzymes, which may be inhibited by hyperinflammation. Therefore, an exaggerated proinflammatory response, as often observed in COVID-19, may decrease midazolam clearance. To develop a population pharmacokinetic model for midazolam in adult intensive care unit patients infected with COVID-19 and to assess the effect of inflammation, reflected by IL-6, on the pharmacokinetics of midazolam. METHODS Midazolam blood samples were collected once a week between March 31 and April 30 2020. Patients were excluded if they concomitantly received CYP3A4 inhibitors, CYP3A4 inducers and/or continuous renal replacement therapy. Midazolam and metabolites were analyzed with an ultra-performance liquid chromatography-tandem mass spectrometry method. A population pharmacokinetic model was developed, using nonlinear mixed effects modelling. IL-6 and CRP, markers of inflammation, were analyzed as covariates. RESULTS The data were described by a one-compartment model for midazolam and the metabolites 1-OH-midazolam and 1-OH-midazolam-glucuronide. The population mean estimate for midazolam clearance was 6.7 L/h (4.8-8.5 L/h). Midazolam clearance was reduced by increased IL-6 and IL-6 explained more of the variability within our patients than CRP. The midazolam clearance was reduced by 24% (6.7-5.1 L/h) when IL-6 increases from population median 116 to 300 pg/mL. CONCLUSIONS Inflammation, reflected by high IL-6, reduces midazolam clearance in critically ill patients with COVID-19. This knowledge may help avoid oversedation, but further research is warranted.
Collapse
Affiliation(s)
- Tim J L Smeets
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Doctor Molewaterplein 40, PO Box 2040, 3015 GD, Rotterdam, The Netherlands.
| | - Abraham J Valkenburg
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Doctor Molewaterplein 40, PO Box 2040, 3015 GD, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Diederik A M P J Gommers
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Sebastian D T Sassen
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Doctor Molewaterplein 40, PO Box 2040, 3015 GD, Rotterdam, The Netherlands
| | - Nicole G M Hunfeld
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Doctor Molewaterplein 40, PO Box 2040, 3015 GD, Rotterdam, The Netherlands
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| |
Collapse
|
17
|
Zhai Q, van der Lee M, van Gelder T, Swen JJ. Why We Need to Take a Closer Look at Genetic Contributions to CYP3A Activity. Front Pharmacol 2022; 13:912618. [PMID: 35784699 PMCID: PMC9243486 DOI: 10.3389/fphar.2022.912618] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
Cytochrome P450 3A (CYP3A) subfamily enzymes are involved in the metabolism of 40% of drugs in clinical use. Twin studies have indicated that 66% of the variability in CYP3A4 activity is hereditary. Yet, the complexity of the CYP3A locus and the lack of distinct drug metabolizer phenotypes has limited the identification and clinical application of CYP3A genetic variants compared to other Cytochrome P450 enzymes. In recent years evidence has emerged indicating that a substantial part of the missing heritability is caused by low frequency genetic variation. In this review, we outline the current pharmacogenomics knowledge of CYP3A activity and discuss potential future directions to improve our genetic knowledge and ability to explain CYP3A variability.
Collapse
|
18
|
Flores-Pérez C, Alfonso Moreno-Rocha L, Luis Chávez-Pacheco J, Angélica Noguez-Méndez N, Flores-Pérez J, Fernanda Alcántara-Morales M, Cortés-Vásquez L, Sarmiento-Argüello L. Sedation level with midazolam: a pediatric surgery approach. Saudi Pharm J 2022; 30:906-917. [PMID: 35903521 PMCID: PMC9315275 DOI: 10.1016/j.jsps.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 05/20/2022] [Indexed: 11/26/2022] Open
Abstract
Midazolam (MDZ) is a short-acting benzodiazepine that is widely used to induce and maintain general anesthesia during diagnostic and therapeutic procedures in pediatric patients due to its sedative properties. The aim of this study was to perform a systematic review without a meta-analysis to identify scientific articles and clinical assays concerning MDZ-induced sedation for a pediatric surgery approach. One hundred and twenty-eight results were obtained. After critical reading, 37 articles were eliminated, yielding 91 publications. Additional items were identified, and the final review was performed with a total of 106 publications. In conclusion, to use MDZ accurately, individual patient characteristics, the base disease state, comorbidities, the treatment burden and other drugs with possible pharmacological interactions or adverse reactions must be considered to avoid direct alterations in the pharmacokinetics and pharmacodynamics of MDZ to obtain the desired effects and avoid overdosing in the pediatric population.
Collapse
|
19
|
Dahmer MK, Yang G, Zhang M, Quasney MW, Sapru A, Weeks HM, Sinha P, Curley MAQ, Delucchi KL, Calfee CS, Flori H, Matthay MA, Bateman ST, Berg MD, Borasino S, Bysani GK, Cowl AS, Bowens CD, Faustino VS, Fineman LD, Godshall AJ, Hirshberg EL, Kirby AL, McLaughlin GE, Medar SS, Oren PP, Schneider JB, Schwarz AJ, Shanley TP, Source LR, Truemper EJ, Vender Heyden MA, Wittmayer K, Zuppa AF, Wypij D. Identification of phenotypes in paediatric patients with acute respiratory distress syndrome: a latent class analysis. THE LANCET. RESPIRATORY MEDICINE 2022; 10:289-297. [PMID: 34883088 PMCID: PMC8897230 DOI: 10.1016/s2213-2600(21)00382-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/04/2021] [Accepted: 08/09/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Previous latent class analysis of adults with acute respiratory distress syndrome (ARDS) identified two phenotypes, distinguished by the degree of inflammation. We aimed to identify phenotypes in children with ARDS in whom developmental differences might be important, using a latent class analysis approach similar to that used in adults. METHODS This study was a secondary analysis of data aggregated from the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) clinical trial and the Genetic Variation and Biomarkers in Children with Acute Lung Injury (BALI) ancillary study. We used latent class analysis, which included demographic, clinical, and plasma biomarker variables, to identify paediatric ARDS (PARDS) phenotypes within a cohort of children included in the RESTORE and BALI studies. The association of phenotypes with clinically relevant outcomes and the performance of paediatric data in adult ARDS classification algorithms were also assessed. FINDINGS 304 children with PARDS were included in this secondary analysis. Using latent class analysis, a two-class model was a better fit for the cohort than a one-class model (p<0·001). Latent class analysis identified two classes: class 1 (181 [60%] of 304 patients with PARDS) and class 2 (123 [40%] of 304 patients with PARDS), referred to as phenotype 1 and 2 hereafter. Phenotype 2 was characterised by higher concentrations of inflammatory biomarkers, a higher incidence of vasopressor use, and more frequent diagnosis of sepsis, consistent with the adult hyperinflammatory phenotype. All levels of severity of PARDS were observed across both phenotypes. Children with the hyperinflammatory phenotype (phenotype 2) had worse clinical outcomes than those with the hypoinflammatory phenotype (phenotype 1), with a longer duration of mechanical ventilation (median 10·0 days [IQR 6·3-21·0] for phenotype 2 vs 6·6 days [4·1-10·8] for phenotype 1, p<0·0001), and higher incidence of mortality (17 [13·8%] of 123 patients vs four [2·2%] of 181 patients, p=0·0001). When using adult phenotype classification algorithms in children, the soluble tumour necrosis factor receptor-1 (sTNFr1), vasopressor use, and interleukin (IL)-6 variables gave an area under the curve (AUC) of 0·956, and the sTNFr1, vasopressor use, and IL-8 variables gave an AUC of 0·954, compared with the gold standard of latent class analysis. INTERPRETATION Latent class analysis identified two phenotypes in children with ARDS with characteristics similar to those in adults, including worse outcomes among patients with the hyperinflammatory phenotype. PARDS phenotypes should be considered in design and analysis of future clinical trials in children. FUNDING US National Institutes of Health.
Collapse
Affiliation(s)
- Mary K Dahmer
- Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Guangyu Yang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Michael W Quasney
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Anil Sapru
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA
| | - Heidi M. Weeks
- Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Pratik Sinha
- Department of Anesthesia, Washington University, St. Louis, MO
| | - Martha AQ Curley
- Department of Family and Community Health (School of Nursing), Division of Anesthesia and Critical Care Medicine (Perelman School of Medicine) University of Pennsylvania, Philadelphia, PA; Research Institute; Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Kevin L Delucchi
- Department of Psychiatry & Behavioral Sciences, University of California, San Francisco, San Francisco, CA
| | - Carolyn S Calfee
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, CA
| | - Heidi Flori
- Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Chen J, Wu Y, He Y, Feng X, Ren Y, Liu S. Combined Effect of CYP2C19 Genetic Polymorphisms and C-Reactive Protein on Voriconazole Exposure and Dosing in Immunocompromised Children. Front Pediatr 2022; 10:846411. [PMID: 35386257 PMCID: PMC8978631 DOI: 10.3389/fped.2022.846411] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/09/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Pediatric patients have significant interindividual variability in voriconazole exposure. The aim of the study was to identify factors associated with voriconazole concentrations and dose requirements to achieve therapeutic concentrations in pediatric patients. METHODS Medical records of pediatric patients were retrospectively reviewed. Covariates associated with voriconazole plasma concentrations and dose requirements were adjusted by using generalized linear mixed-effect models. RESULTS A total of 682 voriconazole steady-state trough concentrations from 91 Chinese pediatric patients were included. Voriconazole exposure was lower in the CYP2C19 normal metabolizer (NM) group compared with the intermediate metabolizer (IM) group and the poor metabolizer (PM) group (p = 0.0016, p < 0.0001). The median daily dose of voriconazole required to achieve therapeutic range demonstrated a significant phenotypic dose effect: 20.8 mg/kg (range, 16.2-26.8 mg/kg) for the CYP2C19 NM group, 18.2 mg/kg (range, 13.3-21.8 mg/kg) for the CYP2C19 IM group, and 15.2 mg/kg (range, 10.7-19.1 mg/kg) for the CYP2C19 PM group, respectively. The extent of impact of C-reactive protein (CRP) levels on voriconazole trough concentrations and dose requirements varied between CYP2C19 phenotypes. Increases of 20, 120, 245, and 395 mg/L from 5 mg/L in CRP levels were associated with increases in voriconazole trough concentration by 22.22, 50, 64.81, and 75% respectively, in the NM group; by 39.26, 94.48, 123.93, and 146.63%, respectively, in the IM group; and by 17.17, 37.34, 46.78, and 53.65%, respectively, in the PM group. Meanwhile, increases of 20, 120, 245, and 395 mg/L from 5 mg/L in CRP levels were associated with increases in voriconazole dose requirements by 7.15, 14.23, 17.35, and 19.43%, respectively, in the PM group; with decreases in voriconazole dose requirements by 3.71, 7.38, 8.97, and 10.03%, respectively, in the NM group; and with decreases by 4, 9.10, 11.05, and 12.35%, respectively, in the IM group. In addition, age and presence of immunosuppressants had significant effects on voriconazole exposure. CONCLUSIONS Our study suggests that CYP2C19 phenotypes, CRP concentrations, age, and the presence of immunosuppressants were factors associated with the pharmacokinetic changes in voriconazole. There was heterogeneity in the effect of CRP on voriconazole plasma concentrations across different CYP2C19 genotypes. Combining relevant factors with dose adaptation strategies in therapeutic drug monitoring may help to reduce the incidence of subtherapeutic and supratherapeutic concentrations in clinical practice.
