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Langille E, Bottaro CS. Development and application of a thin-film molecularly imprinted polymer for the measurement of mycophenolic acid in human plasma. J Clin Lab Anal 2023; 37:e24864. [PMID: 37032424 PMCID: PMC10156102 DOI: 10.1002/jcla.24864] [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: 09/14/2022] [Revised: 12/29/2022] [Accepted: 03/04/2023] [Indexed: 04/11/2023] Open
Abstract
BACKGROUND Mycophenolic acid (MPA) is used to suppress the immune response following organ transplantation; however, complex pharmacokinetic behavior and a large interpersonal variability necessitate therapeutic drug monitoring. To overcome the limitations of current sample preparation techniques, we present a novel thin-film molecularly imprinted polymer (TF-MIP) extraction device as part of a simple, sensitive, and fast method for analysis of MPA from human plasma. METHODS Mycophenolic acid is extracted from plasma using a tailor-made TF-MIP that is subsequently desorbed into an organic solvent system compatible with mass spectrometry. The MIP yielded higher recovery of MPA relative to a corresponding non-imprinted polymer. The method allows for the determination of MPA in 45 min including analysis time and can be scaled for high throughput to process as many as 96 samples per hour. RESULTS The method gave an LOD of 0.3 ng mL-1 and was linear from 5 to 250 ng mL-1 . Patient plasma samples (35 μL) were diluted using charcoal-stripped pooled plasma to a final extraction volume of 700 μL; when MPA in patient plasma is high, this ratio can easily be adjusted to ensure samples are within the method linear range. Intra- and inter-day variability were 13.8% and 4.3% (at 15 ng mL-1 ) and 13.5% and 11.0% (at 85 ng mL-1 ), respectively (n = 3); inter-device variability was 9.6% (n = 10). CONCLUSIONS Low inter-device variability makes these devices suitable for single use in a clinical setting, and the fast and robust method is suitable for therapeutic drug monitoring, where throughput and time-to-result are critical.
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Affiliation(s)
- Evan Langille
- Department of Chemistry, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Christina S Bottaro
- Department of Chemistry, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
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Efficacy and Safety of Switching to Azathioprine for Mycophenolate-Induced Diarrhea in Renal Transplant Recipients. Transplant Proc 2021; 53:1951-1956. [PMID: 34274119 DOI: 10.1016/j.transproceed.2021.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 06/14/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diarrhea is a common adverse effect of mycophenolate treatment in renal transplant recipients. In patients with mycophenolate-induced diarrhea, one option is to switch to mycophenolate to azathioprine. In this study, we aimed to define the safety and efficacy of switching from mycophenolate to azathioprine for mycophenolate-related diarrhea in renal transplant recipients. METHODS A total of 177 patients, 59 of whom were switched to azathioprine because of diarrhea and 118 of whom comprised a matched control group without diarrhea and continued mycophenolate treatment participated in this study. We analyzed the effect of switching to azathioprine from mycophenolate on amelioration of diarrhea and graft survival. RESULTS We observed that 89.8% of patients who switched to azathioprine because of diarrhea had improved diarrhea complaints. Patients switched to azathioprine because of diarrhea had lower glomerular filtration rates (P < .001) and higher proteinuria (P < .001) compared with the control group before the switch. Patients switched to azathioprine compared with a subgroup of 59 control patients were matched to patients switched to azathioprine in terms of baseline renal function and proteinuria in addition to demographic parameters had higher 10-year graft loss compared with patients who continued mycophenolate (P = .03). Particularly in patients with a glomerular filtration rate <30 mL/min at the time of conversion, the risk of early graft loss was high. CONCLUSIONS Although switching from mycophenolate to azathioprine was an effective approach to improve diarrhea, this approach is associated with increased risk of graft loss.
