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Jeong HC, Chae YJ, Shin KH. Predicting the systemic exposure and lung concentration of nafamostat using physiologically-based pharmacokinetic modeling. Transl Clin Pharmacol 2022; 30:201-211. [PMID: 36632076 PMCID: PMC9810492 DOI: 10.12793/tcp.2022.30.e20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 12/31/2022] Open
Abstract
Nafamostat has been actively studied for its neuroprotective activity and effect on various indications, such as coronavirus disease 2019 (COVID-19). Nafamostat has low water solubility at a specific pH and is rapidly metabolized in the blood. Therefore, it is administered only intravenously, and its distribution is not well known. The main purposes of this study are to predict and evaluate the pharmacokinetic (PK) profiles of nafamostat in a virtual healthy population under various dosing regimens. The most important parameters were assessed using a physiologically based pharmacokinetic (PBPK) approach and global sensitivity analysis with the Sobol sensitivity analysis. A PBPK model was constructed using the SimCYP® simulator. Data regarding the in vitro metabolism and clinical studies were extracted from the literature to assess the predicted results. The model was verified using the arithmetic mean maximum concentration (Cmax), the area under the curve from 0 to the last time point (AUC0-t), and AUC from 0 to infinity (AUC0-∞) ratio (predicted/observed), which were included in the 2-fold range. The simulation results suggested that the 2 dosing regimens for the treatment of COVID-19 used in the case reports could maintain the proposed effective concentration for inhibiting severe acute respiratory syndrome coronavirus 2 entry into the plasma and lung tissue. Global sensitivity analysis indicated that hematocrit, plasma half-life, and microsomal protein levels significantly influenced the systematic exposure prediction of nafamostat. Therefore, the PBPK modeling approach is valuable in predicting the PK profile and designing an appropriate dosage regimen.
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Affiliation(s)
- Hyeon-Cheol Jeong
- Research Institute of Pharmaceutical Sciences, College of Pharmacy, Kyungpook National University, Daegu 41566, Korea
| | - Yoon-Jee Chae
- Research Institute of Pharmaceutical Sciences, College of Pharmacy, Woosuk University, Wanju 55338, Korea
| | - Kwang-Hee Shin
- Research Institute of Pharmaceutical Sciences, College of Pharmacy, Kyungpook National University, Daegu 41566, Korea
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Hernández-Mitre MP, Tong SYC, Denholm JT, Dore GJ, Bowen AC, Lewin SR, Venkatesh B, Hills TE, McQuilten Z, Paterson DL, Morpeth SC, Roberts JA. Nafamostat Mesylate for Treatment of COVID-19 in Hospitalised Patients: A Structured, Narrative Review. Clin Pharmacokinet 2022; 61:1331-1343. [PMID: 36040613 PMCID: PMC9425784 DOI: 10.1007/s40262-022-01170-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 01/06/2024]
Abstract
The search for clinically effective antivirals against the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is ongoing. Repurposing of drugs licensed for non–coronavirus disease 2019 (COVID-19) indications has been extensively investigated in laboratory models and in clinical studies with mixed results. Nafamostat mesylate (nafamostat) is a drug licensed in Japan and Korea for indications including acute pancreatitis and disseminated intravascular coagulation. It is available only for continuous intravenous infusion. In vitro human lung cell line studies with nafamostat demonstrate high antiviral potency against SARS-CoV-2 (half maximal inhibitory concentration [IC50] of 0.0022 µM [compared to remdesivir 1.3 µM]), ostensibly via inhibition of the cellular enzyme transmembrane protease serine 2 (TMPRSS2) preventing viral entry into human cells. In addition, the established antithrombotic activity is hypothesised to be advantageous given thrombosis-associated sequelae of COVID-19. Clinical reports to date are limited, but indicate a potential benefit of nafamostat in patients with moderate to severe COVID-19. In this review, we will explore the pre-clinical, pharmacokinetic and clinical outcome data presently available for nafamostat as a treatment for COVID-19. The recruitment to ongoing clinical trials is a priority to provide more robust data on the safety and efficacy of nafamostat as a treatment for COVID-19.