Collapse
Affiliation(s)
- Juan Chen
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ying Wu
- Department of Biostatistics, Guangdong Provincial Key Laboratory of Tropical Disease Research, School of Public Health, Southern Medical University, Guangzhou, China
| | - Yuelin He
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaoqin Feng
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuqiong Ren
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shiting Liu
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, China
| |
Collapse
|
21
|
Thibault C, Zuppa AF. Dexmedetomidine in Children on Extracorporeal Membrane Oxygenation: Pharmacokinetic Data Exploration Using Previously Published Models. Front Pediatr 2022; 10:924829. [PMID: 35832579 PMCID: PMC9271626 DOI: 10.3389/fped.2022.924829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/06/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Dexmedetomidine is a sedative and analgesic increasingly used in children supported with extracorporeal membrane oxygenation (ECMO). No data is available to describe the pharmacokinetics (PK) of dexmedetomidine in this population. METHODS We performed a single-center prospective PK study. Children <18 years old, supported with ECMO, and on a dexmedetomidine infusion as part of their management were prospectively included. PK samples were collected. Dexmedetomidine dosing remained at the discretion of the clinical team. Six population PK models built in pediatrics were selected. Observed concentrations were compared with population predicted concentrations using the PK models. RESULTS Eight children contributed 30 PK samples. None of the PK models evaluated predicted the concentrations with acceptable precision and bias. Four of the six evaluated models overpredicted the concentrations. The addition of a correction factor on clearance improved models' fit. Two of the evaluated models were not applicable to our whole population age range because of their structure. CONCLUSION Most of the evaluated PK models overpredicted the concentrations, potentially indicating increased clearance on ECMO. Population PK models applicable to a broad spectrum of ages and pathologies are more practical in pediatric critical care settings but challenging to develop.
Collapse
Affiliation(s)
- Céline Thibault
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| |
Collapse
|
22
|
Gatti M, Pea F. The Cytokine Release Syndrome and/or the Proinflammatory Cytokines as Underlying Mechanisms of Downregulation of Drug Metabolism and Drug Transport: A Systematic Review of the Clinical Pharmacokinetics of Victim Drugs of this Drug-Disease Interaction Under Different Clinical Conditions. Clin Pharmacokinet 2022; 61:1519-1544. [PMID: 36059001 PMCID: PMC9441320 DOI: 10.1007/s40262-022-01173-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND OBJECTIVE An ever-growing body of evidence supports the impact of cytokine modulation on the patient's phenotypic drug response. The aim of this systematic review was to analyze the clinical studies that assessed the pharmacokinetics of victim drugs of this drug-disease interaction in the presence of different scenarios of cytokine modulation in comparison with baseline conditions. METHODS We conducted a systematic review by searching the PubMed-MEDLINE database from inception until February 2022 to retrieve prospective and/or retrospective observational studies, population pharmacokinetic studies, phase I studies, and/or case series/reports that investigated the impact of cytokine modulation on the pharmacokinetic behavior of victim drugs. Only studies providing quantitative pharmacokinetic data of victim drugs by comparing normal status versus clinical conditions with documented cytokine modulation or by assessing the influence of anti-inflammatory biological agents on metabolism and/or transport of victim drugs were included. RESULTS Overall, 26 studies were included. Rheumatoid arthritis (6/26; 23.1%) and sepsis (5/26; 19.2%) were the two most frequently investigated pro-inflammatory clinical scenarios. The victim drug most frequently assessed was midazolam (14/26; 53.8%; as a probe for cytochrome P450 [CYP] 3A4). Cytokine modulation showed a moderate inhibitory effect on CYP3A4-mediated metabolism (area under the concentration-time curve increase and/or clearance decrease between 1.98-fold and 2.59-fold) and a weak-to-moderate inhibitory effect on CYP1A2, CYP2C9, and CYP2C19-mediated metabolism (in the area under the concentration-time curve increase or clearance decrease between 1.29-fold and 1.97-fold). Anti-interleukin-6 agents showed remarkable activity in counteracting downregulation of CYP3A4-mediated activity (increase in the area under the concentration-time curve between 1.75-fold and 2.56-fold). CONCLUSIONS Cytokine modulation may cause moderate or weak-to-moderate downregulation of metabolism/transport of victim drugs, and this may theoretically have relevant clinical consequences.
Collapse
Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy ,Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy ,Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138 Bologna, Italy
| |
Collapse
|
23
|
Ling J, Yang XP, Dong LL, Jiang Y, Zou SL, Hu N, Chen R. Population pharmacokinetics of ciclosporin in allogeneic hematopoietic stem cell transplant recipients: C-reactive protein as a novel covariate for clearance. J Clin Pharm Ther 2021; 47:483-492. [PMID: 34779003 DOI: 10.1111/jcpt.13569] [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: 08/02/2021] [Revised: 10/26/2021] [Accepted: 11/01/2021] [Indexed: 12/01/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Ciclosporin (CsA), a potent immunosuppressive agent used to prevent graft-versus-host disease in allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients, is characterized by large inter-individual variability and a narrow therapeutic range. The aim of this study was to develop a population pharmacokinetic model for CsA in Chinese allo-HSCT recipients and to identify covariates influencing CsA pharmacokinetics. METHODS A total of 758 retrospective drug monitoring data points were collected after intravenous infusion or oral administration of CsA from 59 patients. Population pharmacokinetic analysis was performed using nonlinear mixed effects modelling expressed by differential equations. Monte Carlo simulation was applied to optimize dosage regimens. The final model was validated using bootstrap and normalized prediction distribution errors. RESULTS AND DISCUSSION The results showed that the daily CsA dose, haematocrit, total bile acid, C-reactive protein (CRP) and co-administration of triazole antifungal agent were identified as significant covariates for clearance (CL) of CsA. The typical value of CL was 19.8 L/h with an inter-individual variability of 13.1%. The volume of distribution was 1340 L. Bioavailability was 67.2% with an inter-individual variability of 8.5%. Dosing simulation based on the developed model indicated that patients with high CRP concentration required a higher daily dose to attain the therapeutic trough concentration. The influence of CRP ultimately on the therapy outcome of CsA is not clear, which needs further study. WHAT IS NEW AND CONCLUSION CRP concentration was identified as a novel marker associated with CsA pharmacokinetics, which should be considered when determining the appropriate dosage of CsA in allo-HSCT recipients.
Collapse
Affiliation(s)
- Jing Ling
- Department of Pharmacy, the First People's Hospital of Changzhou/the Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Xu-Ping Yang
- Department of Pharmacy, the First People's Hospital of Changzhou/the Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Lu-Lu Dong
- Department of Pharmacy, the First People's Hospital of Changzhou/the Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Yan Jiang
- Department of Pharmacy, the First People's Hospital of Changzhou/the Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Su-Lan Zou
- Department of Pharmacy, the First People's Hospital of Changzhou/the Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Nan Hu
- Department of Pharmacy, the First People's Hospital of Changzhou/the Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Rong Chen
- Department of Pharmacy, the First People's Hospital of Changzhou/the Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| |
Collapse
|
24
|
Pre- and Postnatal Maturation are Important for Fentanyl Exposure in Preterm and Term Newborns: A Pooled Population Pharmacokinetic Study. Clin Pharmacokinet 2021; 61:401-412. [PMID: 34773609 PMCID: PMC8891207 DOI: 10.1007/s40262-021-01076-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 10/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Fentanyl is an opioid commonly used to prevent and treat severe pain in neonates; however, its use is off label and mostly based on bodyweight. Given the limited pharmacokinetic information across the entire neonatal age range, we characterized the pharmacokinetics of fentanyl across preterm and term neonates to individualize dosing. METHODS We pooled data from two previous studies on 164 newborns with a median gestational age of 29.0 weeks (range 23.9-42.3), birthweight of 1055 g (range 390-4245), and postnatal age (PNA) of 1 day (range 0-68). In total, 673 plasma samples upon bolus dosing (69 patients; median dose 2.1 μg/kg, median 2 boluses per patient) or continuous infusions (95 patients; median dose 1.1 μg/kg/h for 30 h) with and without boluses were used for population pharmacokinetic modeling in NONMEM® 7.4. RESULTS Clearance in neonates with birthweight of 2000 and 3000 g was 2.8- and 5.0-fold the clearance in a neonate with birthweight of 1000 g, respectively. Fentanyl clearance at PNA of 7, 14, and 21 days was 2.7-fold, 3.8-fold, and 4.6-fold the clearance at 1 day, respectively. Bodyweight-based dosing resulted in large differences in fentanyl concentrations. Depending on PNA and birthweight, fentanyl concentrations increased slowly after the start of therapy for both intermittent boluses and continuous infusion and reached a maximum concentration at 12-48 h. CONCLUSIONS As both prenatal and postnatal maturation are important for fentanyl exposure, we propose a birthweight- and PNA-based dosage regimen. To provide rapid analgesia in the first 24 h of treatment, additional loading doses need to be considered.
