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Masuda S, Lemaitre F, Barten MJ, Bergan S, Shipkova M, van Gelder T, Vinks S, Wieland E, Bornemann-Kolatzki K, Brunet M, de Winter B, Dieterlen MT, Elens L, Ito T, Johnson-Davis K, Kunicki PK, Lawson R, Lloberas N, Marquet P, Millan O, Mizuno T, Moes DJAR, Noceti O, Oellerich M, Pattanaik S, Pawinski T, Seger C, van Schaik R, Venkataramanan R, Walson P, Woillard JB, Langman LJ. Everolimus Personalized Therapy: Second Consensus Report by the International Association of Therapeutic Drug Monitoring and Clinical Toxicology. Ther Drug Monit 2024:00007691-990000000-00267. [PMID: 39331837 DOI: 10.1097/ftd.0000000000001250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 06/09/2024] [Indexed: 09/29/2024]
Abstract
ABSTRACT The Immunosuppressive Drugs Scientific Committee of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology established the second consensus report to guide Therapeutic Drug Monitoring (TDM) of everolimus (EVR) and its optimal use in clinical practice 7 years after the first version was published in 2016. This version provides information focused on new developments that have arisen in the last 7 years. For the general aspects of the pharmacology and TDM of EVR that have retained their relevance, readers can refer to the 2016 document. This edition includes new evidence from the literature, focusing on the topics updated during the last 7 years, including indirect pharmacological effects of EVR on the mammalian target of rapamycin complex 2 with the major mechanism of direct inhibition of the mammalian target of rapamycin complex 1. In addition, various concepts and technical options to monitor EVR concentrations, improve analytical performance, and increase the number of options available for immunochemical analytical methods have been included. Only limited new pharmacogenetic information regarding EVR has emerged; however, pharmacometrics and model-informed precision dosing have been constructed using physiological parameters as covariates, including pharmacogenetic information. In clinical settings, EVR is combined with a decreased dose of calcineurin inhibitors, such as tacrolimus and cyclosporine, instead of mycophenolic acid. The literature and recommendations for specific organ transplantations, such as that of the kidneys, liver, heart, and lungs, as well as for oncology and pediatrics have been updated. EVR TDM for pancreatic and islet transplantation has been added to this edition. The pharmacodynamic monitoring of EVR in organ transplantation has also been updated. These updates and additions, along with the previous version of this consensus document, will be helpful to clinicians and researchers treating patients receiving EVR.
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Affiliation(s)
- Satohiro Masuda
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Himeji Dokkyo University, Himeji, Japan
| | - Florian Lemaitre
- Univ Rennes, CHU Rennes, Inserm, EHESP, IRSET-UMR S 1085, Rennes, France
- INSERM, Centre d'Investigation Clinique 1414, Rennes, France
- FHU SUPPORT, Rennes, France
| | - Markus J Barten
- Department of Cardiac- and Vascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Stein Bergan
- Department of Pharmacology, Oslo University Hospital and Department of Pharmacy, University of Oslo, Norway
| | | | - Teun van Gelder
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Sander Vinks
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- NDA Partners, A Propharma Group Company, Washington District of Columbia
| | | | | | - Mercè Brunet
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Spain
| | - Brenda de Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Maja-Theresa Dieterlen
- Laboratory Management Research Laboratory, Cardiac Surgery Clinic, Heart Center Leipzig GmbH, University Hospital, Leipzig, Germany
| | - Laure Elens
- Integrated Pharmacometrics, Pharmacogenetic and Pharmacokinetics Research Group (PMGK) Louvain Drug for Research Institute (LDRI), Catholic University of Louvain, (UCLouvain), Brussels, Belgium
| | - Taihei Ito
- Department of Organ Transplant Surgery; Fujita Health University School of Medicine, Toyoake Aichi, Japan
| | - Kamisha Johnson-Davis
- University of Utah Health Sciences Center and ARUP Laboratories, Salt Lake City, Utah
| | - Pawel K Kunicki
- Department of Drug Chemistry, Pharmaceutical and Biomedical Analysis, Faculty of Pharmacy, Medical University of Warsaw, Warsaw, Poland
| | - Roland Lawson
- University of Limoges, Inserm U1248, Pharmacology & Transplantation, Limoges, France
| | - Nuria Lloberas
- Nephrology Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Pierre Marquet
- University of Limoges, Inserm U1248, Pharmacology & Transplantation, Limoges, France
- Department of Pharmacology, Toxicology and Pharmacovigilance, CHU de Limoges, France
| | - Olga Millan
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Spain
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Dirk Jan A R Moes
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ofelia Noceti
- National Center for Liver Transplantation and Liver Diseases, Army Forces Hospital, Montevideo, Uruguay
| | - Michael Oellerich
- Department of Clinical Pharmacology, University Medical Center Göttingen, Georg-August-University Göttingen, Göttingen, Germany
| | - Smita Pattanaik
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Tomasz Pawinski
- Department of Drug Chemistry, Pharmaceutical and Biomedical Analysis, Faculty of Pharmacy, Medical University of Warsaw, Warsaw, Poland
| | | | - Ron van Schaik
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy and Department of Pathology, Starzl Transplantation Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Phil Walson
- University Medical School, Göttingen, Germany
| | - Jean-Baptiste Woillard
- Department of Pharmacology, Toxicology and Pharmacovigilance, CHU de Limoges, Limoges, France; and
| | - Loralie J Langman
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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Mao J, Zeng F, Qin W, Hu M, Xu L, Cheng F, Zhong M, Zhang Y. A joint population pharmacokinetic model to assess the high variability of whole-blood and intracellular tacrolimus in early adult renal transplant recipients. Int Immunopharmacol 2024; 137:112535. [PMID: 38908078 DOI: 10.1016/j.intimp.2024.112535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 06/24/2024]
Abstract
Tacrolimus (TAC) has high pharmacokinetic (PK) variability during the early transplantation period. The relationships between whole-blood and intracellular TAC concentrations and clinical outcomes remain controversial. This study identifies the factors affecting the PK variability of TAC and characterizes the relationships between whole-blood and intracellular TAC concentrations. Data regarding whole-blood TAC concentrations of 1,787 samples from 215 renal transplant recipients (<90 days postoperative) across two centers and intracellular TAC concentrations (648 samples) digitized from previous studies were analyzed using nonlinear mixed-effects modeling. The effects of potential covariates were screened, and the distribution of whole-blood to intracellular TAC concentration ratios (RWB:IC) was estimated. The final model was evaluated using bootstrap, goodness of fit, and prediction-corrected visual predictive checks. The optimal dosing regimens and target ranges for each type of immune cell subsets were determined using Monte Carlo simulations. A two-compartment model adequately described the data, and the estimated mean TAC CL/F was 23.6 L·h-1 (relative standard error: 11.5 %). The hematocrit level, CYP3A5*3 carrier status, co-administration with Wuzhi capsules, and tapering prednisolone dose may contribute to the high variability of TAC PK variability during the early post-transplant period. The estimated RWB:IC of all TAC concentrations in peripheral blood mononuclear cells (PBMCs) was 4940, and inter-center variability of PBMCs was observed. The simulated TAC target range in PBMCs was 20.2-85.9 pg·million cells-1. Inter-center variability in intracellular concentrations should be taken into account in further analyses. TAC dosage adjustments can be guided based on PK/PD variability and simulated intracellular concentrations.
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Affiliation(s)
- Junjun Mao
- Department of Pharmacy, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai 200040, China.
| | - Fang Zeng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jie Fang Road, Wuhan, Hubei 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, 1277 Jie Fang Road, Wuhan, Hubei 430022, China
| | - Weiwei Qin
- Department of Pharmacy, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai 200040, China
| | - Min Hu
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jie Fang Road, Wuhan, Hubei 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, 1277 Jie Fang Road, Wuhan, Hubei 430022, China
| | - Luyang Xu
- Department of Pharmacy, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai 200040, China
| | - Fang Cheng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jie Fang Road, Wuhan, Hubei 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, 1277 Jie Fang Road, Wuhan, Hubei 430022, China
| | - Mingkang Zhong
- Department of Pharmacy, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai 200040, China.
| | - Yu Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jie Fang Road, Wuhan, Hubei 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, 1277 Jie Fang Road, Wuhan, Hubei 430022, China.