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Affiliation(s)
| | - Steven Y C Tong
- Victorian Infectious Disease Service, Royal Melbourne Hospital, Melbourne, VIC, Australia.,The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia.,Menzies School of Health Research, Charles Darwin University, Casuarina, NT, Australia
| | - Justin T Denholm
- Victorian Infectious Disease Service, Royal Melbourne Hospital, Melbourne, VIC, Australia.,The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - Gregory J Dore
- Kirby Institute, UNSW Sydney, New South Wales, Australia
| | - Asha C Bowen
- Department of Infectious Diseases, Perth Children's Hospital, Perth, WA, Australia.,Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia
| | - Sharon R Lewin
- Victorian Infectious Disease Service, Royal Melbourne Hospital, Melbourne, VIC, Australia.,The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia.,Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
| | - Balasubramanian Venkatesh
- Intensive Care, Princess Alexandra, and Wesley Hospital, The University of Queensland, Brisbane, QLD, Australia.,The George Institute for Global Health, UNSW Sydney, New South Wales, Australia
| | - Thomas E Hills
- Departments of Immunology and Infectious Diseases, Auckland District Health Broad, Auckland, New Zealand.,Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Zoe McQuilten
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Australia.,Department of Haematology, Monash Health, Melbourne, Australia
| | - David L Paterson
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | | | - Jason A Roberts
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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3
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Oh HS, Kim T, Gu DH, Lee TS, Kim TH, Shin S, Shin BS. Pharmacokinetics of Nafamostat, a Potent Serine Protease Inhibitor, by a Novel LC-MS/MS Analysis. MOLECULES (BASEL, SWITZERLAND) 2022; 27:molecules27061881. [PMID: 35335247 PMCID: PMC8955020 DOI: 10.3390/molecules27061881] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/24/2022] [Accepted: 03/13/2022] [Indexed: 11/16/2022]
Abstract
Nafamostat, a synthetic serine protease inhibitor, has been used for the treatment of inflammatory diseases such as pancreatitis. Recently, an increasing number of studies have shown the promising antiviral effects of nafamostat for the treatment of coronavirus disease-19 (COVID-19). This study aimed to develop a novel liquid chromatography–tandem mass spectrometry (LC-MS/MS) analysis and to characterize the pharmacokinetics of nafamostat in rats. Nafamostat in the rat plasma was extracted by solid phase extraction, and 13C6-nafamostat was used as an internal standard. The quantification limit of nafamostat in the rat plasma was 0.5 ng/mL. The LC-MS/MS method was fully validated and applied to characterize the pharmacokinetics of nafamostat in rats. Following intravenous injection (2 mg/kg), nafamostat in the plasma showed a multiexponential decline with an average elimination half-life (t1/2) of 1.39 h. Following oral administration of nafamostat solutions (20 mg/kg) in 10% dimethyl sulfoxide (DMSO) and in 10% DMSO with 10% Tween 80, nafamostat was rapidly absorbed, and the average oral bioavailability was 0.95% and 1.59%, respectively. The LC-MS/MS method and the pharmacokinetic information of nafamostat could be helpful for the further preclinical and clinical studies of nafamostat.
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Affiliation(s)
- Hyeon Seok Oh
- School of Pharmacy, Sungkyunkwan University, Suwon 16419, Korea; (H.S.O.); (T.K.); (D.-H.G.); (T.S.L.)
| | - Taehyung Kim
- School of Pharmacy, Sungkyunkwan University, Suwon 16419, Korea; (H.S.O.); (T.K.); (D.-H.G.); (T.S.L.)
| | - Dong-Hyeon Gu
- School of Pharmacy, Sungkyunkwan University, Suwon 16419, Korea; (H.S.O.); (T.K.); (D.-H.G.); (T.S.L.)
| | - Tae Suk Lee
- School of Pharmacy, Sungkyunkwan University, Suwon 16419, Korea; (H.S.O.); (T.K.); (D.-H.G.); (T.S.L.)
| | - Tae Hwan Kim
- College of Pharmacy, Daegu Catholic University, Gyeongsan 38430, Korea;
| | - Soyoung Shin
- College of Pharmacy, Wonkwang University, Iksan 54538, Korea;
| | - Beom Soo Shin
- School of Pharmacy, Sungkyunkwan University, Suwon 16419, Korea; (H.S.O.); (T.K.); (D.-H.G.); (T.S.L.)
