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Bruschi G, Pellegrino L, Bisogno AL, Ferreri F, Kassabian B, Seppi D, Favaretto S, Corbetta M, Dainese F. Use of perampanel oral suspension for the treatment of refractory and super-refractory status epilepticus. Epilepsy Behav 2024; 156:109826. [PMID: 38761446 DOI: 10.1016/j.yebeh.2024.109826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION Status epilepticus (SE) is a medical emergency associated with a significant risk of disability and death. The treatment of SE follows a step-wise approach, with limited data on ideal antiseizure medications (ASMs) for refractory and super refractory SE (RSE/SRSE). Perampanel (PER), an AMPA receptor antagonist, has shown promise in animal models but still has limited data in humans. This study tried to evaluate optimal dosage and safety of PER in RSE and SRSE patients. MATERIALS AND METHODS We retrospectively analysed 17 adult patients with RSE (1) or SRSE (16) treated with PER. Demographic and clinical data, including EEG patterns, ASMs administered, PER dosages, and PER plasma concentrations, were collected. For patients receiving a 24 mg PER loading dose (full dose group), the following treatment regimen was applied: 24 mg per day for 48 h following by 16 mg per day. The response to PER was assessed based on electroencephalographic (EEG) improvement from high to low epileptiform activity or from low to the absence of epileptiform activities. Safety was evaluated monitoring hepatic and renal function. RESULTS A response rate of 58.82 % was observed, with significantly higher responses in the full dose group (81.82 %) compared to those receiving PER doses below 24 mg (low dose group) (16.67 %) (p-value = 0.004; OR 0.044, 95 % CI 0.003 to 0.621, p = 0.021). No other clinical factors significantly influenced treatment response. Hepatic enzymes become elevated in most patients (70.59 %) but spontaneously decreased. DISCUSSION Our findings suggest that a 24 mg PER dose administered for 48 h may be more effective in managing RSE and SRSE compared to doses below 24 mg, potentially due to pharmacokinetic factors. CONCLUSION More robust data on PER in RSE and SRSE, including standardized dosing procedures and plasma level monitoring are needed. PER's potential benefits should be explored further, particularly in patients with RSE and SRSE.
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Affiliation(s)
- G Bruschi
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy.
| | - L Pellegrino
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy.
| | - A L Bisogno
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy.
| | - F Ferreri
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy; Department of Clinical Neurophysiology, Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland.
| | - B Kassabian
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy.
| | - D Seppi
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy.
| | - S Favaretto
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy.
| | - M Corbetta
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy; Veneto Institute of Molecular Medicine (VIMM), Padua, Italy.
| | - F Dainese
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy.
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Couderc S, Gabriel A, Decheiver S, N'Zoué Kanga S, Fikanni A, Flint H, Pihan F, Sahar A, Tifrea M, Tifrea A, Marsaud JP, Vandroux D. A Massive Venlafaxine Intoxication: Evolution of Cardiac Toxicity with Venlafaxine and O-Desmethylvenlafaxine Elimination Kinetics: A Grand Round. Ther Drug Monit 2024; 46:133-137. [PMID: 38158602 DOI: 10.1097/ftd.0000000000001167] [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: 03/20/2023] [Accepted: 10/18/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND This study presents the case of a 19-year-old woman who attempted suicide by ingesting 11.25 g of venlafaxine (V). She was admitted to the hospital with severe biventricular dysfunction, progressing to cardiac arrest requiring extracorporeal circulatory life support for 11 days. The pharmacokinetics of venlafaxine during impaired cardiac output and the effect of its active metabolite, the O-desmethylvenlafaxine (ODV), are currently not very well understood. METHODS AND RESULTS Serum concentrations of V and ODV were monitored twice daily for 3 weeks. The maximum concentrations of venlafaxine and ODV were at 14 hours after ingestion, with 29,180 mcg/L for V and 5399 mcg/L for ODV. Half-lives increased, requiring 2 weeks to eliminate the drug. The left ventricular ejection fraction significantly improved when V + ODV was below 1000 mcg/L and remained altered until the ODV concentrations were lower than 400 mcg/L. CONCLUSIONS This report, with complete elimination kinetic of V and ODV in a monodrug intoxication, provides information about the modification of pharmacokinetics in the case of an overdose managed by extracorporeal circulatory life support, the cardiac toxicity of ODV, and the value of the toxic threshold for the active moiety.
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Affiliation(s)
- Sylvain Couderc
- Department of Pharmacology and Toxicology, CHU Dupuytren, Limoges, France; and
| | - Anthony Gabriel
- Cardio-surgical Intensive Care Unit, CHU Dupuytren, Limoges, France
| | - Sarah Decheiver
- Department of Pharmacology and Toxicology, CHU Dupuytren, Limoges, France; and
| | - Sita N'Zoué Kanga
- Department of Pharmacology and Toxicology, CHU Dupuytren, Limoges, France; and
| | - Amine Fikanni
- Cardio-surgical Intensive Care Unit, CHU Dupuytren, Limoges, France
| | - Harry Flint
- Cardio-surgical Intensive Care Unit, CHU Dupuytren, Limoges, France
| | - Franck Pihan
- Cardio-surgical Intensive Care Unit, CHU Dupuytren, Limoges, France
| | - Abdallah Sahar
- Cardio-surgical Intensive Care Unit, CHU Dupuytren, Limoges, France
| | - Marius Tifrea
- Cardio-surgical Intensive Care Unit, CHU Dupuytren, Limoges, France
| | - Andrea Tifrea
- Cardio-surgical Intensive Care Unit, CHU Dupuytren, Limoges, France
| | | | - David Vandroux
- Cardio-surgical Intensive Care Unit, CHU Dupuytren, Limoges, France
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Abdelgawad N, Chirehwa M, Schutz C, Barr D, Ward A, Janssen S, Burton R, Wilkinson RJ, Shey M, Wiesner L, McIlleron H, Maartens G, Meintjes G, Denti P. Pharmacokinetics of antitubercular drugs in patients hospitalized with HIV-associated tuberculosis: a population modeling analysis. Wellcome Open Res 2024; 7:72. [PMID: 37008250 PMCID: PMC10050909 DOI: 10.12688/wellcomeopenres.17660.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2024] [Indexed: 03/05/2024] Open
Abstract
Background Early mortality among hospitalized HIV-associated tuberculosis (TB/HIV) patients is high despite treatment. The pharmacokinetics of rifampicin, isoniazid, and pyrazinamide were investigated in hospitalized TB/HIV patients and a cohort of outpatients with TB (with or without HIV) to determine whether drug exposures differed between groups. Methods Standard first-line TB treatment was given daily as per national guidelines, which consisted of oral 4-drug fixed-dose combination tablets containing 150 mg rifampicin, 75 mg isoniazid, 400 mg pyrazinamide, and 275 mg ethambutol. Plasma samples were drawn on the 3rd day of treatment over eight hours post-dose. Rifampicin, isoniazid, and pyrazinamide in plasma were quantified and NONMEM ® was used to analyze the data. Results Data from 60 hospitalized patients (11 of whom died within 12 weeks of starting treatment) and 48 outpatients were available. Median (range) weight and age were 56 (35 - 88) kg, and 37 (19 - 77) years, respectively. Bioavailability and clearance of the three drugs were similar between TB/HIV hospitalized and TB outpatients. However, rifampicin's absorption was slower in hospitalized patients than in outpatients; mean absorption time was 49.9% and 154% more in hospitalized survivors and hospitalized deaths, respectively, than in outpatients. Higher levels of conjugated bilirubin correlated with lower rifampicin clearance. Isoniazid's clearance estimates were 25.5 L/h for fast metabolizers and 9.76 L/h for slow metabolizers. Pyrazinamide's clearance was more variable among hospitalized patients. The variability in clearance among patients was 1.70 and 3.56 times more for hospitalized survivors and hospitalized deaths, respectively, than outpatients. Conclusions We showed that the pharmacokinetics of first-line TB drugs are not substantially different between hospitalized TB/HIV patients and TB (with or without HIV) outpatients. Hospitalized patients do not seem to be underexposed compared to their outpatient counterparts, as well as hospitalized patients who survived vs who died within 12 weeks of hospitalization.
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Affiliation(s)
- Noha Abdelgawad
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Maxwell Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - David Barr
- Wellcome Trust Liverpool Glasgow Centre for Global Health Research, University of Liverpool, Liverpool, L3 5QA, UK
| | - Amy Ward
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Saskia Janssen
- Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, 19268, The Netherlands
| | - Rosie Burton
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Khayelitsha Hospital, Department of Medicine, Khayelitsha, 7784, South Africa
| | - Robert J. Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
- The Francis Crick Institute, London, NW1 1AT, UK
| | - Muki Shey
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
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Barreto EF, Chang J, Rule AD, Mara KC, Meade LA, Paul J, Jannetto PJ, Athreya AP, Scheetz MH. Population pharmacokinetic model of cefepime for critically ill adults: a comparative assessment of eGFR equations. Antimicrob Agents Chemother 2023; 67:e0081023. [PMID: 37882514 PMCID: PMC10648925 DOI: 10.1128/aac.00810-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/15/2023] [Indexed: 10/27/2023] Open
Abstract
Cefepime exhibits highly variable pharmacokinetics in critically ill patients. The purpose of this study was to develop and qualify a population pharmacokinetic model for use in the critically ill and investigate the impact of various estimated glomerular filtration rate (eGFR) equations using creatinine, cystatin C, or both on model parameters. This was a prospective study of critically ill adults hospitalized at an academic medical center treated with intravenous cefepime. Individuals with acute kidney injury or on kidney replacement therapy or extracorporeal membrane oxygenation were excluded. A nonlinear mixed-effects population pharmacokinetic model was developed using data collected from 2018 to 2022. The 120 included individuals contributed 379 serum samples for analysis. A two-compartment pharmacokinetic model with first-order elimination best described the data. The population mean parameters (standard error) in the final model were 7.84 (0.24) L/h for CL1 and 15.6 (1.45) L for V1. Q was fixed at 7.09 L/h and V2 was fixed at 10.6 L, due to low observed interindividual variation in these parameters. The final model included weight as a covariate for volume of distribution and the eGFRcr-cysC (mL/min) as a predictor of drug clearance. In summary, a population pharmacokinetic model for cefepime was created for critically ill adults. The study demonstrated the importance of cystatin C to prediction of cefepime clearance. Cefepime dosing models which use an eGFR equation inclusive of cystatin C are likely to exhibit improved accuracy and precision compared to dosing models which incorporate an eGFR equation with only creatinine.
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Affiliation(s)
- Erin F. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Jack Chang
- Department of Pharmacy Practice, Chicago College of Pharmacy, Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, Illinois, USA
- Department of Pharmacy, Northwestern Medicine, Chicago, Illinois, USA
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
- Division of Epidemiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin C. Mara
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Laurie A. Meade
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Johar Paul
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul J. Jannetto
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Arjun P. Athreya
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Marc H. Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, Illinois, USA
- Department of Pharmacy, Northwestern Medicine, Chicago, Illinois, USA
| | - for the BLOOM Study Group
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
- Department of Pharmacy Practice, Chicago College of Pharmacy, Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, Illinois, USA
- Department of Pharmacy, Northwestern Medicine, Chicago, Illinois, USA
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
- Division of Epidemiology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
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5
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Chaijamorn W, Phunpon S, Sathienluckana T, Charoensareerat T, Pattharachayakul S, Rungkitwattanakul D, Srisawat N. Lacosamide dosing in patients receiving continuous renal replacement therapy. J Intensive Care 2023; 11:50. [PMID: 37946296 PMCID: PMC10633951 DOI: 10.1186/s40560-023-00700-4] [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: 09/20/2023] [Accepted: 11/05/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Lacosamide is one of the anticonvulsants used in critically ill patients. This study aimed to suggest appropriate lacosamide dosing regimens in critically ill patients receiving continuous renal replacement therapy (CRRT) via Monte Carlo simulations. METHODS Mathematical models were created using published demographic and pharmacokinetics in adult critically ill patients. CRRT modalities with different effluent rates were added into the models. Lacosamide regimens were evaluated on the probability of target attainment (PTA) using pharmacodynamic targets of trough concentrations and area under the curve within a range of 5-10 mg/L and 80.25-143 and 143-231 mg*h/L for the initial 72 h-therapy, respectively. Optimal regimens were defined from regimens that yielded the highest PTA. Each dosing regimen was tested in a group of different 10,000 virtual patients. RESULTS Our results revealed the optimal lacosamide dosing regimen of 300-450 mg/day is recommended for adult patients receiving both CRRT modalities with 20-25 effluent rates. The dose of 600 mg/day was suggested in higher effluent rate of 35 mL/kg/h. Moreover, a patient with body weight > 100 kg was less likely to attain the targets. CONCLUSIONS Volume of distribution, total clearance, CRRT clearance and body weight were significantly contributed to lacosamide dosing. Clinical validation of the finding is strongly indicated.