Collapse
|
25
|
Upadhyay PJ, Vet NJ, Goulooze SC, Krekels EHJ, de Wildt SN, Knibbe CAJ. Midazolam Infusion and Disease Severity Affect the Level of Sedation in Children: A Parametric Time-to-Event Analysis. Pharm Res 2021; 38:1711-1720. [PMID: 34664207 PMCID: PMC8523120 DOI: 10.1007/s11095-021-03113-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 09/16/2021] [Indexed: 12/02/2022]
Abstract
Aim In critically ill mechanically ventilated children, midazolam is used first line for sedation, however its exact sedative effects have been difficult to quantify. In this analysis, we use parametric time-to-event (PTTE) analysis to quantify the effects of midazolam in critically ill children. Methods In the PTTE analysis, data was analyzed from a published study in mechanically ventilated children in which blinded midazolam or placebo infusions were administered during a sedation interruption phase until, based on COMFORT-B and NISS scores, patients became undersedated and unblinded midazolam was restarted. Using NONMEM® v.7.4.3., restart of unblinded midazolam was analysed as event. Patients in the trial were divided into internal and external validation cohorts prior to analysis. Results Data contained 138 events from 79 individuals (37 blinded midazolam; 42 blinded placebo). In the PTTE model, the baseline hazard was best described by a constant function. Midazolam reduced the hazard for restart of unblinded midazolam due to undersedation by 51%. In the blinded midazolam group, time to midazolam restart was 26 h versus 58 h in patients with low versus high disease severity upon admission (PRISM II < 10 versus > 21), respectively. For blinded placebo, these times were 14 h and 33 h, respectively. The model performed well in an external validation with 42 individuals. Conclusion The PTTE analysis effectively quantified the effect of midazolam in prolonging sedation and also the influence of disease severity on sedation in mechanically ventilated critically ill children, and provides a valuable tool to quantify the effect of sedatives. Clinical trial number and registry URL: Netherlands Trial Register, Trial NL1913 (NTR2030), date registered 28 September 2009 https://www.trialregister.nl/trial/1913. Supplementary Information The online version contains supplementary material available at 10.1007/s11095-021-03113-w.
Collapse
Affiliation(s)
- Parth J Upadhyay
- Gorlaeus Laboratories, Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, PO Box 9502, 2300RA, Leiden, The Netherlands
| | - Nienke J Vet
- Department of Paediatrics, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Sebastiaan C Goulooze
- Gorlaeus Laboratories, Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, PO Box 9502, 2300RA, Leiden, The Netherlands
| | - Elke H J Krekels
- Gorlaeus Laboratories, Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, PO Box 9502, 2300RA, Leiden, The Netherlands
| | - Saskia N de Wildt
- Department of Pharmacology & Toxicology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catherijne A J Knibbe
- Gorlaeus Laboratories, Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, PO Box 9502, 2300RA, Leiden, The Netherlands. .,Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands.
| |
Collapse
|
26
|
White CM. Inflammation Suppresses Patients' Ability to Metabolize Cytochrome P450 Substrate Drugs. Ann Pharmacother 2021; 56:809-819. [PMID: 34590872 DOI: 10.1177/10600280211047864] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To assess the impact of inflammation on cytochrome P450 (CYP) drug metabolism in human subjects. DATA SOURCES A PubMed search was done from 1980 to July 2021 limited to human subjects and English language using a search strategy of (((phase I metabolism) OR (CYP) OR (cytochrome P450)) AND (inflammatory OR inflammation)). STUDY SELECTION AND DATA EXTRACTION Narrative review of human studies assessing the impact of inflammation or inflammatory suppression with biologic drugs on CYP drug metabolism were used. DATA SYNTHESIS Patients with inflammatory conditions ranging from fungal, viral, or bacterial infections to noninfectious causes (critical illness, surgical procedure, cancer, or transplantation of stem cells or organs) have suppressed drug metabolism. Markers of inflammation such as C-reactive protein or α-1-acid glycoprotein are correlated with reduced clearance through CYP3A4, CYP1A2, and CYP2C19. Elevated interleukin-6 concentrations are also associated or correlated with reduced clearance for CYP3A4 and CYP2C-19 isoenzymes. There was insufficient information to properly assess CYP2D6. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Health professionals should appreciate that patients with acute or chronic inflammation from infectious or noninfectious causes could have suppressed drug metabolism through CYP3A4, CYP1A2, and CYP2C19. For narrow therapeutic index drugs, such as many of the drugs assessed in this review, that means more judicious drug monitoring to prevent adverse events. CONCLUSIONS Like other types of drug-drug or drug-disease interactions, inflammation can alter the steady-state concentration of CYP metabolized drugs.
Collapse
Affiliation(s)
- C Michael White
- University of Connecticut School of Pharmacy, Storrs, CT, USA.,Hartford Hospital, Hartford, CT, USA
| |
Collapse
|
27
|
Lenoir C, Rodieux F, Desmeules JA, Rollason V, Samer CF. Impact of Inflammation on Cytochromes P450 Activity in Pediatrics: A Systematic Review. Clin Pharmacokinet 2021; 60:1537-1555. [PMID: 34462878 PMCID: PMC8613112 DOI: 10.1007/s40262-021-01064-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2021] [Indexed: 12/22/2022]
Abstract
Background and Objective Cytochromes P450 (CYP) are the major enzymes involved in hepatic metabolism of drugs. Personalization of treatment in pediatrics is a major challenge, as it must not only take into account genetic, environmental, and physiological factors but also ontogeny. Published data in adults show that inflammation had an isoform-specific impact on CYP activities and we aimed to evaluate this impact in the pediatric population. Methods Articles listed in PubMed through 7 January, 2021 that studied the impact of inflammation on CYP activities in pediatrics were included in this systematic review. Sources of inflammation, victim drugs (CYP involved), effect of drug–disease interactions, number and age of subjects, and study design were extracted. Results Twenty-seven studies and case reports were included. The impact of inflammation on CYP activities appeared to be age dependent and isoform-specific, with some drug–disease interactions having significant pharmacokinetic and clinical impact. For example, midazolam clearance decreases by 70%, while immunosuppressant and theophylline concentrations increase three-fold and two-fold with intensive care unit admission and infection. Cytochrome P450 activity appears to return to baseline level when the disease is resolved. Conclusions Studies that have assessed the impact of inflammation on CYP activity are lacking in pediatrics, yet it is a major factor to consider to improve drug efficacy or safety. The scarce current data show that the impact of inflammation is isoform and age dependent. An effort must be made to improve the understanding of the impact of inflammation on CYP activities in children to better individualize treatment.
Collapse
Affiliation(s)
- Camille Lenoir
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), University of Geneva, Geneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Frédérique Rodieux
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Jules A Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), University of Geneva, 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, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Caroline F Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland. .,Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| |
Collapse
|
28
|
Zheng Y, Ye PP, Zhou Y, Wu SY, Liu XT, Du B, Tang BH, Kan M, Nie AQ, Yin R, Wang M, Hao GX, Song LL, Yang XM, Huang X, Su LQ, Wang WQ, van den Anker J, Zhao W. LPS-Induced Inflammation Affects Midazolam Clearance in Juvenile Mice in an Age-Dependent Manner. J Inflamm Res 2021; 14:3697-3706. [PMID: 34377007 PMCID: PMC8349217 DOI: 10.2147/jir.s321492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/23/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Inflammation has a significant impact on CYP3A activity. We hypothesized that this effect might be age dependent. Our objective was to conduct a population pharmacokinetic study of midazolam in mice at different developmental stages with varying degrees of inflammation to verify our hypothesis. Methods Different doses (2 and 5 mg/kg) of lipopolysaccharide (LPS) were used to induce different degrees of systemic inflammation in Swiss mice (postnatal age 9–42 days, n = 220). The CYP3A substrate midazolam was selected as the pharmacological probe to study CYP3A activity. Postnatal age, current body weight, serum amyloid A protein 1 (SAA1) levels and LPS doses were collected as covariates to perform a population pharmacokinetic analysis using NONMEM 7.2. Results A population pharmacokinetic model of midazolam in juvenile and adult mice was established. Postnatal age and current body weight were the most significant and positive covariates for clearance and volume of distribution. LPS dosage was the most significant and negative covariate for clearance. LPS dosage can significantly reduce the clearance of midazolam by 21.8% and 38.7% with 2 mg/kg and 5 mg/kg, respectively. Moreover, the magnitude of the reduction was higher in mice with advancing postnatal age. Conclusion Both inflammation and ontogeny have an essential role in CYP3A activity in mice. The effect of LPS-induced systemic inflammation on midazolam clearance in mice is dependent on postnatal age.
Collapse
Affiliation(s)
- Yi Zheng
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China
| | - Pan-Pan Ye
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, 250014, People's Republic of China
| | - Yue Zhou
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China
| | - Su-Ying Wu
- Shandong University of Traditional Chinese Medicine, Jinan, People's Republic of China
| | - Xi-Ting Liu
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China
| | - Bin Du
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China
| | - Bo-Hao Tang
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China
| | - Min Kan
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China
| | - Ai-Qing Nie
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China
| | - Rui Yin
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China
| | - Meng Wang
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China
| | - Lin-Lin Song
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, 250014, People's Republic of China
| | - Xin-Mei Yang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, 250014, People's Republic of China
| | - Xin Huang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, 250014, People's Republic of China
| | - Le-Qun Su
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, 250014, People's Republic of China
| | - Wen-Qi Wang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, 250014, People's Republic of China
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA.,Departments of Pediatrics, Pharmacology & Physiology, Genomics & Precision Medicine, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA.,Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Wei Zhao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China.,Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, 250014, People's Republic of China
| |
Collapse
|
29
|
Aulin LB, de Lange DW, Saleh MA, van der Graaf PH, Völler S, van Hasselt JC. Biomarker-Guided Individualization of Antibiotic Therapy. Clin Pharmacol Ther 2021; 110:346-360. [PMID: 33559152 PMCID: PMC8359228 DOI: 10.1002/cpt.2194] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/02/2021] [Indexed: 12/11/2022]
Abstract
Treatment failure of antibiotic therapy due to insufficient efficacy or occurrence of toxicity is a major clinical challenge, and is expected to become even more urgent with the global rise of antibiotic resistance. Strategies to optimize treatment in individual patients are therefore of crucial importance. Currently, therapeutic drug monitoring plays an important role in optimizing antibiotic exposure to reduce treatment failure and toxicity. Biomarker-based strategies may be a powerful tool to further quantify and monitor antibiotic treatment response, and reduce variation in treatment response between patients. Host response biomarkers, such as CRP, procalcitonin, IL-6, and presepsin, could potentially carry significant information to be utilized for treatment individualization. To achieve this, the complex interactions among immune system, pathogen, drug, and biomarker need to be better understood and characterized. The purpose of this tutorial is to discuss the use and evidence of currently available biomarker-based approaches to inform antibiotic treatment. To this end, we also included a discussion on how treatment response biomarker data from preclinical, healthy volunteer, and patient-based studies can be further characterized using pharmacometric and system pharmacology based modeling approaches. As an illustrative example of how such modeling strategies can be used, we describe a case study in which we quantitatively characterize procalcitonin dynamics in relation to antibiotic treatments in patients with sepsis.
