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Mahmood I. Prediction of total and renal clearance of renally secreted drugs in neonates and infants (≤3 months of age). J Clin Transl Res 2022; 8:445-452. [PMID: 36452002 PMCID: PMC9706311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Renal excretion is a major route of elimination for many drugs. Renal clearance is the sum of three processes: glomerular filtration, tubular secretion, and tubular re-absorption. Tubular secretion is an active transport process and is immature at birth. In the neonates, renal tubular secretion can be important for the elimination of those drugs which are renally secreted, such as penicillins and cephalosporins. AIM The objective of this study was to evaluate the predictive performances of three models to predict total and renal clearance of renally secreted drugs in neonates (≤3 months of age). METHODS From the literature, clearance values for 12 renally secreted drugs for neonates and adults were obtained. Three models were used to predict the clearances of these drugs. The predictive performances of these models were evaluated by comparing the predicted values of total and renal clearance with the observed clearance values in the neonates. RESULTS There were 12 drugs with 22 observations (preterm and term neonates, ≤3 months of age) for total clearance and six drugs with eight observations for renal clearance. For both total and renal clearance, a prediction error of <50% was observed by all three models evaluated in this study. CONCLUSIONS The proposed models can predict mean total and renal clearances of renally secreted drugs in preterm and term neonates (≤3 months of age) with reasonable accuracy (50% prediction error) and are of practical value during neonatal drug development. RELEVANCE FOR PATIENTS The work may help in dose selection for neonates for medicines that are renally secreted.
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Affiliation(s)
- Iftekhar Mahmood
- Mahmood Clinical Pharmacology Consultancy, LLC, 1709, Piccard DR, Rockville, MD 20850, USA
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Mahmood I. A comparison of different methods for the first-in-pediatric dose selection. J Clin Transl Res 2022; 8:369-381. [PMID: 36518546 PMCID: PMC9741938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND AND AIM To conduct a pediatric clinical trial, it is important to optimize pediatric dose as accurately as possible. This is mainly because due to ethical reasons, children cannot be given several doses to evaluate pharmacokinetics, safety, and efficacy of a drug. METHODS In this study, several simple methods to project a first-in-pediatric dose to initiate a clinical trial were evaluated. These methods were as follows:(1) Weight-based pediatric dose prediction (allometric scaling), (2) Salisbury rule (weight-based method), and (3) pediatric dose prediction based on predicted clearance. These methods were compared with the dose given to children in clinical practice. The methods were also compared with whole-body physiologically based pharmacokinetic (PBPK) model (n = 11). A ±30% prediction error (predicted vs. observed) was considered acceptable. RESULTS There were 27 drugs with 113 observations (different age groups from preterm neonates to adolescents). At least, ≤30% prediction error in pediatric dose projection was noted for more than 70% observations. The predictive performance of all the proposed methods was comparable with the whole-body PBPK. CONCLUSIONS The proposed methods are simple and accurate and can be developed on a spreadsheet in a very short period of time. RELEVANCE FOR PATIENTS The study provides an estimate of first-in-pediatric dose by simple methods to initiate pediatric clinical trials. Especially, Salisbury rule is based on body weight and is very simple and works fairly well in children >30 kg body weight and can be even used in clinical settings.