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Affiliation(s)
- Weerachai Chaijamorn
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Pathum Wan, Bangkok, 10330, Thailand.
| | | | | | | | - Sutthiporn Pattharachayakul
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla, Thailand
| | - Dhakrit Rungkitwattanakul
- Department of Clinical and Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, DC, USA
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Academic of Science, Royal Society of Thailand, Bangkok, Thailand
- Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand
- Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Singh S, Gaur S. Virtually selected phytochemicals from edible seeds as possible potential medicaments for hypercholesterolemia: an in silico approach. J Biomol Struct Dyn 2023; 41:8690-8700. [PMID: 36259535 DOI: 10.1080/07391102.2022.2135604] [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: 12/06/2021] [Accepted: 10/08/2022] [Indexed: 10/24/2022]
Abstract
Hypercholesterolemia is one of the major health concerns in today's time. Bioactive compounds from various sources have been implicated in managing the conditions of Hypercholesterolemia. With advancements in research, several edible seeds have been explored in managing the disease. This study employs in silico approach to gain insights into the binding interactions of the bioactive compounds which are reportedly present in Edible seeds, against the protein HMG-CoA reductase, which plays a crucial role in cholesterol metabolism. The bioactive compounds were virtually screened and selected based on molecular docking studies which revealed the strong binding interactions of HMG-CoA reductase with Acacetin (-7.6 kcal/mol), Irilone (-7.5 kcal/mol), Orobanchol (-7.5 kcal/mol), Diadzein (-7.4 kcal/mol) and Malvidin (-7.4 kcal/mol). These compounds largely conformed to drug likeliness criteria and ADME properties with lesser mutagenic, hepatotoxic effects and higher absorption percentage in human intestine. Moreover, we performed molecular dynamics simulation studies for docked complexes to explore their stability under simulated conditions. Data gathered from this study will support the future in vitro and in vivo research in development of potential medicaments using the bioactive compounds from edible seeds for management of hypercholesterolemia.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
- Shubhi Singh
- Department of Biotechnology, Jaypee Institute of Information Technology, Noida, India
| | - Smriti Gaur
- Department of Biotechnology, Jaypee Institute of Information Technology, Noida, India
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Roué M, Guédon AF, Lapidus N, Razazi K, Hariri G, Morawiec E, Desnos C, Ederhy S, Cohen A, Mekontso Dessap A, Fartoukh M, Labbé V. In-hospital outcomes after acute myocardial infarction with obstructive coronary artery disease in critically ill patients hospitalized for non-cardiac disease. Ann Intensive Care 2023; 13:87. [PMID: 37725298 PMCID: PMC10509106 DOI: 10.1186/s13613-023-01188-9] [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: 05/22/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Acute myocardial infarction (AMI) is one of the major cardiac complications in patients hospitalized in the intensive care unit (ICU) for non-cardiac disease. A better knowledge of ischemic and bleeding risks in these patients is needed to identify those most likely to benefit from specific cardiac management. We therefore assessed the incidence and predictors of a composite outcome of severe ischemic event (AMI recurrence, ischemic stroke), major bleeding, or all-cause death in this setting. METHODS In this multicenter retrospective study, all consecutive adult patients admitted for non-cardiac disease to four French university hospital ICUs between January 2012 and December 2018 who had an AMI with obstructive coronary artery disease (OCAD) during the ICU stay were considered for inclusion. AMI with OCAD was defined as an elevated cardiac troponin value associated with at least one sign (clinical, electrocardiographic, or echocardiographic) suggestive of myocardial ischemia and presence of OCAD on coronary angiography. The primary endpoint was in-hospital occurrence of the composite outcome. RESULTS Ninety-six patients [median age 69 years, 22 women (23%), 59 with sepsis (61%), 35 with ST elevation (37%), median sequential organ failure assessment (SOFA) of 8 on the day of AMI] were included. The median peak cardiac troponin value was 131 (IQR 44-303) times the upper reference limit. Dual antiplatelet, therapeutic anticoagulation, and early mechanical reperfusion therapies were administered in 61 (64%), 68 (71%), and 47 (49%) patients, respectively. The composite outcome occurred in 48 (50%) patients. Severe ischemic events occurred in 17 (18%) patients and major bleeding in 26 (27%) patients; 26 patients (27%) died in the hospital. AMI management was not significantly different in patients with and without the composite outcome. A history of arterial hypertension (HR 2.05, 95% CI 1.01-4.16) and high SOFA score at the time of AMI (HR 1.07, 95% CI 1.00-1.15) were independent risk factors for the composite outcome. CONCLUSIONS Patients who have an AMI with OCAD during an ICU stay for non-cardiac disease are at risk of a composite outcome of severe ischemia, major bleeding, and death. A history of arterial hypertension and high SOFA scores were independent hazards for poor prognosis.
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Affiliation(s)
- Morgan Roué
- Service de Médecine Intensive Réanimation, Département Médico-Universitaire APPROCHES, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Paris, France
| | - Alexis F Guédon
- Sorbonne Université, Public Health Department, Saint Antoine Hospital, AP-HP, Paris, France
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique IPLESP, AP-HP, Paris, France
| | - Nathanaël Lapidus
- Sorbonne Université, Public Health Department, Saint Antoine Hospital, AP-HP, Paris, France
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique IPLESP, AP-HP, Paris, France
| | - Keyvan Razazi
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Département Médico-Universitaire Médecine, AP-HP, Créteil, France
- Université Paris Est, Groupe de Recherche Clinique GR05 CARMAS, Institut Mondor de Recherche Biomédicale, INSERM, Créteil, France
| | - Geoffroy Hariri
- Service de Médecine Intensive Réanimation, Hôpital Saint-Antoine, AP-HP, Sorbonne Université, Paris, France
| | - Elise Morawiec
- Service de Médecine Intensive Réanimation, Hôpital La Pitié-Salpêtrière, AP-HP, Sorbonne Université, Paris, France
| | - Cyrielle Desnos
- Service de Médecine Intensive Réanimation, Département Médico-Universitaire APPROCHES, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Paris, France
| | - Stéphane Ederhy
- Department of Cardiology, UNICO Cardio-Oncology Program, Hôpital Saint-Antoine, AP-HP, Paris, France
- INSERM U 856, Paris, France
| | - Ariel Cohen
- Department of Cardiology, UNICO Cardio-Oncology Program, Hôpital Saint-Antoine, AP-HP, Paris, France
- INSERM U 856, Paris, France
- Sorbonne Université, UMR-S ICAN 1166, Paris, France
| | - Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Département Médico-Universitaire Médecine, AP-HP, Créteil, France
- Université Paris Est, Groupe de Recherche Clinique GR05 CARMAS, Institut Mondor de Recherche Biomédicale, INSERM, Créteil, France
| | - Muriel Fartoukh
- Service de Médecine Intensive Réanimation, Département Médico-Universitaire APPROCHES, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Paris, France
- Université Paris Est, Groupe de Recherche Clinique GR05 CARMAS, Institut Mondor de Recherche Biomédicale, INSERM, Créteil, France
| | - Vincent Labbé
- Service de Médecine Intensive Réanimation, Département Médico-Universitaire APPROCHES, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Paris, France.
- Université Paris Est, Groupe de Recherche Clinique GR05 CARMAS, Institut Mondor de Recherche Biomédicale, INSERM, Créteil, France.
- Service des Soins Intensifs, Hôpital Universitaire Bruxelles, Université Libre de Bruxelles, Brussels, Belgium.
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Van Den Broek AK, Visser CE, Veenstra J, Van Den Berg BTJ, Prins JM, Van Hest RM. The effect of the acute phase of infection on absorption of and exposure to orally administered antibiotics in non-critically ill, hospitalized patients. J Antimicrob Chemother 2023; 78:389-396. [PMID: 36433818 PMCID: PMC9890209 DOI: 10.1093/jac/dkac401] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 10/25/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES During the acute phase of infection, IV antibiotics are preferred to ensure adequate systemic exposure. To assess whether adequate exposure may also be achieved with oral antibiotics, we investigated exposure to oral antibiotics and PTA during the acute phase of infection and after defervescence. METHODS We enrolled hospitalized, non-critically ill febrile patients treated with IV antibiotics other than amoxicillin or ciprofloxacin. The study consisted of two visits: when patients had received <24 h IV treatment; and when patients had become afebrile. On both visits, patients received one additional dose of 750 mg amoxicillin, or 500 mg ciprofloxacin, depending on the presumed infection, after which serial blood samples were obtained. The primary endpoint was the ratio of the AUC during the febrile and the afebrile phase. The AUCs were considered to be equivalent when the ratio of the mean AUCs and its 90% CI was contained within the acceptance interval of 80%-125%. The secondary endpoint was PTA. RESULTS Forty-four patients (15 amoxicillin, 29 ciprofloxacin) completed both study visits. The median time between the two study visits was 65.8 h (range 33.8-427.4). The ratio of the mean AUCs (study visit 1/study visit 2) was 97% (90% CI of 80%-117%) for amoxicillin and 112% (90% CI of 108%-116%) for ciprofloxacin. The PTA for amoxicillin and ciprofloxacin did not differ between the two phases and was adequate to treat common pathogens. CONCLUSIONS The acute phase of infection in non-critically ill febrile patients does not influence the exposure to, or PTA of, orally administered amoxicillin and ciprofloxacin. This might justify earlier IV-to-oral switching.
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Affiliation(s)
- A K Van Den Broek
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C E Visser
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J Veenstra
- Department of Internal Medicine, OLVG, location West, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands
| | - B T J Van Den Berg
- Department of Pulmonology, OLVG, location West, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands
| | - J M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R M Van Hest
- Department of Hospital Pharmacy, Division of Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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9
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Morales Castro D, Dresser L, Granton J, Fan E. Pharmacokinetic Alterations Associated with Critical Illness. Clin Pharmacokinet 2023; 62:209-220. [PMID: 36732476 PMCID: PMC9894673 DOI: 10.1007/s40262-023-01213-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2023] [Indexed: 02/04/2023]
Abstract
Haemodynamic, metabolic, and biochemical derangements in critically ill patients affect drug pharmacokinetics and pharmacodynamics making dose optimisation particularly challenging. Appropriate therapeutic dosing depends on the knowledge of the physiologic changes caused by the patient's comorbidities, underlying disease, resuscitation strategies, and polypharmacy. Critical illness will result in altered drug protein binding, ionisation, and volume of distribution; it will also decrease oral drug absorption, intestinal and hepatic metabolism, and renal clearance. In contrast, the resuscitation strategies and the use of vasoactive drugs may oppose these effects by leading to a hyperdynamic state that will increase blood flow towards the major organs including the brain, heart, kidneys, and liver, with the subsequent increase of drug hepatic metabolism and renal excretion. Metabolism is the main mechanism for drug clearance and is one of the main pharmacokinetic processes affected; it is influenced by patient-specific factors, such as comorbidities and genetics; therapeutic-specific factors, including drug characteristics and interactions; and disease-specific factors, like organ dysfunction. Moreover, organ support such as mechanical ventilation, renal replacement therapy, and extracorporeal membrane oxygenation may contribute to both inter- and intra-patient variability of drug pharmacokinetics. The combination of these competing factors makes it difficult to predict drug response in critically ill patients. Pharmacotherapy targeted to therapeutic goals and therapeutic drug monitoring is currently the best option for the safe care of the critically ill. The aim of this paper is to review the alterations in drug pharmacokinetics associated with critical illness and to summarise the available evidence.
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Affiliation(s)
- Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, 585 University Avenue, 9-MaRS, Toronto, ON, M5G 2N2, Canada. .,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.
| | - Linda Dresser
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - John Granton
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, 585 University Avenue, 9-MaRS, Toronto, ON, M5G 2N2, Canada.,Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, 585 University Avenue, 9-MaRS, Toronto, ON, M5G 2N2, Canada.,Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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10
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Perumal R, Naidoo K, Naidoo A, Letsoalo MP, Esmail A, Joubert I, Denti P, Wiesner L, Padayatchi N, Maartens G, Dheda K. The impact of enteral feeding and therapeutic monitoring of rifampicin with dose escalation in critically ill patients with tuberculosis. Int J Infect Dis 2023; 126:174-180. [PMID: 36462574 DOI: 10.1016/j.ijid.2022.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/14/2022] [Accepted: 11/27/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Critically ill patients with tuberculosis (TB) face a high mortality risk and require effective treatment. There is a paucity of data on rifampicin pharmacokinetics, the impact of continuous enteral feeding on drug absorption, and the potential of therapeutic drug monitoring (TDM) to optimize drug exposure in these patients. METHODS We performed a sequential pharmacokinetic study to determine the impact of feeding and TDM with rifampicin dose escalation in critically ill patients with TB. Noncompartmental pharmacokinetic analysis was performed. RESULTS Among 20 critically ill patients (40% were HIV-infected), median rifampicin Cmax (maximum serum concentration) in the fasted and fed states were 5.1 µg/ml versus 3.3 µg/ml, respectively (P <0.0001; geometric mean ratio 1.95; 90% confidence interval 1.46-2.60). The proportion of patients with low rifampicin concentrations in the fasted and fed states was 80% vs 100% (P-value = 0.1336). Optimized dosing led to a per-patient median rifampicin dosing of 24.6 mg/kg and a median Cmax increase from 2.4 µg/ml to 17.8 µg/ml (P-value = 0.0005; geometric mean ratio 8.29; 90% confidence interval 3.88-17.74). TDM-guided dose escalation increased the proportion of patients achieving the suggested target rifampicin concentration compared with standard dosing (83% vs 0%, P-value = 0.004). CONCLUSION We found low rifampicin concentrations in all patients receiving continuous enteral feeding. TDM-guided dose escalation provided an effective strategy to achieve target drug exposure in these critically ill patients with TB.
