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D'Angelo CR. Diagnostic, Pathologic, and Therapeutic Considerations for Primary CNS Lymphoma. JCO Oncol Pract 2024; 20:195-202. [PMID: 37967301 DOI: 10.1200/op.23.00294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/27/2023] [Accepted: 10/12/2023] [Indexed: 11/17/2023] Open
Abstract
Primary CNS lymphoma (PCNSL) is a rare lymphoma representing 3% of CNS malignancies. The diagnosis is complicated by the unique risks associated with brain biopsy, and the treatment is similarly complicated by the restriction of effective therapeutics able to cross the blood-brain barrier. Currently, the majority of individuals diagnosed with this disease are immunocompetent although immune deficiency related to HIV or immunosuppressive therapy remains an important risk factor. Improvements in both frontline therapy and consolidation options, including the use of hematopoietic stem-cell transplantation, have translated to improved survival. Unfortunately, patients experiencing relapsed or refractory disease often fare poorly. Here, we review key clinical, pathologic, and therapeutic aspects of PCNSL and highlight challenging clinical scenarios that may be encountered by the treating oncologist.
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Jeong SH, Jang JH, Lee YB. Is Gender an Important Factor in the Precision Medicine Approach to Levocetirizine? Pharmaceutics 2024; 16:146. [PMID: 38276516 PMCID: PMC10818372 DOI: 10.3390/pharmaceutics16010146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 01/27/2024] Open
Abstract
Currently, there is insufficient information on the variability in levocetirizine pharmacometrics among individuals, a crucial aspect for establishing its clinical use. The gender differences in pharmacokinetics and the extent of variation in pharmacodynamics have not been definitively identified. The primary goal of this study was to investigate gender differences in levocetirizine pharmacokinetics and quantitatively predict and compare how these gender-related pharmacokinetic differences impact pharmacodynamics, using population pharmacokinetic-pharmacodynamic modeling. Bioequivalence results for levocetirizine (only from the control formulation) were obtained from both healthy Korean men and women. Physiological and biochemical parameters for each individual were utilized as pharmacokinetic comparison and modeling data between genders. Pharmacodynamic modeling was performed using reported data on antihistamine responses following levocetirizine exposure. Gender, weight, body surface area, peripheral distribution volume, albumin, central-peripheral inter-compartmental clearance, and the fifth sequential absorption rate constant were explored as effective covariates. A comparison of the model simulation results showed a higher maximum concentration and faster plasma loss in females than in males, resulting in a faster recovery to baseline of the antihistamine effect; however, the absolute differences between genders in the mean values were not large within 10 ng/mL (for plasma concentrations) or % (wheal and flare size changes). Regarding the pharmacokinetics and pharmacodynamics of levocetirizine, the gender effect may not be significant when applying the usual dosage (5 mg/day). This study will be useful for bridging the knowledge gap in scientific precision medicine by introducing previously unconfirmed information regarding gender differences in levocetirizine pharmacometrics.
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Affiliation(s)
- Seung-Hyun Jeong
- College of Pharmacy, Sunchon National University, 255 Jungang-ro, Suncheon-Si 57922, Jeollanam-do, Republic of Korea; (S.-H.J.); (J.-H.J.)
- College of Pharmacy and Research Institute of Life and Pharmaceutical Sciences, Sunchon National University, Suncheon-Si 57922, Republic of Korea
| | - Ji-Hun Jang
- College of Pharmacy, Sunchon National University, 255 Jungang-ro, Suncheon-Si 57922, Jeollanam-do, Republic of Korea; (S.-H.J.); (J.-H.J.)