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Hu L, Liu J, Fan Q, Zhang S. Mung Bean (Vigna radiata L.) Soup Decreases Tacrolimus Blood Trough Level. Am J Ther 2024; 31:e489-e491. [PMID: 38976537 DOI: 10.1097/mjt.0000000000001696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Affiliation(s)
| | | | - Qiuyu Fan
- Rheumatology, Wuhan Hospital of Traditional Chinese and Western Medicine, Wuhan, China
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van Dommelen JEM, Grootjans H, Uijtendaal EV, Ruigrok D, Luijk B, van Luin M, Bult W, de Lange DW, Kusadasi N, Droogh JM, Egberts TCG, Verschuuren EAM, Sikma MA. Tacrolimus Variability and Clinical Outcomes in the Early Post-lung Transplantation Period: Oral Versus Continuous Intravenous Administration. Clin Pharmacokinet 2024; 63:683-693. [PMID: 38581638 PMCID: PMC11106167 DOI: 10.1007/s40262-024-01368-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND AND OBJECTIVE High variability in tacrolimus pharmacokinetics directly after lung transplantation (LuTx) may increase the risk for acute kidney injury (AKI) and transplant rejection. The primary objective was to compare pharmacokinetic variability in patients receiving tacrolimus orally versus intravenously early after LuTx. METHODS Pharmacokinetic and clinical data from 522 LuTx patients transplanted between 2010 and 2020 in two university hospitals were collected to compare orally administered tacrolimus to intravenous tacrolimus early post-transplantation. Tacrolimus blood concentration variability, measured as intrapatient variability (IPV%) and percentage of time within the therapeutic range (TTR%), was analyzed within the first 14 days after LuTx. Secondary outcomes were AKI, acute rejection, length of stay in the intensive care unit (ICU), and mortality in the ICU and during hospital admission. RESULTS We included 224 patients in the oral and 298 in the intravenous group. The mean adjusted IPV% was 10.8% (95% confidence interval [CI] 6.9-14.6; p < 0.001) higher in the oral group (27.2%) than the intravenous group (16.4%). The mean TTR% was 7.3% (95% CI - 11.3 to - 3.4; p < 0.001) lower in the oral group (39.6%) than in the intravenous group (46.9%). The incidence of AKI was 46.0% for oral and 42.6% for intravenous administration (adjusted odds ratio [OR] 1.2; 95% CI 0.8-1.8; p = 0.451). The frequencies of clinically diagnosed acute rejection in the oral and intravenous groups were nonsignificant (24.6% vs 17.8%; OR 1.5 [95% CI 1.0-2.3; p = 0.059]). ICU and hospital mortality rate and ICU length of stay were similar. CONCLUSIONS Administering tacrolimus orally directly after LuTx leads to a higher variability in blood concentrations compared to intravenous administration. There was no difference in the occurrence of AKI or transplant rejection.
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Affiliation(s)
- Julia E M van Dommelen
- Department of Clinical Pharmacy, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Heleen Grootjans
- Department of Internal Medicine, Section Nephrology, University Medical Center Groningen, Groningen, The Netherlands
- Department of Pulmonology, Tuberculosis and Lung Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Esther V Uijtendaal
- Department of Clinical Pharmacy, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Dieuwertje Ruigrok
- Department of Pulmonary Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bart Luijk
- Department of Pulmonary Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Matthijs van Luin
- Department of Clinical Pharmacy, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Wouter Bult
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Dylan W de Lange
- Department of Intensive Care and Dutch Poisons Information Center, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Nuray Kusadasi
- Department of Intensive Care, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Joep M Droogh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Toine C G Egberts
- Department of Clinical Pharmacy, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Erik A M Verschuuren
- Department of Pulmonology, Tuberculosis and Lung Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maaike A Sikma
- Department of Intensive Care and Dutch Poisons Information Center, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands.
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5
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Zhang W, Zhang X, Han J, Zhang W, Xu J, Zhang X, Bian H, Meng C, Shang D, Zhou Y, Wang D, Feng B. Case report: Paralytic ileus resulted from nirmatrelvir/ritonavir-tacrolimus drug-drug interaction in a systemic lupus erythematosus patient with COVID-19. Front Pharmacol 2024; 15:1389187. [PMID: 38601471 PMCID: PMC11004316 DOI: 10.3389/fphar.2024.1389187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 03/18/2024] [Indexed: 04/12/2024] Open
Abstract
Patients with systemic autoimmune rheumatic diseases are at a high risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and effective antiviral treatments including nirmatrelvir/ritonavir can improve their outcomes. However, there might be potential drug-drug interactions when these patients take nirmatrelvir/ritonavir together with immunosuppressants with a narrow therapeutic window, such as tacrolimus and cyclosporine. We present a case of paralytic ileus resulting from tacrolimus toxicity mediated by the use of nirmatrelvir/ritonavir in a patient with systemic lupus erythematosus (SLE). A 37-year-old female SLE patient was prescribed nirmatrelvir/ritonavir without discontinuing tacrolimus. She presented to the emergency room with symptoms of paralytic ileus including persistent abdominal pain, nausea, and vomiting, which were verified to be associated with tacrolimus toxicity. The blood concentration of tacrolimus was measured >30 ng/mL. Urgent medical intervention was initiated, while tacrolimus was withheld. The residual concentration was brought within the appropriate range and tacrolimus was resumed 8 days later. Physicians must be aware of the potential DDIs when prescribing nirmatrelvir/ritonavir, especially to those taking immunosuppresants like tacrolimus.
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Affiliation(s)
- Wei Zhang
- Department of Poisoning and Occupational Diseases, Shandong Provincial Hospital, Shandong University, Jinan, China
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xingguo Zhang
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Poisoning and Occupational Diseases, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Jinming Han
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Wen Zhang
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Jiarui Xu
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Poisoning and Occupational Diseases, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xin Zhang
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Hongjun Bian
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Chong Meng
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Deya Shang
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yi Zhou
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Dawei Wang
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Baobao Feng
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Poisoning and Occupational Diseases, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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Teng H, Hu X, Liu N. HDL-C and creatinine levels at 1 month are associated with patient 12-month survival rate after kidney transplantation. Pharmacogenet Genomics 2024; 34:33-42. [PMID: 37906625 DOI: 10.1097/fpc.0000000000000514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
BACKGROUND Many factors affect the survival rate after kidney transplantation, including laboratory tests, medicine therapy and pharmacogenomics. Tacrolimus, mycophenolate mofetil and methylprednisolone were used as an immunosuppressive regimen after kidney transplantation. The primary goal of this study was to investigate the factors affecting the tacrolimus concentrations and mycophenolate mofetil area under the curve of mycophenolic acid AUC-MPA. Secondary goals were to study the association between perioperative period laboratory tests, medicine therapy, CYP3A5 genetic polymorphisms, and survival rate in kidney renal transplant patients. METHODS A total of 303 patients aged above 18 years were enrolled in this study. Their clinical characteristics, laboratory tests, and medicine therapy regimens were collected. We followed the patients for survival for 1 year after kidney transplantation. RESULTS Multivariable logistic analyses reveal that age greater than 50 years, and the CY3A5 *3*3 genotype were independently, positively, and significantly related to tacrolimus C/D ratio at 7 days. At 1 month of follow-up, only CYP3A5 *3*3 was associated with tacrolimus C/D ratio. Basiliximab, Imipenem and cilastatin sodium, sex were associated with mycophenolate mofetil AUC-MPA at 7 days. In the COX regression analysis, a high-density lipoprotein cholesterol level≥1 mmol/L was identified as a positive independent risk factors for the survival rate, while a creatinine level ≥200 μmol/L was a negatively independent risk factors for survival rate. CONCLUSION These results suggest that age, genes, and drug-drug interaction can affect the concentration of tacrolimus.
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Affiliation(s)
- Haolin Teng
- Department of Urology, The First Hospital of Jilin University
| | - Xinyuan Hu
- Key Laboratory of Organ Regeneration & Transplantation of the Ministry of Education, Genetic Diagnosis Center, The First Hospital of Jilin University, Changchun, China
| | - Nian Liu
- Department of Urology, The First Hospital of Jilin University
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Ebid AHI, Ismail DA, Lotfy NM, Mahmoud MA, El-Sharkawy M. Effect of CYP3A4*22, CYP3A5*3 and POR*28 genetic polymorphisms on calcineurin inhibitors dose requirements in early phase renal transplant patients. Pharmacogenet Genomics 2024; 34:43-52. [PMID: 38050720 DOI: 10.1097/fpc.0000000000000516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
OBJECTIVE This study aimed to investigate the combined effect of CYP3A5*3, CYP3A4*22, and POR*28 genetic polymorphisms on tacrolimus and cyclosporine dose requirements. METHODS One hundred thirty renal transplant patients placed on either tacrolimus or cyclosporine were recruited, where the effect of CYP3A5*3, CYP3A4*22, and POR*28 genetic polymorphisms on their dose requirements were studied at days 14, 30, and 90 post-transplantations. RESULTS The POR*28 allele frequency in the studied population was 29.61%. The tacrolimus dose-adjusted trough concentration ratio (C0/D) was significantly lower in the fast metabolizers group ( CYP3A5*1/POR*28(CT/TT ) carriers) than in the poor metabolizers group ( CYP3A5*3/*3/CYP3A4*22 carriers) throughout the study (14, 30, and 90 days) ( P = 0.001, <0.001, and 0.003, respectively). Meanwhile, there was no significant effect of this gene combination on cyclosporine C0/D. CONCLUSION Combining the CYP3A5*3, POR*28 , and CYP3A4*22 genotypes can have a significant effect on early tacrolimus dose requirements determination and adjustments. However, it does not have such influence on cyclosporine dose requirements.