Collapse
Affiliation(s)
- Linda B.S. Aulin
- Division of Systems Biomedicine and PharmacologyLeiden Academic Centre for Drug ResearchLeiden UniversityLeidenThe Netherlands
| | - Dylan W. de Lange
- Department of Intensive Care MedicineUniversity Medical CenterUniversity UtrechtUtrechtThe Netherlands
| | - Mohammed A.A. Saleh
- Division of Systems Biomedicine and PharmacologyLeiden Academic Centre for Drug ResearchLeiden UniversityLeidenThe Netherlands
| | - Piet H. van der Graaf
- Division of Systems Biomedicine and PharmacologyLeiden Academic Centre for Drug ResearchLeiden UniversityLeidenThe Netherlands
- CertaraCanterburyUK
| | - Swantje Völler
- Division of Systems Biomedicine and PharmacologyLeiden Academic Centre for Drug ResearchLeiden UniversityLeidenThe Netherlands
- Pharmacy, Leiden Academic Centre for Drug ResearchLeiden UniversityLeidenThe Netherlands
| | - J.G. Coen van Hasselt
- Division of Systems Biomedicine and PharmacologyLeiden Academic Centre for Drug ResearchLeiden UniversityLeidenThe Netherlands
| |
Collapse
|
30
|
Hartman SJF, Brüggemann RJ, Orriëns L, Dia N, Schreuder MF, de Wildt SN. Pharmacokinetics and Target Attainment of Antibiotics in Critically Ill Children: A Systematic Review of Current Literature. Clin Pharmacokinet 2021; 59:173-205. [PMID: 31432468 PMCID: PMC7007426 DOI: 10.1007/s40262-019-00813-w] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pharmacokinetics (PK) are severely altered in critically ill patients due to changes in volume of distribution (Vd) and/or drug clearance (Cl). This affects the target attainment of antibiotics in critically ill children. We aimed to identify gaps in current knowledge and to compare published PK parameters and target attainment of antibiotics in critically ill children to healthy children and critically ill adults. METHODS Systematic literature search in PubMed, EMBASE and Web of Science. Articles were labelled as relevant when they included information on PK of antibiotics in critically ill, non-neonatal, pediatric patients. Extracted PK-parameters included Vd, Cl, (trough) concentrations, AUC, probability of target attainment, and elimination half-life. RESULTS 50 relevant articles were identified. Studies focusing on vancomycin were most prevalent (17/50). Other studies included data on penicillins, cephalosporins, carbapenems and aminoglycosides, but data on ceftriaxone, ceftazidime, penicillin and metronidazole could not be found. Critically ill children generally show a higher Cl and larger Vd than healthy children and critically ill adults. Reduced target-attainment was described in critically ill children for multiple antibiotics, including amoxicillin, piperacillin, cefotaxime, vancomycin, gentamicin, teicoplanin, amikacin and daptomycin. 38/50 articles included information on both Vd and Cl, but a dosing advice was given in only 22 articles. CONCLUSION The majority of studies focus on agents where TDM is applied, while other antibiotics lack data altogether. The larger Vd and higher Cl in critically ill children might warrant a higher dose or extended infusions of antibiotics in this patient population to increase target-attainment. Studies frequently fail to provide a dosing advice for this patient population, even if the necessary information is available. Our study shows gaps in current knowledge and encourages future researchers to provide dosing advice for special populations whenever possible.
Collapse
Affiliation(s)
- Stan J F Hartman
- Department of Pharmacology-Toxicology, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | | | - Lynn Orriëns
- Department of Pharmacology-Toxicology, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Nada Dia
- Department of Pharmacology-Toxicology, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Michiel F Schreuder
- Division of Pediatric Nephrology, Department of Pediatrics, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Saskia N de Wildt
- Department of Pharmacology-Toxicology, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.,Department of Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands.,Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
31
|
Goulooze SC, Ista E, van Dijk M, Tibboel D, Krekels EHJ, Knibbe CAJ. Towards Evidence-Based Weaning: a Mechanism-Based Pharmacometric Model to Characterize Iatrogenic Withdrawal Syndrome in Critically Ill Children. AAPS JOURNAL 2021; 23:71. [PMID: 34002290 PMCID: PMC8128736 DOI: 10.1208/s12248-021-00586-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 03/22/2021] [Indexed: 11/30/2022]
Abstract
For the management of iatrogenic withdrawal syndrome (IWS) in children, a quantitative understanding of the dynamics of IWS of commonly used opioids and sedatives is lacking. Here, we introduce a new mechanism-based pharmacokinetic-pharmacodynamic (PKPD) modeling approach for studying IWS in pediatric clinical datasets. One thousand seven hundred eighty-two NRSwithdrawal scores of IWS severity were analyzed, which were collected from 81 children (age range: 1 month–18 years) that received opioids or sedatives by continuous infusion for 5 days or more. These data were successfully fitted with a PKPD model consisting of a plasma and a dependence compartment that well characterized the dynamics of IWS from morphine, fentanyl, and ketamine. The results suggest that (1) instead of decreasing the infusion rate by a set percentage at set intervals, it would be better to lengthen the weaning period when higher infusion rates are administered prior to weaning; (2) for fentanyl specifically, the risk of IWS might be lower when weaning with smaller dose reductions every 12 h instead of weaning with greater dose reductions every 48 h. The developed PKPD model can be used to evaluate the risk of IWS over time and the extent to which it is affected by different weaning strategies. The results yield hypotheses that could guide future clinical research on optimal weaning strategies. The mechanism-based PKPD modeling approach can be applied in other datasets to characterize the IWS dynamics of other drugs used in pediatric intensive care.
Collapse
Affiliation(s)
- Sebastiaan C Goulooze
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333, CC, Leiden, The Netherlands.,LAP&P Consultants BV, Leiden, The Netherlands
| | - Erwin Ista
- Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Monique van Dijk
- Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.,Division of Nursing Science, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dick Tibboel
- Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Elke H J Krekels
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333, CC, Leiden, The Netherlands
| | - Catherijne A J Knibbe
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333, CC, Leiden, The Netherlands. .,Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.
| |
Collapse
|
32
|
Sedation With Midazolam After Cardiac Surgery in Children With and Without Down Syndrome: A Pharmacokinetic-Pharmacodynamic Study. Pediatr Crit Care Med 2021; 22:e259-e269. [PMID: 33031353 DOI: 10.1097/pcc.0000000000002580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare the pharmacokinetics and pharmacodynamics of IV midazolam after cardiac surgery between children with and without Down syndrome. DESIGN Prospective, single-center observational trial. SETTING PICU in a university-affiliated pediatric teaching hospital. PATIENTS Twenty-one children with Down syndrome and 17 without, 3-36 months, scheduled for cardiac surgery with cardiopulmonary bypass. INTERVENTIONS Postoperatively, nurses regularly assessed the children's pain and discomfort with the validated COMFORT-Behavioral scale and Numeric Rating Scale for pain. A loading dose of morphine (100 µg/kg) was administered after coming off bypass; thereafter, morphine infusion was commenced at 40 µg/kg/hr. Midazolam was started if COMFORT-Behavioral scale score of greater than 16 and Numeric Rating Scale score of less than 4 (suggestive of undersedation). Plasma midazolam and metabolite concentrations were measured for population pharmacokinetic- and pharmacodynamic analysis using nonlinear mixed effects modeling (NONMEM) (Version VI; GloboMax LLC, Hanover, MD) software. MEASUREMENTS AND MAIN RESULTS Twenty-six children (72%) required midazolam postoperatively (15 with Down syndrome and 11 without; p = 1.00). Neither the cumulative midazolam dose (p = 0.61) nor the time elapsed before additional sedation was initiated (p = 0.71), statistically significantly differed between children with and without Down syndrome. Population pharmacokinetic and pharmacodynamics analysis revealed no statistically significant differences between the children with and without Down syndrome. Bodyweight was a significant covariate for the clearance of 1-OH-midazolam to 1-OH-glucuronide (p = 0.003). Pharmacodynamic analysis revealed a marginal effect of the midazolam concentration on the COMFORT-Behavioral score. CONCLUSIONS The majority of children with and without Down syndrome required additional sedation after cardiac surgery. This pharmacokinetic and pharmacodynamic analysis does not provide evidence for different dosing of midazolam in children with Down syndrome after cardiac surgery.
Collapse
|
33
|
Simon F, Gautier-Veyret E, Truffot A, Chenel M, Payen L, Stanke-Labesque F, Tod M. Modeling Approach to Predict the Impact of Inflammation on the Pharmacokinetics of CYP2C19 and CYP3A4 Substrates. Pharm Res 2021; 38:415-428. [PMID: 33686560 DOI: 10.1007/s11095-021-03019-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/18/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE For decades, inflammation has been considered a cause of pharmacokinetic variability, mainly in relation to the inhibitory effect of pro-inflammatory cytokines on the expression level and activity of cytochrome P450 (CYP). In vitro and clinical studies have shown that two major CYPs, CYP2C19 and CYP3A4, are both impaired. The objective of the present study was to quantify the impact of the inflammatory response on the activity of both CYPs in order to predict the pharmacokinetic profile of their substrates according to systemic C-reactive protein (CRP). METHODS The relationships between CRP concentration and both CYPs activities were estimated and validated using clinical data first on midazolam then on voriconazole. Finally, clinical data on omeprazole were used to validate the findings. For each substrate, a physiologically based pharmacokinetics model was built using a bottom-up approach, and the relationships between CRP level and CYP activities were estimated by a top-down approach. After incorporating the respective relationships, we compared the predictions and observed drug concentrations. RESULTS Changes in pharmacokinetic profiles and parameters induced by inflammation seem to be captured accurately by the models. CONCLUSIONS These findings suggest that the pharmacokinetics of CYP2C19 and CYP3A4 substrates can be predicted depending on the CRP concentration.
