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Pharmacokinetics of Fentanyl and Its Derivatives in Children: A Comprehensive Review. Clin Pharmacokinet 2019; 57:125-149. [PMID: 28688027 DOI: 10.1007/s40262-017-0569-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Fentanyl and its derivatives sufentanil, alfentanil, and remifentanil are potent opioids. A comprehensive review of the use of fentanyl and its derivatives in the pediatric population was performed using the National Library of Medicine PubMed. Studies were included if they contained original pharmacokinetic parameters or models using established routes of administration in patients younger than 18 years of age. Of 372 retrieved articles, 44 eligible pharmacokinetic studies contained data of 821 patients younger than 18 years of age, including more than 46 preterm infants, 64 full-term neonates, 115 infants/toddlers, 188 children, and 28 adolescents. Underlying diagnoses included congenital heart and pulmonary disease and abdominal disorders. Routes of drug administration were intravenous, epidural, oral-transmucosal, intranasal, and transdermal. Despite extensive use in daily clinical practice, few studies have been performed. Preterm and term infants have lower clearance and protein binding. Pharmacokinetics was not altered by chronic renal or hepatic disease. Analyses of the pooled individual patients' data revealed that clearance maturation relating to body weight could be best described by the Hill function for sufentanil (R 2 = 0.71, B max 876 mL/min, K 50 16.3 kg) and alfentanil (R 2 = 0.70, B max (fixed) 420 mL/min, K 50 28 kg). The allometric exponent for estimation of clearance of sufentanil was 0.99 and 0.75 for alfentanil clearance. Maturation of remifentanil clearance was described by linear regression to bodyweight (R 2 = 0.69). The allometric exponent for estimation of remifentanil clearance was 0.76. For fentanyl, linear regression showed only a weak correlation between clearance and bodyweight in preterm and term neonates (R 2 = 0.22) owing to a lack of data in older age groups. A large heterogeneity regarding study design, clinical setting, drug administration, laboratory assays, and pharmacokinetic estimation was observed between studies introducing bias into the analyses performed in this review. A limitation of this review is that pharmacokinetic data, based on different modes of administration, dosing schemes, and parameter estimation methods, were combined.
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Chang J, Shen Y, Huang Y, Sun Y, Cai MH, Niu J, Zhang LM, Zheng JJ, Zhang MZ. Population Pharmacokinetic Modeling of Remifentanil in Infants with Unrepaired Tetralogy of Fallot. Eur J Drug Metab Pharmacokinet 2018; 44:53-62. [PMID: 29915955 DOI: 10.1007/s13318-018-0489-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although there is literature suggesting that pathophysiologic changes in children with congenital heart disease alter the pharmacokinetics of anesthetics and may result in dosage adjustment, limited information exists regarding the pharmacokinetics of remifentanil in infants with unrepaired tetralogy of Fallot (TOF). The objectives of the current analysis were to characterize the population pharmacokinetics of remifentanil in infants, and to evaluate the effects of TOF on remifentanil's pharmacokinetics. METHODS Twenty-seven infants (16 with TOF and 11 with normal cardiac anatomy; aged 114-360 days) scheduled to undergo elective surgery under general anesthesia were recruited in the study. All children received remifentanil 1 μg/kg/min intravenously for anesthesia induction and early maintenance [until ~ 20 min before cardiopulmonary bypass (CPB) for patients with TOF]. Serial arterial blood samples were drawn and analyzed. Population pharmacokinetics of remifentanil was characterized using NONMEM software. The estimates were standardized to a 70-kg adult using a per-kilogram model. RESULTS A two-compartment disposition model adequately described the pharmacokinetics of remifentanil. Besides body weight, the introduction of any other covariates, including TOF status, did not improve the model significantly (P > 0.05). The population parameter estimates for systemic clearance (Cl1) and inter-compartment clearances (Cl2) were 6.03 × (WT/70 kg) and 1.23 × (WT/70 kg) L/min, respectively, and central volume of distribution (V1) and peripheral volumes of distribution (V2) were 19.6 × (WT/70 kg) and 21.7 × (WT/70 kg) L, respectively. CONCLUSIONS Unrepaired TOF does not change the pharmacokinetics of remifentanil, suggesting a similar dosage for infants with TOF compared to normal cardiac anatomy infants. CLINICAL TRIAL REGISTRATION The patient enrollment in this study started at 2012, so we do not have clinic trial number, but we still think this is a valuable research and hope it could be considered for publication.