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Affiliation(s)
| | - Dina A Ismail
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Misr International University
| | - Neama M Lotfy
- Department of Technology of Medical Laboratory, Faculty of Applied Health Sciences Technology, Badr University
| | - Mohamed A Mahmoud
- Department of Pharmacy Practice, Faculty of Pharmacy, Helwan University
| | - Magdy El-Sharkawy
- Department of Internal Medicine & Nephrology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Guo P, Zhang R, Zhou J, Li P, Liu Y, Shi S. Intracellular tacrolimus concentration correlates with impaired renal function through regulation of the IS-AHR-ABC transporter in peripheral blood mononuclear cells. Int Immunopharmacol 2024; 126:111233. [PMID: 37979449 DOI: 10.1016/j.intimp.2023.111233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 11/11/2023] [Accepted: 11/12/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUNDS Tacrolimus (TAC) concentration in peripheral blood mononuclear cells (PBMCs) is regarded as a better predictor of its immunosuppressive effect than the TAC concentration in whole blood. However, whether the exposure of TAC in PBMCs or WB was altered in post-transplant recipients with renal impairment remains unclear. METHODS We investigated the relationship of trough TAC concentration in WB and PBMCs with renal functions in post-transplant recipients. The pharmacokinetic profiles of TAC in PBMCs and WB in the two chronic kidney disease (CKD) rat models were examined using UPLC-MS/MS. Western blotting and reverse transcription-quantitative polymerase chain reaction (RT-qPCR) were used to analyze the expression of proteins and mRNAs related to TAC metabolism and transport, respectively. In addition, the effects of uremic toxins on human PBMCs were investigated using whole-transcriptome sequencing (RNA sequencing [RNA-seq]). RESULTS We observed a decrease in the trough TAC concentration in PBMCs in the recipients with estimated glomerular filtration rate (eGFR) < 90 mL/min, compared with those of recipients with eGFR > 90 mL/min, but there was no difference in blood based on TAC concentrations (C0Blood). In a 150-patient post-transplant cohort, no significant relationship was observed between PBMCs and WB concentrations of TAC, and the eGFR value was correlated with TAC C0PBMCs but not with TAC C0Blood. In two CKD rat models, the TAC pharmacokinetic profile in the PBMCs was significantly lower than that in the control group; however, the blood TAC pharmacokinetic profiles in the two groups were similar. Transcriptome results showed that co-incubation of human PBMCs with uremic toxins upregulated the expression of AHR, ABCB1, and ABCC2. Compared to control rats, plasma IS increased by 1.93- and 2.26-fold and the expression of AHR, P-gp, and MRP2 in PBMCs was higher in AD and 5/6 nephrectomy (NX) rats, without modifying the expression of other proteins related to TAC exposure. CONCLUSION The pharmacokinetics of TAC in PBMCs changed with a decline in renal function. Uremic toxins accumulate during renal insufficiency, which activates AHR, upregulates the expression of P-gp and MRP2, and affects their intracellular concentrations. Our findings suggest that monitoring TAC concentrations in PBMCs is more important than monitoring WB concentrations in post-transplant recipients with renal impairment.
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Affiliation(s)
- Pengpeng Guo
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Rui Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Jinping Zhou
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Peixia Li
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Yani Liu
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China.
| | - Shaojun Shi
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China.
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9
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Chen F, Yang X, Li H, Zeng X, Deng Z, Wang H, Jin Y, Qiu C, Shi Z. Improved LC-MS/MS method for the simultaneous quantification of tacrolimus and cyclosporine A in human blood and application to therapeutic drug monitoring. Biomed Chromatogr 2023; 37:e5751. [PMID: 37772369 DOI: 10.1002/bmc.5751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 08/28/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023]
Abstract
In order to facilitate therapeutic drug monitoring of tacrolimus and cyclosporine A in clinical practice, a simple, rapid, robust, sensitive and specific LC-MS/MS assay was developed and validated for the simultaneous determination of tacrolimus and cyclosporine A in human whole blood. Erythrocytes were destroyed using internal standard solution with 10% (w/v) zinc sulfate in water. The analytes were extracted from 100 μl of whole blood by protein precipitation with acetonitrile. Chromatographic separation was conducted on a Kinetex PFP column (60°C) by a gradient elution with a flow rate of 0.450 ml/min in 2.5 min. Quantitative analysis was performed using electrospray ionization and multiple reaction monitoring in positive ionization mode. The method was fully validated as per current guidelines on bioanalytical methodologies of the US Food and Drug Administration and European Medicines Agency. The method developed was applied successfully in analyzing clinical samples from patients administered tacrolimus or cyclosporine A. The sample treatment procedure was rationalized and improved to fulfill the complete target extraction. The chromatography conditions were optimized to achieve rapid and accurate quantification of both analytes. This method may be beneficial as a constructive input for the therapeutic drug monitoring of tacrolimus and cyclosporine A in obtaining individualized therapy.
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Affiliation(s)
- Feng Chen
- Department of Clinical Pharmacy, Hunan University of Medicine General Hospital, Huaihua, China
| | - Xiaoxia Yang
- Department of Endocrine Metabolism and Clinical Nutrition, Hunan University of Medicine General Hospital, Huaihua, China
| | - Huanhuan Li
- Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, China
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Xiaodan Zeng
- Department of Clinical Pharmacy, Hunan University of Medicine General Hospital, Huaihua, China
- Department of Evidence-Based Medicine and Clinical Center, Hunan University of Medicine General Hospital, Huaihua, China
| | - Ziwei Deng
- Department of Clinical Pharmacy, Hunan University of Medicine General Hospital, Huaihua, China
- Department of Evidence-Based Medicine and Clinical Center, Hunan University of Medicine General Hospital, Huaihua, China
| | - Hongqiang Wang
- Department of Clinical Pharmacy, Hunan University of Medicine General Hospital, Huaihua, China
- Department of Evidence-Based Medicine and Clinical Center, Hunan University of Medicine General Hospital, Huaihua, China
| | - Yuanxiang Jin
- Department of Clinical Pharmacy, Hunan University of Medicine General Hospital, Huaihua, China
- Department of Evidence-Based Medicine and Clinical Center, Hunan University of Medicine General Hospital, Huaihua, China
| | - Chengfeng Qiu
- Department of Clinical Pharmacy, Hunan University of Medicine General Hospital, Huaihua, China
- Department of Evidence-Based Medicine and Clinical Center, Hunan University of Medicine General Hospital, Huaihua, China
| | - Zhihua Shi
- Department of Clinical Pharmacy, Hunan University of Medicine General Hospital, Huaihua, China
- Department of Evidence-Based Medicine and Clinical Center, Hunan University of Medicine General Hospital, Huaihua, China
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Chen K, Jiang F, Zhou Q, Dong X, He T, Li Y, Luo Z, Duan W, Yang H. Latent tuberculosis infection in myasthenia gravis patients on immunosuppressive therapy: high incidence yet moderate reactivation rate. Ann Med 2023; 55:2282182. [PMID: 38375813 PMCID: PMC10812855 DOI: 10.1080/07853890.2023.2282182] [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: 07/17/2023] [Accepted: 11/03/2023] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Immunosuppressive therapies (ISTs) are mainstays for management of myasthenia gravis (MG). Meanwhile, latent tuberculosis infection (LTBI) is common in the setting of high-burden countries. However, the prevalence of LTBI among MG patients and whether receiving ISTs for MG would aggravate LTBI reactivation remain unknown. METHODS We retrospectively analyzed the frequency of LTBI via interferon-gamma release assay (IGRA) positivity among hospitalized MG patients from both rural and urban areas in a tertiary hospital, and those receiving ISTs were followed up to investigate the reactivation risk of LTBI. RESULTS A total of 300 MG patients with determinate IGRA results were enrolled, where the frequency of LTBI was 35.0%. Male (OR = 1.910, 95% CI: 1.181-3.089, p = .008) and elderly (OR = 1.044, 95% CI: 1.027-1.061, p < .001) patients were prone to LTBI. Of those with LTBI, 78 individuals on ISTs were successfully followed up for a median duration of 18.3 (8.5-24.0) months, of which 25 (32.1%) received anti-tuberculosis (TB) treatments. The rate of various degrees of adverse events was 82.1% over the course of the follow-up, but was not different between individuals with and without therapies against TB (χ2 < 0.001, p > .999). Only 1 patient eventually reported lymph node and intestinal TB, with the incidence rate of LTBI reactivation preliminarily estimated to be 0.81 per 100 person years. CONCLUSION The frequency of LTBI is high in our MG cohort, especially among those with advanced age and males. However, receiving immunosuppressives seems not to increase the risk of LTBI reactivation. LTBI screening is strongly recommended for all MG patients ready to receive ISTs, while preventive anti-TB chemotherapy should be prescribed after weighing potential benefits against the risk of side effects in those with LTBI. In-depth investigation is still entailed to further verify these findings due to the limitation of the retrospective single-center design of our study.