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Affiliation(s)
- Rubeshan Perumal
- Centre for Lung Infection and Immunity Unit, Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa; Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, South Africa Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa; Medical Research Council-Centre for the AIDS Programme of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, South Africa Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa; Medical Research Council-Centre for the AIDS Programme of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa
| | - Anushka Naidoo
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, South Africa Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa
| | - Marothi P Letsoalo
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, South Africa Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa
| | - Aliasgar Esmail
- Centre for Lung Infection and Immunity Unit, Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Ivan Joubert
- Division of Critical Care Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, South Africa Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa; Medical Research Council-Centre for the AIDS Programme of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Keertan Dheda
- Centre for Lung Infection and Immunity Unit, Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa; South African Medical Research Council Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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11
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Wijdicks EFM. Identifying encephalopathies from acute metabolic derangements. J Intern Med 2022; 292:846-857. [PMID: 35809045 DOI: 10.1111/joim.13538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Metabolic derangements, when acute and severe, affect brain function. This presents mostly with a marked decline in the level of consciousness, resulting in impaired responsiveness, abnormal receptivity, impaired content, and loss of memory retention. The term metabolic encephalopathy has been used but is conjecture that can be challenged in the age of modern neuroimaging. We now recognize that many metabolic encephalopathies may involve structural lesions and at an early stage. Common clinical conundrums are the evaluation of the degree of brain injury and its recoverability. This review discusses the appropriate terminology for these conditions, the diagnostic approach, therapy recommendations, and prediction of recovery potential. In evaluating a presumed metabolic cause for encephalopathy, we must (1) search for and rule out structural injury to the brain despite an obvious explanatory metabolic derangement, (2) recognize that several confounding conditions often co-exist, and (3) acknowledge that resolution of brain dysfunction may be protracted despite normalization of laboratory values.
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Affiliation(s)
- Eelco F M Wijdicks
- Division of Neurocritical Care and Hospital Neurology, Mayo Clinic, Rochester, Minnesota, USA
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12
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Abdelgawad N, Chirehwa M, Schutz C, Barr D, Ward A, Janssen S, Burton R, Wilkinson RJ, Shey M, Wiesner L, McIlleron H, Maartens G, Meintjes G, Denti P. Pharmacokinetics of antitubercular drugs in patients hospitalized with HIV-associated tuberculosis: a population modeling analysis. Wellcome Open Res 2022; 7:72. [PMID: 37008250 PMCID: PMC10050909 DOI: 10.12688/wellcomeopenres.17660.2] [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] [Accepted: 11/03/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Early mortality among hospitalized HIV-associated tuberculosis (TB/HIV) patients is high despite treatment. The pharmacokinetics of rifampicin, isoniazid, and pyrazinamide were investigated in hospitalized TB/HIV patients and a cohort of outpatients with TB (with or without HIV) to determine whether drug exposures differed between groups. METHODS Standard first-line TB treatment was given daily as per national guidelines, which consisted of oral 4-drug fixed-dose combination tablets containing 150 mg rifampicin, 75 mg isoniazid, 400 mg pyrazinamide, and 275 mg ethambutol. Plasma samples were drawn on the 3rd day of treatment over eight hours post-dose. Rifampicin, isoniazid, and pyrazinamide in plasma were quantified and NONMEM ® was used to analyze the data. RESULTS Data from 60 hospitalized patients (11 of whom died within 12 weeks of starting treatment) and 48 outpatients were available. Median (range) weight and age were 56 (35 - 88) kg, and 37 (19 - 77) years, respectively. Bioavailability and clearance of the three drugs were similar between TB/HIV hospitalized and TB outpatients. However, rifampicin's absorption was slower in hospitalized patients than in outpatients; mean absorption time was 49.9% and 154% more in hospitalized survivors and hospitalized deaths, respectively, than in outpatients. Higher levels of conjugated bilirubin correlated with lower rifampicin clearance. Isoniazid's clearance estimates were 25.5 L/h for fast metabolizers and 9.76 L/h for slow metabolizers. Pyrazinamide's clearance was more variable among hospitalized patients. The variability in clearance among patients was 1.70 and 3.56 times more for hospitalized survivors and hospitalized deaths, respectively, than outpatients. Conclusion. We showed that the pharmacokinetics of first-line TB drugs are not substantially different between hospitalized TB/HIV patients and TB (with or without HIV) outpatients. Hospitalized patients do not seem to be underexposed compared to their outpatient counterparts, as well as hospitalized patients who survived vs who died within 12 weeks of hospitalization.
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Affiliation(s)
- Noha Abdelgawad
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Maxwell Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - David Barr
- Wellcome Trust Liverpool Glasgow Centre for Global Health Research, University of Liverpool, Liverpool, L3 5QA, UK
| | - Amy Ward
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Saskia Janssen
- Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, 19268, The Netherlands
| | - Rosie Burton
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Khayelitsha Hospital, Department of Medicine, Khayelitsha, 7784, South Africa
| | - Robert J. Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
- The Francis Crick Institute, London, NW1 1AT, UK
| | - Muki Shey
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
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13
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Neupane B, Pandya H, Pandya T, Austin R, Spooner N, Rudge J, Mulla H. Inflammation and cardiovascular status impact midazolam pharmacokinetics in critically ill children: An observational, prospective, controlled study. Pharmacol Res Perspect 2022; 10:e01004. [PMID: 36036654 PMCID: PMC9422629 DOI: 10.1002/prp2.1004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/12/2022] [Accepted: 07/26/2022] [Indexed: 12/02/2022] Open
Abstract
Altered physiology caused by critical illness may change midazolam pharmacokinetics and thereby result in adverse reactions and outcomes in this vulnerable patient population. This study set out to determine which critical illness-related factors impact midazolam pharmacokinetics in children using population modeling. This was an observational, prospective, controlled study of children receiving IV midazolam as part of routine care. Children recruited into the study were either critically-ill receiving continuous infusions of midazolam or otherwise well, admitted for elective day-case surgery (control) who received a single IV bolus dose of midazolam. The primary outcome was to determine the population pharmacokinetics and identify covariates that influence midazolam disposition during critical illness. Thirty-five patients were recruited into the critically ill arm of the study, and 54 children into the control arm. Blood samples for assessing midazolam and 1-OH-midazolam concentrations were collected opportunistically (critically ill arm) and in pre-set time windows (control arm). Pharmacokinetic modeling demonstrated a significant change in midazolam clearance with acute inflammation (measured using C-Reactive Protein), cardio-vascular status, and weight. Simulations predict that elevated C-Reactive Protein and compromised cardiovascular function in critically ill children result in midazolam concentrations up to 10-fold higher than in healthy children. The extremely high concentrations of midazolam observed in some critically-ill children indicate that the current therapeutic dosing regimen for midazolam can lead to over-dosing. Clinicians should be aware of this risk and intensify monitoring for oversedation in such patients.
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Affiliation(s)
- Bikalpa Neupane
- Department of Respiratory Sciences, College of Life SciencesUniversity of LeicesterLeicesterUK
- Jenny Lind Children's HospitalNorfolk and Norwich University Hospital NHS TrustNorwichUK
| | - Hitesh Pandya
- Department of Respiratory Sciences, College of Life SciencesUniversity of LeicesterLeicesterUK
| | - Tej Pandya
- Royal Bolton NHS Foundation TrustFarnworthUK
| | | | - Neil Spooner
- Spooner Bioanalytical Solutions LimitedHertfordUK
| | | | - Hussain Mulla
- Department of Respiratory Sciences, College of Life SciencesUniversity of LeicesterLeicesterUK
- Department of PharmacyUniversity Hospitals of Leicester NHS TrustLeicesterUK
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14
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Abstract
INTRODUCTION Platelets play a key role in arterial thrombosis and antiplatelet therapy is pivotal in the treatment of cardiovascular disease. Current antiplatelet drugs target different pathways of platelet activation and show specific pharmacodynamic and pharmacokinetic characteristics, implicating clinically relevant drug-drug interactions. AREAS COVERED This article reviews the role of platelets in hemostasis and cardiovascular thrombosis, and discusses the key pharmacodynamics, drug-drug interactions and reversal strategies of clinically used antiplatelet drugs. EXPERT OPINION Antiplatelet therapies target distinct pathways of platelet activation: thromboxane A2 synthesis, adenosine diphosphate-mediated signaling, integrin αIIbβ3 (GPIIb/IIIa), thrombin-mediated platelet activation via the PAR1 receptor and phosphodiesterases. Key clinical drug-drug interactions of antiplatelet agents involve acetylsalicylic acid - ibuprofen, clopidogrel - omeprazole, and morphine - oral P2Y12 inhibitors, all of which lead to an attenuated antiplatelet effect. Platelet function and genetic testing and the use of scores (ARC-HBR, PRECISE-DAPT, ESC ischemic risk definition) may contribute to a more tailored antiplatelet therapy. High on-treatment platelet reactivity presents a key problem in the acute management of ST-elevation myocardial infarction (STEMI). A treatment strategy involving early initiation of an intravenous antiplatelet agent may be able to bridge the gap of insufficient platelet inhibition in high ischemic risk patients with STEMI.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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15
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Ewoldt TMJ, Abdulla A, Hunfeld N, Li L, Smeets TJL, Gommers D, Koch BCP, Endeman H. The impact of sepsis on hepatic drug metabolism in critically ill patients: a narrative review. Expert Opin Drug Metab Toxicol 2022; 18:413-421. [PMID: 35912845 DOI: 10.1080/17425255.2022.2106215] [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: 11/04/2022]
Abstract
INTRODUCTION Hepatic drug metabolism is important in improving drug dosing strategies in sepsis. Pharmacokinetics in the critically ill population are severely altered due to changes in absorption, distribution, excretion and metabolization. Hepatic drug metabolism might be altered due to changes in hepatic blood flow, drug metabolizing protein availability, and protein binding. The purpose of this review is to examine evidence on whether hepatic drug metabolism is significantly affected in septic patients, and to provide insights in the need for future research. AREAS COVERED This review describes the effect of sepsis on hepatic drug metabolism in humans. Clinical trials, pathophysiological background information and example drug groups are further discussed. The literature search has been conducted in Embase, Medline ALL Ovid, and Cochrane CENTRAL register of trials. EXPERT OPINION Limited research has been conducted on drug metabolism in the sepsis population, with some trials having researched healthy individuals using endotoxin injections. Notwithstanding this limitation, hepatic drug metabolism seems to be decreased for certain drugs in sepsis. More research on the pharmacokinetic behavior of hepatic metabolized drugs in sepsis is warranted, using inflammatory biomarkers, hemodynamic changes, mechanical ventilation, organ support, and catecholamine infusion as possible confounders.
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Affiliation(s)
- Tim M J Ewoldt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicole Hunfeld
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Letao Li
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tim J L Smeets
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
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16
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Abdelgawad N, Chirehwa M, Schutz C, Barr D, Ward A, Janssen S, Burton R, Wilkinson RJ, Shey M, Wiesner L, McIlleron H, Maartens G, Meintjes G, Denti P. A comparison of the population pharmacokinetics of rifampicin, isoniazid and pyrazinamide between hospitalized and non-hospitalized tuberculosis patients with or without HIV. Wellcome Open Res 2022; 7:72. [PMID: 37008250 PMCID: PMC10050909 DOI: 10.12688/wellcomeopenres.17660.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Early mortality among hospitalized HIV-associated tuberculosis (TB/HIV) patients is high despite treatment. The pharmacokinetics of rifampicin, isoniazid, and pyrazinamide were investigated in hospitalized TB/HIV patients and a cohort of outpatients with TB (with or without HIV) to determine whether drug exposures differed between groups. METHODS Standard first-line TB treatment was given daily as per national guidelines, which consisted of oral 4-drug fixed-dose combination tablets containing 150 mg rifampicin, 75 mg isoniazid, 400 mg pyrazinamide, and 275 mg ethambutol. Plasma samples were drawn on the 3rd day of treatment over eight hours post-dose. Rifampicin, isoniazid, and pyrazinamide in plasma were quantified and NONMEM ® was used to analyze the data. RESULTS Data from 60 hospitalized patients (11 of whom died within 12 weeks of starting treatment) and 48 outpatients were available. Median (range) weight and age were 56 (35 - 88) kg, and 37 (19 - 77) years, respectively. Bioavailability and clearance of the three drugs were similar between TB/HIV hospitalized and TB outpatients. However, rifampicin's absorption was slower in hospitalized patients than in outpatients; mean absorption time was 49.9% and 154% more in hospitalized survivors and hospitalized deaths, respectively, than in outpatients. Higher levels of conjugated bilirubin correlated with lower rifampicin clearance. Isoniazid's clearance estimates were 25.5 L/h for fast metabolizers and 9.76 L/h for slow metabolizers. Pyrazinamide's clearance was more variable among hospitalized patients. The variability in clearance among patients was 1.70 and 3.56 times more for hospitalized survivors and hospitalized deaths, respectively, than outpatients. Conclusion. We showed that the pharmacokinetics of first-line TB drugs are not substantially different between hospitalized TB/HIV patients and TB (with or without HIV) outpatients. Hospitalized patients do not seem to be underexposed compared to their outpatient counterparts.