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Affiliation(s)
- Jing Chang
- Department of Anesthesiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Rd, Shanghai, 200127, China.,Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yang Shen
- Department of Anesthesiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Rd, Shanghai, 200127, China.,Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yue Huang
- Department of Anesthesiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Rd, Shanghai, 200127, China.,Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Sun
- Department of Anesthesiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Rd, Shanghai, 200127, China.,Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mei-Hua Cai
- Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Niu
- Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Li-Ming Zhang
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ji-Jian Zheng
- Department of Anesthesiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Rd, Shanghai, 200127, China.,Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ma-Zhong Zhang
- Department of Anesthesiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Rd, Shanghai, 200127, China. .,Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Zeilmaker GA, Pokorna P, Mian P, Wildschut ED, Knibbe CAJ, Krekels EHJ, Allegaert K, Tibboel D. Pharmacokinetic considerations for pediatric patients receiving analgesia in the intensive care unit; targeting postoperative, ECMO and hypothermia patients. Expert Opin Drug Metab Toxicol 2018; 14:417-428. [PMID: 29623729 DOI: 10.1080/17425255.2018.1461836] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Adequate postoperative analgesia in pediatric patients in the intensive care unit (ICU) matters, since untreated pain is associated with negative outcomes. Compared to routine postoperative patients, children undergoing hypothermia (HT) or extracorporeal membrane oxygenation (ECMO), or recovering after cardiac surgery likely display non-maturational differences in pharmacokinetics (PK) and pharmacodynamics (PD). These differences warrant additional dosing recommendations to optimize pain treatment. Areas covered: Specific populations within the ICU will be discussed with respect to expected variations in PK and PD for various analgesics. We hereby move beyond maturational changes and focus on why PK/PD may be different in children undergoing HT, ECMO or cardiac surgery. We provide a stepwise manner to develop PK-based dosing regimens using population PK approaches in these populations. Expert opinion: A one-dose to size-fits-all for analgesia is suboptimal, but for several commonly used analgesics the impact of HT, ECMO or cardiac surgery on average PK parameters in children is not yet sufficiently known. Parameters considering both maturational and non-maturational covariates are important to develop population PK-based dosing advices as part of a strategy to optimize pain treatment.
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Affiliation(s)
- Gerdien A Zeilmaker
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Paula Pokorna
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,b Department of Pediatrics, General Faculty Hospital Prague, First Faculty of Medicine , Charles University and General University Hospital in Prague , Prague , Czech Republic.,c Institute of Pharmacology, First Faculty of Medicine , Charles University and General University Hospital in Prague , Prague , Czech Republic
| | - Paola Mian
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Enno D Wildschut
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Catherijne A J Knibbe
- d Division of Pharmacology , LACDR, Leiden University , Leiden , The Netherlands.,e Department of Clinical Pharmacy , St. Antonius Hospital , Nieuwegein , The Netherlands
| | - Elke H J Krekels
- d Division of Pharmacology , LACDR, Leiden University , Leiden , The Netherlands
| | - Karel Allegaert
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,f Department of Development and Regeneration , KU Leuven , Leuven , Belgium
| | - Dick Tibboel
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
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Yang S, Noh H, Hahn J, Jin BH, Min KL, Bae SK, Kim J, Park MS, Hong T, Wi J, Chang MJ. Population pharmacokinetics of remifentanil in critically ill patients receiving extracorporeal membrane oxygenation. Sci Rep 2017; 7:16276. [PMID: 29176598 PMCID: PMC5701170 DOI: 10.1038/s41598-017-16358-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/10/2017] [Indexed: 11/09/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is associated with pharmacokinetic (PK) changes of drugs. It presents considerable challenges to providing optimal dosing regimens for patients receiving ECMO. We aimed to describe the population PK of remifentanil in critically ill adult patients receiving venoartrial extracorporeal membrane oxygenation (VA-ECMO) and to identify determinants associated with altered remifentanil concentrations. The population PK model of remifentanil was developed using nonlinear mixed effects modelling (NONMEM). Fifteen adult patients who received a continuous infusion of remifentanil during VA-ECMO participated in the study. The PK of remifentanil was best described by a one-compartment model with additive and proportional residual errors. Remifentanil concentrations were affected by sex and ECMO pump speed. The final PK model included the effect of sex and ECMO pump speed on clearance is developed as followed: clearance (L/h) = 366 × 0.502sex × (ECMO pump speed/2350)2.04 and volume (L) = 41. Remifentanil volume and clearance were increased in adult patients on VA-ECMO compared with previously reported patients not on ECMO. We suggest that clinicians should consider an increased remifentanil dosing to achieve the desired level of sedation and provide a dosing regimen according to sex and ECMO pump speed.