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Affiliation(s)
- Kangzhi Chen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Fei Jiang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Qian Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiaohua Dong
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Ting He
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhaohui Luo
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Weiwei Duan
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
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11
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Wang CB, Zhang YJ, Zhao MM, Zhao L. Dosage optimization of tacrolimus based on the glucocorticoid dose and pharmacogenetics in adult patients with systemic lupus erythematosus. Int Immunopharmacol 2023; 124:110866. [PMID: 37678026 DOI: 10.1016/j.intimp.2023.110866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/25/2023] [Accepted: 08/26/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND The purpose of the study was to develop a genotype-incorporated population pharmacokinetic (PPK) model of tacrolimus (TAC) in adults with systemic lupus erythematosus (SLE) to investigate the factors influencing TAC pharmacokinetics and to develop an individualized dosing regimen based on the model. In addition, a non-genotype-incorporated model was also established to assess its predictive performance compared to the genotype-incorporated model. METHODS A total of 365 trough concentrations from 133 adult SLE patients treated with TAC were collected to develop a genotype-incorporated PPK model and a non-genotype-incorporated PPK model of TAC using a nonlinear mixed-effects model (NONMEM). External validation of the two models was performed using data from an additional 29 patients. Goodness-of-fit diagnostic plots, bootstrap method, and normalized predictive distribution error test were used to validate the predictive performance and stability of the final models. The goodness-of-fit of the two final models was compared using the Akaike information criterion (AIC). The dosing regimen was optimized using Monte Carlo simulations based on the developed optimal model. RESULTS The typical value of the apparent clearance (CL/F) of TAC estimated in the final genotype-incorporated model was 14.3 L h-1 with inter-individual variability of 27.6%. CYP3A5 polymorphism and coadministered medication were significant factors affecting TAC-CL/F. CYP3A5 rs776746 GG genotype carriers had only 77.3% of the TAC-CL/F of AA or AG genotype carriers. Omeprazole reduced TAC-CL/F by 3.7 L h-1 when combined with TAC, while TAC-CL/F increased nonlinearly as glucocorticoid dose increased. Similar findings were demonstrated in the non-genotype-incorporated PPK model. Comparing these two models, the genotype-incorporated PPK model was superior to the non-genotype-incorporated PPK model (AIC = 643.19 vs. 657.425). Monte Carlo simulation based on the genotype-incorporated PPK model indicated that CYP3A5 rs776746 AA or AG genotype carriers required a 1/2-1 fold higher dose of TAC than GG genotype carriers to achieve the target concentration. And as the daily dose of prednisone increases, the dose of TAC required to reach the target concentration increases appropriately. CONCLUSIONS We developed the first pharmacogenetic-based PPK model of TAC in adult patients with SLE and proposed a dosing regimen based on glucocorticoid dose and CYP3A5 genotype according to the model, which could facilitate individualized dosing for TAC.
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Affiliation(s)
- Cheng-Bin Wang
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yu-Jia Zhang
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Ming-Ming Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China.
| | - Limei Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China.
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Henkel L, Jehn U, Thölking G, Reuter S. Tacrolimus-why pharmacokinetics matter in the clinic. FRONTIERS IN TRANSPLANTATION 2023; 2:1160752. [PMID: 38993881 PMCID: PMC11235362 DOI: 10.3389/frtra.2023.1160752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/07/2023] [Indexed: 07/13/2024]
Abstract
The calcineurin inhibitor (CNI) Tacrolimus (Tac) is the most prescribed immunosuppressant drug after solid organ transplantation. After renal transplantation (RTx) approximately 95% of recipients are discharged with a Tac-based immunosuppressive regime. Despite the high immunosuppressive efficacy, its adverse effects, narrow therapeutic window and high intra- and interpatient variability (IPV) in pharmacokinetics require therapeutic drug monitoring (TDM), which makes treatment with Tac a major challenge for physicians. The C/D ratio (full blood trough level normalized by daily dose) is able to classify patients receiving Tac into two major metabolism groups, which were significantly associated with the clinical outcomes of patients after renal or liver transplantation. Therefore, the C/D ratio is a simple but effective tool to identify patients at risk of an unfavorable outcome. This review highlights the challenges of Tac-based immunosuppressive therapy faced by transplant physicians in their daily routine, the underlying causes and pharmacokinetics (including genetics, interactions, and differences between available Tac formulations), and the latest data on potential solutions to optimize treatment of high-risk patients.
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Affiliation(s)
- Lino Henkel
- Department of Medicine D, University of Münster, Münster, Germany
| | - Ulrich Jehn
- Department of Medicine D, University of Münster, Münster, Germany
| | - Gerold Thölking
- Department of Medicine D, University of Münster, Münster, Germany
- Department of Internal Medicine and Nephrology, University Hospital of Münster Marienhospital Steinfurt, Steinfurt, Germany
| | - Stefan Reuter
- Department of Medicine D, University of Münster, Münster, Germany
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Rower JE, McKnite A, Hong B, Daly KP, Hope KD, Cabrera AG, Molina KM. External assessment and refinement of a population pharmacokinetic model to guide tacrolimus dosing in pediatric heart transplant. Pharmacotherapy 2023; 43:650-658. [PMID: 37328271 PMCID: PMC10527671 DOI: 10.1002/phar.2836] [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: 11/02/2022] [Revised: 05/03/2023] [Accepted: 05/03/2023] [Indexed: 06/18/2023]
Abstract
STUDY OBJECTIVE The immunosuppressant tacrolimus is a first-line agent to prevent graft rejection following pediatric heart transplant; however, it suffers from extensive inter-patient variability and a narrow therapeutic window. Personalized tacrolimus dosing may improve transplant outcomes by more efficiently achieving and maintaining therapeutic tacrolimus concentrations. We sought to externally validate a previously published population pharmacokinetic (PK) model that was constructed with data from a single site. DATA SOURCE Data were collected from Seattle, Texas, and Boston Children's Hospitals, and assessed using standard population PK modeling techniques in NONMEMv7.2. MAIN RESULTS While the model was not successfully validated for use with external data, further covariate searching identified weight (p < 0.0001 on both volume and elimination rate) as a model-significant covariate. This refined model acceptably predicted future tacrolimus concentrations when guided by as few as three concentrations (median prediction error = 7%; median absolute prediction error = 27%). CONCLUSION These findings support the potential clinical utility of a population PK model to provide personalized tacrolimus dosing guidance.
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Affiliation(s)
- Joseph E. Rower
- Department of Pharmacology and Toxicology, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
- Center for Human Toxicology, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
| | - Autumn McKnite
- Department of Pharmacology and Toxicology, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
| | - Borah Hong
- Division of Pediatric Cardiology, University of Washington and Seattle Children’s Hospital, Seattle, Washington, USA
| | - Kevin P. Daly
- Department of Pediatric Cardiology, Harvard Medical School/Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Kyle D. Hope
- Lillie Frank Abercrombie Division of Pediatric Cardiology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Antonio G. Cabrera
- Lillie Frank Abercrombie Division of Pediatric Cardiology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Cardiology, University of Utah/Intermountain Primary Children’s Hospital, Salt Lake City, Utah, USA
| | - Kimberly M. Molina
- Division of Pediatric Cardiology, University of Utah/Intermountain Primary Children’s Hospital, Salt Lake City, Utah, USA
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Modi S, Kahwash R, Kissling K. Case Report: tacrolimus toxicity in the setting of concurrent Paxlovid use in a heart-transplant recipient. Eur Heart J Case Rep 2023; 7:ytad193. [PMID: 37252201 PMCID: PMC10220502 DOI: 10.1093/ehjcr/ytad193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 09/07/2022] [Accepted: 04/13/2023] [Indexed: 05/31/2023]
Abstract
Background Tacrolimus toxicity in patient's status post-orthotropic heart transplantation is not commonly reported. Given its narrow therapeutic window and drug-drug interactions, it must be closely monitored by providers who are experienced in transplant management. There are no case series of patients with tacrolimus toxicity in the setting of treatment for Sars-2-CoV-19 (COVID 19) for heart-transplant recipients. We present a case of tacrolimus toxicity in the setting of concurrent ritonavir-nirmatrelvir (Paxlovid) use. Case summary The patient was a 74-year-old male with a prior significant history of heart transplantation and on maintenance immunosuppression with tacrolimus. He contracted COVID-19 and was prescribed antiviral therapy with Paxlovid by an outside provider prior to admission. The patient complained of severe headaches, dehydration, and tremors. After eliminating acute intracranial processes with imaging, laboratory investigation revealed a severely elevated tacrolimus level with acute renal injury. The patient was taken off tacrolimus and treated conservatively with intravenous hydration. The symptoms improved, particularly the headaches. He was discharged with instructions to resume his home dosing of tacrolimus and return to clinic in 1 week with a repeat trough level. The subsequent trough level was no longer supra-therapeutic. Discussion Tacrolimus has a potent drug-drug interaction with Paxlovid (ritonavir-nirmatrelvir) and can be supra-therapeutic. Toxicity is associated with multiple adverse effects, including but not limited to, acute renal injury, neurotoxicity, and infections due to over-immunosuppression. As Paxlovid is effective in treating Sars-2-CoV-19 in heart-transplant recipients, knowledge and understanding of drug-drug interactions is crucial in preventing and mitigating toxicity.