- Correspondence: ; Tel.: +82-31-290-7705
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Cho YS, Shin JG. Physiologically-based pharmacokinetic modeling of nafamostat to support dose selection for treatment of pediatric patients with COVID-19. Transl Clin Pharmacol 2022; 30:24-36. [PMID: 35419314 PMCID: PMC8979760 DOI: 10.12793/tcp.2022.30.e4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/14/2022] [Accepted: 02/25/2022] [Indexed: 12/15/2022] Open
Abstract
Pediatric patients with coronavirus disease 2019 (COVID-19) are increasing, and severe cases such as multisystem inflammatory syndrome are being reported. Nafamostat, a repurposing drug, is currently being explored for the treatment of COVID-19 in adults. However, the data supporting its exposure in pediatrics remains scarce. Physiologically-based pharmacokinetic (PBPK) modeling enables the prediction of drug exposure in pediatrics based on ontogeny of metabolic enzymes and age dependent anatomical and physiological changes. The study aimed to establish a PBPK model of nafamostat in adults, then scale the adult PBPK model to children for predicting pediatric exposures of nafamostat and an optimal weight-based nafamostat dose in pediatric population. The developed model adequately described adult exposure data in healthy volunteers following i.v. administration with three doses (10, 20, and 40 mg). Scaling adult PBPK models to five pediatric groups predicted that as age advances from neonate to adult, the exposure of nafamostat slightly increased from neonate to infant, steadily decreased from infant to child, and then increased from child to adult after the administration of 0.2 mg/kg/h for 14 days, a dosing regimen being conducted in a clinical trial for COVID-19. Based on the fold change of predicted area under the curve for the respective pediatric group over those of adults, weight-based dosages for each pediatric group may be suggested. The novel PBPK model described in this study may be useful to investigate nafamostat pharmacokinetics in a pediatric subgroup further.
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Affiliation(s)
- Yong-Soon Cho
- Center for Personalized Precision Medicine of Tuberculosis (cPMTb), Inje University College of Medicine, Busan 47392, Korea
- Department of Pharmacology and Clinical Pharmacology, PharmacoGenomics Research Center, Inje University College of Medicine, Busan 47392, Korea
| | - Jae-Gook Shin
- Center for Personalized Precision Medicine of Tuberculosis (cPMTb), Inje University College of Medicine, Busan 47392, Korea
- Department of Pharmacology and Clinical Pharmacology, PharmacoGenomics Research Center, Inje University College of Medicine, Busan 47392, Korea
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Zeitlinger M, Koch BCP, Bruggemann R, De Cock P, Felton T, Hites M, Le J, Luque S, MacGowan AP, Marriott DJE, Muller AE, Nadrah K, Paterson DL, Standing JF, Telles JP, Wölfl-Duchek M, Thy M, Roberts JA. Pharmacokinetics/Pharmacodynamics of Antiviral Agents Used to Treat SARS-CoV-2 and Their Potential Interaction with Drugs and Other Supportive Measures: A Comprehensive Review by the PK/PD of Anti-Infectives Study Group of the European Society of Antimicrobial Agents. Clin Pharmacokinet 2020; 59:1195-1216. [PMID: 32725382 PMCID: PMC7385074 DOI: 10.1007/s40262-020-00924-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
There is an urgent need to identify optimal antiviral therapies for COVID-19 caused by SARS-CoV-2. We have conducted a rapid and comprehensive review of relevant pharmacological evidence, focusing on (1) the pharmacokinetics (PK) of potential antiviral therapies; (2) coronavirus-specific pharmacodynamics (PD); (3) PK and PD interactions between proposed combination therapies; (4) pharmacology of major supportive therapies; and (5) anticipated drug-drug interactions (DDIs). We found promising in vitro evidence for remdesivir, (hydroxy)chloroquine and favipiravir against SARS-CoV-2; potential clinical benefit in SARS-CoV-2 with remdesivir, the combination of lopinavir/ritonavir (LPV/r) plus ribavirin; and strong evidence for LPV/r plus ribavirin against Middle East Respiratory Syndrome (MERS) for post-exposure prophylaxis in healthcare workers. Despite these emerging data, robust controlled clinical trials assessing patient-centred outcomes remain imperative and clinical data have already reduced expectations with regard to some drugs. Any therapy should be used with caution in the light of potential drug interactions and the uncertainty of optimal doses for treating mild versus serious infections.