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Affiliation(s)
- Seungwon Yang
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Hayeon Noh
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Jongsung Hahn
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Byung Hak Jin
- Department of Pharmaceutical Medicine and Regulatory Sciences, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, Republic of Korea
- Deparment of Clinical Pharmacology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyoung Lok Min
- Department of Pharmaceutical Medicine and Regulatory Sciences, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Soo Kyung Bae
- College of Pharmacy, The Catholic University of Korea, Bucheon, Kyunggido, Republic of Korea
| | - Jiseon Kim
- College of Pharmacy, The Catholic University of Korea, Bucheon, Kyunggido, Republic of Korea
| | - Min Soo Park
- Department of Pharmaceutical Medicine and Regulatory Sciences, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, Republic of Korea
- Deparment of Clinical Pharmacology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Taegon Hong
- Deparment of Clinical Pharmacology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Wi
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Min Jung Chang
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Republic of Korea.
- Department of Pharmaceutical Medicine and Regulatory Sciences, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, Republic of Korea.
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Correction to: Pharmacokinetics of Fentanyl and Its Derivatives in Children: A Comprehensive Review. Clin Pharmacokinet 2017; 57:393-417. [PMID: 29178007 DOI: 10.1007/s40262-017-0609-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Fentanyl and its derivatives sufentanil, alfentanil, and remifentanil are potent opioids. A comprehensive review of the use of fentanyl and its derivatives in the pediatric population was performed using the National Library of Medicine PubMed. Studies were included if they contained original pharmacokinetic parameters or models using established routes of administration in patients younger than 18 years of age. Of 372 retrieved articles, 44 eligible pharmacokinetic studies contained data of 821 patients younger than 18 years of age, including more than 46 preterm infants, 64 full-term neonates, 115 infants/toddlers, 188 children, and 28 adolescents. Underlying diagnoses included congenital heart and pulmonary disease and abdominal disorders. Routes of drug administration were intravenous, epidural, oral-transmucosal, intranasal, and transdermal. Despite extensive use in daily clinical practice, few studies have been performed. Preterm and term infants have lower clearance and protein binding. Pharmacokinetics was not altered by chronic renal or hepatic disease. Analyses of the pooled individual patients' data revealed that clearance maturation relating to body weight could be best described by the Hill function for sufentanil (R 2 = 0.71, B max 876 mL/min, K 50 16.3 kg) and alfentanil (R 2 = 0.70, B max (fixed) 420 mL/min, K 50 28 kg). The allometric exponent for estimation of clearance of sufentanil was 0.99 and 0.75 for alfentanil clearance. Maturation of remifentanil clearance was described by linear regression to bodyweight (R 2 = 0.69). The allometric exponent for estimation of remifentanil clearance was 0.76. For fentanyl, linear regression showed only a weak correlation between clearance and bodyweight in preterm and term neonates (R 2 = 0.22) owing to a lack of data in older age groups. A large heterogeneity regarding study design, clinical setting, drug administration, laboratory assays, and pharmacokinetic estimation was observed between studies introducing bias into the analyses performed in this review. A limitation of this review is that pharmacokinetic data, based on different modes of administration, dosing schemes, and parameter estimation methods, were combined.