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Affiliation(s)
| | - Rami Kahwash
- Cardiovascular Medicine, The Ross Heart Hospital at The Ohio State University Wexner Medical Center, 473 W. 12th Avenue, Columbus, OH 43210, USA
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Maruyama Y, Maejima Y, Hirabayashi K, Morokawa H, Okura E, Saito S, Nakazawa Y. Factors Affecting Day-to-Day Variations in Tacrolimus Concentration among Children and Young Adults Undergoing Allogeneic Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2023; 29:270.e1-270.e8. [PMID: 36682473 DOI: 10.1016/j.jtct.2023.01.014] [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: 09/06/2022] [Revised: 12/16/2022] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Abstract
Tacrolimus is widely used as prophylaxis for graft-versus-host disease (GVHD) in allogeneic stem cell transplantation (allo-HSCT). It has a narrow therapeutic index range; high tacrolimus concentrations are associated with toxicity, whereas low concentrations are associated with an increased risk of GVHD. Although dose adjustments based on therapeutic drug monitoring are performed, unexpected large variations in tacrolimus concentration are sometimes encountered. The available evidence suggests that the factors affecting tacrolimus concentration are not fully understood. This study was aimed primarily at investigating the factors affecting day-to-day variations in tacrolimus concentration in children and young adults who received continuous tacrolimus infusion after allo-HSCT. The secondary objective was to identify the factors causing large variations (>20%) in tacrolimus concentrations. This retrospective cohort study comprised 123 consecutive pediatric and young adult patients (age <25 years) who received continuous i.v. tacrolimus infusion after allo-HSCT at Shinshu University Hospital, Matsumoto, Japan, between January 2009 and December 2021. To compare day-to-day variations in tacrolimus concentration without consideration of the tacrolimus dose, 2 consecutive days when the tacrolimus dose was not changed were selected from between the first post-allo-HSCT day of a tacrolimus concentration >7 ng/mL and day 28 post-allo-HSCT. Subsequently, information for the subsequent 24 hours was collected along with the tacrolimus concentrations and hematocrit values. Tacrolimus concentration was determined using whole blood samples. Tacrolimus concentrations were significantly higher in patients who received red blood cell concentrate (RCC) transfusions (P < .0001) and methotrexate (P = .0162), patients with persistent fever (P = .0056), and patients with a decline in fever (P = .0003). In contrast, tacrolimus concentrations were significantly lower in patients who received platelet concentrate (PC) transfusions (P < .0001), who redeveloped fever (P = .0261), and who had a replaced tacrolimus administration route set (P = .0008). Variations in tacrolimus concentration were significantly correlated with variations in hematocrit (r = .556; P < .0001). Body weight (P < .0001), RCC transfusion (P < .0001), methotrexate use (P = .0333), persistent fever (P = .0150), and decline in fever (P = .0073) were associated with a sharp increase in tacrolimus concentration. In contrast, body weight (P < .0001), PC transfusion (P = .0025), and replacement of the tacrolimus administration route set (P = .0025) were associated with a sharp decrease in tacrolimus concentration. RCC and PC transfusions, fever, methotrexate administration, and replacement of the tacrolimus administration route set were independent factors affecting day-to-day variations in tacrolimus concentration. In addition to these factors, low body weight was a risk factor for both sharp increases and decreases in tacrolimus concentration. These findings suggest the need for better control of tacrolimus concentration using whole blood samples.
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Affiliation(s)
- Yuta Maruyama
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuya Maejima
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Koichi Hirabayashi
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan.
| | - Hirokazu Morokawa
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Eri Okura
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shoji Saito
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yozo Nakazawa
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
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Song X, Liu F, Gao H, Yan M, Zhang F, Zhao J, Qin Y, Li Y, Zhang Y. Compare the performance of multiple machine learning models in predicting tacrolimus concentration for infant patients with living donor liver transplantation. Pediatr Transplant 2023; 27:e14379. [PMID: 36039686 DOI: 10.1111/petr.14379] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/20/2022] [Accepted: 08/02/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND This study aims to establish multiple ML models and compare their performance in predicting tacrolimus concentration for infant patients who received LDLT within 3 months after transplantation. METHODS Retrospectively collected basic information and relevant biochemical indicators of included infant patients. CMIA was used to determine tacrolimus C0 . PCR was used to determine the donors' and recipients' CYP3A5 genotypes. Multivariate stepwise regression analysis and stepwise elimination covariates were used for covariates selection. Thirteen machine learning algorithms were applied for the development of prediction models. APE, the ratio of the APE ≤3 ng ml-1 and ideal rate (the proportion of the predicted value with a relative error of 30% or less) were used to evaluate the predictive performance of the model. RESULTS A total of 163 infant patients were included in this study. In the case of the optimal combination of covariates, the Ridge model had the lowest APE, 2.01 (0.85, 3.35 ng ml-1 ). The highest ratio of the APE ≤3 ng ml-1 was the LAR model (71.77%). And the Ridge model showed the highest ideal rate (55.05%). For the Ridge model, GRWR was the most important predictor. CONCLUSIONS Compared with other ML models, the Ridge model had good predictive performance and potential clinical application.
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Affiliation(s)
- XueWu Song
- First Central Clinical College of Tianjin Medical University, Tianjin, China
| | - FangHao Liu
- College of Computer Science, Tianjin Key Laboratory of Network and Data Security Technology, Nankai University, Tianjin, China
| | - HuiEr Gao
- Department of Pharmacy, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - MeiLing Yan
- Department of Pharmacy, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - FeiYu Zhang
- First Central Clinical College of Tianjin Medical University, Tianjin, China
| | - Jia Zhao
- First Central Clinical College of Tianjin Medical University, Tianjin, China
| | - YinPeng Qin
- Department of Pharmacy, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - Yue Li
- College of Computer Science, KLMDASR, Key Laboratory for Medical Data Analysis and Statistical Research, Nankai University, Tianjin, China
| | - Yi Zhang
- Department of Pharmacy, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
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Zhang F, Wu X, Wu K, Yu M, Liu B, Wang H. Predicting the Pharmacokinetics of Orally Administered Drugs across BCS Classes 1-4 by Virtual Bioequivalence Model. Mol Pharm 2023; 20:395-408. [PMID: 36469444 DOI: 10.1021/acs.molpharmaceut.2c00688] [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: 12/12/2022]
Abstract
To evaluate the influence of solubility and permeability on the pharmacokinetic prediction performance of orally administered drugs using avirtual bioequivalence (VBE) model, a total of 23 orally administered drugs covering Biopharmaceutics Classification System (BCS) classes 1-4 were selected. A VBE model (i.e., a physiologically based pharmacokinetic model integrated with dissolution data) based on a B2O simulator was applied for pharmacokinetic (PK) prediction in a virtual population. Parameter sensitivity analysis was used for input parameter selection. The predictive performances of PK parameters (i.e., AUC0-t, Cmax, and Tmax), PK profiles, and bioequivalence (BE) results were evaluated using the twofold error, average fold error (AFE), absolute average fold error (AAFE), and BE reassessment metrics. All models successfully simulated the mean PK profiles, with AAFE < 2 and AFE ranging from 0.58 to 1.66. As for the PK parameters, except for the time of peak concentration, Tmax, of isosorbide mononitrate, other simulated PK parameters were all within a twofold error. The simulated PK behaviors were comparable to the observed ones, both for test (T) and reference (R) products, and the simulated T/R arithmetic mean ratios were all within 0.88-1.16 of the observed values. These four evaluation metrics were distributed equally among BCS class 1-4 drugs. The VBE model showed powerful performance to predict the PK behavior of orally administered drugs with various combinations of solubility and permeability, irrespective of the BCS category.