Collapse
Affiliation(s)
- Florian Simon
- EA3738, Faculté de médecine de Lyon-Sud, Université de Lyon 1, 69921, Université de Lyon 1, Oullins cedex, France. .,Laboratoire de biochimie-toxicologie, Centre hospitalier Lyon-Sud, Hospices civils de Lyon, Pierre Bénite, Lyon, France.
| | - Elodie Gautier-Veyret
- Laboratoire de Pharmacologie, Pharmacogenetique et Toxicologie, Centre Hospitalier Universitaire des Alpes, 38043, Grenoble, France.,University Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, 38000, Grenoble, France
| | - Aurélie Truffot
- Laboratoire de Pharmacologie, Pharmacogenetique et Toxicologie, Centre Hospitalier Universitaire des Alpes, 38043, Grenoble, France
| | - Marylore Chenel
- Institut de recherches internationales Servier, Direction of clinical PK and pharmacometrics, Suresnes, France
| | - Léa Payen
- Laboratoire de biochimie-toxicologie, Centre hospitalier Lyon-Sud, Hospices civils de Lyon, Pierre Bénite, Lyon, France
| | - Françoise Stanke-Labesque
- Laboratoire de Pharmacologie, Pharmacogenetique et Toxicologie, Centre Hospitalier Universitaire des Alpes, 38043, Grenoble, France.,University Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, 38000, Grenoble, France
| | - Michel Tod
- EA3738, Faculté de médecine de Lyon-Sud, Université de Lyon 1, 69921, Université de Lyon 1, Oullins cedex, France
| |
Collapse
|
34
|
van Groen BD, Krekels EHJ, Mooij MG, van Duijn E, Vaes WHJ, Windhorst AD, van Rosmalen J, Hartman SJF, Hendrikse NH, Koch BCP, Allegaert K, Tibboel D, Knibbe CAJ, de Wildt SN. The Oral Bioavailability and Metabolism of Midazolam in Stable Critically Ill Children: A Pharmacokinetic Microtracing Study. Clin Pharmacol Ther 2021; 109:140-149. [PMID: 32403162 PMCID: PMC7818442 DOI: 10.1002/cpt.1890] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/15/2020] [Indexed: 12/21/2022]
Abstract
Midazolam is metabolized by the developmentally regulated intestinal and hepatic drug-metabolizing enzyme cytochrome P450 (CYP) 3A4/5. It is frequently administered orally to children, yet knowledge is lacking on the oral bioavailability in term neonates up until 1 year of age. Furthermore, the dispositions of the major metabolites 1-OH-midazolam (OHM) and 1-OH-midazolam-glucuronide (OHMG) after oral administration are largely unknown for the entire pediatric age span. We aimed to fill these knowledge gaps with a pediatric [14 C]midazolam microtracer population pharmacokinetic study. Forty-six stable, critically ill children (median age 9.8 (range 0.3-276.4) weeks) received a single oral [14 C]midazolam microtracer (58 (40-67) Bq/kg) when they received a therapeutic continuous intravenous midazolam infusion and had an arterial line in place enabling blood sampling. For midazolam, in a one-compartment model, bodyweight was a significant predictor for clearance (0.98 L/hour) and volume of distribution (8.7 L) (values for a typical individual of 5 kg). The typical oral bioavailability in the population was 66% (range 25-85%). The exposures of OHM and OHMG were highest for the youngest age groups and significantly decreased with postnatal age. The oral bioavailability of midazolam, largely reflective of intestinal and hepatic CYP3A activity, was on average lower than the reported 49-92% for preterm neonates, and higher than the reported 21% for children> 1 year of age and 30% for adults. As midazolam oral bioavailability varied widely, systemic exposure of other CYP3A-substrate drugs after oral dosing in this population may also be unpredictable, with risk of therapy failure or toxicity.
Collapse
Affiliation(s)
- Bianca D. van Groen
- Intensive Care and Pediatric SurgeryErasmus Medical Center – Sophia Children’s HospitalRotterdamThe Netherlands
| | - Elke H. J. Krekels
- Leiden Academic Center for Drug ResearchLeiden UniversityLeidenThe Netherlands
| | - Miriam G. Mooij
- Department of PediatricsLeiden University Medical CentreLeidenThe Netherlands
| | | | | | - Albert D. Windhorst
- Amsterdam University Medical Centers – Location VU Medical CenterAmsterdamThe Netherlands
| | - Joost van Rosmalen
- Department of BiostatisticsErasmus Medical CenterRotterdamthe Netherlands
| | - Stan J. F. Hartman
- Department of Pharmacology and ToxicologyRadboud University Medical CenterRadboud Institute for Health SciencesNijmegenThe Netherlands
| | - N. Harry Hendrikse
- Amsterdam University Medical Centers – Location VU Medical CenterAmsterdamThe Netherlands
| | - Birgit C. P. Koch
- Department of Hospital PharmacyErasmus Medical CenterRotterdamThe Netherlands
| | - Karel Allegaert
- Department of Hospital PharmacyErasmus Medical CenterRotterdamThe Netherlands
- Katholieke Universiteit LeuvenLeuvenBelgium
| | - Dick Tibboel
- Intensive Care and Pediatric SurgeryErasmus Medical Center – Sophia Children’s HospitalRotterdamThe Netherlands
| | - Catherijne A. J. Knibbe
- Leiden Academic Center for Drug ResearchLeiden UniversityLeidenThe Netherlands
- St Antonius HospitalNieuwegeinThe Netherlands
| | - Saskia N. de Wildt
- Intensive Care and Pediatric SurgeryErasmus Medical Center – Sophia Children’s HospitalRotterdamThe Netherlands
- Department of Pharmacology and ToxicologyRadboud University Medical CenterRadboud Institute for Health SciencesNijmegenThe Netherlands
| |
Collapse
|
35
|
Abdulla A, Edwina EE, Flint RB, Allegaert K, Wildschut ED, Koch BCP, de Hoog M. Model-Informed Precision Dosing of Antibiotics in Pediatric Patients: A Narrative Review. Front Pediatr 2021; 9:624639. [PMID: 33708753 PMCID: PMC7940353 DOI: 10.3389/fped.2021.624639] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 02/03/2021] [Indexed: 12/17/2022] Open
Abstract
Optimal pharmacotherapy in pediatric patients with suspected infections requires understanding and integration of relevant data on the antibiotic, bacterial pathogen, and patient characteristics. Because of age-related physiological maturation and non-maturational covariates (e.g., disease state, inflammation, organ failure, co-morbidity, co-medication and extracorporeal systems), antibiotic pharmacokinetics is highly variable in pediatric patients and difficult to predict without using population pharmacokinetics models. The intra- and inter-individual variability can result in under- or overexposure in a significant proportion of patients. Therapeutic drug monitoring typically covers assessment of pharmacokinetics and pharmacodynamics, and concurrent dose adaptation after initial standard dosing and drug concentration analysis. Model-informed precision dosing (MIPD) captures drug, disease, and patient characteristics in modeling approaches and can be used to perform Bayesian forecasting and dose optimization. Incorporating MIPD in the electronic patient record system brings pharmacometrics to the bedside of the patient, with the aim of a consisted and optimal drug exposure. In this narrative review, we evaluated studies assessing optimization of antibiotic pharmacotherapy using MIPD in pediatric populations. Four eligible studies involving amikacin and vancomycin were identified from 418 records. Key articles, independent of year of publication, were also selected to highlight important attributes of MIPD. Although very little research has been conducted until this moment, the available data on vancomycin indicate that MIPD is superior compared to conventional dosing strategies with respect to target attainment. The utility of MIPD in pediatrics needs to be further confirmed in frequently used antibiotic classes, particularly aminoglycosides and beta-lactams.
Collapse
Affiliation(s)
- Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Elma E Edwina
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Robert B Flint
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands.,Division of Neonatology, Department of Pediatrics, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Enno D Wildschut
- Department of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Matthijs de Hoog
- Department of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| |
Collapse
|
36
|
de Jong LM, Jiskoot W, Swen JJ, Manson ML. Distinct Effects of Inflammation on Cytochrome P450 Regulation and Drug Metabolism: Lessons from Experimental Models and a Potential Role for Pharmacogenetics. Genes (Basel) 2020; 11:genes11121509. [PMID: 33339226 PMCID: PMC7766585 DOI: 10.3390/genes11121509] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/07/2020] [Accepted: 12/14/2020] [Indexed: 12/18/2022] Open
Abstract
Personalized medicine strives to optimize drug treatment for the individual patient by taking into account both genetic and non-genetic factors for drug response. Inflammation is one of the non-genetic factors that has been shown to greatly affect the metabolism of drugs—primarily through inhibition of cytochrome P450 (CYP450) drug-metabolizing enzymes—and hence contribute to the mismatch between the genotype predicted drug response and the actual phenotype, a phenomenon called phenoconversion. This review focuses on inflammation-induced drug metabolism alterations. In particular, we discuss the evidence assembled through human in-vitro models on the effect of inflammatory mediators on clinically relevant CYP450 isoform levels and their metabolizing capacity. We also present an overview of the current understanding of the mechanistic pathways via which inflammation in hepatocytes may modulate hepatic functions that are critical for drug metabolism. Furthermore, since large inter-individual variability in response to inflammation is observed in human in-vitro models and clinical studies, we evaluate the potential role of pharmacogenetic variability in the inflammatory signaling cascade and how this can modulate the outcome of inflammation on drug metabolism and response.