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Affiliation(s)
- Noha Abdelgawad
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Maxwell Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - David Barr
- Wellcome Trust Liverpool Glasgow Centre for Global Health Research, University of Liverpool, Liverpool, L3 5QA, UK
| | - Amy Ward
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Saskia Janssen
- Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, 19268, The Netherlands
| | - Rosie Burton
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Khayelitsha Hospital, Department of Medicine, Khayelitsha, 7784, South Africa
| | - Robert J. Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
- The Francis Crick Institute, London, NW1 1AT, UK
| | - Muki Shey
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
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17
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Xu Y, Tian X, Wang W, Tian W, Zhang T, Sun J, Zhou Q, Shao C. Pharmacokinetics of Esomeprazole in Critically Ill Patients. Front Med (Lausanne) 2022; 8:621406. [PMID: 35198568 PMCID: PMC8858832 DOI: 10.3389/fmed.2021.621406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/20/2021] [Indexed: 11/30/2022] Open
Abstract
Background Esomeprazole, a potent proton pump inhibitor (PPI), is widely used for the prevention of stress ulcers in intensive care unit (ICU) patients. Objective This study investigates the pharmacokinetics (PK) of esomeprazole in critically ill patients. Methods The study included eligible adult ICU patients who received endotracheal intubation assisted mechanical ventilation for more than 48 h and had at least an extra risk factor for stress ulcers. All enrolled patients received once-daily intravenous (IV) esomeprazole 40 mg. After the first dose of esomeprazole was administrated, serial blood samples were collected at 3, 5, 15, 30 min and 1, 2, 4, 6, 8, and 10 h. The total sample concentrations of esomeprazole were measured by UPLC-MS/MS. Esomeprazole PK parameters were analyzed using noncompartmental analysis. Results A total of 30 patients were evaluable. Mean age and body mass index (BMI) were 61.97 years and 23.14. PK sampling on the first dose resulted in the following median (IQR) parameters: AUC0−∞ 8.06 (6.65–9.47) mg·h/L; MRT0−∞ 4.70 (3.89–5.51) h; t1/2 3.29 (2.7–3.87) h; V 24.89 (22.09–27.69) L; CL 6.13 (5.01–7.26) L/h; and Cmax 2.56 (2.30–2.82) mg/L. Conclusions According to the label of esomeprazole, our study showed different esomeprazole PK parameters in ICU patients compared with healthy volunteers. Esomeprazole has unique pharmacokinetic parameters in critically ill patients.
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Affiliation(s)
- Yanyan Xu
- Department of Pharmacy, Lishui Municipal Central Hospital, Lishui, China
| | - Xin Tian
- Department of Intensive Care Medicine, Lishui Municipal Central Hospital, Lishui, China
| | - Wei Wang
- Department of Intensive Care Medicine, Lishui Municipal Central Hospital, Lishui, China
| | - Weiqiang Tian
- Department of Pharmacy, Lishui Municipal Central Hospital, Lishui, China
| | - Tao Zhang
- Department of Intensive Care Medicine, Lishui Municipal Central Hospital, Lishui, China
| | - Jian Sun
- Department of Intensive Care Medicine, Lishui Municipal Central Hospital, Lishui, China
| | - Qingyun Zhou
- Department of General Surgery, Lishui Municipal Central Hospital, Lishui, China
| | - Chuxiao Shao
- Department of General Surgery, Lishui Municipal Central Hospital, Lishui, China
- *Correspondence: Chuxiao Shao
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Differential Effects of Gamma-Aminobutyric Acidergic Sedatives on Risk of Post-Extubation Delirium in the ICU: A Retrospective Cohort Study From a New England Health Care Network. Crit Care Med 2022; 50:e434-e444. [PMID: 34982739 DOI: 10.1097/ccm.0000000000005425] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate whether different gamma-aminobutyric acidergic (GABAergic) sedatives such as propofol and benzodiazepines carry differential risks of post-extubation delirium in the ICU. DESIGN Retrospective cohort study. SETTING Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA). PATIENTS Ten thousand five hundred and one adult patients mechanically ventilated for over 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We tested the hypothesis that benzodiazepine versus propofol-based sedation is associated with fewer delirium-free days within 14 days after extubation. Further, we hypothesized that the measured sedation level evoked by GABAergic drugs is a better predictor of delirium than the drug dose administered. The proportion of GABAergic drug-induced deep sedation was defined as the ratio of days with a mean Richmond Agitation-Sedation Scale of less than or equal to -3 during mechanical ventilation. Multivariable regression and effect modification analyses were used. Delirium-free days were lower in patients who received a high proportion of deep sedation using benzodiazepine compared with propofol-based sedation (adjusted absolute difference, -1.17 d; 95% CI, -0.64 to -1.69; p < 0.001). This differential effect was magnified in elderly patients (age > 65) and in patients with liver or kidney failure (p-for-interaction < 0.001) but not observed in patients who received a low proportion of deep sedation (p = 0.95). GABAergic-induced deep sedation days during mechanical ventilation was a better predictor of post-extubation delirium than the GABAergic daily average effective dose (area under the curve 0.76 vs 0.69; p < 0.001). CONCLUSIONS Deep sedation during mechanical ventilation with benzodiazepines compared with propofol is associated with increased risk of post-extubation delirium. Our data do not support the view that benzodiazepine-based compared with propofol-based sedation in the ICU is an independent risk factor of delirium, as long as deep sedation can be avoided in these patients.
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Teder K, Maddison L, Soeorg H, Meos A, Karjagin J. The Pharmacokinetic Profile and Bioavailability of Enteral N-Acetylcysteine in Intensive Care Unit. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57111218. [PMID: 34833436 PMCID: PMC8620940 DOI: 10.3390/medicina57111218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/01/2021] [Accepted: 11/05/2021] [Indexed: 12/24/2022]
Abstract
Background and Objectives: N-acetylcysteine (NAC) is a mucolytic agent used to prevent ventilator-associated pneumonia in intensive care units. This study aimed to evaluate the oral bioavailability of NAC in critically ill patients with pneumonia, isolated acute brain injury and abdominal sepsis. Materials and Methods: This quantitative and descriptive study compared NAC's pharmacokinetics after intravenous and enteral administration. 600 mg of NAC was administered in both ways, and the blood levels for NAC were measured. Results: 18 patients with pneumonia, 19 patients with brain injury and 17 patients with abdominal sepsis were included in the population pharmacokinetic modelling. A three-compartmental model without lag-time provided the best fit to the data. Oral bioavailability was estimated as 11.6% (95% confidence interval 6.3-16.9%), similar to bioavailability in healthy volunteers and patients with chronic pulmonary diseases. Conclusions: The bioavailability of enteral NAC of ICU patients with different diseases is similar to the published data on healthy volunteers.
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Affiliation(s)
- Kersti Teder
- Institute of Pharmacy, University of Tartu, Nooruse 1, 50411 Tartu, Estonia;
- Pharmacy Department, Tartu University Hospital, L. Puusepa 8, 50406 Tartu, Estonia
- Correspondence: ; Tel.: +372-566-849-33
| | - Liivi Maddison
- Institute of Clinical Medicine, University of Tartu, L. Puusepa 8, 50406 Tartu, Estonia; (L.M.); (J.K.)
- Clinic of Anaesthesiology and Intensive Care, Tartu University Hospital, L. Puusepa 8, 50406 Tartu, Estonia
| | - Hiie Soeorg
- Department of Microbiology, Institute of Biomedicine and Translational Medicine, University of Tartu, Ravila 19, 50411 Tartu, Estonia;
| | - Andres Meos
- Institute of Pharmacy, University of Tartu, Nooruse 1, 50411 Tartu, Estonia;
| | - Juri Karjagin
- Institute of Clinical Medicine, University of Tartu, L. Puusepa 8, 50406 Tartu, Estonia; (L.M.); (J.K.)
- Clinic of Anaesthesiology and Intensive Care, Tartu University Hospital, L. Puusepa 8, 50406 Tartu, Estonia
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20
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Lewis TC, Merchan C, Toy B, Goldenberg RM, Geraci TC, Chang SH, Galloway AC, Smith DE, Moazami N. Impact of CytoSorb Hemoadsorption on Sedation Requirements in Patients With Severe COVID-19 on Venovenous Extracorporeal Membrane Oxygenation. ASAIO J 2021; 67:856-861. [PMID: 34339400 DOI: 10.1097/mat.0000000000001513] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hemoadsorption with CytoSorb has been used as an adjunct in the treatment of severe coronavirus disease 2019 (COVID-19)-related respiratory failure. It remains unknown if CytoSorb hemoadsorption will alter sedative and analgesic dosing in critically ill patients on venovenous extracorporeal membrane oxygenation (VV-ECMO). We conducted a retrospective review of patients with severe COVID-19 requiring VV-ECMO for respiratory support. Patients who were enrolled in a clinical study of CytoSorb were compared with patients on VV-ECMO alone. Data were collected for the 72-hour CytoSorb therapy and an additional 72 hours post-CytoSorb, or a corresponding control time period. Sedative and analgesic doses were totaled for each day and converted to midazolam or fentanyl equivalents, respectively. The primary endpoint, change in sedative and analgesic requirements over time, were compared using a two-way mixed analysis of variance. Of the 30 patients cannulated for VV-ECMO for COVID-19, 4 were excluded, leaving 8 patients in the CytoSorb arm and 18 in the Control. There was no effect of CytoSorb therapy on midazolam equivalents over the 72-hour therapy (p = 0.71) or the 72 hours post-CytoSorb (p = 0.11). In contrast, there was a significant effect of CytoSorb therapy on fentanyl equivalents over the first 72 hours (p = 0.01), but this was not consistent over the 72-hours post-CytoSorb (p = 0.23). CytoSorb therapy led to significant increases in analgesic requirements without impacting sedative requirements. Further research is needed to define the relevance of CytoSorb hemoadsorption on critical care pharmacotherapy.
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Affiliation(s)
- Tyler C Lewis
- From the Department of Pharmacy, NYU Langone Health, New York, New York
- Transplant Institute, NYU Langone Health, New York, New York
| | - Cristian Merchan
- From the Department of Pharmacy, NYU Langone Health, New York, New York
| | - Bridget Toy
- Transplant Institute, NYU Langone Health, New York, New York
| | - Ronald M Goldenberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, NYU Langone Health, New York, New York
| | - Travis C Geraci
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Stephanie H Chang
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Aubrey C Galloway
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Deane E Smith
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
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21
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Campesi I, Racagni G, Franconi F. Just a Reflection: Does Drug Repurposing Perpetuate Sex-Gender Bias in the Safety Profile? Pharmaceuticals (Basel) 2021; 14:730. [PMID: 34451827 PMCID: PMC8402096 DOI: 10.3390/ph14080730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 02/08/2023] Open
Abstract
Vaccines constitute a strategy to reduce the burden of COVID-19, but the treatment of COVID-19 is still a challenge. The lack of approved drugs for severe COVID-19 makes repurposing or repositioning of approved drugs a relevant approach because it occurs at lower costs and in a shorter time. Most preclinical and clinical tests, including safety and pharmacokinetic profiles, were already performed. However, infective and inflammatory diseases such as COVID-19 are linked with hypoalbuminemia and downregulation of both phase I and phase II drug-metabolizing enzymes and transporters, which can occur in modifications of pharmacokinetics and consequentially of safety profiles. This appears to occur in a sex- and gender-specific way because of the sex and gender differences present in the immune system and inflammation, which, in turn, reflect on pharmacokinetic parameters. Therefore, to make better decisions about drug dosage regimens and to increases the safety profile in patients suffering from infective and inflammatory diseases such as COVID-19, it is urgently needed to study repurposing or repositioning drugs in men and in women paying attention to pharmacokinetics, especially for those drugs that are previously scarcely evaluated in women.
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Affiliation(s)
- Ilaria Campesi
- Department of Biomedical Science, University of Sassari, 07100 Sassari, Italy
- National Laboratory of Pharmacology and Gender Medicine, National Institute of Biostructure and Biosystem, 07100 Sassari, Italy;
| | - Giorgio Racagni
- Department of Pharmacological and Biomolecular Sciences, University of Milan, 20133 Milan, Italy;
| | - Flavia Franconi
- National Laboratory of Pharmacology and Gender Medicine, National Institute of Biostructure and Biosystem, 07100 Sassari, Italy;
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22
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Bass GA, Dzierba AL, Taylor B, Lane-Fall M, Kaplan LJ. Tertiary peritonitis: considerations for complex team-based care. Eur J Trauma Emerg Surg 2021; 48:811-825. [PMID: 34302503 PMCID: PMC8308068 DOI: 10.1007/s00068-021-01750-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/18/2021] [Indexed: 12/14/2022]
Abstract
Peritonitis, as a major consequence of hollow visceral perforation, anastomotic disruption, ischemic necrosis, or other injuries of the gastrointestinal tract, often drives acute care in the emergency department, operating room, and the ICU. Chronic critical illness (CCI) represents a devastating challenge in modern surgical critical care where successful interventions have fostered a growing cohort of patients with prolonged dependence on mechanical ventilation and other organ supportive therapies who would previously have succumbed much earlier in the acute phase of critical illness. An important subset of CCI patients are those who have survived an emergency abdominal operation, but who subsequently require prolonged open abdomen management complicated by persistent peritoneal space infection or colonization, fistula formation, and gastrointestinal (GI) tract dysfunction; these patients are described as having tertiary peritonitis (TP).The organ dysfunction cascade in TP terminates in death in between 30 and 64% of patients. This narrative review describes key—but not all—elements in a framework for the coordinate multiprofessional team-based management of a patient with tertiary peritonitis to mitigate this risk of death and promote recovery. Given the prolonged critical illness course of this unique patient population, early and recurrent Palliative Care Medicine consultation helps establish goals of care, support adjustment to changes in life circumstance, and enable patient and family centered care.