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Affiliation(s)
- Fan Zhang
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, State Key Laboratory of Complex Severe and Rare Diseases, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, Beijing Key Laboratory of Clinical PK & PD Investigation for Innovative Drugs, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100730, China
| | - Xiaofei Wu
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, State Key Laboratory of Complex Severe and Rare Diseases, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, Beijing Key Laboratory of Clinical PK & PD Investigation for Innovative Drugs, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100730, China
| | - Keheng Wu
- Yinghan Pharmaceutical Technology (Shanghai) Co., Ltd, Shanghai201100, China
| | - Mengyang Yu
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, State Key Laboratory of Complex Severe and Rare Diseases, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, Beijing Key Laboratory of Clinical PK & PD Investigation for Innovative Drugs, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100730, China
| | - Bo Liu
- Wuhan Institute of Technology, Wuhan, Hubei430205, China
| | - Hongyun Wang
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, State Key Laboratory of Complex Severe and Rare Diseases, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, Beijing Key Laboratory of Clinical PK & PD Investigation for Innovative Drugs, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100730, China
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Téllez Arévalo AM, Quaye A, Rojas-Rodríguez LC, Poole BD, Baracaldo-Santamaría D, Tellez Freitas CM. Synthetic Pharmacotherapy for Systemic Lupus Erythematosus: Potential Mechanisms of Action, Efficacy, and Safety. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:56. [PMID: 36676680 PMCID: PMC9866503 DOI: 10.3390/medicina59010056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022]
Abstract
The pharmacological treatment of systemic lupus erythematosus (SLE) aims to decrease disease activity, progression, systemic compromise, and mortality. Among the pharmacological alternatives, there are chemically synthesized drugs whose efficacy has been evaluated, but which have the potential to generate adverse events that may compromise adherence and response to treatment. Therapy selection and monitoring will depend on patient characteristics and the safety profile of each drug. The aim of this review is to provide a comprehensive understanding of the most important synthetic drugs used in the treatment of SLE, including the current treatment options (mycophenolate mofetil, azathioprine, and cyclophosphamide), review their mechanism of action, efficacy, safety, and, most importantly, provide monitoring parameters that should be considered while the patient is receiving the pharmacotherapy.
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Affiliation(s)
- Angélica María Téllez Arévalo
- Department of Physiological Sciences, School of Medicine, Pontificia Universidad Javeriana, Carrera 7 No. 40–62, Bogotá 110231, Colombia
| | - Abraham Quaye
- Department of Microbiology and Molecular Biology, Brigham Young University, Provo, UT 84602, USA
| | - Luis Carlos Rojas-Rodríguez
- Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
| | - Brian D. Poole
- Department of Microbiology and Molecular Biology, Brigham Young University, Provo, UT 84602, USA
| | - Daniela Baracaldo-Santamaría
- Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
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Cai XJ, Li RD, Li JH, Tao YF, Zhang QB, Shen CH, Zhang XF, Wang ZX, Jiao Z. Prospective population pharmacokinetic study of tacrolimus in adult recipients early after liver transplantation: A comparison of Michaelis-Menten and theory-based pharmacokinetic models. Front Pharmacol 2022; 13:1031969. [DOI: 10.3389/fphar.2022.1031969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022] Open
Abstract
Background and Objective: Tacrolimus, a calcineurin inhibitor widely used as a potent immunosuppressant to prevent graft rejection, exhibits nonlinear kinetics in patients with kidney transplantation and nephrotic syndrome. However, whether nonlinear drug metabolism occurs in adult patients undergoing liver transplantation remains unclear, as do the main underlying mechanisms. Therefore, here we aimed to further confirm the characteristics of nonlinearity through a large sample size, and determine the potential influence of nonlinearity and its possible mechanisms.Methods: In total, 906 trough concentrations from 176 adult patients (150 men/26 women; average age: 50.68 ± 9.71 years, average weight: 64.54 ± 11.85 kg after first liver transplantation) were included in this study. Population pharmacokinetic analysis was performed using NONMEM®. Two modeling strategies, theory-based linear compartmental and nonlinear Michaelis–Menten (MM) models, were evaluated and compared. Potential covariates were screened using a stepwise approach. Bootstrap, prediction-, and simulation-based diagnostics (prediction-corrected visual predictive checks) were performed to determine model stability and predictive performance. Finally, Monte Carlo simulations based on the superior model were conducted to design dosing regimens.Results: Postoperative days (POD), Aspartate aminotransferase (AST), daily tacrolimus dose, triazole antifungal agent (TAF) co-therapy, and recipient CYP3A5*3 genotype constituted the main factors in the theory-based compartmental final model, whereas POD, Total serum bilirubin (TBIL), Haematocrit (HCT), TAF co-therapy, and recipient CYP3A5*3 genotype were important in the nonlinear MM model. The theory-based final model exhibited 234 L h−1 apparent plasma clearance and 11,000 L plasma distribution volume. The maximum dose rate (Vmax) of the nonlinear MM model was 6.62 mg day−1; the average concentration at steady state at half-Vmax (Km) was 6.46 ng ml−1. The nonlinear MM final model was superior to the theory-based final model and used to propose dosing regimens based on simulations.Conclusion: Our findings demonstrate that saturated tacrolimus concentration-dependent binding to erythrocytes and the influence of daily tacrolimus dose on metabolism may partly contribute to nonlinearity. Further investigation is needed is need to explore the causes of nonlinear pharmacokinetic of tacrolimus. The nonlinear MM model can provide reliable support for tacrolimus dosing optimization and adjustment in adult patients undergoing liver transplantation.
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Miedziaszczyk M, Bajon A, Jakielska E, Primke M, Sikora J, Skowrońska D, Idasiak-Piechocka I. Controversial Interactions of Tacrolimus with Dietary Supplements, Herbs and Food. Pharmaceutics 2022; 14:pharmaceutics14102154. [PMID: 36297591 PMCID: PMC9611668 DOI: 10.3390/pharmaceutics14102154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/04/2022] [Accepted: 10/07/2022] [Indexed: 12/05/2022] Open
Abstract
Tacrolimus is an immunosuppressive calcineurin inhibitor used to prevent rejection in allogeneic organ transplant recipients, such as kidney, liver, heart or lung. It is metabolized in the liver, involving the cytochrome P450 (CYP3A4) isoform CYP3A4, and is characterized by a narrow therapeutic window, dose-dependent toxicity and high inter-individual and intra-individual variability. In view of the abovementioned facts, the aim of the study is to present selected interactions between tacrolimus and the commonly used dietary supplements, herbs and food. The review was based on the available scientific literature found in the PubMed, Scopus and Cochrane databases. An increase in the serum concentration of tacrolimus can be caused by CYP3A4 inhibitors, such as grapefruit, pomelo, clementine, pomegranate, ginger and turmeric, revealing the side effects of this drug, particularly nephrotoxicity. In contrast, CYP3A4 inducers, such as St. John’s Wort, may result in a lack of therapeutic effect by reducing the drug concentration. Additionally, the use of Panax ginseng, green tea, Schisandra sphenanthera and melatonin in patients receiving tacrolimus is highly controversial. Therefore, since alternative medicine constitutes an attractive treatment option for patients, modern healthcare should emphasize the potential interactions between herbal medicines and synthetic drugs. In fact, each drug or herbal supplement should be reported by the patient to the physician (concordance) if it is taken in the course of immunosuppressive therapy, since it may affect the pharmacokinetic and pharmacodynamic parameters of other preparations.