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Bentata Y. Mycophenolates: The latest modern and potent immunosuppressive drugs in adult kidney transplantation: What we should know about them? Artif Organs 2020; 44:561-576. [DOI: 10.1111/aor.13623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/25/2019] [Accepted: 12/20/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Yassamine Bentata
- Nephrology and Kidney Transplantation Unit University Hospital Mohammed VI University Mohammed First Oujda Morocco
- Laboratory of Epidemiology Clinical Research and Public Health Medical School University Mohammed First Oujda Morocco
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Celiac-like Enteropathy Associated With Mycophenolate Sodium in Renal Transplant Recipients. Transplant Direct 2018; 4:e375. [PMID: 30255135 PMCID: PMC6092177 DOI: 10.1097/txd.0000000000000812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 05/24/2018] [Accepted: 05/30/2018] [Indexed: 01/19/2023] Open
Abstract
Background Although colonic injury is a well-known complication of mycophenolic acid (MPA), the involvement of the upper gastrointestinal tract is less extensively documented. We present the occurrence of celiac-like duodenopathy manifested as a severe diarrhea syndrome in 2 renal transplant recipients on enteric-coated mycophenolate sodium. Methods The patients belong to a setting of 16 renal transplant recipients under MPA suffering from chronic diarrhea in the absence of MPA-related colitis. Results Both patients had a history of persistent diarrhea with significant weight loss. Colonic mucosa was unremarkable, whereas duodenal biopsies revealed celiac-like changes with increased epithelial cell apoptosis. Clinical symptoms completely resolved, and follow-up biopsies demonstrated normalization of histology after enteric-coated mycophenolate sodium withdrawal and switching to azathioprine. Conclusions Celiac-like enteropathy seems to represent a rare side effect of MPA-associated immunosuppressive therapy and should be taken into account in the differential diagnosis of diarrhea in transplant recipients treated with MPA particularly in the absence of MPA-related colitis. As macroscopic lesions are usually missing, blind duodenal biopsies are necessary to establish the diagnosis.
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Abstract
The adverse effects of mycophenolate mofetil on the colon are well known. However, isolated small intestinal involvement resulting in diarrhea and severe weight loss is infrequently reported in the literature. We present the case of a 45-year-old woman on mycophenolate mofetil following renal transplant, who presented with abdominal pain and weight loss. An esophagogastroduodenoscopy and colonoscopy with biopsies were normal. A small bowel capsule study revealed extensive enteropathy of jejunum and ileum that was confirmed on a push enteroscopy with biopsies. Her symptoms completely resolved after being switched to enteric-coated mycophenolic acid.
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Chou HH, Chen MJ, Chiou YY. Enteric-coated mycophenolate sodium in pediatric lupus nephritis: a retrospective cohort study. Clin Exp Nephrol 2015; 20:628-636. [DOI: 10.1007/s10157-015-1171-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 09/22/2015] [Indexed: 02/04/2023]
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Pharmacology and toxicology of mycophenolate in organ transplant recipients: an update. Arch Toxicol 2014; 88:1351-89. [PMID: 24792322 DOI: 10.1007/s00204-014-1247-1] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 04/15/2014] [Indexed: 12/22/2022]
Abstract
This review aims to provide an update of the literature on the pharmacology and toxicology of mycophenolate in solid organ transplant recipients. Mycophenolate is now the antimetabolite of choice in immunosuppressant regimens in transplant recipients. The active drug moiety mycophenolic acid (MPA) is available as an ester pro-drug and an enteric-coated sodium salt. MPA is a competitive, selective and reversible inhibitor of inosine-5'-monophosphate dehydrogenase (IMPDH), an important rate-limiting enzyme in purine synthesis. MPA suppresses T and B lymphocyte proliferation; it also decreases expression of glycoproteins and adhesion molecules responsible for recruiting monocytes and lymphocytes to sites of inflammation and graft rejection; and may destroy activated lymphocytes by induction of a necrotic signal. Improved long-term allograft survival has been demonstrated for MPA and may be due