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Affiliation(s)
- Iftekhar Mahmood
- Mahmood Clinical Pharmacology Consultancy, LLC, Rockville, Maryland, USA
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Hu TM. A General Biphasic Bodyweight Model for Scaling Basal Metabolic Rate, Glomerular Filtration Rate, and Drug Clearance from Birth to Adulthood. AAPS J 2022; 24:67. [PMID: 35538161 DOI: 10.1208/s12248-022-00716-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/26/2022] [Indexed: 02/06/2023] Open
Abstract
The objective of this study is to propose a unified, continuous, and bodyweight-only equation to quantify the changes of human basal metabolic rate (BMR), glomerular filtration rate (GFR), and drug clearance (CL) from infancy to adulthood. The BMR datasets were retrieved from a comprehensive historical database of male and female subjects (0.02 to 64 years). The CL datasets for 17 drugs and the GFR dataset were generated from published maturation and growth models with reported parameter values. A statistical approach was used to simulate the model-generated CL and GFR data for a hypothetical population with 26 age groups (from 0 to 20 years). A biphasic equation with two power-law functions of bodyweight was proposed and evaluated as a general model using nonlinear regression and dimensionless analysis. All datasets universally reveal biphasic curves with two distinct linear segments on log-log plots. The biphasic equation consists of two reciprocal allometric terms that asymptotically determine the overall curvature. The fitting results show a superlinear scaling phase (asymptotic exponent >1; ca. 1.5-3.5) and a sublinear scaling phase (asymptotic exponent <1; ca. 0.5-0.7), which are separated at the phase transition bodyweight ranging from 5 to 20 kg with a mean value of 10 kg (corresponding to 1 year of age). The dimensionless analysis generalizes and offers quantitative realization of the maturation and growth process. In conclusion, the proposed mixed-allometry equation is a generic model that quantitatively describes the phase transition in the human maturation process of diverse human functions.
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Affiliation(s)
- Teh-Min Hu
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, 112, Taiwan.
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Wu Y, Allegaert K, Flint RB, Simons SHP, Krekels EHJ, Knibbe CAJ, Völler S. Prediction of glomerular filtration rate maturation across preterm and term neonates and young infants using inulin as marker. AAPS J 2022; 24:38. [PMID: 35212832 DOI: 10.1208/s12248-022-00688-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 01/30/2022] [Indexed: 11/30/2022] Open
Abstract
Describing glomerular filtration rate (GFR) maturation across the heterogeneous population of preterm and term neonates and infants is important to predict the clearance of renally cleared drugs. This study aims to describe the GFR maturation in (pre)term neonates and young infants (PNA < 90 days) using individual inulin clearance data (CLinulin). To this end, published GFR maturation models were evaluated by comparing their predicted GFR with CLinulin retrieved from literature. The best model was subsequently optimized in NONMEM V7.4.3 to better fit the CLinulin values. Our study evaluated seven models and collected 381 individual CLinulin values from 333 subjects with median (range) birthweight (BWb) 1880 g (580-4950), gestational age (GA) 34 weeks (25-43), current weight (CW) 1890 g (480-6200), postnatal age (PNA) 3 days (0-75), and CLinulin 2.20 ml/min (0.43-17.90). The De Cock 2014 model (covariates: BWb and PNA) performed the best in predicting CLinulin, followed by the Rhodin 2009 model (covariates: CW and postmenstrual age). The final optimized model shows that GFR at birth is determined by BWb, thereafter the maturation rate of GFR is dependent on PNA and GA, with a higher GA showing an overall faster maturation. To conclude, using individual CLinulin data, we found that a model for neonatal GFR requires a distinction between prenatal maturation quantified by BWb and postnatal maturation. To capture postnatal GFR maturation in (pre)term neonates and young infants, we developed an optimized model in which PNA-related maturation was dependent on GA.
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Affiliation(s)
- Yunjiao Wu
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands.,Departments of Development and Regeneration and Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Robert B Flint
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC 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, Leiden, The Netherlands
| | - Catherijne A J Knibbe
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.,Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Swantje Völler
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands. .,Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands. .,Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.