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Kim HS. Clinical application of intravenous anesthetic infusion with use of a pharmacokinetic-pharmacodynamic model in children. Anesth Pain Med (Seoul) 2017. [DOI: 10.17085/apm.2017.12.4.291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
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Cho YJ, Jo WY, Oh H, Koo CH, Oh J, Cho JY, Yu KS, Jeon Y, Kim TK. Performance of the Minto model for the target-controlled infusion of remifentanil during cardiopulmonary bypass. Anaesthesia 2017; 72:1196-1205. [PMID: 28891056 DOI: 10.1111/anae.14019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2017] [Indexed: 02/05/2023]
Abstract
We studied the predictive performance of the Minto pharmacokinetic model during cardiopulmonary bypass in patients undergoing cardiac surgery. Patients received remifentanil target-controlled infusion using the Minto model during total intravenous anaesthesia with propofol. From 56 patients, 275 arterial blood samples were drawn before, during and after bypass to determine the plasma concentration of remifentanil, and the predicted concentrations were recorded at each time. For pooled data, the median prediction error and median absolute prediction error were 21.3% and 21.8%, respectively, and 22.1% and 22.3% during bypass. Both were 148.4% during hypothermic circulatory arrest and measured concentrations were more than three times greater than predicted (26.9 (17.0) vs. 7.1 (1.6) ng.ml-1 ). The Minto model showed considerable bias but overall acceptable precision during bypass. The target concentration of remifentanil should be reduced when using the Minto model during hypothermic circulatory arrest.
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Affiliation(s)
- Y J Cho
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - W Y Jo
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - H Oh
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - C-H Koo
- CHA Bundang Medical Centre, Department of Anaesthesiology and Pain Medicine, Seongnam-si, South Korea
| | - J Oh
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, South Korea
| | - J-Y Cho
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, South Korea
| | - K-S Yu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, South Korea
| | - Y Jeon
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - T K Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
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Zeilmaker-Roest GA, Wildschut ED, van Dijk M, Anderson BJ, Breatnach C, Bogers AJJC, Tibboel D. An international survey of management of pain and sedation after paediatric cardiac surgery. BMJ Paediatr Open 2017; 1:e000046. [PMID: 29637103 PMCID: PMC5862168 DOI: 10.1136/bmjpo-2017-000046] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 05/26/2017] [Accepted: 05/28/2017] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The mainstay of pain treatment after paediatric cardiac surgery is the use of opioids. Current guidelines for its optimal use are based on small, non-randomised clinical trials, and data on the pharmacokinetics (PK) and pharmacodynamics (PD) of opioids are lacking. This study aims at providing an overview of international hospital practices on the treatment of pain and sedation after paediatric cardiac surgery. DESIGN A multicentre survey study assessed the management of pain and sedation in children aged 0-18 years after cardiac surgery. SETTING Pediatric intensive care units (PICU)of 19 tertiary children's hospitals worldwide were invited to participate. The focus of the survey was on type and dose of analgesic and sedative drugs and the tools used for their pharmacodynamic assessment. RESULTS Fifteen hospitals (response rate 79%) filled out the survey. Morphine was the primary analgesic in most hospitals, and its doses for continuous infusion ranged from 10 to 60 mcg kg-1 h-1 in children aged 0-36 months. Benzodiazepines were the first choice for sedation, with midazolam used in all study hospitals. Eight hospitals (53%) reported routine use of sedatives with pain treatment. Overall, type and dosing of analgesic and sedative drugs differed substantially between hospitals. All participating hospitals used validated pain and sedation assessment tools. CONCLUSION There was a large variation in the type and dosing of drugs employed in the treatment of pain and sedation after paediatric cardiac surgery. As a consequence, there is a need to rationalise pain and sedation management for this vulnerable patient group.