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Affiliation(s)
- Miłosz Miedziaszczyk
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, 60-355 Poznan, Poland
- Correspondence:
| | - Aleksander Bajon
- Student’s Scientific Section of Nephrology and Clinical Transplantology, 61-701 Poznan, Poland
| | - Ewelina Jakielska
- Student’s Scientific Section of Nephrology and Clinical Transplantology, 61-701 Poznan, Poland
| | - Marta Primke
- Student’s Scientific Section of Nephrology and Clinical Transplantology, 61-701 Poznan, Poland
| | - Jędrzej Sikora
- Student’s Scientific Section of Nephrology and Clinical Transplantology, 61-701 Poznan, Poland
| | - Dagmara Skowrońska
- Student’s Scientific Section of Nephrology and Clinical Transplantology, 61-701 Poznan, Poland
| | - Ilona Idasiak-Piechocka
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, 60-355 Poznan, Poland
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21
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Effects of NR1I2 and ABCB1 Genetic Polymorphisms on Everolimus Pharmacokinetics in Japanese Renal Transplant Patients. Int J Mol Sci 2022; 23:ijms231911742. [PMID: 36233042 PMCID: PMC9570057 DOI: 10.3390/ijms231911742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/19/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
The purpose of this study was to evaluate the effects of NR1I2 (7635G>A and 8055C>T) and ABCB1 (1236C>T, 2677G>T/A, and 3435C>T) genetic polymorphisms on everolimus pharmacokinetics in 98 Japanese renal transplant patients. On day 15 after everolimus administration, blood samples were collected just prior to and 1, 2, 3, 4, 6, 9, and 12 h after administration. The dose-adjusted area under the blood concentration−time curve (AUC0-12) of everolimus was significantly lower in patients with the NR1I2 8055C/C genotype than in those with other genotypes (p = 0.022) and was significantly higher in male patients than female patients (p = 0.045). Significant correlations between the dose-adjusted AUC0-12 of everolimus and age (p = 0.001), aspartate transaminase (p = 0.001), and alanine transaminase (p = 0.005) were found. In multivariate analysis, aging (p = 0.008) and higher alanine transaminase levels (p = 0.032) were independently predictive of a higher dose-adjusted everolimus AUC0-12. Aging and hepatic dysfunction in patients may need to be considered when evaluating dose reductions in everolimus. In renal transplant patients, management using everolimus blood concentrations after administration may be more important than analysis of NR1I2 8055C>T polymorphism before administration.
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22
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Liao M, Wang M, Zhu X, Zhao L, Zhao M. Tacrolimus Population Pharmacokinetic Model in Adult Chinese Patients with Nephrotic Syndrome and Dosing Regimen Identification Using Monte Carlo Simulations. Ther Drug Monit 2022; 44:615-624. [PMID: 36101928 DOI: 10.1097/ftd.0000000000001008] [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: 12/23/2021] [Accepted: 03/13/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The study aimed to establish a population pharmacokinetic (PPK) model of tacrolimus for Chinese patients with nephrotic syndrome using the patient's genotype and Wuzhi capsule dosage as the main test factors. METHODS Ninety-six adult patients with nephrotic syndrome, who were receiving tacrolimus treatment, were enrolled. A nonlinear mixed-effects model was used to determine the influencing factors of interindividual tacrolimus metabolism variation and establish a PPK model. To optimize the tacrolimus dosage, 10,000 Monte Carlo simulations were performed. RESULTS The 1-chamber model of first-order absorption and elimination was the most suitable model for the data in this study. The typical population tacrolimus clearance (CL/F) value was 16.9 L/h. The percent relative standard error (RSE%) of CL/F was 12%. Increased Wuzhi capsule and albumin doses both decreased the tacrolimus CL/F. In CYP3A5 homozygous mutation carriers, the CL/F was 39% lower than that of carriers of the wild-type and heterozygous mutation. The tacrolimus CL/F in patients who were coadministered glucocorticoids was 1.23-fold higher than that of the control. According to the patient genotype and combined use of glucocorticoids, 26 combinations of Wuzhi capsule and tacrolimus doses were matched. The Monte Carlo simulation identified the most suitable combination scheme. CONCLUSIONS An improved tacrolimus PPK model for patients with nephrotic syndrome was established, and the most suitable combination of Wuzhi capsule and tacrolimus doses was identified, thus, facilitating the selection of a more economical and safe administration regimen.
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Affiliation(s)
- Minghao Liao
- Department of Pharmacy, Shengjing Hospital of China Medical University ; and
- School of Life Science and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Minglu Wang
- Department of Pharmacy, Shengjing Hospital of China Medical University ; and
| | - Xu Zhu
- Department of Pharmacy, Shengjing Hospital of China Medical University ; and
| | - Limei Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University ; and
- School of Life Science and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Mingming Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University ; and
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23
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Liu L, Huang X, Zhou Y, Han Y, Zhang J, Zeng F, Huang Y, Zhou H, Zhang Y. CYP3A4/5 genotypes and age codetermine tacrolimus concentration and dosage in pediatric heart transplant recipients. Int Immunopharmacol 2022; 111:109164. [PMID: 35998509 DOI: 10.1016/j.intimp.2022.109164] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/04/2022] [Accepted: 08/11/2022] [Indexed: 11/05/2022]
Abstract
Tacrolimus (TAC) is the cornerstone of immunosuppressive therapy for pediatric heart transplantation (HTx) recipients. However, little information is known on the interaction of developmental and genetic variants on TAC disposition in this population, which makes TAC dose optimization more difficult. The aim of study was to investigate the relationship between genotypes and age on TAC concentrations and dosage during the early post-operation period in pediatric HTx recipients. Sixty-six pediatric HTx recipients were enrolled and divided into three groups according to the age (<6, ≥6-≤12, 12-18 years old). CYP3A4/5, POR and ABCB1 polymorphisms were genotyped. The associations between genotypes and age on TAC dose-adjusted trough concentrations (C0/D), dose requirement as well as acute kidney injury (AKI) were evaluated. CYP3A5*3 and CYP3A4*1G were significantly correlated with TAC C0/D and dose requirement in the pediatric recipients ≥ 6 years. The C0/D in children aged ≥ 6-≤12 years and 12-18 years is 2.8 and 4.2 fold of these < 6 years old, respectively. TAC dose requirements in children aged < 6 years were 2.4 times and 3.5 times of these aged ≥ 6-≤12 years and 12-18 years, respectively. Among the same CYP3A5*3 or CYP3A4*1G genotypes, age was positively increased with TAC C0/D and negatively correlated with targeted dose. No genetic variants were found to be associated with AKI during the early post-operation period. CYP3A4/5 genotypes and age should be taken into consideration to TAC dosage in pediatric HTx recipients.
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Affiliation(s)
- Li Liu
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Xiao Huang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Ying Zhou
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Yong Han
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Jing Zhang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Fang Zeng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Yifei Huang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Hong Zhou
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Yu Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
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24
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Cohen EA, DeVietro LM, Richardson BA, Odinet JS, Toledo AH, Marin EP, Szempruch KR. Evaluating Potentially Inappropriate Medications in Older Kidney Transplant Recipients. J Patient Saf 2022; 18:457-461. [PMID: 35948295 DOI: 10.1097/pts.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Beers Criteria and the Screening Tool of Older Persons' Prescriptions (STOPP) Criteria/Screening Tool to Alert to Right Treatment Criteria are used to assess potentially inappropriate prescribing and medications, which could pose a harm to those of older age. The purpose of this study was to assess and compare the use of Beers and STOPP Criteria in older kidney transplant recipients. METHODS This was a dual-center, retrospective chart review from May 1, 2014, to March 1, 2018, including kidney transplant recipients 65 years and older. Those who underwent a dual transplant or had incomplete medical records were excluded. Outcomes included number of potentially inappropriate medications (PIMs) comparing Beers and STOPP Criteria on transplant admission, number of PIMs on admission compared with discharge, and readmissions within 3 months related to these medications. RESULTS A total of 121 recipients were evaluated. On admission, 60 medications were listed on the STOPP Criteria compared with 106 medications on the Beers Criteria. When comparing PIMs on admission to discharge, there was a 38% decrease in the number of medications on discharge using the STOPP Criteria, whereas there was a 9% increase using the Beers Criteria. CONCLUSIONS Older recipients were more likely to be on a medication listed in the Beers Criteria on admission and have a new medication listed in the Beers Criteria upon discharge compared with the STOPP Criteria.
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Affiliation(s)
| | - Lena M DeVietro
- University of St Joseph School of Pharmacy, Hartford, Connecticut
| | - Brock A Richardson
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Johlee S Odinet
- Department of Pharmacy, Ochsner Medical Center, New Orleans, Louisiana
| | - Alexander H Toledo
- Department of Surgery-Abdominal Transplant, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Ethan P Marin
- Department of Medicine-Nephrology, Yale New Haven Hospital, New Haven, Connecticut
| | - Kristen R Szempruch
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina
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25
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Rose DT, Gandhi SM, Bedard RA, Mondy KE, Chu AL, Gamble KC, Gee AT, Kundra MA, Williams AL, Lee BK. Supratherapeutic tacrolimus concentrations with nirmatrelvir/ritonavir in solid organ transplant recipients requiring hospitalization: A case series using rifampin for reversal. Open Forum Infect Dis 2022; 9:ofac238. [PMID: 35854994 PMCID: PMC9277654 DOI: 10.1093/ofid/ofac238] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/11/2022] [Indexed: 11/30/2022] Open
Abstract
Nirmatrelvir/ritonavir was recently granted emergency use authorization for mild to moderate coronavirus disease 2019. Drug–drug interactions between ritonavir and tacrolimus are underappreciated by nontransplant providers. We describe 2 solid organ transplant recipients prescribed nirmatrelvir/ritonavir for outpatient use who developed tacrolimus toxicity requiring hospitalization and were managed with rifampin for toxicity reversal.