to inhibition of monocyte chemoattractant protein 1 or fibroblast proliferation. Recent research also suggested a differential effect of mycophenolate on the regulatory T cell/helper T cell balance which could potentially encourage immune tolerance. Lower exposure to calcineurin inhibitors (renal sparing) appears to be possible with concomitant use of MPA in renal transplant recipients without undue risk of rejection. MPA displays large between- and within-subject pharmacokinetic variability. At least three studies have now reported that MPA exhibits nonlinear pharmacokinetics, with bioavailability decreasing significantly with increasing doses, perhaps due to saturable absorption processes or saturable enterohepatic recirculation. The role of therapeutic drug monitoring (TDM) is still controversial and the ability of routine MPA TDM to improve long-term graft survival and patient outcomes is largely unknown. MPA monitoring may be more important in high-immunological recipients, those on calcineurin-inhibitor-sparing regimens and in whom unexpected rejection or infections have occurred. The majority of pharmacodynamic data on MPA has been obtained in patients receiving MMF therapy in the first year after kidney transplantation. Low MPA area under the concentration time from 0 to 12 h post-dose (AUC0-12) is associated with increased incidence of biopsy-proven acute rejection although AUC0-12 optimal cut-off values vary across study populations. IMPDH monitoring to identify individuals at increased risk of rejection shows some promise but is still in the experimental stage. A relationship between MPA exposure and adverse events was identified in some but not all studies. Genetic variants within genes involved in MPA metabolism (UGT1A9, UGT1A8, UGT2B7), cellular transportation (SLCOB1, SLCO1B3, ABCC2) and targets (IMPDH) have been reported to effect MPA pharmacokinetics and/or response in some studies; however, larger studies across different ethnic groups that take into account genetic linkage and drug interactions that can alter a patient's phenotype are needed before any clinical recommendations based on patient genotype can be formulated. There is little data on the pharmacology and toxicology of MPA in older and paediatric transplant recipients.
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Abstract
INTRODUCTION To discuss the significance of the recent observational case series from the Swiss Toxicological Information Centre (STIC). Mycophenolic acid (MPA) and its prodrug mycophenolate mofetil are immunosuppressive agents that are frequently prescribed in renal transplant recipients, and their safety profiles must be established. AREAS COVERED This case series and systemic literature analysis consists of 15 cases of MPA overdose from the STIC and a systemic analysis of the literature over the past 18 years. This study focuses on acute overdosing, the effects of which are presumably mild. In contrast, the effects of long-term overdosing may be much more severe. Substantial underreporting is likely. The pharmacokinetic monitoring of MPA is rarely performed, which is both striking and does not coincide with findings in academic literature. The scant data on pharmacokinetic monitoring presented demonstrated that MPA has a short terminal half-life, which suggests that decontamination and activated charcoal treatment in acute overdose may not be necessary. EXPERT OPINION The case series and systematic literature analysis of acute mycophenolate overdose represent an important contribution toward increasing the safety of MPA therapy.
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Affiliation(s)
- Guido Filler
- University of Western Ontario, Children's Hospital, Schulich School of Medicine & Dentistry, London Health Sciences Centre, Department of Paediatrics , 800 Commissioners Road East, London, ON N6A 5W9 , Canada
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Alghamdi HM. Acute Acalculous Cholecystitis Perforation in a Child Non-Surgical Management. Gastroenterology Res 2012; 5:174-176. [PMID: 27785201 PMCID: PMC5051088 DOI: 10.4021/gr450w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2012] [Indexed: 12/12/2022] Open
Abstract
Spontaneous gallbladder perforation (SGP) is a rare but fatal complication usually associated with acute calculus cholecystitis. Mostly seen in adult patient and rarely reported in children. We report a rare case of aculcoulus gallbladder perforation in a 15 years old child post kidney transplant managed by percutaneous cholecystostomy tube drainage.