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Affiliation(s)
- Gary Alan Bass
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104 USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
- European Society of Trauma and Emergency Surgery, Visceral Trauma Section, Philadelphia, USA
| | - Amy L. Dzierba
- Department of Pharmacy, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY USA
| | - Beth Taylor
- Department of Research for Patient Care Services, Barnes-Jewish Hospital, St. Louis, MO USA
| | - Meghan Lane-Fall
- Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5 Dulles, Philadelphia, PA 19104 USA
| | - Lewis J. Kaplan
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104 USA
- Surgical Services, Section of Surgical Critical Care, Corporal Michael J Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104 USA
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Optimizing Antimicrobial Drug Dosing in Critically Ill Patients. Microorganisms 2021; 9:microorganisms9071401. [PMID: 34203510 PMCID: PMC8305961 DOI: 10.3390/microorganisms9071401] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 12/23/2022] Open
Abstract
A fundamental step in the successful management of sepsis and septic shock is early empiric antimicrobial therapy. However, for this to be effective, several decisions must be addressed simultaneously: (1) antimicrobial choices should be adequate, covering the most probable pathogens; (2) they should be administered in the appropriate dose, (3) by the correct route, and (4) using the correct mode of administration to achieve successful concentration at the infection site. In critically ill patients, antimicrobial dosing is a common challenge and a frequent source of errors, since these patients present deranged pharmacokinetics, namely increased volume of distribution and altered drug clearance, which either increased or decreased. Moreover, the clinical condition of these patients changes markedly over time, either improving or deteriorating. The consequent impact on drug pharmacokinetics further complicates the selection of correct drug schedules and dosing during the course of therapy. In recent years, the knowledge of pharmacokinetics and pharmacodynamics, drug dosing, therapeutic drug monitoring, and antimicrobial resistance in the critically ill patients has greatly improved, fostering strategies to optimize therapeutic efficacy and to reduce toxicity and adverse events. Nonetheless, delivering adequate and appropriate antimicrobial therapy is still a challenge, since pathogen resistance continues to rise, and new therapeutic agents remain scarce. We aim to review the available literature to assess the challenges, impact, and tools to optimize individualization of antimicrobial dosing to maximize exposure and effectiveness in critically ill patients.
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Setting the Beta-Lactam Therapeutic Range for Critically Ill Patients: Is There a Floor or Even a Ceiling? Crit Care Explor 2021; 3:e0446. [PMID: 34136822 PMCID: PMC8202642 DOI: 10.1097/cce.0000000000000446] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Beta-lactam antibiotics exhibit high interindividual variability in drug concentrations in patients with critical illness which led to an interest in the use of therapeutic drug monitoring to improve effectiveness and safety. To implement therapeutic drug monitoring, it is necessary to define the beta-lactam therapeutic range-in essence, what drug concentration would prompt a clinician to make dose adjustments up or down. This objective of this narrative review was to summarize evidence for the "floor" (for effectiveness) and "ceiling" (for toxicity) for the beta-lactam therapeutic range to be used with individualized therapeutic drug monitoring. DATA SOURCES Research articles were sourced from PubMed using search term combinations of "pharmacokinetics," "pharmacodynamics," "toxicity," "neurotoxicity," "therapeutic drug monitoring," "beta-lactam," "cefepime," "meropenem," "piperacillin/tazobactam," "ICU," and "critical illness." STUDY SELECTION Articles were selected if they included preclinical, translational, or clinical data on pharmacokinetic and pharmacodynamic thresholds for effectiveness and safety for beta-lactams in critical illness. DATA SYNTHESIS Experimental data indicate a beta-lactam concentration above the minimum inhibitory concentration of the organism for greater than or equal to 40-60% of the dosing interval is needed, but clinical data indicate that higher concentrations may be preferrable. In the first 48 hours of critical illness, a free beta-lactam concentration at or above the susceptibility breakpoint of the most likely pathogen for 100% of the dosing interval would be reasonable (typically based on Pseudomonas aeruginosa). After 48 hours, the lowest acceptable concentration could be tailored to 1-2× the observed minimum inhibitory concentration of the organism for 100% of the dosing interval (often a more susceptible organism). Neurotoxicity is the primary dose-dependent adverse effect of beta-lactams, but the evidence remains insufficient to link a specific drug concentration to greater risk. CONCLUSIONS As studies advance the understanding of beta-lactam exposure and response in critically ill patients, it is essential to clearly define the acceptable therapeutic range to guide regimen selection and adjustment.
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Abstract
BACKGROUND The pharmacokinetic (PK) data of ganciclovir (GCV), a first-line antiviral treatment for cytomegalovirus infections, in critically ill patients are limited. This study aimed at characterizing GCV population PK and interindividual variability (IIV) in intensive care unit (ICU) patients. Secondary objectives were to identify patient characteristics responsible for IIV and simulate GCV exposure for different dosing regimens. METHOD In this retrospective observational study, clinical data and serum GCV levels were collected from ICU patients on intravenous GCV. PK modeling, covariate analyses, and explorative Monte Carlo dosing simulations (MCS) were performed using nonlinear mixed-effects modeling. Bootstrap and visual predictive checks were used to determine model adequacy. RESULTS In total, 128 GCV measurements were obtained from 34 patients. GCV PK conformed to a 1-compartment model with first-order elimination. After multivariate analyses, only the estimated glomerular filtration rate calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula (P < 0.001) was included as a covariate. In the final model, the estimated clearance (CL) and volume of distribution (V1) were 2.3 L/h and 42 L, respectively, for a patient with the median CKD-EPI of the population (65 mL/min per 1.73 m). The association between CKD-EPI and CL decreased the residual variability from 0.56 to 0.43 and V1-IIV from 114% to 80%, whereas CL-IIV changed from 43% to 47%. MCS revealed that a substantial number of patients may not achieve the GCV PK/pharmacodynamic target trough level (>1.5 mg/L) when administering the label-recommended dose reductions for patients with CKD-EPI <50 mL/min. CONCLUSIONS A large IIV was observed in GCV PK among ICU patients. CKD-EPI could partially explain the IIV, although a large part of the variability remains unclear. MCS suggested that recommended dose reductions for CKD-EPI <50 mL/min may lead to subtherapeutic plasma GCV levels in these patients.
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26
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van den Broek AK, Prins JM, Visser CE, van Hest RM. Systematic review: the bioavailability of orally administered antibiotics during the initial phase of a systemic infection in non-ICU patients. BMC Infect Dis 2021; 21:285. [PMID: 33743592 PMCID: PMC7981967 DOI: 10.1186/s12879-021-05919-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/15/2021] [Indexed: 12/18/2022] Open
Abstract
Background The systemic response to an infection might influence the pharmacokinetics of antibiotics. To evaluate the desired possibility of an earlier (< 24 h) IV-to-oral switch therapy in febrile non-ICU, hospitalized patients, a systematic review was performed to assess the effect of the initial phase of a systemic infection on the bioavailability of orally administered antibiotics in such patients. Methods An electronic search was conducted in MEDLINE and Embase up to July 2020. Studies were selected when outcome data were collected during the initial stage of a febrile disease. Outcome data were (maximum) serum concentrations, time of achieving maximum serum concentration, and the area-under-the-plasma-concentration-time curve or bioavailability of orally administered antibiotics. Risk of bias was assessed. Results We identified 9 studies on 6 antibiotics. Ciprofloxacin was the most frequently studied drug. Outcomes of the studies were heterogeneous and generally had a high risk of bias. Three small studies, two on ciprofloxacin and one on clarithromycin, compared the pharmacokinetics of febrile patients with those of clinically recovered patients and suggested that bioavailability was not altered in these patients. Other studies either compared the pharmacokinetics in febrile patients with reported pharmacokinetic values from earlier studies in healthy volunteers (n = 2), or provided no comparison at all and were non-conclusive (n = 4). Conclusion There is a clear knowledge gap regarding the bioavailability of orally administered antibiotics in non-ICU patients during the initial phase of a systemic infection. Well-designed studies on this topic are necessary to elucidate whether patients can benefit from the advantages of an earlier IV-to-oral switch. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-05919-w.
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Affiliation(s)
- Annemieke K van den Broek
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Caroline E Visser
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Reinier M van Hest
- Department of Hospital Pharmacy, Division of Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
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Wicha SG, Märtson AG, Nielsen EI, Koch BCP, Friberg LE, Alffenaar JW, Minichmayr IK. From Therapeutic Drug Monitoring to Model-Informed Precision Dosing for Antibiotics. Clin Pharmacol Ther 2021; 109:928-941. [PMID: 33565627 DOI: 10.1002/cpt.2202] [Citation(s) in RCA: 127] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/01/2021] [Indexed: 12/14/2022]
Abstract
Therapeutic drug monitoring (TDM) and model-informed precision dosing (MIPD) have evolved as important tools to inform rational dosing of antibiotics in individual patients with infections. In particular, critically ill patients display altered, highly variable pharmacokinetics and often suffer from infections caused by less susceptible bacteria. Consequently, TDM has been used to individualize dosing in this patient group for many years. More recently, there has been increasing research on the use of MIPD software to streamline the TDM process, which can increase the flexibility and precision of dose individualization but also requires adequate model validation and re-evaluation of existing workflows. In parallel, new minimally invasive and noninvasive technologies such as microneedle-based sensors are being developed, which-together with MIPD software-have the potential to revolutionize how patients are dosed with antibiotics. Nonetheless, carefully designed clinical trials to evaluate the benefit of TDM and MIPD approaches are still sparse, but are critically needed to justify the implementation of TDM and MIPD in clinical practice. The present review summarizes the clinical pharmacology of antibiotics, conventional TDM and MIPD approaches, and evidence of the value of TDM/MIPD for aminoglycosides, beta-lactams, glycopeptides, and linezolid, for which precision dosing approaches have been recommended.
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Affiliation(s)
- Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Anne-Grete Märtson
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lena E Friberg
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Jan-Willem Alffenaar
- Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Camperdown, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia.,Westmead Hospital, Wentworthville, Australia
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Boullata JI. Enteral Medication for the Tube-Fed Patient: Making This Route Safe and Effective. Nutr Clin Pract 2020; 36:111-132. [PMID: 33373487 DOI: 10.1002/ncp.10615] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/15/2020] [Indexed: 12/26/2022] Open
Abstract
The administration of medication through an enteral access device requires important forethought. Meeting a patient's therapeutic needs requires achieving expected drug bioavailability without increasing the risk for toxicity, therapeutic failure, or feeding tube occlusion. Superimposing gut dysfunction, critical illness, or enteral nutrition-drug interaction further increases the need for a systematic approach to prescribing, evaluating, and preparing a drug for administration through an enteral access device. This review will explain the fundamental factors involved in drug bioavailability through the gut, address the influencing considerations for the enterally fed patient, and describe best practices for enteral drug preparation and administration.
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Affiliation(s)
- Joseph I Boullata
- Department of Clinical Nutrition Support Services, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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29
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[Pharmacokinetic modifications and pharmacokinetic/pharmacodynamic optimization of beta-lactams in ICU]. ANNALES PHARMACEUTIQUES FRANÇAISES 2020; 79:346-360. [PMID: 33309603 DOI: 10.1016/j.pharma.2020.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/06/2020] [Accepted: 11/16/2020] [Indexed: 01/12/2023]
Abstract
Pharmacokinetic modifications in critically ill patients and those induced by ICU therapeutics raise a lot of issues about antibiotic dose adaptation. Beta-lactams are anti-infectious widely used in ICU. Frequent beta-lactam underdoses induce a risk of therapeutic failure potentially lethal and of emergence of bacterial resistance. Overdoses expose to a neurotoxic and nephrotoxic risk. Therefore, an understanding of pharmacokinetics modifications appears to be essential. A global pharmacokinetic/pharmacodynamic approach is required, including use of prolonged or continued beta-lactam infusions to optimise probability of pharmacokinetic/pharmacodynamic target attainment. Beta-lactam therapeutic drug monitoring should also be considered. Experts agree to target a free plasma betalactam concentration above four times the MIC of the causative bacteria for 100 % of the dosing interval. Bayesian methods could permit individualized doses adaptations.
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Cole LP, Jepson R, Dawson C, Humm K. Hypertension, retinopathy, and acute kidney injury in dogs: A prospective study. J Vet Intern Med 2020; 34:1940-1947. [PMID: 32677736 PMCID: PMC7517860 DOI: 10.1111/jvim.15839] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 06/08/2020] [Accepted: 06/13/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Systemic hypertension (SH) is a potential complication of acute kidney injury (AKI) in dogs. OBJECTIVE To describe the prevalence of SH and hypertensive retinopathy in dogs with AKI, to investigate the relationship between SH and severity of AKI and to assess possible factors associated with SH. ANIMALS Fifty-two dogs with AKI. METHODS Prospective observational study of dogs presenting to a tertiary referral center that fulfilled the International Renal Interest Society (IRIS) guidelines for the diagnosis of AKI. Systolic blood pressure measurement, urine protein/creatinine ratio (UPCR), urine output, presence of hypertensive retinopathy and fluid overload (FO), survival to discharge and duration of hospitalization were subsequently assessed. The prevalence of SH was calculated and the relationship between SH and recorded factors was examined by nonparametric statistics. RESULTS The prevalence of SH (≥160 mm Hg) on admission or during hospitalization was 75% (39/52) and in 56% (22/39) of cases this was severe (≥180 mm Hg). Sixteen percent (7/43) of dogs had evidence of hypertensive retinopathy and 77% (24/31) dogs had UPCR >0.5. Forty-two percent (22/52) dogs had FO on admission or during hospitalization. There was no association between SH and IRIS AKI grade, oligo/anuria, survival to discharge, duration of hospitalization or proteinuria. Dogs with FO on presentation were more likely to be hypertensive at admission compared to dogs without FO (P = .02). Dogs that did not survive to discharge were more likely to have FO (P = .007). CONCLUSIONS AND CLINICAL IMPORTANCE Systemic hypertension is common in dogs with AKI. Systemic hypertension might be associated with FO, which itself is associated with nonsurvival. Monitoring for SH and FO is therefore warranted in dogs with AKI.