| | - Yong-Bok Lee
- College of Pharmacy, Chonnam National University, 77 Yongbong-ro, Buk-gu, Gwangju 61186, Republic of Korea
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Yang Y, Liu Z, Chen J, Wang X, Jiao Z, Wang Z. Factors influencing methotrexate pharmacokinetics highlight the need for individualized dose adjustment: a systematic review. Eur J Clin Pharmacol 2024; 80:11-37. [PMID: 37934204 DOI: 10.1007/s00228-023-03579-0] [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: 07/04/2023] [Accepted: 10/07/2023] [Indexed: 11/08/2023]
Abstract
PURPOSE To develop a population pharmacokinetic (PPK) model for methotrexate (MTX) dosage for all ages, assess the association between concentration and clearance, and determine covariates affecting MTX disposition. METHODS We compared MTX PK profiles among neonates, children, and adults by performing a systematic literature search for published population MTX models and conducted a Monte Carlo-based meta-analysis. Subsequently, we evaluated study quality and covariates significantly affecting dosage regimens and compared LDMTX and HDMTX PK profiles. RESULTS Of the total 40 studies included, 34 were HDMTX, and six were LDMTX studies. For HDMTX, three studies involving neonates reported estimated apparent clearances (median, range) of 0.53 (0.27-0.77) L/kg/h; for 14 studies involving children, 0.23 (0.07-0.23) L/kg/h; and for 13 involving adults, 0.11 (0.03-0.22) L/kg/h. Neonates had a higher volume of distribution than children and adults. For LDMTX studies, apparent clearance was 0.085 (0.05-1.68) L/kg/h, and volume of distribution was 0.25 (0.018-0.47) L/kg, lower than those of HDMTX studies, with large between-subject variability. Bodyweight significantly influenced apparent clearance and volume of distribution, whereas renal function mainly influenced clearance. Mutations in certain genes reduced MTX clearance by 8-35.3%, whereas those in others increased it by 15-48%. Body surface area (BSA) significantly influenced apparent clearance with a median reduction of 51% when BSA increased in pediatric patients. CONCLUSIONS Methotrexate dosage regimens were primarily based on body surface area and renal function. Further studies are needed to evaluate MTX pharmacokinetics and pharmacodynamics in both children (especially infants) and adults.
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Affiliation(s)
- Yunyun Yang
- Department of Pharmacy, Shanghai Changhai Hospital, the First Affiliated Hospital of Navy Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Zhengyue Liu
- Department of Pharmacy, Shanghai Changhai Hospital, the First Affiliated Hospital of Navy Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Jingxia Chen
- Department of Pharmacy, Shanghai Changhai Hospital, the First Affiliated Hospital of Navy Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Xuebin Wang
- Department of Pharmacy, Shanghai Changhai Hospital, the First Affiliated Hospital of Navy Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 Huaihai West Road, Shanghai, 200030, China.
| | - Zhuo Wang
- Department of Pharmacy, Shanghai Changhai Hospital, the First Affiliated Hospital of Navy Medical University, 168 Changhai Rd, Shanghai, 200433, China.
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Taylor ZL, Miller TP, Poweleit EA, DeGroote NP, Pommert L, Awoniyi O, Board SG, Ugboh N, Joshi V, Ambrosino N, Chavana A, Bernhardt MB, Schafer ES, O'Brien MM, Castellino SM, Ramsey LB. Clinical covariates that improve the description of high dose methotrexate pharmacokinetics in a diverse population to inform MTXPK.org. Clin Transl Sci 2023; 16:2130-2143. [PMID: 37503924 PMCID: PMC10651646 DOI: 10.1111/cts.13600] [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: 04/18/2023] [Revised: 06/20/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023] Open
Abstract
The MTXPK.org webtool was launched in December 2019 and was developed to facilitate model-informed supportive care and optimal use of glucarpidase following the administration of high-dose methotrexate (HDMTX). One limitation identified during the original development of the MTXPK.org tool was the perceived generalizability because the modeled population comprised solely of Nordic pediatric patients receiving 24-h infusions for the treatment of acute lymphoblastic leukemia. The goal of our study is to describe the pharmacokinetics of HDMTX from a diverse patient population (e.g., races, ethnicity, indications for methotrexate, and variable infusion durations) and identify meaningful factors that account for methotrexate variability and improve the model's performance. To do this, retrospectively analyzed pharmacokinetic and toxicity data from pediatric and adolescent young adult patients who were receiving HDMTX (>0.5 g/m2 ) for the treatment of a cancer diagnosis from three pediatric medical centers. We performed population pharmacokinetic modeling referencing the original MTXPK.org NONMEM model (includes body surface area and serum creatinine as covariates) on 1668 patients, 7506 administrations of HDMTX, and 30,250 concentrations. Our results support the parameterizations of short infusion duration (<8 h) and the presence of Down syndrome on methotrexate clearance, the parameterization of severe hypoalbuminemia (<2.5 g/dL) on the intercompartmental clearance (Q2 and Q3), and the parameterization of pleural effusion on the volume of distribution (V1 and V2). These novel parameterizations will increase the generalizability of the MTXPK.org model once they are added to the webtool.
