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Ayyar VS, Jaiprasart P, Geist B, Huang Devine Z, Case M, Hazra A, Hsu CH, Chintala M, Wang W. Translational PK/PD and model-informed development of JNJ-67842125, a F ab reversal agent for JNJ-64179375, a long-acting thrombin inhibitor. Br J Pharmacol 2021; 178:3943-3958. [PMID: 34008170 DOI: 10.1111/bph.15533] [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: 05/07/2020] [Revised: 04/30/2021] [Accepted: 05/06/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Antigen-binding fragment (Fab ) reversal agents were developed to reverse, in bleeding emergency, the long-acting anticoagulant effect of JNJ-64179375 (JNJ-9375), a monoclonal antibody that binds exosite-1 on thrombin. EXPERIMENTAL APPROACH The pharmacokinetic and pharmacodynamic (PK/PD) activities of three reversal agents of varying in vitro binding affinities to JNJ-9375 were characterised in cynomolgus monkeys. The time course of JNJ-9375 anticoagulant activity and reversal effects of each agent were evaluated. A mechanism-based PK/PD model, which integrated free serum concentrations of reversal agent, total and free serum concentrations of JNJ-9375, and thrombin time, was developed to quantitatively relate JNJ-9375 neutralisation to reversal of induced thrombin time prolongation. Model-based allometric scale-up of the lead reversal agent and the PK/PD relationship of JNJ-9375 in healthy volunteers were utilised to predict clinical dosing regimens. KEY RESULTS Lowering of free JNJ-9375 by the reversal agents corresponded with reversal of thrombin time prolongation. Total JNJ-9375 displayed typical mAb clearance at 2.75 ml·day-1 ·kg-1 , whereas reversal agents cleared faster between 1400 and 2400 ml·day-1 ·kg-1 . The model-estimated in vivo KD values for JNJ-9375 reversal agents were 9 nM (ICHB-256), 0.4 nM (ICHB-281) and 13.7 pM (ICHB-164), in rank-ordered agreement of their KD values determined in vitro. The three reversal agents exhibited different neutralisation characteristics in vivo, governed primarily by their binding kinetics to JNJ-9375. The model predicted a priori free JNJ-9375 kinetics after dosing ICHB-164 (JNJ-67842125) and JNJ-9375 under a different regimen. CONCLUSION AND IMPLICATIONS The results enabled selection of JNJ-67842125 as the reversal agent for JNJ-9375.
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Affiliation(s)
- Vivaswath S Ayyar
- Biologics Development Sciences, Janssen BioTherapeutics, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA.,Clinical Pharmacology and Pharmacometrics, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Pharavee Jaiprasart
- Biologics Development Sciences, Janssen BioTherapeutics, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA.,Clinical Pharmacology and Pharmacometrics, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Brian Geist
- Biologics Development Sciences, Janssen BioTherapeutics, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Zheng Huang Devine
- Cardiovascular and Metabolism, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Martin Case
- New Platforms and Technology, Janssen BioTherapeutics, Janssen Research & Development, LLC, San Diego, California, USA
| | - Anasuya Hazra
- Clinical Pharmacology and Pharmacometrics, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Chyi-Hung Hsu
- Clinical Pharmacology and Pharmacometrics, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Madhu Chintala
- Cardiovascular and Metabolism, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Weirong Wang
- Clinical Pharmacology and Pharmacometrics, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
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Betten DP, Vohra RB, Cook MD, Matteucci MJ, Clark RF. Antidote Use in the Critically Ill Poisoned Patient. J Intensive Care Med 2016; 21:255-77. [PMID: 16946442 DOI: 10.1177/0885066606290386] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The proper use of antidotes in the intensive care setting when combined with appropriate general supportive care may reduce the morbidity and mortality associated with severe poisonings. The more commonly used antidotes that may be encountered in the intensive care unit ( N-acetylcysteine, ethanol, fomepizole, physostigmine, naloxone, flumazenil, sodium bicarbonate, octreotide, pyridoxine, cyanide antidote kit, pralidoxime, atropine, digoxin immune Fab, glucagon, calcium gluconate and chloride, deferoxamine, phytonadione, botulism antitoxin, methylene blue, and Crotaline snake antivenom) are reviewed. Proper indications for their use and knowledge of the possible adverse effects accompanying antidotal therapy will allow the physician to appropriately manage the severely poisoned patient.