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Hornik CP, Yogev R, Mourani PM, Watt KM, Sullivan JE, Atz AM, Speicher D, Al-Uzri A, Adu-Darko M, Payne EH, Gelber CE, Lin S, Harper B, Melloni C, Cohen-Wolkowiez M, Gonzalez D. Population Pharmacokinetics of Milrinone in Infants, Children, and Adolescents. J Clin Pharmacol 2019; 59:1606-1619. [PMID: 31317556 PMCID: PMC6813877 DOI: 10.1002/jcph.1499] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 07/03/2019] [Indexed: 11/09/2022]
Abstract
Milrinone is a type 3 phosphodiesterase inhibitor used to improve cardiac output in critically ill infants and children. Milrinone is primarily excreted unchanged in the urine, raising concerns for toxic accumulation in the setting of renal dysfunction of critical illness. We developed a population pharmacokinetic model of milrinone using nonlinear mixed-effects modeling in NONMEM to perform dose-exposure simulations in children with variable renal function. We included children aged <21 years who received intravenous milrinone per clinical care. Plasma milrinone concentrations were measured using a validated liquid chromatography-tandem mass spectrometry assay (range 1-5000 ng/mL). We performed dose-exposure simulations targeting steady-state therapeutic concentrations of 100-300 ng/mL previously established in adults and children with cardiac dysfunction. We simulated concentrations over 48 hours in typical subjects with decreasing creatinine clearance (CrCl), estimated using the updated bedside Schwartz equation. Seventy-four patients contributed 111 plasma samples (concentration range, 4-634 ng/mL). The median (range) postmenstrual age (PMA) was 3.7 years (0-18), and median weight (WT) was 13.1 kg (2.6-157.7). The median serum creatinine and CrCl were 0.5 mg/dL (0.1-3.1) and 117.2 mL/min/1.73 m2 (13.1-261.3), respectively. A 1-compartment model characterized the pharmacokinetic data well. The final model parameterization was: Clearance (L/h) = 15.9*(WT [kg] / 70)0.75 * (PMA1.12 / (67.71.12 +PMA1.12 )*(CrCl / 117)0.522 ; and Volume of Distribution (L) = 32.2*(WT [kg] / 70). A loading dose of 50 µg/kg followed by a continuous infusion of 0.5 µg/kg/min resulted in therapeutic concentrations, except when CrCl was severely impaired at ≤30 mL/min/1.73 m2 . In this setting, a 25 µg/kg loading dose and 0.25 µg/kg/min continuous infusion resulted in therapeutic exposures.
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Affiliation(s)
- Christoph P. Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Ram Yogev
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | | | - Kevin M. Watt
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Janice E. Sullivan
- University of Louisville Norton Children’s Hospital, Louisville, KY, USA
| | - Andrew M. Atz
- Medical University of South Carolina Children’s Hospital, Charleston, SC, USA
| | - David Speicher
- Rainbow Babies and Children’s Hospital, Cleveland, OH, USA
| | - Amira Al-Uzri
- Oregon Health and Science University, Portland, OR, USA
| | | | | | | | - Susan Lin
- The EMMES Corporation, Rockville, MD, USA
| | - Barrie Harper
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Chiara Melloni
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Abstract
Preterm birth is associated with adverse renal health outcomes including hypertension, chronic kidney disease, and an increased rate of progression to end-stage renal failure. This review explores the antenatal, perinatal, and postnatal factors that affect the functional nephron mass of an individual and contribute to long-term kidney outcome. Health-care professionals have opportunities to increase their awareness of the risks to kidney health in this population. Optimizing maternal health around the time of conception and during pregnancy, providing kidney-focused supportive care in the NICU during postnatal nephrogenesis, and avoiding accelerating nephron loss throughout life may all contribute to improved long-term outcomes. There is a need for ongoing research into the long-term kidney outcomes of preterm survivors in mid-to-late adulthood as well as a need for further research into interventions that may improve ex utero nephrogenesis.