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Affiliation(s)
- Hanan M Alghamdi
- King Fahad Specialist Hospital-Dammam, Saudi Arabia; University of Dammam, Saudi Arabia
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Malekinejad H, Cheraghi H, Alizadeh A, Khadem-Ansari M, Tehrani A, Varasteh S. Nitric Oxide and Acute Phase Proteins Are Involved in Pathogenesis of Mycophenolate Mofetil–Induced Gastrointestinal Disorders in Rats. Transplant Proc 2011; 43:2741-6. [DOI: 10.1016/j.transproceed.2011.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 04/19/2011] [Indexed: 10/17/2022]
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Matz M, Naik M, Mashreghi MF, Glander P, Neumayer HH, Budde K. Evaluation of the novel protein kinase C inhibitor sotrastaurin as immunosuppressive therapy after renal transplantation. Expert Opin Drug Metab Toxicol 2010; 7:103-13. [PMID: 21142580 DOI: 10.1517/17425255.2011.540238] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE OF THE FIELD The prevalence of acute renal allograft rejection has decreased substantially in past decades due to new and more specific immunosuppressive compounds but improvements in long-term graft function have not been achieved. There is a large need for new immunosuppressive agents that lack toxicity of current agents such as calcineurin inhibitors but show high synergistic efficiency in preventing rejection processes. AREAS COVERED IN THIS REVIEW This review summarizes data concerning the pharmacokinetics, pharmacodynamics and clinical efficacy of the new PKC inhibitor sotrastaurin with a focus on renal transplantation. The article contains information that has been presented at international transplant meetings and congresses and that has been published between 2006 and 2010. Additionally, current ongoing trials are described in detail. WHAT THE READER WILL GAIN Immunosuppressive regimens after kidney transplantation consist of a combination of several agents in order to minimize drug toxicity. Therefore, the reader is presented with the most up-to-date/current developments in sotrastaurin applications in Phase I and II trials with emphasis on data maintained from studies that combined sotrastaurin with established agents such as mycophenolic acid and tacrolimus. TAKE HOME MESSAGE Several trials are ongoing and planned to determine the optimal immunosuppressive regimen to benefit from sotrastaurin's distinct mechanism of action.
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Affiliation(s)
- Mareen Matz
- Med. Klinik mS Nephrologie, Universitätsmedizin Charité, Berlin, Germany.
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Filler G, Sharma AP, Levy DM, Yasin A. Random pharmacokinetic profiles of EC-MPS in children with autoimmune disease. Pediatr Rheumatol Online J 2010; 8:1. [PMID: 20047676 PMCID: PMC2819250 DOI: 10.1186/1546-0096-8-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Accepted: 01/04/2010] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND : Therapy with mycophenolate mofetil (MMF) has become a valuable therapeutic option in children with autoimmune disease. MMF prescription in children with autoimmune diseases differs from that in transplant recipients in terms of different dosing regimen, and concomitant administration of other immunosuppressive medications. Recently, another formulation of the same active compound, mycophenolic acid (MPA), has become available as enteric-coated Mycophenolate Sodium (EC-MPS). Dosing and pharmacokinetics of EC-MPS in pediatric autoimmune disease have never been studied. METHOD S: We therefore performed a pilot study on 6 patients, who were treated with EC-MPS. All patients underwent 1-2 full 10-point pharmacokinetic (PK) profiles over a 12-hour dosing interval. We compared the results with that of 22 similar patients on MMF therapy. RESULTS : Median EC-MPS dose was 724 mg/m2 (range 179-933 mg/m2). The MPA Area-Under-The-(Time-Concentration)-Curves (AUCs) on MMF and EC-MPS were comparable (54.4 mg x h/L on MMF and 44.0 mg x h/L on EC-MPS, n.s., Mann Whitney). After correcting for bioequivalence, the dose-normalized AUCs were also similar on both the formulations. However, PK profiles on EC-MPS were quite random, and time to maximum concentration varied from 30 minutes to 720 minutes. The concentration at six-hour correlated best with the AUC. This was different from a homogenous PK-profile on MPA. CONCLUSIONS : EC-MPS has a different PK profile from MMF. The data suggest that patients on EC-MPS must undergo a complete PK profile to assess adequate exposure. The 6-hour concentration provides an estimate of the exposure and should be targeted between 3-4 mg/L.