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Affiliation(s)
- Zachary L. Taylor
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Tamara P. Miller
- Department of PediatricsEmory University School of MedicineAtlantaGeorgiaUSA
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGeorgiaUSA
| | - Ethan A. Poweleit
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Division of Research in Patient ServicesCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of Biomedical InformaticsUniversity of CincinnatiCincinnatiOhioUSA
- Division of Biomedical InformaticsCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Nicholas P. DeGroote
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGeorgiaUSA
| | - Lauren Pommert
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of OncologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Oluwafunbi Awoniyi
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGeorgiaUSA
| | - Sarah G. Board
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Division of Research in Patient ServicesCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Ngozi Ugboh
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGeorgiaUSA
| | - Vivek Joshi
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGeorgiaUSA
| | - Nick Ambrosino
- Division of OncologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Ashley Chavana
- Department of PediatricsBaylor College of MedicineHoustonTexasUSA
| | - Melanie B. Bernhardt
- Department of PediatricsBaylor College of MedicineHoustonTexasUSA
- Texas Children's Cancer CenterHoustonTexasUSA
| | - Eric S. Schafer
- Department of PediatricsBaylor College of MedicineHoustonTexasUSA
- Texas Children's Cancer CenterHoustonTexasUSA
| | - Maureen M. O'Brien
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of OncologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Sharon M. Castellino
- Department of PediatricsEmory University School of MedicineAtlantaGeorgiaUSA
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGeorgiaUSA
| | - Laura B. Ramsey
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Research in Patient ServicesCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
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Zhang JC, Stotts MJ, Horton B, Schiff D. Hepatotoxicity from high-dose methotrexate in primary central nervous system lymphoma. Neurooncol Pract 2023; 10:291-300. [PMID: 37188158 PMCID: PMC10180358 DOI: 10.1093/nop/npad008] [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: 02/13/2023] Open
Abstract
Background High-dose methotrexate (HDMTX) is a mainstay of primary central nervous system lymphoma (PCNSL) treatment. Transient hepatotoxicity from HDMTX has been characterized in pediatric patients but not in adults. We sought to characterize hepatotoxicity in adult PCNSL patients undergoing HDMTX treatment. Methods Retrospective study of 65 PCNSL patients treated at the University of Virginia from 02/01/2002 to 04/01/2020 was performed. Hepatotoxicity was defined using National Cancer Institute Common Toxicity Criteria (CTC) for adverse events, fifth version. High-grade hepatotoxicity was defined as a bilirubin or aminotransferase CTC grade of 3 or 4. Relationships between clinical factors and hepatotoxicity were assessed with logistic regression. Results Most patients (90.8%) had a rise of at least one aminotransferase CTC grade during HDMTX treatment. 46.2% had high-grade hepatotoxicity based on aminotransferase CTC grade. No patients developed high-grade bilirubin CTC grades during chemotherapy. Liver enzyme test values decreased to low CTC grade or normal in 93.8% of patients after the conclusion of HDMTX treatment without treatment regimen changes. Prior ALT elevation (P = .0120) was a statistically significant predictor of high-grade hepatotoxicity during treatment. Prior history of hypertension was associated with increased risk of toxic serum methotrexate levels during any cycle (P = .0036). Conclusions Hepatotoxicity develops in the majority of HDMTX-treated PCNSL patients. Transaminase values decreased to low or normal CTC grades in almost all patients after treatment, without modification of MTX dosage. Prior ALT elevation may predict patients' increased hepatotoxicity risk, and hypertension history may be a risk factor for delayed MTX excretion.