Collapse
Affiliation(s)
- Laura M. de Jong
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research (LACDR), Leiden University, 2333 CC Leiden, The Netherlands; (L.M.d.J.); (W.J.)
| | - Wim Jiskoot
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research (LACDR), Leiden University, 2333 CC Leiden, The Netherlands; (L.M.d.J.); (W.J.)
| | - Jesse J. Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center (LUMC), 2333 ZA Leiden, The Netherlands;
- Leiden Network for Personalised Therapeutics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Martijn L. Manson
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research (LACDR), Leiden University, 2333 CC Leiden, The Netherlands; (L.M.d.J.); (W.J.)
- Leiden Network for Personalised Therapeutics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Correspondence:
| |
Collapse
|
37
|
Chavant A, Gautier-Veyret E, Chhun S, Guilhaumou R, Stanke-Labesque F. [Pharmacokinetic changes related to acute infection. Examples from the SARS-CoV-2 pandemic]. Therapie 2020; 76:319-333. [PMID: 33129512 PMCID: PMC7833468 DOI: 10.1016/j.therap.2020.10.001] [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: 08/05/2020] [Revised: 09/18/2020] [Accepted: 10/12/2020] [Indexed: 01/08/2023]
Abstract
The knowledge of factors of pharmacokinetic variability is important in order to personalize pharmacological treatment, particularly for drugs with a narrow therapeutic range for which pharmacological therapeutic monitoring is recommended. Inflammation is a protective response against acute infections and injuries that contributes to intra- and inter-individual variability in drug exposure by modulating the activity of enzymes involved in drug metabolism, and by altering the binding of drugs to plasma proteins. The understanding of the impact of inflammation on drug metabolism and the related clinical consequences allow to better take into consideration the effect of inflammation on the variability of drug exposure. We first summarized the molecular mechanisms by which inflammation contributes to the inhibition of drug metabolism enzymes. We then presented an updated overview of the consequences of the outcome of acute infectious event on pharmacokinetic exposure of drugs with a narrow therapeutic range and that are substrates of cytochrome P450, and the related clinical consequences. Finally, in the context of the COVID-19 pandemic, we reported examples of drug overexposures in COVID- 19 infected patients.
Collapse
Affiliation(s)
- Anaëlle Chavant
- Laboratoire de pharmacologie-pharmacogénétique-toxicologie, pôle de biologie et pathologie, CHU Grenoble Alpes, 38700 La Tronche, France
| | - Elodie Gautier-Veyret
- Laboratoire de pharmacologie-pharmacogénétique-toxicologie, pôle de biologie et pathologie, CHU Grenoble Alpes, 38700 La Tronche, France; University Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, 38043 Grenoble, France
| | - Stéphanie Chhun
- UFR de médecine Paris centre, 75015 Paris, France; Institut Necker-Enfants Malades (INEM), Inserm U1151-CNRS UMR 8253, 75015 Paris, France; Laboratoire d'immunologie biologique, département médico universitaire BioPhyGen, hôpital universitaire Necker-enfants malades, AP-HP, 75015 Paris, France
| | - Romain Guilhaumou
- Unité de pharmacologie clinique et pharmacovigilance AP-HM, 13354 Marseille, France; Aix Marseille Univ, Inserm, INS Inst Neurosci Syst, 13354 Marseille, France
| | - Françoise Stanke-Labesque
- Laboratoire de pharmacologie-pharmacogénétique-toxicologie, pôle de biologie et pathologie, CHU Grenoble Alpes, 38700 La Tronche, France; University Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, 38043 Grenoble, France.
| |
Collapse
|
38
|
Allegaert K, van den Anker J. Ontogeny of Phase I Metabolism of Drugs. J Clin Pharmacol 2020; 59 Suppl 1:S33-S41. [PMID: 31502685 DOI: 10.1002/jcph.1483] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 06/17/2019] [Indexed: 12/17/2022]
Abstract
Capturing ontogeny of enzymes involved in phase I metabolism is crucial to improve prediction of dose-concentration and concentration-effect relationships throughout infancy and childhood. Once captured, these patterns can be integrated in semiphysiologically or physiology-based pharmacokinetic models to support predictions in specific pediatric settings or to support pediatric drug development. Although these translational efforts are crucial, isoenzyme-specific ontogeny-based models should also incorporate data on variability of maturational and nonmaturational covariates (eg, disease, treatment modalities, pharmacogenetics). Therefore, this review provides a summary of the ontogeny of phase I drug-metabolizing enzymes, indicating current knowledge gaps and recent progresses. Furthermore, we tried to illustrate that straightforward translation of isoenzyme-specific ontogeny to predictions does not allow full exploration of scenarios of potential variability related to maturational (non-age-related variability, other isoenzymes or transporters) or nonmaturational (disease, pharmacogenetics) covariates, and necessitates integration in a "systems" concept.
Collapse
Affiliation(s)
- Karel Allegaert
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| |
Collapse
|
39
|
Francoeur C, Welsh SS, Ichord R, Abend NS, Topjian AA, Zuppa AF. Assessment of midazolam pharmacokinetics in the treatment of status epilepticus. Seizure 2020; 81:310-314. [PMID: 32947180 DOI: 10.1016/j.seizure.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/27/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVES Refractory status epilepticus (RSE) is often treated with midazolam boluses and continuous infusions, but there is considerable variability in dosing and efficacy. We aimed to evaluate the performance of a clinical midazolam dose escalation pathway for the treatment of pediatric RSE that was designed based on a novel midazolam pharmacokinetic model. DESIGN Prospective pharmacokinetic study of midazolam bolus and escalation of continuous midazolam infusion. SETTING Pediatric Intensive Care Unit in quaternary-care academic hospital. SUBJECTS Children between two months to seventeen years of age who received clinically-indicated midazolam infusion for treatment of RSE. INTERVENTION Blood sampled at regular intervals during treatment. Main study outcome measure was the accuracy of a pharmacokinetic model to predict serum midazolam concentrations. MEASUREMENTS AND MAIN RESULTS We analysed data from six subjects. Three subjects had serum midazolam concentrations close to those predicted by our initial model (accuracy 88.9-170.2 %) which incorporates body weight, hepatic function, and renal function. For the other three subjects, all of whom were receiving pre-existing chronic benzodiazepine therapy prior to the RSE episode, the model grossly overestimated serum concentrations (predictive error 420.3-722.5 %). Once the model was corrected for the impact of pre-existing chronic benzodiazepine use on clearance, predicted concentrations more closely reflected those measured in subjects. CONCLUSION We evaluated a clinical midazolam RSE treatment pathway but discovered that the model on which the pathway was based was not accurate for all patients. We therefore developed a novel pharmacokinetic midazolam model in children with RSE treated with continuous midazolam infusion. This model incorporates body weight, hepatic and renal function, and importantly, a correction factor for pre-existing chronic benzodiazepine use. Once validated, this model may guide dosing and drive the development of more effective treatment pathways for continuous midazolam in RSE.
Collapse
Affiliation(s)
- Conall Francoeur
- Department of Pediatrics, CHU de Québec - Université Laval Research Center, Canada.
| | - Sarah S Welsh
- Division of Pediatric Critical Care Medicine, Hasbro Children's Hospital, Providence, RI, United States
| | - Rebecca Ichord
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Nicholas S Abend
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| |
Collapse
|
40
|
van Groen BD, Allegaert K, Tibboel D, de Wildt SN. Innovative approaches and recent advances in the study of ontogeny of drug metabolism and transport. Br J Clin Pharmacol 2020; 88:4285-4296. [PMID: 32851677 PMCID: PMC9545189 DOI: 10.1111/bcp.14534] [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: 04/29/2020] [Revised: 08/10/2020] [Accepted: 08/16/2020] [Indexed: 11/30/2022] Open
Abstract
The disposition of a drug is driven by various processes, such as drug metabolism, drug transport, glomerular filtration and body composition. These processes are subject to developmental changes reflecting growth and maturation along the paediatric continuum. However, knowledge gaps exist on these changes and their clinical impact. Filling these gaps may aid better prediction of drug disposition and creation of age-appropriate dosing guidelines. We present innovative approaches to study these developmental changes in relation to drug metabolism and transport. First, analytical methods such as including liquid chromatography-mass spectrometry for proteomic analyses allow quantitation of the expressions of a wide variety of proteins, e.g. membrane transporters, in a small piece of organ tissue. The latter is specifically important for paediatric research, where tissues are scarcely available. Second, innovative study designs using radioactive labelled microtracers allowed study-without risk for the child-of the oral bioavailability of compounds used as markers for certain drug metabolism pathways. Third, the use of modelling and simulation to support dosing recommendations for children is supported by both the European Medicines Agency and the US Food and Drug Administration. This may even do away with the need for a paediatric trial. Physiologically based pharmacokinetics models, which include age-specific physiological information are, therefore, increasingly being used, not only to aid paediatric drug development but also to improve existing drug therapies.
Collapse
Affiliation(s)
- Bianca D van Groen
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Pharmacy and Pharmaceutical Sciences, KU Leuven, Leuven, Belgium.,Department of Clinical Pharmacy, Erasmus MC, Rotterdam, the Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Saskia N de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Pharmacology and Toxicology, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
41
|
Stanke-Labesque F, Gautier-Veyret E, Chhun S, Guilhaumou R. Inflammation is a major regulator of drug metabolizing enzymes and transporters: Consequences for the personalization of drug treatment. Pharmacol Ther 2020; 215:107627. [PMID: 32659304 PMCID: PMC7351663 DOI: 10.1016/j.pharmthera.2020.107627] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/06/2020] [Indexed: 12/22/2022]
Abstract
Inflammation is an evolutionary process that allows survival against acute infection or injury. Inflammation is also a pathophysiological condition shared by numerous chronic diseases. In addition, inflammation modulates important drug-metabolizing enzymes and transporters (DMETs), thus contributing to intra- and interindividual variability of drug exposure. A better knowledge of the impact of inflammation on drug metabolism and its related clinical consequences would help to personalize drug treatment. Here, we summarize the kinetics of inflammatory mediators and the underlying transcriptional and post-transcriptional mechanisms by which they contribute to the inhibition of important DMETs. We also present an updated overview of the effect of inflammation on the pharmacokinetic parameters of most of the drugs that are DMET substrates, for which therapeutic drug monitoring is recommended. Furthermore, we provide opinions on how to integrate the inflammatory status into pharmacogenetics, therapeutic drug monitoring, and population pharmacokinetic strategies to improve the personalization of drug treatment for each patient.