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Affiliation(s)
- David P Betten
- Department of Emergency Medicine, Sparrow Health System, Michigan State University College of Human Medicine, Lansing, Michigan 48912-1811, USA.
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Castello LM, Negro S, Santi F, Zanotti I, Vidali M, Bagnati M, Bellomo G, Avanzi GC. Accidental digitoxin intoxication: an interplay between laboratory and clinical medicine. Biochem Med (Zagreb) 2012; 22:380-4. [PMID: 23092069 PMCID: PMC3900044 DOI: 10.11613/bm.2012.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Two Italian adults arrived at the Emergency Department referring diarrhea, nausea and vomiting for 4 days; weakness, fatigue and visual hallucinations were also complained of. Patients reported the ingestion of some leaves of a plant, which they supposed to be “donkey ears”, a week before. Physical examination showed hypotension and bradycardia and ECG examination disclosed sinus rhythm and repolarization abnormalities (scooping of the ST-T complex) in both patients and a 2:1 AV block in the man. Materials and methods: Digoxin concentration was evaluated twice for each patient (at the admission and after 4 hours) by the automated immunoassay system ADVIA Centaur®. Digitoxin concentration was evaluated by liquid chromatography-mass spectrometry (LC-MS/MS). Results: Despite clinical picture was suggestive of digitalis intoxication, digoxin levels were undetectable. Due to the more severe clinical picture, the male patient was treated with anti-digoxin antibodies (Digifab®) achieving a good clinical improvement and remission of the AV block within two hours. Initial diagnosis was confirmed by LC-MS/MS showing high digitoxin concentrations, but digoxin was undetectable. Patients remained stable and 48 hours later were discharged from the hospital. Conclusion: Whereas digoxin determination frequently relies on monoclonal antibodies which do not cross-react to digitoxin, polyclonal antibodies constituting Digifab® recognize a large spectrum of cardiac glycosides, including digitoxin. This report emphasizes the primary role of the clinical approach to patients in the emergency setting and how an active communication and a continuous sharing of professional experiences between Laboratory and Clinicians ensure an early and correct diagnosis.
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Affiliation(s)
- Luigi M Castello
- Medicina e Chirurgia d'Accettazione e d'Urgenza, Azienda Ospedaliero-Universitaria Maggiore della Carità, Scuola di Specializzazione in Medicina d'Emergenza-Urgenza, Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, Novara, Italy
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Dager WE, Sanoski CA, Wiggins BS, Tisdale JE. Pharmacotherapy considerations in advanced cardiac life support. Pharmacotherapy 2007; 26:1703-29. [PMID: 17125434 DOI: 10.1592/phco.26.12.1703] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Cardiac arrest and sudden cardiac death remain major causes of mortality. Early intervention has been facilitated by emergency medical response systems and the development of training programs in basic life support and advanced cardiac life support (ACLS). Despite the implementation of these programs, the likelihood of a meaningful outcome in many life-threatening situations remains poor. Pharmacotherapy plays a role in the management of patients with cardiac arrest, with new guidelines for ACLS available in 2005 providing recommendations for the role of specific drug therapies. Epinephrine continues as a recommended means to facilitate defibrillation in patients with pulseless ventricular tachycardia or ventricular fibrillation; vasopressin is an alternative. Amiodarone is the primary antiarrhythmic drug that has been shown to be effective for facilitation of defibrillation in patients with pulseless ventricular tachycardia or fibrillation and is also used for the management of atrial fibrillation and hemodynamically stable ventricular tachycardia. Epinephrine and atropine are the primary agents used for the management of asystole and pulseless electrical activity. Treatment of electrolyte abnormalities, severe hypotension, pulmonary embolism, acute ischemic stroke, and toxicologic emergencies are important components of ACLS management. Selection of the appropriate drug, dose, and timing and route of administration are among the many challenges faced in this setting. Pharmacists who are properly educated and trained regarding the use of pharmacotherapy for patients requiring ACLS can help maximize the likelihood of positive patient outcomes.