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Affiliation(s)
- Amanda Dyson
- Centenary Hospital for Women and Children and Department of Neonatology, Canberra Hospital, Woden, Australia
- Australian National University, Canberra, Australia
| | - Alison L Kent
- University of Rochester and Division of Neonatology, Golisano Children's Hospital at URMC, Rochester, NY
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Mahmood I, Tegenge MA. A Comparative Study Between Allometric Scaling and Physiologically Based Pharmacokinetic Modeling for the Prediction of Drug Clearance From Neonates to Adolescents. J Clin Pharmacol 2018; 59:189-197. [DOI: 10.1002/jcph.1310] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 08/09/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Iftekhar Mahmood
- Office of Tissue & Advanced Therapies; Center for Biologics Evaluation and Research; Food & Drug Administration; Silver Spring MD USA
| | - Million A. Tegenge
- Office of Biostatistics & Epidemiology; Center for Biologics Evaluation and Research; Food & Drug Administration; Silver Spring MD USA
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Mahmood I. Misconceptions and issues regarding allometric scaling during the drug development process. Expert Opin Drug Metab Toxicol 2018; 14:843-854. [PMID: 29999428 DOI: 10.1080/17425255.2018.1499725] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Allometry is the study of size and its consequences. The simple hypothesis of allometric scaling is that all physiological parameters are proportional to body size or body mass. This review examines the development of theory-based allometry or fixed exponents (0.75 and 1.0 for basal metabolic rate and volume, respectively) and the evidence for or against the theory. The main focus of this report is to show the readers that there is enough evidence from experimental data that negate the concept of theory-based allometry in biology, physiology, and pharmacokinetics. Areas covered: In this review, the history of the development of theoretical allometry and the strong evidence against theory-based allometry demonstrated by experimental data is provided. During drug development, allometry is applied to both inter-species (from animals to humans) and intra-species (adults to children) scaling. These two forms of allometric scaling in the context of theory-based allometry are discussed and provide insight on scientific progress that refute theory-based allometry. Expert opinion: Theory-based allometry is a mere theory and experimental data and real-life observations strongly negate the existence of such a theory. Pharmacostatistical and physiological models based on theory-based allometry can be misleading and incorrect because the theory-based allometric exponent 0.75 is not universal. The exponents of allometry are data dependent and are not fixed in the universe.
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Affiliation(s)
- Iftekhar Mahmood
- a Office of Tissue & Advance Therapies (OTAT) , Center for Biologics Evaluation and Research, Food & Drug Administration , Silver Spring , MD , USA
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Brussee JM, Calvier EAM, Krekels EHJ, Välitalo PAJ, Tibboel D, Allegaert K, Knibbe CAJ. Children in clinical trials: towards evidence-based pediatric pharmacotherapy using pharmacokinetic-pharmacodynamic modeling. Expert Rev Clin Pharmacol 2016; 9:1235-44. [PMID: 27269200 DOI: 10.1080/17512433.2016.1198256] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION In pediatric pharmacotherapy, many drugs are still used off-label, and their efficacy and safety is not well characterized. Different efficacy and safety profiles in children of varying ages may be anticipated, due to developmental changes occurring across pediatric life. AREAS COVERED Beside pharmacokinetic (PK) studies, pharmacodynamic (PD) studies are urgently needed. Validated PKPD models can be used to derive optimal dosing regimens for children of different ages, which can be evaluated in a prospective study before implementation in clinical practice. Strategies should be developed to ensure that formularies update their drug dosing guidelines regularly according to the most recent advances in research, allowing for clinicians to integrate these guidelines in daily practice. Expert commentary: We anticipate a trend towards a systems-level approach in pediatric modeling to optimally use the information gained in pediatric trials. For this approach, properly designed clinical PKPD studies will remain the backbone of pediatric research.
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Affiliation(s)
- Janneke M Brussee
- a Division of Pharmacology, Leiden Academic Centre for Drug Research , Leiden University , Leiden , The Netherlands
| | - Elisa A M Calvier
- a Division of Pharmacology, Leiden Academic Centre for Drug Research , Leiden University , Leiden , The Netherlands
| | - Elke H J Krekels
- a Division of Pharmacology, Leiden Academic Centre for Drug Research , Leiden University , Leiden , The Netherlands
| | - Pyry A J Välitalo
- a Division of Pharmacology, Leiden Academic Centre for Drug Research , Leiden University , Leiden , The Netherlands
| | - Dick Tibboel
- b Intensive Care and Department of Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Karel Allegaert
- b Intensive Care and Department of Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,c Department of Development and Regeneration , KU Leuven , Leuven , Belgium
| | - Catherijne A J Knibbe
- a Division of Pharmacology, Leiden Academic Centre for Drug Research , Leiden University , Leiden , The Netherlands.,d Department of Clinical Pharmacy , St. Antonius Hospital , Nieuwegein , The Netherlands
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