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Affiliation(s)
- Laura Pearl Cole
- Clinical Science & Services, Royal Veterinary CollegeHatfieldUnited Kingdom
| | - Rosanne Jepson
- Clinical Science & Services, Royal Veterinary CollegeHatfieldUnited Kingdom
| | - Charlotte Dawson
- Clinical Science & Services, Royal Veterinary CollegeHatfieldUnited Kingdom
| | - Karen Humm
- Clinical Science & Services, Royal Veterinary CollegeHatfieldUnited Kingdom
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Abstract
Since in vitro studies and a preliminary clinical report suggested the efficacy of chloroquine for COVID-19-associated pneumonia, there is increasing interest in this old antimalarial drug. In this article, we discuss the pharmacokinetics and safety of chloroquine that should be considered in light of use in SARS-CoV-2 infections. Chloroquine is well absorbed and distributes extensively resulting in a large volume of distribution with an apparent and terminal half-life of 1.6 days and 2 weeks, respectively. Chloroquine is metabolized by cytochrome P450 and renal clearance is responsible for one third of total clearance. The lack of reliable information on target concentrations or doses for COVID-19 implies that for both adults and children, doses that proved effective and safe in malaria should be considered, such as ‘loading doses’ in adults (30 mg/kg over 48 h) and children (70 mg/kg over 5 days), which reported good tolerability. Here, plasma concentrations were < 2.5 μmol/L, which is associated with (minor) toxicity. While the influence of renal dysfunction, critical illness, or obesity seems small, in critically ill patients, reduced absorption may be anticipated. Clinical experience has shown that chloroquine has a narrow safety margin, as three times the adult therapeutic dosage for malaria can be lethal when given as a single dose. Although infrequent, poisoning in children is extremely dangerous where one to two tablets can potentially be fatal. In conclusion, the pharmacokinetic and safety properties of chloroquine suggest that chloroquine can be used safely for an acute virus infection, under corrected QT monitoring, but also that the safety margin is small, particularly in children.
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Shabani M, Shokouhi S, Moradi O, Saffaei A, Sahraei Z. Tocilizumab administration in patients with SARS-CoV-2 infection: Subcutaneous injection vs intravenous infusion. J Med Virol 2020; 93:69-70. [PMID: 32492210 PMCID: PMC7300729 DOI: 10.1002/jmv.26124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Minoosh Shabani
- Department of Infectious Diseases and Tropical Medicine, Loghman Hakim HospitalShahid Beheshti University of Medical SciencesTehranIran
- Infectious Diseases and Tropical Medicine Research CenterShahid Beheshti University of Medical SciencesTehranIran
| | - Shervin Shokouhi
- Department of Infectious Diseases and Tropical Medicine, Loghman Hakim HospitalShahid Beheshti University of Medical SciencesTehranIran
- Infectious Diseases and Tropical Medicine Research CenterShahid Beheshti University of Medical SciencesTehranIran
| | - Omid Moradi
- Student Research Committee, Department of Clinical Pharmacy, School of PharmacyShahid Beheshti University of Medical SciencesTehranIran
| | - Ali Saffaei
- Student Research Committee, Department of Clinical Pharmacy, School of PharmacyShahid Beheshti University of Medical SciencesTehranIran
| | - Zahra Sahraei
- Department of Clinical Pharmacy, School of PharmacyShahid Beheshti University of Medical SciencesTehranIran
- Loghman Hakim HospitalShahid Beheshti University of Medical SciencesTehranIran
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Cevik M, Orkin C, Sax PE. Emergent Resistance to Dolutegravir Among INSTI-Naïve Patients on First-line or Second-line Antiretroviral Therapy: A Review of Published Cases. Open Forum Infect Dis 2020; 7:ofaa202. [PMID: 32587877 PMCID: PMC7304932 DOI: 10.1093/ofid/ofaa202] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 05/28/2020] [Indexed: 12/17/2022] Open
Abstract
None of the licensing studies of dolutegravir (DTG) reported any treatment-emergent resistance among DTG-treated individuals, though virological failure in treatment-naïve and treatment-experienced, integrase strand transfer inhibitor (INSTI)–naïve individuals has been reported in clinical practice. While the spectrum of dolutegravir-selected mutations and their effects on clinical outcome have been described, the clinical characteristics of these rare but important virological failure cases are often overlooked. In this perspective piece, we focus on key clinical aspects of emergent resistance to DTG among treatment-naïve and treatment-experienced INSTI-naïve patients, with an aim to inform clinical decision-making. Poor adherence and HIV disease factors contribute to emergent drug resistance, even in regimens with high resistance barriers. Patients with severe immunosuppression or poor adherence are under-represented in licensing studies, and these patients may be at higher risk of treatment failure with DTG resistance, which requires close clinical and laboratory follow-up.
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Affiliation(s)
- Muge Cevik
- Infection and Global Health Research, School of Medicine, University of St Andrews, St Andrews, UK.,NHS Lothian Infection Service, Specialist Virology Laboratory, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Chloe Orkin
- Blizzard Institute, Queen Mary University of London, London, UK.,Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Paul E Sax
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Enteral Acetaminophen Bioavailability in Pediatric Intensive Care Patients Determined With an Oral Microtracer and Pharmacokinetic Modeling to Optimize Dosing. Crit Care Med 2020; 47:e975-e983. [PMID: 31609773 DOI: 10.1097/ccm.0000000000004032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Decreasing morbidity and mortality by rationalizing drug treatment in the critically ill is of paramount importance but challenging as the underlying clinical condition may lead to large variation in drug disposition and response. New microtracer methodology is now available to gain knowledge on drug disposition in the intensive care. On the basis of studies in healthy adults, physicians tend to assume that oral doses of acetaminophen will be completely absorbed and therefore prescribe the same dose per kilogram for oral and IV administration. As the oral bioavailability of acetaminophen in critically ill children is unknown, we designed a microtracer study to shed a light on this issue. DESIGN An innovative microtracer study design with population pharmacokinetics. SETTING A tertiary referral PICU. PATIENTS Stable critically ill children, 0-6 years old, and already receiving IV acetaminophen. INTERVENTIONS Concomitant administration of an oral C radiolabeled acetaminophen microtracer (3 ng/kg) with IV acetaminophen treatment (15 mg/kg every 6 hr). MEASUREMENTS Blood was drawn from an indwelling arterial or central venous catheter up to 24 hours after C acetaminophen microtracer administration. Acetaminophen concentrations were measured by liquid chromatography-mass spectrometry and C concentrations by accelerated mass spectrometry. MAIN RESULTS In 47 patients (median age of 6.1 mo; Q1-Q3, 1.8-20 mo) the mean enteral bioavailability was 72% (range, 11-91%). With a standard dose (15 mg/kg 4 times daily), therapeutic steady-state concentrations were 2.5 times more likely to be reached with IV than with oral administration. CONCLUSIONS Microtracer studies present a new opportunity to gain knowledge on drug disposition in the intensive care. Using this modality in children in the pediatric intensive care, we showed that enteral administration of acetaminophen results in less predictable exposure and higher likelihood of subtherapeutic blood concentration than does IV administration. IV dosing may be preferable to ensure adequate pain relief.
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Schutz C, Chirehwa M, Barr D, Ward A, Janssen S, Burton R, Wilkinson RJ, Shey M, Wiesner L, Denti P, McIlleron H, Maartens G, Meintjes G. Early antituberculosis drug exposure in hospitalized patients with human immunodeficiency virus-associated tuberculosis. Br J Clin Pharmacol 2020; 86:966-978. [PMID: 31912537 PMCID: PMC7163385 DOI: 10.1111/bcp.14207] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/28/2019] [Accepted: 12/16/2019] [Indexed: 12/30/2022] Open
Abstract
AIMS Patients hospitalized at the time of human immunodeficiency virus-associated tuberculosis (HIV-TB) diagnosis have high early mortality. We hypothesized that compared to outpatients, there would be lower anti-TB drug exposure in hospitalized HIV-TB patients, and amongst hospitalized patients exposure would be lower in patients who die or have high lactate (a sepsis marker). METHODS We performed pharmacokinetic sampling in hospitalized HIV-TB patients and outpatients. Plasma rifampicin, isoniazid and pyrazinamide concentrations were measured in samples collected predose and at 1, 2.5, 4, 6 and 8 hours on the third day of standard anti-TB therapy. Twelve-week mortality was ascertained for inpatients. Noncompartmental pharmacokinetic analysis was performed. RESULTS Pharmacokinetic data were collected in 59 hospitalized HIV-TB patients and 48 outpatients. Inpatient 12-week mortality was 11/59 (19%). Rifampicin, isoniazid and pyrazinamide exposure was similar between hospitalized and outpatients (maximum concentration [Cmax ]: 7.4 vs 8.3 μg mL-1 , P = .223; 3.6 vs 3.5 μg mL-1 , P = .569; 50.1 vs 46.8 μg mL-1 , P = .081; area under the concentration-time curve from 0 to 8 hours: 41.0 vs 43.8 mg h L-1 , P = 0.290; 13.5 vs 12.4 mg h L-1 , P = .630; 316.5 vs 292.2 mg h L-1 , P = .164, respectively) and not lower in inpatients who died. Rifampicin and isoniazid Cmax were below recommended ranges in 61% and 39% of inpatients and 44% and 35% of outpatients. Rifampicin exposure was higher in patients with lactate >2.2 mmol L-1 . CONCLUSION Mortality in hospitalized HIV-TB patients was high. Early anti-TB drug exposure was similar to outpatients and not lower in inpatients who died. Rifampicin and isoniazid Cmax were suboptimal in 61% and 39% of inpatients and rifampicin exposure was higher in patients with high lactate. Treatment strategies need to be optimized to improve survival.
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Affiliation(s)
- Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular Medicine, University of Cape TownObservatorySouth Africa,Department of MedicineUniversity of Cape TownObservatorySouth Africa
| | - Maxwell Chirehwa
- Division of Clinical Pharmacology, Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - David Barr
- Wellcome Trust Liverpool Glasgow Centre for Global Health ResearchUniversity of LiverpoolLiverpoolUK
| | - Amy Ward
- Wellcome Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular Medicine, University of Cape TownObservatorySouth Africa,Department of MedicineUniversity of Cape TownObservatorySouth Africa
| | - Saskia Janssen
- Amsterdam University Medical CentreUniversity of AmsterdamAmsterdamNetherlands
| | - Rosie Burton
- Department of MedicineUniversity of Cape TownObservatorySouth Africa,Khayelitsha Hospital, Department of MedicineCape TownSouth Africa
| | - Robert J. Wilkinson
- Wellcome Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular Medicine, University of Cape TownObservatorySouth Africa,Department of MedicineUniversity of Cape TownObservatorySouth Africa,Department of Infectious DiseasesImperial CollegeLondonUK,The Francis Crick InstituteLondonUK
| | - Muki Shey
- Wellcome Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular Medicine, University of Cape TownObservatorySouth Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Helen McIlleron
- Wellcome Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular Medicine, University of Cape TownObservatorySouth Africa,Division of Clinical Pharmacology, Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular Medicine, University of Cape TownObservatorySouth Africa,Division of Clinical Pharmacology, Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular Medicine, University of Cape TownObservatorySouth Africa,Department of MedicineUniversity of Cape TownObservatorySouth Africa
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Stillhart C, Vučićević K, Augustijns P, Basit AW, Batchelor H, Flanagan TR, Gesquiere I, Greupink R, Keszthelyi D, Koskinen M, Madla CM, Matthys C, Miljuš G, Mooij MG, Parrott N, Ungell AL, de Wildt SN, Orlu M, Klein S, Müllertz A. Impact of gastrointestinal physiology on drug absorption in special populations––An UNGAP review. Eur J Pharm Sci 2020; 147:105280. [DOI: 10.1016/j.ejps.2020.105280] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 02/10/2020] [Accepted: 02/24/2020] [Indexed: 02/07/2023]
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Preclinical models to optimize treatment of tuberculous meningitis - A systematic review. Tuberculosis (Edinb) 2020; 122:101924. [PMID: 32501258 DOI: 10.1016/j.tube.2020.101924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/19/2020] [Accepted: 03/20/2020] [Indexed: 01/04/2023]
Abstract
Tuberculous meningitis (TBM) is the most devastating form of TB, resulting in death or neurological disability in up to 50% of patients affected. Treatment is similar to that of pulmonary TB, despite poor cerebrospinal fluid (CSF) penetration of the cornerstone anti-TB drug rifampicin. Considering TBM pathology, it is critical that optimal drug concentrations are reached in the meninges, brain and/or the surrounding CSF. These type of data are difficult to collect in TBM patients. This review aims to identify and describe a preclinical model representative for human TBM which can provide the indispensable data needed for future pharmacological characterization and prioritization of new TBM regimens in the clinical setting. We reviewed existing literature on treatment of TBM in preclinical models: only eight articles, all animal studies, could be identified. None of the animal models completely recapitulated human disease and in most of the animal studies key pharmacokinetic data were missing, making the comparison with human exposure and CNS distribution, and the study of pharmacokinetic-pharmacodynamic relationships impossible. Another 18 articles were identified using other bacteria to induce meningitis with treatment including anti-TB drugs (predominantly rifampicin, moxifloxacin and levofloxacin). Of these articles the pharmacokinetics, i.e. plasma exposure and CSF:plasma ratios, of TB drugs in meningitis could be evaluated. Exposures (except for levofloxacin) agreed with human exposures and also most CSF:plasma ratios agreed with ratios in humans. Considering the lack of an ideal preclinical pharmacological TBM model, we suggest a combination of 1. basic physicochemical drug data combined with 2. in vitro pharmacokinetic and efficacy data, 3. an animal model with adequate pharmacokinetic sampling, microdialysis or imaging of drug distribution, all as a base for 4. physiologically based pharmacokinetic (PBPK) modelling to predict response to TB drugs in treatment of TBM.