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Affiliation(s)
- William E Dager
- University of California-Davis Medical Center, and the School of Medicine, University of California-Davis, Sacramento, California 95817-2201, USA.
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DiDomenico RJ, Walton SM, Sanoski CA, Bauman JL. Analysis of the use of digoxin immune fab for the treatment of non-life-threatening digoxin toxicity. J Cardiovasc Pharmacol Ther 2000; 5:77-85. [PMID: 11150387 DOI: 10.1053/xv.2000.5590] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Studies indicate that digoxin toxicity often results in lengthy hospitalizations and considerable costs, both of which may be decreased through the routine use of digoxin immune Fab (FAB). METHODS A computer-based decision analysis model was developed to compare the treatment of non-life-threatening digoxin toxicity with either FAB or standard therapy from the hospital perspective. A cost-minimization analysis was then performed to compare overall total costs (primary endpoint) for each treatment branch. A secondary endpoint of length of hospital stay (LOS) was also compared between the 2 groups. Clinical variables (serum digoxin concentration [SDC], creatinine clearance [Clcr], and body weight), event probabilities, and other model-specific variables were varied in univariate and multivariate sensitivity analyses. RESULTS FAB was associated with an incremental cost of $54 compared with standard therapy ($2,784 vs. $2,730, respectively) but reduced LOS by 1.5 days (1.5 days vs. 3.0 days, respectively). Sensitivity analyses show that FAB is less costly at SDC > 3.5 ng/mL and Clcr < 22 mL/min. FAB reduced LOS at SDC > 2.3 ng/mL. Monte Carlo simulation revealed that FAB was less costly in 37% of the cases and reduced LOS 72% of the time compared with standard therapy. CONCLUSIONS The abbreviated LOS associated with the use of FAB in patients with non-life-threatening digoxin toxicity may translate into lower treatment costs in many clinical scenarios, making it a cost-saving alternative to standard therapy in patients with high SDC and renal dysfunction.
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Affiliation(s)
- R J DiDomenico
- Departments of Pharmacy Practice and Pharmacy Administration at the College of Pharmacy, University of Illinois at Chicago, IL, USA
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Dart RC, Sidki A, Sullivan JB, Egen NB, Garcia RA. Ovine desipramine antibody fragments reverse desipramine cardiovascular toxicity in the rat. Ann Emerg Med 1996; 27:309-15. [PMID: 8599489 DOI: 10.1016/s0196-0644(96)70265-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
STUDY OBJECTIVE To develop a model of severe desipramine cardiovascular toxicity and to determine whether partial neutralization of the antigen by desipramine-specific Fab antibody fragments ameliorates its cardiovascular effects. METHODS We administered desipramine to rats until the QRS interval tripled in duration and mean arterial pressure (MAP) was less than 100 mm Hg. Animals were then assigned to one of six groups: (1) no treatment, (2) normal saline solution control treatment (.9% NaCl infusion equal to the volume of Fab infusion), (3) nonimmune Fab control treatment (infusion of Fab equal to that in the 9.6% neutralization treatment), (4) 9.6% desipramine Fab (infusion of ovine desipramine Fab equal to 9.6% of an equimolar neutralization), (5) 19.2% desipramine Fab, and (6) 30.0% desipramine Fab. RESULTS QRS-interval duration, heart rate, and MAP were recorded for 60 minutes. Animals in groups 1 through 3 demonstrated slow and incomplete improvement. Animals in groups 4 through 6 showed improvement in QRS-interval duration and heart rate within 4 minutes (P<.05) compared with untreated animals. A dose-response relationship was evident; animals given the highest dose of desipramine-specific Fab showed the greatest improvement. CONCLUSION Partial neutralization of desipramine by specific Fab fragments produces rapid improvement of QRS-interval duration and heart rate in a rat model of severe desipramine toxicity.
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Affiliation(s)
- R C Dart
- Department of Surgery, University of Arizona, Tucson, USA
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