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Affiliation(s)
- Guido Filler
- Department of Pediatrics, University of Western Ontario, Ontario, Canada
| | | | - Deborah M Levy
- Department of Pediatrics, University of Western Ontario, Ontario, Canada
| | - Abeer Yasin
- Department of Pediatrics, University of Western Ontario, Ontario, Canada
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Feichtiger H, Wieland E, Armstrong VW, Shipkova M. The acyl glucuronide metabolite of mycophenolic acid induces tubulin polymerization in vitro. Clin Biochem 2009; 43:208-13. [PMID: 19744471 DOI: 10.1016/j.clinbiochem.2009.08.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2009] [Revised: 08/09/2009] [Accepted: 08/21/2009] [Indexed: 02/01/2023]
Abstract
OBJECTIVES The acyl glucuronide (AcMPAG) of mycophenolic acid (MPA) forms covalent protein adducts and possesses antiproliferative properties independent of IMPDH inhibition. The underlying mechanism is unknown. Disorganized tubulin polymerization prevents cell cycle progression. We investigated whether AcMPAG interacts with tubulin polymerization. DESIGN AND METHODS AcMPAG (1.0-100 microM) was incubated with bovine tubulin in the presence of GTP. Polymerization was followed at 340 nm. The time until onset and the extent of polymerization were determined. MPA (100 microM), phenolic glucuronide MPAG (100 microM), and paclitaxel (10 microM) served as controls. RESULTS MPAG was without effect. The AcMPAG effect on tubulin polymerization was dose dependent and significantly stronger (about 2.5-fold) than that of MPA (n=4; p<0.05), but weaker than paclitaxel. CONCLUSIONS MPA and AcMPAG can induce tubulin polymerization in the presence of GTP with AcMPAG being significantly stronger. This property of AcMPAG may contribute to its IMPDH independent antiproliferative effect.
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Affiliation(s)
- Horst Feichtiger
- Zentralinstitut für Klinische Chemie und Laboratoriumsmedizin, Klinikum Stuttgart, Stuttgart, Germany
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Staatz CE, Smith AJ, Tett SE. A comparison of mycophenolate use in Australia and Northern Europe, and the impact on the pharmaceutical benefits scheme. Pharmacoepidemiol Drug Saf 2009; 18:386-92. [PMID: 19253908 DOI: 10.1002/pds.1726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
PURPOSE The aim of this study was to characterise utilisation of mycophenolate in Australian transplant recipients from 2001 to 2007; to identify specific patterns of mycophenolate mofetil and enteric-coated mycophenolate sodium usage; to examine expenditure on mycophenolate prescription and to compare Australian usage with Danish, Finish and Netherlands populations. METHODS Data on mycophenolate usage were obtained from Medicare Australia, Finish and Danish Medicines Agency and Netherlands Healthcare Insurance Board databases. Utilisation of mycophenolate was described as daily defined dose (DDD/per 1000 population/day). RESULTS From 2001 to 2007, utilisation of mycophenolate in Australia increased approximately 30-fold. In 2007, mycophenolate sodium accounted for 8.3% of mycophenolate total DDDs. In 2007, AUD$4,890,000 was spent on mycophenolate prescription. In 2006, utilisation of mycophenolate was five- to eight-fold higher in Northern Europe compared to Australia. Renal transplant rates per 1000 population/year were similar across countries. CONCLUSIONS Differences in the rate of mycophenolate utilisation between Northern Europe and Australia exist and may be due to differences in approved indications between countries, prescribing habits, or because of a more mature market in Europe. If the Australian market increases to that of North Europe the cost of prescribing mycophenolate will eventually be in the vicinity of AUD$20-80 million.
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