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Blanton LS, Wilson NM, Quade BR, Walker DH. Susceptibility of Rickettsia rickettsii to Tigecycline in a Cell Culture Assay and Animal Model for Rocky Mountain Spotted Fever. Am J Trop Med Hyg 2020; 101:1091-1095. [PMID: 31516114 DOI: 10.4269/ajtmh.19-0445] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Rocky Mountain spotted fever (RMSF), caused by Rickettsia rickettsii, is a severe tick-borne infection endemic to the Americas. Oral doxycycline is effective, but during severe life-threatening disease, intravenous therapy is recommended. Unfortunately, intravenous formulations of doxycycline are not always available. Therefore, we aimed to determine the susceptibility of R. rickettsii to an alternative parenteral agent, tigecycline, in vitro and in vivo. To determine the minimum inhibitory concentration of tigecycline, R. rickettsii-inoculated Vero cells were incubated with medium containing tigecycline. At various time points, monolayers were collected and R. rickettsii was quantified via real-time polymerase chain reaction (PCR). The growth of R. rickettsii was inhibited in the presence of ≥ 0.5 µg/mL of tigecycline. To determine the effectiveness of tigecycline in vivo, guinea pigs were inoculated with R. rickettsii. Five days after inoculation, they were treated twice daily with subcutaneous tigecycline 3.75 mg/kg or subcutaneous doxycycline 5 mg/kg. Treated animals improved, whereas untreated controls remained ill. Tissues were collected for quantitative PCR-determined bacterial loads on day 8. Median bacterial loads in the tigecycline group were less than those in untreated animals: liver (0 versus 2.9 × 104 copies/mg), lung (0 versus 8.3 × 103 copies/mg), skin (2.6 × 102 versus 2.2 × 105 copies/mg), spleen (0 versus 1.3 × 104 copies/mg), and testes (0 versus 1.0 × 105 copies/mg, respectively). There were no significant differences in the bacterial loads between doxycycline-treated versus tigecycline-treated guinea pigs. These data indicate that tigecycline is effective against R. rickettsii in cell culture and in an animal model of RMSF.
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Affiliation(s)
- Lucas S Blanton
- Department of Internal Medicine-Infectious Diseases, University of Texas Medical Branch, Galveston, Texas
| | - Nicholas M Wilson
- School of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Bethany R Quade
- Department of Internal Medicine-Infectious Diseases, University of Texas Medical Branch, Galveston, Texas
| | - David H Walker
- Department of Pathology, University of Texas Medical Branch, Galveston, Texas
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Michel J, Hofbeck M, Merz T, Kumpf M, Meiers A, Neunhoeffer F. Gamma-hydroxybutyrate: is it a feasible alternative to midazolam in long-term mechanically ventilated children? Curr Med Res Opin 2019; 35:1721-1726. [PMID: 31079504 DOI: 10.1080/03007995.2019.1618253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aim: Benzodiazepines like midazolam are commonly used for long-term sedation of critically ill children requiring mechanical ventilation. Tolerance to midazolam may occur in these patients resulting in a ceiling effect with insufficient or missing sedative response to increases of midazolam infusion or bolus application. The aim of this study was to evaluate the feasibility of a drug rotation protocol replacing continuous infusion of midazolam with gamma-hydroxybutyrate (GHB) to counteract midazolam tolerance. Methods: This retrospective, observational study was conducted in a 14-bed pediatric intensive care unit of a tertiary referral center. Thirty-three mechanically ventilated children with tolerance to midazolam who received continuous infusion of GHB were included. Success of drug rotation from midazolam to GHB was defined as adequate sedation with GHB and subsequent reduction of required doses of midazolam. Results: In our cohort, drug rotation for at least 2 days could be successfully performed in 10 out of 34 children resulting in subsequent reduction of required doses of midazolam. Drug rotation to GHB failed in 24 patients due to insufficient sedation resulting in a premature termination of the protocol. In these children, dosing of midazolam could not be reduced following drug rotation. We could not identify factors which predict success or failure of drug rotation from midazolam to GHB. Conclusions: The data from our single-center study suggest that drug rotation from midazolam to GHB may be worth trying in children with midazolam tolerance during long-term sedation, but physicians should be aware of possible treatment failure.
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Affiliation(s)
- Jörg Michel
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
| | - Timo Merz
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
| | - Anna Meiers
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
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Takahashi Y, Sakuma M, Murayama H, Morimoto T. Effect of baseline renal and hepatic function on the incidence of adverse drug events: the Japan Adverse Drug Events study. Drug Metab Pers Ther 2019; 33:165-173. [PMID: 30414364 DOI: 10.1515/dmpt-2018-0018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/03/2018] [Indexed: 11/15/2022]
Abstract
Background The impact of renal and hepatic dysfunction on the morbidity and mortality of inpatients with adverse drug events (ADEs) is uncertain in daily clinical practice. The objective of this study was to investigate the effect of renal and hepatic function on ADEs and inpatients' morbidity and mortality. Methods The Japan Adverse Drug Events (JADE) study was a prospective cohort study carried out at three tertiary-care teaching hospitals in Japan. Participants were consecutive inpatients (n=3459) aged 15 years or older. We evaluated the effect of renal and hepatic function on the occurrence of ADEs, and assessed how they affected length of hospital stay (LOS) and in-hospital mortality. We used the estimated glomerular filtration rate to quantify renal function and categorized patients into three groups (normal, ≥60 mL/min/1.73 mm; moderate, ≥30 and <60 mL/min/1.73 mm; severe, <30 mL/min/1.73 mm). We defined patients as having hepatic dysfunction when at least one data point (total bilirubin, aspartate aminotransferase, alanine aminotransferase, or gamma glutamyltransferase) was beyond a cutoff value. Results We analyzed the laboratory data of 2508 patients. There was a significant difference in the occurrence of ADEs among the three GFR categories (normal, 20%; moderate, 26%; severe, 22%; p=0.02). More ADEs occurred in patients with hepatic dysfunction (25% vs. 20%, p=0.01). LOS was significantly longer in those with ADEs stratified either by renal or by hepatic dysfunction (p<0.0001). ADEs were independently associated with in-hospital mortality, adjusting for renal and hepatic function (p<0.0001). Conclusions Inpatients' organ dysfunction increased ADEs, and ADEs were associated with both LOS and in-hospital mortality independently, irrespective of renal and hepatic function.
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Affiliation(s)
- Yuri Takahashi
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Mio Sakuma
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hiroki Murayama
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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Pharmacokinetics and toxicity of high-dose baclofen in ICU patients. Prog Neuropsychopharmacol Biol Psychiatry 2019; 92:450-456. [PMID: 30826461 DOI: 10.1016/j.pnpbp.2019.02.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/20/2019] [Accepted: 02/27/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND High-dose baclofen could prove beneficial in patients with unhealthy alcohol use in intensive care units (ICU). However, the pharmacokinetic properties of baclofen are unknown in this population. Our objectives were to investigate the pharmacokinetics of baclofen and the relationship between baclofen exposure and its toxicity in the ICU. MATERIALS AND METHODS As part of a healthcare quality improvement project, we conducted a prospective, single-center study in a surgical intensive care unit at Nantes University Hospital in order to assess our local protocol of sedation in patients with consumption of alcohol above the recommended limits by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Baclofen pharmacokinetics were investigated by a non-compartment analysis and a population approach in 20 patients under mechanical ventilation. After a baclofen loading dose on day 1, daily doses were divided into 3 intakes adapted to glomerular filtration rate (GFR) and blood samples were withdrawn on day 3 for pharmacokinetic analysis. Baclofen was administered until extubation or tracheostomy and agitation-related events as well as the potential side effects of baclofen were noted. RESULTS In this population, pharmacokinetic parameters [absorption latency time = 0.37 h, absorption constant rate = 2.2 h-1, apparent volume of distribution = 105 L, apparent clearance (l/h) = 13.5 × (GFR/103)0.839] were characterized by modified absorption and the influence of renal function: renal failure significantly increased baclofen exposure (p = .007) and significantly decreased baclofen clearance (p = .007) compared with patients without renal failure. When comparing patients with or without possible signs of baclofen toxicity, no difference was found regarding baclofen exposure (p = .34) and plasma peak concentration (p = .26). CONCLUSIONS The a priori planned algorithm for dose adaptation according to renal clearance appeared to be suitable in our population. Daily administration of 150 mg of baclofen in ICU patients with preserved renal function did not lead to toxic concentrations in the plasma. A dose reduction of approximately 40%, 60% and 70% in patients with mild, moderate and severe renal failure could be suggested.
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Ruiz J, Gordon M, Villarreal E, Peruccioni M, Marqués MR, Poveda-Andrés JL, Castellanos-Ortega Á, Ramirez P. Impact of voriconazole plasma concentrations on treatment response in critically ill patients. J Clin Pharm Ther 2019; 44:572-578. [PMID: 30851209 DOI: 10.1111/jcpt.12817] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/13/2019] [Accepted: 01/18/2019] [Indexed: 12/21/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Several authors have demonstrated the relationship between voriconazole concentrations and the risk of therapeutic failure and adverse events However, the information about voriconazole concentrations in the critically ill patient is scarce. The aim of this study was to analyse the plasma concentrations and pharmacokinetic behaviour of voriconazole in critically ill patients and their association with the treatment response and development of toxicity. METHODS A prospective, observational study was conducted. Patients admitted to an intensive care unit and on treatment with intravenous voriconazole were included. Plasma concentrations were measured between days 4 and 7 from the start of the treatment. The pharmacokinetic analysis was performed using the NONMEM® software. A regression model was used to evaluate the variables associated with the values outside the therapeutic range, as well as the relationship between the plasma concentrations and the treatment response and the development of hepatotoxicity. RESULTS AND DISCUSSION A total of 33 patients were included. Plasma concentrations outside the therapeutic range (1-5.5 mg/L) were observed in 15 patients, being above the established range in 9 (27.3%) cases, and below it in 6 (18.2%) cases. The presence of a bilirubin value of >1.5 mg/dL and a C-reactive protein >100 mg/dL was associated with supra-therapeutic concentrations. Voriconazole concentrations greater than 5.5 mg/dL were associated with the development of hepatotoxicity. WHAT IS NEW AND CONCLUSIONS There is a wide variation in voriconazole concentrations in critically ill patients, being associated with a high frequency of adverse events. Close monitoring of these values is required in order to decrease the risk of therapeutic failure and toxicity.
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Affiliation(s)
- Jesus Ruiz
- Intensive Care Unit, IIS La Fe. Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Mónica Gordon
- Intensive Care Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Esther Villarreal
- Intensive Care Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Marcela Peruccioni
- Intensive Care Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | | | | | - Paula Ramirez
- Intensive Care Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Nguyen H, Pan A, Smollin C, Cantrell LF, Kearney T. An 11-year retrospective review of cyproheptadine use in serotonin syndrome cases reported to the California Poison Control System. J Clin Pharm Ther 2019; 44:327-334. [DOI: 10.1111/jcpt.12796] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/10/2018] [Accepted: 12/12/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Hien Nguyen
- School of Pharmacy; University of California San Francisco; San Francisco California
- Alta Bates Summit Medical Center; Oakland California
| | - Angel Pan
- School of Pharmacy; University of California San Francisco; San Francisco California
- Santa Clara Valley Medical Center; Fruitdale California
| | - Craig Smollin
- California Poison Control System- San Francisco Division, Department of Clinical Pharmacy, School of Pharmacy; University of California; San Francisco California
- Department of Emergency Medicine; University of California San Francisco; San Francisco California
| | - Lee F. Cantrell
- California Poison Control System- San Francisco Division, Department of Clinical Pharmacy, School of Pharmacy; University of California; San Francisco California
| | - Tom Kearney
- School of Pharmacy; University of California San Francisco; San Francisco California
- California Poison Control System- San Francisco Division, Department of Clinical Pharmacy, School of Pharmacy; University of California; San Francisco California
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Jahns FP, Ben-Hamouda N, Kirsch M, Roumy A, Liaudet L. Intravenous zanamivir for influenza myocarditis and enteral malabsorption. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:332. [PMID: 30514347 PMCID: PMC6280537 DOI: 10.1186/s13054-018-2263-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 11/15/2018] [Indexed: 12/03/2022]
Affiliation(s)
- Fritz-Patrick Jahns
- Department of Intensive Care Medicine and Burns, Lausanne University Hospital Medical Center, CHUV, 1011, Lausanne, Switzerland
| | - Nawfel Ben-Hamouda
- Department of Intensive Care Medicine and Burns, Lausanne University Hospital Medical Center, CHUV, 1011, Lausanne, Switzerland.