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Affiliation(s)
- Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | | | | | - Pieter De Cock
- Department of Pharmacy 2, Heymans Institute of Pharmacology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Timothy Felton
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Maya Hites
- Clinic of Infectious Diseases, CUB-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, CA, USA
| | - Sonia Luque
- Pharmacy Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar D'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Alasdair P MacGowan
- Bristol Centre for Antimicrobial Research and Evaluation, Infection Sciences, Severn Pathology Partnership, North Bristol NHS Trust, Southmead Hospital, Westbury-On-Trym, Bristol, UK
| | - Deborah J E Marriott
- St. Vincent's Hospital, Darlinghurst, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Anouk E Muller
- HaaglandenMC, The Hague and ErasmusMC, Rotterdam, The Netherlands
| | - Kristina Nadrah
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - David L Paterson
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Joseph F Standing
- Infection, Inflammation and Immunity, Great Ormond Street Institute of Child Health, University College London, London, UK
- Department of Pharmacy, Great Ormond Street Hospital for Children, London, UK
| | - João P Telles
- Department of Infectious Diseases, AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Michael Wölfl-Duchek
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Michael Thy
- Infectious Diseases Department and Intensive Care Unit, Hospital Bichat, Paris, France
- EA7323, Evaluation of Perinatal and Paediatric Therapeutics and Pharmacology, University Paris Descartes, Paris, France
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine and Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia.
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
- The University of Queensland Centre for Clinical Research, The University of Queensland, Royal Brisbane and Women's Hospital, Butterfield St, Herston, QLD, 4029, Australia.
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Inman RD, Chiu B. Nafamostat mesylate, a serine protease inhibitor, demonstrates novel antimicrobial properties and effectiveness in Chlamydia-induced arthritis. Arthritis Res Ther 2012; 14:R150. [PMID: 22716645 PMCID: PMC3446536 DOI: 10.1186/ar3886] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2012] [Revised: 05/08/2012] [Accepted: 06/20/2012] [Indexed: 02/05/2023] Open
Abstract
Introduction Effective treatment of reactive arthritis would ideally achieve both control of inflammation and eradication of persisting arthritogenic pathogens. We use a model of experimental Chlamydia trachomatis-induced arthritis (CtIA) to evaluate the effectiveness of nafamostat mesilate (NM), a serine protease inhibitor with complement-modifying effects and anticoagulant properties. To date clinical use of NM has largely been in Asia and has been primarily confined to inflammatory states such as pancreatitis. Methods In vitro studies examined inhibition of Chlamydia proliferation using fibroblast cell lines as targets and phase contrast microscopy. In vivo studies used an established protocol, experimental CtIA, induced in Lewis rats by injection of synoviocyte-packaged C. trachomatis. NM was dissolved in water and administered by daily intraperitoneal injection at a dose of 10 mg/kg beginning the day prior to the administration of Chlamydia. Readouts in vivo included (i) joint swelling, (ii) histopathology scoring of severity of arthritis, (iii) host clearance of the pathogen (by ELISA, the IDEIA PCE Chlamydia). Results NM exerted a dose-dependent inhibition of chlamydial proliferation in vitro. Without NM, the mean number of inclusion bodies (IB) per well was 17,886 (± 1415). At 5 μg/mL NM, there were 8,490 (± 756) IB, at 25 μg/mL NM there were 35 IB and at 50 μg/mL NM no IB was observed. Chlamydial antigens in each well along the concentration gradient were assayed by ELISA, demonstrating that at 25 μg/mL NM inhibition of Chlamydia was almost complete. In the experimental arthritis model, joint swelling was significantly reduced with NM treatment: average joint width for the NM-treated animals was 8.55 mm (s.d. ± 0.6578, n = 10) versus 11.18 mm (s.d. ± 0.5672, n = 10) in controls (P < 0.001). Histopathology scoring indicated that NM resulted in a marked attenuation of the inflammatory infiltration and joint damage: mean pathology score in NM-treated animals was 10.9 (± 2.45, n = 11) versus 15.9 (± 1.45, n = 10) in controls (P < 0.0001). With respect to persistence of Chlamydia within the synovial tissues, NM treatment was accompanied by a reduction in the microbial load in the joint: mean optical density (O.D.) for ELISA with NM treatment was 0.05 (± 0.02, n = 4) versus 0.18 (± 0.05, n = 4) in controls (P < 0.001). Conclusions NM is a protease inhibitor not previously recognized to possess antimicrobial properties. The present study demonstrates for the first time that NM exerts significant impact on C. trachomatis-induced arthritis and suggests that such approaches may prove clinically useful in chronic reactive arthritis.
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Affiliation(s)
- Robert D Inman
- Division of Genetics and Development, Toronto Western Research Institute, 399 Bathurst Street, Toronto, M5T 2S8, Canada.
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