Collapse
Affiliation(s)
- Françoise Stanke-Labesque
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, Grenoble 38000, France; Laboratory of Pharmacology-Pharmacogenetics-Toxicology, Pôle de Biologie et Pathologie, CHU Grenoble Alpes, France.
| | - Elodie Gautier-Veyret
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, Grenoble 38000, France; Laboratory of Pharmacology-Pharmacogenetics-Toxicology, Pôle de Biologie et Pathologie, CHU Grenoble Alpes, France
| | - Stephanie Chhun
- Faculty of Medicine, Paris University, Paris, France; Institut Necker-Enfants Malades (INEM), INSERM U1151-CNRS UMR 8253, Paris, France; AP-HP, Paris Centre, Laboratory of Immunology, Necker-Enfants Malades Hospital, Paris, France
| | - Romain Guilhaumou
- Clinical Pharmacology and Pharmacovigilance Unit, AP-HM, Marseille, France; Aix Marseille Univ, INSERM, INS Inst Neurosci Syst, Marseille, France
| |
Collapse
|
42
|
Smit C, Peeters MYM, van den Anker JN, Knibbe CAJ. Chloroquine for SARS-CoV-2: Implications of Its Unique Pharmacokinetic and Safety Properties. Clin Pharmacokinet 2020; 59:659-669. [PMID: 32306288 PMCID: PMC7165255 DOI: 10.1007/s40262-020-00891-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Since in vitro studies and a preliminary clinical report suggested the efficacy of chloroquine for COVID-19-associated pneumonia, there is increasing interest in this old antimalarial drug. In this article, we discuss the pharmacokinetics and safety of chloroquine that should be considered in light of use in SARS-CoV-2 infections. Chloroquine is well absorbed and distributes extensively resulting in a large volume of distribution with an apparent and terminal half-life of 1.6 days and 2 weeks, respectively. Chloroquine is metabolized by cytochrome P450 and renal clearance is responsible for one third of total clearance. The lack of reliable information on target concentrations or doses for COVID-19 implies that for both adults and children, doses that proved effective and safe in malaria should be considered, such as 'loading doses' in adults (30 mg/kg over 48 h) and children (70 mg/kg over 5 days), which reported good tolerability. Here, plasma concentrations were < 2.5 μmol/L, which is associated with (minor) toxicity. While the influence of renal dysfunction, critical illness, or obesity seems small, in critically ill patients, reduced absorption may be anticipated. Clinical experience has shown that chloroquine has a narrow safety margin, as three times the adult therapeutic dosage for malaria can be lethal when given as a single dose. Although infrequent, poisoning in children is extremely dangerous where one to two tablets can potentially be fatal. In conclusion, the pharmacokinetic and safety properties of chloroquine suggest that chloroquine can be used safely for an acute virus infection, under corrected QT monitoring, but also that the safety margin is small, particularly in children.
Collapse
Affiliation(s)
- Cornelis Smit
- Pediatric Pharmacology and Pharmacometrics Research Center, University of Basel Children's Hospital, Basel, Switzerland
- Department of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Mariska Y M Peeters
- Department of Clinical Pharmacy, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - John N van den Anker
- Pediatric Pharmacology and Pharmacometrics Research Center, University of Basel Children's Hospital, Basel, Switzerland
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
| | - Catherijne A J Knibbe
- Department of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.
- Department of Clinical Pharmacy, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.
| |
Collapse
|
43
|
Stillhart C, Vučićević K, Augustijns P, Basit AW, Batchelor H, Flanagan TR, Gesquiere I, Greupink R, Keszthelyi D, Koskinen M, Madla CM, Matthys C, Miljuš G, Mooij MG, Parrott N, Ungell AL, de Wildt SN, Orlu M, Klein S, Müllertz A. Impact of gastrointestinal physiology on drug absorption in special populations––An UNGAP review. Eur J Pharm Sci 2020; 147:105280. [DOI: 10.1016/j.ejps.2020.105280] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 02/10/2020] [Accepted: 02/24/2020] [Indexed: 02/07/2023]
|
44
|
Midazolam Dose Optimization in Critically Ill Pediatric Patients With Acute Respiratory Failure: A Population Pharmacokinetic-Pharmacogenomic Study. Crit Care Med 2020; 47:e301-e309. [PMID: 30672747 DOI: 10.1097/ccm.0000000000003638] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To develop a pharmacokinetic-pharmacogenomic population model of midazolam in critically ill children with primary respiratory failure. DESIGN Prospective pharmacokinetic-pharmacogenomic observational study. SETTING Thirteen PICUs across the United States. PATIENTS Pediatric subjects mechanically ventilated for acute respiratory failure, weight greater than or equal to 7 kg, receiving morphine and/or midazolam continuous infusions. INTERVENTIONS Serial blood sampling for drug quantification and a single blood collection for genomic evaluation. MEASUREMENTS AND MAIN RESULTS Concentrations of midazolam, the 1' (1`-hydroxymidazolam metabolite) and 4' (4`-hydroxymidazolam metabolite) hydroxyl, and the 1' and 4' glucuronide metabolites were measured. Subjects were genotyped using the Illumina HumanOmniExpress genome-wide single nucleotide polymorphism chip. Nonlinear mixed effects modeling was performed to develop the pharmacokinetic-pharmacogenomic model. Body weight, age, hepatic and renal functions, and the UGT2B7 rs62298861 polymorphism are relevant predictors of midazolam pharmacokinetic variables. The estimated midazolam clearance was 0.61 L/min/70kg. Time to reach 50% complete mature midazolam and 1`-hydroxymidazolam metabolite/4`-hydroxymidazolam metabolite clearances was 1.0 and 0.97 years postmenstrual age. The final model suggested a decrease in midazolam clearance with increase in alanine transaminase and a lower clearance of the glucuronide metabolites with a renal dysfunction. In the pharmacogenomic analysis, rs62298861 and rs28365062 in the UGT2B7 gene were in high linkage disequilibrium. Minor alleles were associated with a higher 1`-hydroxymidazolam metabolite clearance in Caucasians. In the pharmacokinetic-pharmacogenomic model, clearance was expected to increase by 10% in heterozygous and 20% in homozygous for the minor allele with respect to homozygous for the major allele. CONCLUSIONS This work leveraged available knowledge on nonheritable and heritable factors affecting midazolam pharmacokinetic in pediatric subjects with primary respiratory failure requiring mechanical ventilation, providing the basis for a future implementation of an individual-based approach to sedation.
Collapse
|
45
|
Kos MK, Miksić M, Jovanović M, Roškar R, Grosek Š, Grabnar I. Maturation of midazolam clearance in critically ill children with severe bronchiolitis: A population pharmacokinetic analysis. Eur J Pharm Sci 2019; 141:105095. [PMID: 31626965 DOI: 10.1016/j.ejps.2019.105095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/24/2019] [Accepted: 09/29/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of the present study was to develop a population pharmacokinetic model of midazolam, and to evaluate the influence of maturation process and other variability factors in critically ill children with severe acute bronchiolitis, who received a long-term intravenous infusion of midazolam. METHODS In the study were included 49 critically ill children of both genders (from 0 to 130 weeks of age) with severe acute bronchiolitis hospitalised in intensive care units. Nonlinear mixed effects modelling approach was applied for data analyses and simulations. RESULTS The final model is a two-compartment model that includes the effects of body weight using allometric scaling with fixed exponents and maturation of clearance. For a typical subject, scaled to the adult body weight of 70 kg, population pharmacokinetic values were estimated at 8.52 L/h for clearance (when maturation function was 1), 25.5 L/h for intercompartmental clearance, and 5.71 L and 39.8 L for the volume of the central and peripheral compartment, respectively. Based on the final model, maturation reaches 50% of the adult clearance in 45.9 weeks of postmenstrual age. The influence of gender, ABCB1 genotype and biochemical parameters on midazolam clearance was not detected. Results of simulations indicate the need for reduced dosing in certain groups of patients in order to maintain plasma concentrations of midazolam within recommended values. CONCLUSIONS The developed population pharmacokinetic model can contribute to the dosing optimisation of midazolam, especially in critically ill children as it includes the influence of size and maturation of clearance, which are important parameters for achieving the desired plasma concentrations of midazolam.
Collapse
Affiliation(s)
- Mojca Kerec Kos
- Faculty of Pharmacy, University of Ljubljana, Askerceva cesta 7, Ljubljana 1000, Slovenia.