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Affiliation(s)
- Joy C Zhang
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Matthew J Stotts
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Bethany Horton
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - David Schiff
- Departments of Neurology, Neurological Surgery, and Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
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Yang Y, Wang C, Chen Y, Wang X, Jiao Z, Wang Z. External evaluation and systematic review of population pharmacokinetic models for high-dose methotrexate in cancer patients. Eur J Pharm Sci 2023; 186:106416. [PMID: 37119861 DOI: 10.1016/j.ejps.2023.106416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/26/2023] [Accepted: 02/28/2023] [Indexed: 05/01/2023]
Abstract
Several population pharmacokinetic (PPK) models have been established to optimize the therapeutic regimen and reduce the toxicity of high-dose methotrexate (HDMTX) in patients with cancer. However, their predictive performance when extrapolated to different clinical centers was unknown. In this study, we aimed to externally evaluate the predictive ability of HDMTX PPK models and determine the potential influencing factors. We searched the literature and determined the predictive performance of the selected models using methotrexate concentrations in 721 samples from 60 patients in the First Affiliated Hospital of the Navy Medical University. Prediction-based diagnostics and simulation-based normalized prediction distribution errors (NPDE) were used to evaluate the predictive performance of the models. The influence of prior information was also assessed using Bayesian forecasting, and the potential factors affecting model predictability were investigated. Thirty models extracted from published PPK studies were assessed. Prediction-based diagnostics showed that the number of compartments potentially influenced model transferability, and simulation-based NPDE indicated model misspecification. Bayesian forecasting significantly improved the predictive performance of the models. Various factors, including bioassays, covariates, and population diagnosis, influence model extrapolation. The published models were unsatisfactory for all prediction-based diagnostics, except for the 24 h methotrexate concentration monitoring and simulation-based diagnostics, making them inappropriate for direct extrapolation. Moreover, Bayesian forecasting combined therapeutic drug monitoring could improve the predictive performance of the models.
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Affiliation(s)
- Yunyun Yang
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China; Department of Pharmacy, Shanghai Changhai Hospital, First Affiliated Hospital of Navy Medical University, Shanghai 200433, China
| | - Chenyu Wang
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Yueting Chen
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Xuebin Wang
- Department of Pharmacy, Shanghai Changhai Hospital, First Affiliated Hospital of Navy Medical University, Shanghai 200433, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China.
| | - Zhuo Wang
- Department of Pharmacy, Shanghai Changhai Hospital, First Affiliated Hospital of Navy Medical University, Shanghai 200433, China.
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Optimum Methotrexate Exposure in Patients With Suspected or Confirmed CNS Invasive Hematological Malignancies: A Systematic Critical Review. Ther Drug Monit 2023; 45:287-292. [PMID: 35971672 DOI: 10.1097/ftd.0000000000001022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 06/13/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND METHODS The present review aims to evaluate the current state-of-the-art dosing regimens of high-dose (HD) and intrathecal methotrexate (MTX) using therapeutic drug monitoring (TDM) to optimize its therapeutic response and minimize associated toxicity, particularly in the central nervous system (CNS). RESULTS MTX is administered systemically in a HD regimen (>1 g/m 2 ) for the treatment of various hematological neoplasms. HD-MTX treatment becomes complicated by marked interindividual drug elimination variability. TDM is specified to manage this high variability. Approximately 3%-7% of adults with acute lymphoblastic leukemia are diagnosed with CNS involvement, and the incidence of CNS relapse in patients, despite receiving prophylaxis, ranges from 5% to 10%. HD-MTX penetrates the blood-brain barrier and can be administered intrathecally, making this drug an important component of chemotherapy regimens for patients with hematologic malignancies involving the CNS or those at high risk of CNS relapse. CONCLUSIONS The major evidence found was that an MTX area under the curve target between 1000 and 1100 μmol hour -1 L is associated with better clinical outcomes. However, there seems to be a clinical gap in the prospective validation of HD and IT MTX management to optimize clinical outcomes and minimize toxicity, using the relationship between exposure level (area under the curve MTX) and optimal response to MTX, at systemic and CNS exposure.