| | - Matthias Kirsch
- Department of Cardiovascular Surgery, Lausanne University Hospital Medical Center, 1011, Lausanne, Switzerland
| | - Aurélien Roumy
- Department of Cardiovascular Surgery, Lausanne University Hospital Medical Center, 1011, Lausanne, Switzerland
| | - Lucas Liaudet
- Department of Intensive Care Medicine and Burns, Lausanne University Hospital Medical Center, CHUV, 1011, Lausanne, Switzerland
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Lewis TC, Cortes J, Altshuler D, Papadopoulos J. Venous Thromboembolism Prophylaxis: A Narrative Review With a Focus on the High-Risk Critically Ill Patient. J Intensive Care Med 2018; 34:877-888. [PMID: 30165770 DOI: 10.1177/0885066618796486] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Venous thromboembolism (VTE) is a major health concern associated with significant morbidity and mortality. Critically ill patients are at an increased risk of VTE compared to general medical patients due to unique risk factors: prolonged immobilization, invasive lines and devices, certain medications, and acquired thrombophilia. Furthermore, VTE in the critically ill is associated with increased duration of mechanical ventilation, increased length of intensive care unit and hospital stay, and a trend toward increased mortality. Clinical practice guidelines therefore recommend VTE prophylaxis with either subcutaneous heparin or low-molecular-weight heparin for all critically ill patients without contraindication. Yet, many patients will develop VTE despite appropriate pharmacologic prophylaxis, which has led to interest in risk-stratifying critically ill patients for more aggressive prophylaxis strategies. Recent research identified patients at highest risk of failure of thromboprophylaxis and provided insight into the pathophysiologic mechanisms. Obesity and the receipt of vasopressors are 2 risk factors consistently identified in observational studies; further clinical data support decreased absorption of anticoagulant administered via the subcutaneous route as the likely mechanism behind thromboprophylaxis failure in these patient populations. Several studies have investigated novel thromboprophylaxis strategies to circumvent pharmacokinetic limitations in patients who are obese or on vasopressors: increased fixed-dose, weight-based subcutaneous, or continuous intravenous infusion of a prophylactic dose of anticoagulant has shown promise in limited studies; however, the results have yet to demonstrate superiority compared to current standard-of-care. This review discusses observational studies identifying patients at risk of thromboprophylaxis failure and critiques clinical studies evaluating novel thromboprophylaxis strategies in high-risk, critically ill patients with a focus on their limitations. Future studies are currently being conducted that will provide further guidance into the appropriate use of individualized thromboprophylaxis.
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Affiliation(s)
- Tyler C Lewis
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
| | - Jennifer Cortes
- Department of Pharmacy Services, Memorial Hermann-Texas Medical Center, Houston, TX, USA
| | - Diana Altshuler
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
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Rohracher A, Kalss G, Neuray C, Höfler J, Dobesberger J, Kuchukhidze G, Kreidenhuber R, Florea C, Thomschewski A, Novak HF, Pilz G, Leitinger M, Trinka E. Perampanel in patients with refractory and super-refractory status epilepticus in a neurological intensive care unit: A single-center audit of 30 patients. Epilepsia 2018; 59 Suppl 2:234-242. [PMID: 30043411 DOI: 10.1111/epi.14494] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2018] [Indexed: 11/29/2022]
Abstract
In refractory status epilepticus (SE), γ-aminobutyric acidergic drugs become less effective and glutamate plays a major role in seizure perpetuation. Data on the efficacy of perampanel (PER) in treatment of refractory SE in humans are limited. Here, we present a single-center case series of patients with refractory SE who received PER orally in an intensive care unit. We retrospectively analyzed treatment response, outcome, and adverse effects of all patients with refractory SE in our Neurological Intensive Care Unit who received add-on PER between September 2012 and February 2018. Thirty patients with refractory SE (median = 72 years, range = 18-91, 77% women) were included. In 14 patients (47%), a high-dose approach was used, with a median initial dose of 24 mg (range = 16-32). In five patients (17%), SE could be terminated after PER administration (median dose = 6 mg, range = 6-20 mg, 2/5 patients in high-dose group). Clinical response was observed after a median of 24 hours (range = 8-48 hours), whereas electroencephalogram resolved after a median of 60 hours (range = 12-72 hours). Time to treatment response tended to be shorter in patients receiving high-dose PER (median clinical response = 16 hours vs 18 hours; electroencephalographic response = 24 hours vs 72 hours), but groups were too small for statistical analysis. Continuous cardiorespiratory monitoring showed no changes in cardiorespiratory function after "standard" and "high-dose" treatment. Elevated liver enzymes without clinical symptoms were observed after a median of 6 days in seven of 30 patients (23%; 57% high dose vs 43% standard dose), of whom six also received treatment with phenytoin (PHT). Outcome was unfavorable (death, persistent vegetative state) in 13 patients (43%; 39% high dose vs 61% standard dose), and good recovery (no significant disability, moderate disability) was achieved in nine patients (56% high dose vs 44% standard dose). Oral PER in loading doses up to 32 mg were well tolerated but could terminate SE only in a few patients (5/30; 17%). Long duration of SE, route of administration, and severe underlying brain dysfunction might be responsible for the modest result. An intravenous formulation is highly desired to explore the full clinical utility in the treatment of refractory SE.
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Affiliation(s)
- Alexandra Rohracher
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Caroline Neuray
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Julia Höfler
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Judith Dobesberger
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Giorgi Kuchukhidze
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria.,Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Rudolf Kreidenhuber
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Cristina Florea
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | | | - Helmut F Novak
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Georg Pilz
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Markus Leitinger
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
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Masman AD, Tibboel D, Baar FPM, van Dijk M, Mathot RAA, van Gelder T. Prevalence and Implications of Abnormal Laboratory Results in Patients in the Terminal Phase of Life. J Palliat Med 2018; 19:822-9. [PMID: 27494223 DOI: 10.1089/jpm.2015.0548] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pathophysiological changes at the end of life may affect pharmacokinetics of drugs. However, caregivers typically do not extensively monitor patients' laboratory parameters at the end of life. OBJECTIVE Our aim was to describe laboratory parameters of hospice patients in the week before death. METHODS A cohort study was conducted on available laboratory results in the week before death, including clinical chemistry and hematology tests. RESULTS Laboratory data of 125 patients in a palliative care center were included, assessed at a median of 3 days before death. Eighty percent of patients had anemia and almost all had hypoalbuminemia (97%). Elevated levels of gamma-glutamyl transferase (gGT) were found in 75%, of alkaline phosphatase (ALP) in 60%, of aspartate aminotransferase (ASAT) in 60%, and of calcium (Ca) in 68%. Alanine aminotransferase (ALAT), bilirubin, sodium (Na), and potassium (K) were abnormal in from 8.8% to 36.0% of patients. A previous unknown poor kidney function was found in 60% of patients. Thirteen patients (22%) with a regular morphine prescription and one patient treated with a non-steroidal anti-inflammatory drug (NSAID) had severe kidney failure. CONCLUSIONS Abnormal laboratory results were expected due to the pathophysiological changes that occur during the last phase of life. Remarkably, however, electrolytes (Na and K) were balanced even shortly before death. Estimated glomerular filtration rate (eGFR), reflecting the kidney function, seems the most clinically relevant laboratory parameter, because it may guide drug choice and dosing.
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Affiliation(s)
- Anniek D Masman
- 1 Palliative Care Centre , Laurens Cadenza, Rotterdam, the Netherlands .,2 Pain Expertise Centre, Erasmus MC-Sophia Children's Hospital , Rotterdam, the Netherlands
| | - Dick Tibboel
- 2 Pain Expertise Centre, Erasmus MC-Sophia Children's Hospital , Rotterdam, the Netherlands .,3 Intensive Care, Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, the Netherlands
| | - Frans P M Baar
- 1 Palliative Care Centre , Laurens Cadenza, Rotterdam, the Netherlands .,2 Pain Expertise Centre, Erasmus MC-Sophia Children's Hospital , Rotterdam, the Netherlands
| | - Monique van Dijk
- 2 Pain Expertise Centre, Erasmus MC-Sophia Children's Hospital , Rotterdam, the Netherlands .,3 Intensive Care, Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, the Netherlands
| | - Ron A A Mathot
- 4 Hospital Pharmacy-Clinical Pharmacology , Academic Medical Centre, Amsterdam, the Netherlands
| | - Teun van Gelder
- 5 Department of Hospital Pharmacy, Erasmus Medical Centre , Rotterdam, the Netherlands
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Foskett A, Manley C, Naramore R, Gordon IK, Stewart BM, Khanna C. Tolerability of oral sorafenib in pet dogs with a diagnosis of cancer. VETERINARY MEDICINE-RESEARCH AND REPORTS 2017; 8:97-102. [PMID: 30050861 PMCID: PMC6042486 DOI: 10.2147/vmrr.s149678] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Sorafenib is a multi-target small molecule inhibitor of the RAF kinase family and VEGFR-2/PDGFR. The US Food and Drug Administration approved sorafenib in human patients with liver, thyroid, or renal carcinoma. The aim of this study was to help guide future pharmacokinetic (PK) studies of sorafenib in dogs with a cancer diagnosis. Client-owned dogs were eligible if they had a cytologic or histologic diagnosis of cancer. Patients were enrolled at escalating doses of sorafenib. Patients were evaluable for the study if they received at least one dose of sorafenib and presented 1 week later for a follow-up examination, blood work, and assessment of drug tolerability. The goal of this study was not to define a maximum tolerated dose as may be reasonable in conventional cytotoxic chemotherapy drugs, but rather to describe the tolerability of this drug in dogs with a cancer diagnosis, as a prequel to future sorafenib PK studies. No patients in the study had any evidence of adverse events that were attributable to sorafenib. Doses of 3 mg/kg were well tolerated and associated with a suggestion of clinical activity, supportive of future PK, and pharmacodynamic analysis. Such future studies are recommended at this dose to define the associated exposure achieved and determine a reasonable schedule for sorafenib administration.
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Maraolo AE, Cascella M, Corcione S, Cuomo A, Nappa S, Borgia G, De Rosa FG, Gentile I. Management of multidrug-resistant Pseudomonas aeruginosa in the intensive care unit: state of the art. Expert Rev Anti Infect Ther 2017; 15:861-871. [PMID: 28803496 DOI: 10.1080/14787210.2017.1367666] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Alberto Enrico Maraolo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Marco Cascella
- Division of Anesthesia, Department of Anesthesia and Pain Medicine, Istituto Nazionale Tumori – IRCCS - Fondazione G. Pascale, Naples, Italy
| | - Silvia Corcione
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Arturo Cuomo
- Division of Anesthesia, Department of Anesthesia and Pain Medicine, Istituto Nazionale Tumori – IRCCS - Fondazione G. Pascale, Naples, Italy
| | - Salvatore Nappa
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Guglielmo Borgia
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | | | - Ivan Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
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50
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An observational study examining the effects of a surgically induced inflammatory response on the distribution of morphine and its metabolites into cerebrospinal fluid. Can J Anaesth 2017; 64:1009-1022. [PMID: 28710563 DOI: 10.1007/s12630-017-0933-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 05/25/2017] [Accepted: 07/05/2017] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Morphine is administered intravenously for pain management in the perioperative period. The effect of the inflammatory response to surgery on morphine distribution across the blood-brain barrier (BBB) in humans was investigated. We hypothesized that a graded surgically induced, systemic inflammatory response alters cerebrospinal fluid (CSF) levels of morphine, morphine-3-glucuronide (M3G), and morphine-6-glucuronide (M6G) through a temporary reduction in BBB drug efflux transporter function. METHODS We conducted a prospective pharmacokinetic study of the plasma and CSF distribution of the P-glycoprotein (PGP) substrate morphine in 33 patients undergoing open thoracic (n = 18) or endovascular (n = 15) aortic aneurysm repair. Morphine was administered with induction of anesthesia and in the intensive care unit. Plasma and CSF concentrations of interleukin (IL)-6, morphine, M3G, M6G, and albumin were measured prior to surgery (baseline), during surgery, and postoperatively every six hours until removal of the CSF drain. The area under the curve (AUC) was determined for plasma and CSF IL-6, morphine, M3G, and M6G concentrations vs time. The primary endpoint measures were the correlations between the morphine, M6G, and M3G AUC CSF/plasma ratios and systemic inflammation as quantified by the time-normalized IL-6 exposure, which was calculated for each individual by dividing the total exposure (AUC) by time (t). A Bonferroni corrected P < 0.017 indicated a significant correlation. RESULTS Plasma and CSF IL-6 concentrations increased postoperatively. The median [interquartile range] IL-6 exposures were significantly higher in the open vs endovascular surgical group for plasma (105 [40-256] pg·mL-1 vs 29 [16-70] pg·mL-1, respectively; P = 0.013) and CSF (79 [26-133] pg·mL-1 vs 16 [9-80] pg·mL-1, respectively; P = 0.013). For the primary endpoint, the plasma IL-6 AUC/t did not correlate with the CSF accumulation of morphine (r = -0.009; P = 0.96) or M3G (r = 0.37; P = 0.04) when corrected for surgical procedure, age, and sex. There were insufficient data on CSF concentration to complete the primary analysis for M6G. CONCLUSION Morphine distribution into the CSF was not significantly altered in patients undergoing thoracic aortic aneurysm repair. This suggests that BBB PGP function may not be affected by the perioperative inflammatory response. TRIAL REGISTRATION www.clinicaltrials.gov , NCT 00878371. Registered 7 April 2009.
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