| | - Mirjana Miksić
- Division of Paediatrics, University Medical Centre Maribor, Ljubljanska ulica 5, Maribor 2000, Slovenia; Division of Gynaecology and Perinatology, Department of Perinatology, University Medical Centre Maribor, Ljubljanska ulica 5, Maribor 2000, Slovenia
| | - Marija Jovanović
- Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, Belgrade 11221, Serbia
| | - Robert Roškar
- Faculty of Pharmacy, University of Ljubljana, Askerceva cesta 7, Ljubljana 1000, Slovenia
| | - Štefan Grosek
- Division of Surgery, Department of Paediatric Surgery and Intensive Therapy, University Medical Centre Ljubljana, Bohoriceva ulica 20, Ljubljana 1525, Slovenia; Department of Perinatology, Divison of Gynecology and Obstetrics, University Medical Centre Ljubljana, Šlajmerjeva 3, Ljubljana 1000, Slovenia; Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana 1000, Slovenia
| | - Iztok Grabnar
- Faculty of Pharmacy, University of Ljubljana, Askerceva cesta 7, Ljubljana 1000, Slovenia
| |
Collapse
|
46
|
van Groen BD, Vaes WH, Park BK, Krekels EHJ, van Duijn E, Kõrgvee LT, Maruszak W, Grynkiewicz G, Garner RC, Knibbe CAJ, Tibboel D, de Wildt SN, Turner MA. Dose-linearity of the pharmacokinetics of an intravenous [ 14 C]midazolam microdose in children. Br J Clin Pharmacol 2019; 85:2332-2340. [PMID: 31269280 PMCID: PMC6783587 DOI: 10.1111/bcp.14047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/17/2019] [Accepted: 06/20/2019] [Indexed: 01/27/2023] Open
Abstract
Aims Drug disposition in children may vary from adults due to age‐related variation in drug metabolism. Microdose studies present an innovation to study pharmacokinetics (PK) in paediatrics; however, they should be used only when the PK is dose linear. We aimed to assess dose linearity of a [14C]midazolam microdose, by comparing the PK of an intravenous (IV) microtracer (a microdose given simultaneously with a therapeutic midazolam dose), with the PK of a single isolated microdose. Methods Preterm to 2‐year‐old infants admitted to the intensive care unit received [14C]midazolam IV as a microtracer or microdose, followed by dense blood sampling up to 36 hours. Plasma concentrations of [14C]midazolam and [14C]1‐hydroxy‐midazolam were determined by accelerator mass spectrometry. Noncompartmental PK analysis was performed and a population PK model was developed. Results Of 15 infants (median gestational age 39.4 [range 23.9–41.4] weeks, postnatal age 11.4 [0.6–49.1] weeks), 6 received a microtracer and 9 a microdose of [14C]midazolam (111 Bq kg−1; 37.6 ng kg−1). In a 2‐compartment PK model, bodyweight was the most significant covariate for volume of distribution. There was no statistically significant difference in any PK parameter between the microdose and microtracer, nor in the area under curve ratio [14C]1‐OH‐midazolam/[14C]midazolam, showing the PK of midazolam to be linear within the range of the therapeutic and microdoses. Conclusion Our data support the dose linearity of the PK of an IV [14C]midazolam microdose in children. Hence, a [14C]midazolam microdosing approach may be used as an alternative to a therapeutic dose of midazolam to study developmental changes in hepatic CYP3A activity in young children.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Catherijne A J Knibbe
- Leiden University, Leiden, The Netherlands.,Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Dick Tibboel
- Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Saskia N de Wildt
- Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.,Radboud University, Nijmegen, the Netherlands
| | | |
Collapse
|
47
|
Cheung KWK, van Groen BD, Spaans E, van Borselen MD, de Bruijn AC, Simons‐Oosterhuis Y, Tibboel D, Samsom JN, Verdijk RM, Smeets B, Zhang L, Huang S, Giacomini KM, de Wildt SN. A Comprehensive Analysis of Ontogeny of Renal Drug Transporters: mRNA Analyses, Quantitative Proteomics, and Localization. Clin Pharmacol Ther 2019; 106:1083-1092. [PMID: 31127606 PMCID: PMC6777991 DOI: 10.1002/cpt.1516] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/23/2019] [Indexed: 12/21/2022]
Abstract
Human renal membrane transporters play key roles in the disposition of renally cleared drugs and endogenous substrates, but their ontogeny is largely unknown. Using 184 human postmortem frozen renal cortical tissues (preterm newborns to adults) and a subset of 62 tissue samples, we measured the mRNA levels of 11 renal transporters and the transcription factor pregnane X receptor (PXR) with quantitative real‐time polymerase chain reaction, and protein abundance of nine transporters using liquid chromatography tandem mass spectrometry selective reaction monitoring, respectively. Expression levels of p‐glycoprotein, urate transporter 1, organic anion transporter 1, organic anion transporter 3, and organic cation transporter 2 increased with age. Protein levels of multidrug and toxin extrusion transporter 2‐K and breast cancer resistance protein showed no difference from newborns to adults, despite age‐related changes in mRNA expression. Multidrug and toxin extrusion transporter 1, glucose transporter 2, multidrug resistance‐associated protein 2, multidrug resistance‐associated protein 4 (MRP4), and PXR expression levels were stable. Using immunohistochemistry, we found that MRP4 localization in pediatric samples was similar to that in adult samples. Collectively, our study revealed that renal drug transporters exhibited different rates and patterns of maturation, suggesting that renal handling of substrates may change with age.
Collapse
Affiliation(s)
- Kit Wun Kathy Cheung
- Department of Bioengineering and Therapeutic SciencesUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
- Office of Clinical PharmacologyOffice of Translational SciencesCenter for Drug Evaluation & ResearchUS Food and Drug AdministrationSilver SpringMarylandUSA
- Oak Ridge Institute for Science and Education (ORISE Fellow)Oak RidgeTennesseeUSA
| | - Bianca D. van Groen
- Intensive Care and Department of Pediatric SurgeryErasmus MC‐Sophia Children's HospitalRotterdamThe Netherlands
| | - Edwin Spaans
- Intensive Care and Department of Pediatric SurgeryErasmus MC‐Sophia Children's HospitalRotterdamThe Netherlands
- CDTS Consulting BV & SDD Consulting BVEtten‐LeurThe Netherlands
| | | | | | | | - Dick Tibboel
- Intensive Care and Department of Pediatric SurgeryErasmus MC‐Sophia Children's HospitalRotterdamThe Netherlands
| | - Janneke N. Samsom
- Department of PediatricsErasmus MC‐Sophia Children's HospitalRotterdamThe Netherlands
| | | | - Bart Smeets
- Department of PathologyRadboudumcNijmegenThe Netherlands
| | - Lei Zhang
- Office of Research and StandardsOffice of Generic DrugsCenter for Drug Evaluation & ResearchUS Food and Drug AdministrationSilver SpringMarylandUSA
| | - Shiew‐Mei Huang
- Office of Clinical PharmacologyOffice of Translational SciencesCenter for Drug Evaluation & ResearchUS Food and Drug AdministrationSilver SpringMarylandUSA
| | - Kathleen M. Giacomini
- Department of Bioengineering and Therapeutic SciencesUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Saskia N. de Wildt
- Intensive Care and Department of Pediatric SurgeryErasmus MC‐Sophia Children's HospitalRotterdamThe Netherlands
- Department of Pharmacology and ToxicologyRadboud UniversityNijmegenThe Netherlands
| |
Collapse
|
48
|
Völler S, Flint RB, Beggah F, Reiss I, Andriessen P, Zimmermann LJI, van den Anker JN, Liem KD, Koch BCP, de Wildt S, Knibbe CAJ, Simons SHP. Recently Registered Midazolam Doses for Preterm Neonates Do Not Lead to Equal Exposure: A Population Pharmacokinetic Model. J Clin Pharmacol 2019; 59:1300-1308. [PMID: 31093992 PMCID: PMC6767398 DOI: 10.1002/jcph.1429] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 04/04/2019] [Indexed: 11/11/2022]
Abstract
Although midazolam is a frequently used sedative in neonatal intensive care units, its use in preterm neonates has been off-label. Recently, a new dosing advice for midazolam for sedation on intensive care units has been included in the label (0.03 mg/[kg·h] for preterm neonates <32 weeks and 0.06 mg/[kg·h] for neonates >32 weeks). Concentration-time data of a prospective multicenter study (29 patients, median gestational age 26.7 [range 24.0-31.1 weeks]) were combined with previously published data (26 patients, median gestational age 28.1 [range 26.3-33.6 weeks]), and a population pharmacokinetic model describing the maturation of midazolam pharmacokinetics was developed in NONMEM 7.3. Clearance was 73.7 mL/h for a neonate weighing 1.1 kg and changed nonlinearly with body weight (exponent 1.69). Volume of distribution increased linearly with body weight and was 1.03 L for a neonate weighing 1.1 kg. Simulations of the newly registered dosing show considerable differences in steady-state concentrations in preterm neonates. To reach similar steady-state concentrations of 400 µg/mL (±100 µg/mL), a dose of 0.03 mg/(kg·h) is adequate for neonates ≥1 kg and ≤2 kg but would have to be reduced to 0.02 mg/(kg·h) (-33%) in neonates <1 kg and increased to 0.04 mg/(kg·h) (+33%) in neonates weighing >2 kg and ≤2.5 kg. The impact of the observed differences in exposure is difficult to assess because no target concentrations have yet been defined for midazolam, but the current analysis shows that one should be cautious in giving dosage advice based on historical data with a lack of reliable pharmacokinetic and effect data.
Collapse
Affiliation(s)
- Swantje Völler
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands.,Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert B Flint
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Fouzi Beggah
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands.,Université de Montpellier, Montpellier, France
| | - Irwin Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter Andriessen
- Department of Pediatrics, Division of Neonatology, Máxima Medical Center, Veldhoven, The Netherlands
| | - Luc J I Zimmermann
- Department of Pediatrics, Maastricht University Medical Center, School of Oncology and Developmental Biology, School of Mental Health and Neuroscience, Maastricht, The Netherlands
| | - John N van den Anker
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA.,Division of Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Kian D Liem
- Department of Pediatrics, Division of Neonatology, Radboud, University Medical Center, Nijmegen, The Netherlands
| | - Birgit C P Koch
- Department of Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Saskia de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catherijne A J Knibbe
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands.,Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
49
|
Abstract
BACKGROUND It is well-known that the pharmacokinetics of various drugs are influenced by inflammation. This study evaluated the relationship between C-reactive protein (CRP; an inflammation marker) and the pharmacokinetics of perampanel. METHODS Among 111 patients who underwent measurement of both CRP and perampanel, 23 patients had a serum CRP level exceeding 1.5 mg/dL (CRP-positive). We compared the concentration/dose ratio (CD ratio) of perampanel in these 23 patients between the times when they were CRP-positive and CRP-negative. To evaluate the effect of CRP on the CD ratio, multiple regression analysis was performed with the following covariates: CRP-positive status, body weight, and use of phenytoin, carbamazepine, or phenobarbital, and combinations of these drugs. RESULTS In 10 patients using enzyme-inducing antiepileptic drugs (AEDs), the mean CD ratio increased by 53.5% [from 1389 to 2132 (ng/mL)/(mg/kg)] when they were CRP-positive. In 13 patients without enzyme-inducing AEDs, the mean CD ratio increased by 100.8% [from 3826 ng/mL to 7683 (ng/mL)/(mg/kg)] when they were CRP-positive. By multiple regression analysis, the CRP level was a significant independent determinant of the CD ratio of perampanel. Despite a marked increase of the CD ratio, no adverse events were reported. CONCLUSIONS Irrespective of concomitant administration of enzyme-inducing AEDs, the serum perampanel concentration showed a marked increase in patients with inflammation. However, this increase was not associated with central nervous system toxicity. Although it is unknown whether the concentration of free and/or bound perampanel was increased, it seems likely that dose reduction is unnecessary for elevation of the serum perampanel level in patients with inflammation.
Collapse
|
50
|
|