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Nagamine A, Araki T, Yashima H, Kamimura A, Shiraishi T, Yanagawa T, Obayashi K, Yamamoto K. Target concentration achievement for efficacy and safety of patients with osteosarcoma treated with high-dose methotrexate based on individual pharmacokinetics: A retrospective study. Oncol Lett 2022; 25:70. [PMID: 36688106 PMCID: PMC9843304 DOI: 10.3892/ol.2022.13656] [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: 08/19/2022] [Accepted: 11/08/2022] [Indexed: 12/30/2022] Open
Abstract
In the high-dose methotrexate (HD-MTX) treatment of patients with osteosarcoma, a dose-adjustment method using individual pharmacokinetic parameters (PK method) to optimize the concentration was developed in 2010. However, to the best of our knowledge, the clinical usefulness of the PK method has not been verified until now. In the present retrospective study, to assess the usefulness of the PK method, the achievement rate of an effective and safe concentration range was evaluated. A total of 43 patients with osteosarcoma who were administered HD-MTX therapy (43 first courses and 200 subsequent courses) were enrolled. The MTX dose in the first course was determined using a common method based on body surface area (BSA method); a total of 8-12 g/m2 was administered as an initial dose for 1 h and a maintenance dose for 5 h. In the subsequent courses, loading and maintenance doses were calculated by the PK method based on the serum MTX concentration profile of the previous course. The effective target concentration during 1-6 h after the start of MTX administration was 700-1,000 µmol/l, whereas the target safe MTX level was less than 10, 1 and 0.1 µmol/l at 24, 48 and 72 h, respectively. Notably, the rate of achieving the effective target concentration was significantly higher when using the PK method as compared to that when using the BSA method. The achievement rate of the safe target concentration at 24, 48 and 72 h when using the PK method was significantly higher. Additionally, the incidence of abnormal laboratory values of aspartate aminotransferase and alanine aminotransferase was significantly lower when using the PK method. Therefore, the PK method was suggested to be very useful in HD-MTX therapy for patients with osteosarcoma.
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Affiliation(s)
- Ayumu Nagamine
- Education Center for Clinical Pharmacy, Faculty of Pharmacy, Takasaki University of Health and Welfare, Takasaki, Gunma 370-0033, Japan,Department of Clinical Pharmacology and Therapeutics, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan
| | - Takuya Araki
- Department of Clinical Pharmacology and Therapeutics, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan,Department of Pharmacy, Gunma University Hospital, Maebashi, Gunma 371-8511, Japan,Correspondence to: Dr Takuya Araki, Department of Clinical Pharmacology and Therapeutics, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan, E-mail:
| | - Hideaki Yashima
- Department of Pharmacy, Gunma University Hospital, Maebashi, Gunma 371-8511, Japan
| | - Akane Kamimura
- Laboratory of Clinical Pharmacy, Faculty of Pharmacy, Takasaki University of Health and Welfare, Takasaki, Gunma 370-0033, Japan
| | - Takumi Shiraishi
- Laboratory of Clinical Pharmacy, Faculty of Pharmacy, Takasaki University of Health and Welfare, Takasaki, Gunma 370-0033, Japan
| | - Takashi Yanagawa
- Department of Orthopedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan,Department of Musculoskeletal Oncology, Gunma Prefectural Cancer Center, Ota, Gunma 373-0828, Japan
| | - Kyoko Obayashi
- Education Center for Clinical Pharmacy, Faculty of Pharmacy, Takasaki University of Health and Welfare, Takasaki, Gunma 370-0033, Japan,Department of Clinical Pharmacology and Therapeutics, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan,Laboratory of Clinical Pharmacy, Faculty of Pharmacy, Takasaki University of Health and Welfare, Takasaki, Gunma 370-0033, Japan
| | - Koujirou Yamamoto
- Department of Clinical Pharmacology and Therapeutics, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan,Department of Pharmacy, Gunma University Hospital, Maebashi, Gunma 371-8511, Japan
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de Toledo M, de la Fuente E, Ramos C, Ferreiros-Martinez R, Muro I, Vieira A, de Toledo MP, Lagares A, Sobrado M, Ovejero-Benito MC. Extensive pharmacokinetic variability of Levetiracetam. ¿Are doctors aware? Epilepsy Res 2022; 187:107029. [DOI: 10.1016/j.eplepsyres.2022.107029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 09/18/2022] [Accepted: 09/27/2022] [Indexed: 11/03/2022]
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