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Affiliation(s)
- Gerdien A Zeilmaker-Roest
- Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.,Cardio-Thoracic Surgery, Erasmus MC, Rotterdam, South Holland, The Netherlands
| | - Enno D Wildschut
- Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Monique van Dijk
- Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Brian J Anderson
- Intensive Care, Starship Children's Hospital, Auckland, New Zealand
| | - Cormac Breatnach
- Intensive Care, Our Lady's Children's Hospital, Crumlin, Ireland
| | - Ad J J C Bogers
- Cardio-Thoracic Surgery, Erasmus MC, Rotterdam, South Holland, The Netherlands
| | - Dick Tibboel
- Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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Frymoyer A, Su F, Grimm PC, Sutherland SM, Axelrod DM. Theophylline Population Pharmacokinetics and Dosing in Children Following Congenital Heart Surgery With Cardiopulmonary Bypass. J Clin Pharmacol 2016; 56:1084-93. [PMID: 26712558 DOI: 10.1002/jcph.697] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 12/17/2015] [Indexed: 01/11/2023]
Abstract
Children undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) frequently develop acute kidney injury due to renal ischemia. Theophylline, which improves renal perfusion via adenosine receptor inhibition, is a potential targeted therapy. However, children undergoing cardiac surgery and CPB commonly have alterations in drug pharmacokinetics. To help understand optimal aminophylline (salt formulation of theophylline) dosing strategies in this population, a population-based pharmacokinetic model was developed using nonlinear mixed-effects modeling (NONMEM) from 71 children (median age 5 months; 90% range 1 week to 10 years) who underwent cardiac surgery requiring CPB and received aminophylline as part of a previous randomized controlled trial. A 1-compartment model with linear elimination adequately described the pharmacokinetics of theophylline. Weight scaled via allometry was a significant predictor of clearance and volume. In addition, allometric scaled clearance increased with age implemented as a power maturation function. Compared to prior reports in noncardiac children, theophylline clearance was markedly reduced across age. In the final population pharmacokinetic model, optimized empiric dosing regimens were developed via Monte Carlo simulations. Doses 50% to 75% lower than those recommended in noncardiac children were needed to achieve target serum concentrations of 5 to 10 mg/L.
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Affiliation(s)
- Adam Frymoyer
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Felice Su
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Paul C Grimm
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | | | - David M Axelrod
- Department of Pediatrics, Stanford University, Stanford, CA, USA
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Cella M, Danhof M, Della Pasqua O. Adaptive trials in paediatric development: dealing with heterogeneity and uncertainty in pharmacokinetic differences in children. Br J Clin Pharmacol 2012; 74:346-53. [PMID: 22256787 DOI: 10.1111/j.1365-2125.2012.04187.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIMS To assess whether an adaptive design in early clinical trials based on the paradigm of variable dosing and controlled exposure can provide better dosing recommendations compared with the standard fixed dose approach. METHODS In a clinical trial simulation setting, a paediatric study was simulated using a pharmacokinetic model previously developed for abacavir. Plasma concentrations following the current recommended dose (8 mg kg⁻¹) were taken at standard sampling times, exposures (AUC) were calculated and doses individually adapted to reach the target exposure (i.e. effective exposure in adults). A second round of simulations followed with the adapted doses, and the resulting concentrations were fitted again with the same model. Exposure distributions in both conditions (i.e. fixed dose and controlled exposure) were compared with the target exposure. RESULTS The AUC distribution after the current dose resulted in a median exposure of 6.43 mg h l⁻¹ (90th percentile 3.13-10.67 mg h l⁻¹). A total of 61 of 128 subjects showed AUC values either too low or to high compared with the target exposure. After dose adjustment, the median exposure was 6.94 mg h l⁻¹ (5.57-8.25 mg h l⁻¹), and only 14 subjects deviated from the target range. CONCLUSIONS Adaptive randomization can be used to optimize dosing regimens in early paediatric clinical trials. The randomization of patients to target exposure rather than dose increases the probability of demonstrating efficacy (i.e. study power) compared with dose-controlled trials. Furthermore, it contributes to further understanding of the role of dose on the total heterogeneity in clinical response.
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Affiliation(s)
- Massimo Cella
- LACDR, Division of Pharmacology, Leiden University, Leiden, The Netherlands
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12
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Are there still limitations for the use of target-controlled infusion in children? Curr Opin Anaesthesiol 2010; 23:356-62. [DOI: 10.1097/aco.0b013e32833938db] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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