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Affiliation(s)
- Dusten T. Rose
- Ascension Seton, Dell Seton Medical Center at The University of Texas, Department of Pharmacy, Austin, TX, USA
- College of Pharmacy, University of Texas at Austin, Austin, TX, USA
| | - Saurin M. Gandhi
- Dell Medical School at the University of Texas at Austin, Department of Internal Medicine, Austin, TX, USA
| | - Rachael A. Bedard
- Ascension Seton, Dell Seton Medical Center at The University of Texas, Department of Pharmacy, Austin, TX, USA
- Dell Seton Medical Center at the University of Texas at Austin; Kidney and Pancreas Transplant Program, Austin, TX, USA
| | - Kristin E. Mondy
- Dell Medical School at the University of Texas at Austin; Division of Infectious Diseases, Department of Internal Medicine, Austin, TX, USA
| | - Alexander L. Chu
- Department of Medical Education, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
| | - Kelly C. Gamble
- Ascension Seton, Dell Seton Medical Center at The University of Texas, Department of Pharmacy, Austin, TX, USA
| | - Amanda T. Gee
- Ascension Seton, Dell Seton Medical Center at The University of Texas, Department of Pharmacy, Austin, TX, USA
| | - Monica A. Kundra
- Dell Medical School at the University of Texas at Austin, Department of Internal Medicine, Austin, TX, USA
| | - Amber L. Williams
- Ascension Seton, Dell Seton Medical Center at The University of Texas, Department of Pharmacy, Austin, TX, USA
| | - Brian K. Lee
- Dell Seton Medical Center at the University of Texas at Austin; Division of Nephrology, Department of Internal Medicine, Austin, TX, USA
- Dell Seton Medical Center at the University of Texas at Austin; Kidney and Pancreas Transplant Program, Austin, TX, USA
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26
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Løhde LW, Bentzon A, Kornblit BT, Roos P, Fink-Jensen A. Possible Tacrolimus-Related Neuropsychiatric Symptoms: One Year After Allogeneic Hematopoietic Cell Transplantation: A Case Report. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2022; 15:11795476221087053. [PMID: 35342316 PMCID: PMC8941686 DOI: 10.1177/11795476221087053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 02/21/2022] [Indexed: 11/17/2022]
Abstract
Tacrolimus is a calcineurin inhibitor (CNI), an immunosuppressive agent used to
prevent graft versus host disease following allogeneic hematopoietic cell
transplantation (HCT). Side-effects of tacrolimus treatment include
neuropsychiatric symptoms, for example, affective disturbances, psychosis, and
akinetic mutism. The onset of side-effects is independent of tacrolimus blood
concentration and can occur years after treatment initiation. To our knowledge,
case-reports describing tacrolimus-induced neuropsychiatric symptoms following
HCT are sparse. This article reports the case of a 60-year-old woman with T-cell
prolymphocytic leukemia, who developed memory loss, affective disturbances, and
delusions, 1-year after HCT, and tacrolimus treatmentinitiation. Upon hospital
admission, she was motionless and mute, albeit easily roused. The routine
physical examination was without pathological findings. Blood work and
microbiological analyses of blood and cerebrospinal fluid were normal. The
neuroimaging showed chronic structural changes without relation to the debut of
neuropsychiatric symptoms. Tacrolimus was discontinued on suspicion of
tacrolimus-induced neuropsychiatric symptoms. The patient recovered within
48 hours of discontinuation. She was switch to prednisone treatment, and there
has been no reemergence of neuropsychiatric symptoms since.
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Affiliation(s)
| | | | | | - Peter Roos
- Department of Neurology and Neuroscience, Rigshospitalet, Denmark
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27
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An Integrated Clinical and Genetic Prediction Model for Tacrolimus Levels in Pediatric Solid Organ Transplant Recipients. Transplantation 2022; 106:597-606. [PMID: 33755393 PMCID: PMC8862776 DOI: 10.1097/tp.0000000000003700] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are challenges in achieving and maintaining therapeutic tacrolimus levels after solid organ transplantation (SOT). The purpose of this genome-wide association study was to generate an integrated clinical and genetic prediction model for tacrolimus levels in pediatric SOT. METHODS In a multicenter prospective observational cohort study (2015-2018), children <18 years old at their first SOT receiving tacrolimus as maintenance immunosuppression were included (455 as discovery cohort; 322 as validation cohort). Genotyping was performed using a genome-wide single nucleotide polymorphism (SNP) array and analyzed for association with tacrolimus trough levels during 1-y follow-up. RESULTS Genome-wide association study adjusted for clinical factors identified 25 SNPs associated with tacrolimus levels; 8 were significant at a genome-wide level (P < 1.025 × 10-7). Nineteen SNPs were replicated in the validation cohort. After removing SNPs in strong linkage disequilibrium, 14 SNPs remained independently associated with tacrolimus levels. Both traditional and machine learning approaches selected organ type, age at transplant, rs776746, rs12333983, and rs12957142 SNPs as the top predictor variables for dose-adjusted 36- to 48-h posttacrolimus initiation (T1) levels. There was a significant interaction between age and organ type with rs776476*1 SNP (P < 0.05). The combined clinical and genetic model had lower prediction error and explained 30% of the variation in dose-adjusted T1 levels compared with 18% by the clinical and 12% by the genetic only model. CONCLUSIONS Our study highlights the importance of incorporating age, organ type, and genotype in predicting tacrolimus levels and lays the groundwork for developing an individualized age and organ-specific genotype-guided tacrolimus dosing algorithm.
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Grundman JB, Wolfsdorf JI, Marks BE. Post-Transplantation Diabetes Mellitus in Pediatric Patients. Horm Res Paediatr 2022; 93:510-518. [PMID: 33789298 DOI: 10.1159/000514988] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/22/2021] [Indexed: 11/19/2022] Open
Abstract
More than 80% of pediatric solid organ transplant (SOT) recipients now survive into young adulthood and many encounter transplant-related complications. Post-transplantation diabetes mellitus (PTDM), sometimes also referred to as post-transplant diabetes or new onset diabetes after transplant, occurs in 3-20% of pediatric SOT recipients depending upon the organ transplanted, age at transplantation, immunosuppressive regimen, family history, and time elapsed since transplant. To diagnose PTDM, hyperglycemia must persist beyond the initial hospitalization for transplantation when a patient is on stable doses of immunosuppressive medications. Though standard diagnostic criteria used by the American Diabetes Association (ADA) to diagnose diabetes are employed, clinicians need to be aware of the limitations of using these criteria in this unique patient population. Management of PTDM parallels strategies used for type 2 diabetes (T2D), while also carefully considering comorbidities and potential interactions with immunosuppressive medications in these patients. In caring for patients with PTDM, it is important to be familiar with these interactions and comorbidities in order to coordinate care with the transplant team and optimize outcomes for these patients.
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Affiliation(s)
- Jody B Grundman
- Division of Endocrinology, Children's National Hospital, Washington, District of Columbia, USA
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Brynn E Marks
- Division of Endocrinology, Children's National Hospital, Washington, District of Columbia, USA.,George Washington University School of Medicine, Washington, District of Columbia, USA
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Yang S, Le J, Peng R, Wang S, Li Y. Influence of Tacrolimus on Serum Vitamin A Levels in Patients After Renal Transplantation. Lab Med 2021; 53:296-301. [PMID: 34878545 DOI: 10.1093/labmed/lmab102] [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] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Patients after renal transplantation exhibit high levels of vitamin A, which has been previously suspected to be related with immunosuppressive medication. However, this possibility has not yet been systematically studied. MATERIALS AND METHODS Altogether, 116 patients were included and divided into 2 groups based on serum creatinine levels. The mean values of vitamin A levels between the 2 groups were compared using the Student's t-test. The Pearson's correlation coefficient was calculated to assess the association between vitamin A and tacrolimus. RESULTS Elevated vitamin A levels were found in both groups, and patients with kidney dysfunction after transplantation showed higher levels of vitamin A than patients with recovered kidney function. Most important, we could not identify any significant correlations between vitamin A level and tacrolimus for both groups. After long-term and short-term monitoring for different patients, obvious individual differences emerged. Such results generally ruled out previous suspicions regarding causality between immunosuppressive medication (tacrolimus) and vitamin A elevation after renal transplantation. CONCLUSION Patients after renal transplantation showed higher serum vitamin A levels than people with a normal medical exam, even if their graft function was restored. The cause of this abnormality did not seem to be related with tacrolimus.
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Affiliation(s)
- Shulin Yang
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan, China
| | - Juan Le
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan, China
| | - Rui Peng
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shaoting Wang
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yan Li
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan, China
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30
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Sallustio BC. Monitoring Intra-cellular Tacrolimus Concentrations in Solid Organ Transplantation: Use of Peripheral Blood Mononuclear Cells and Graft Biopsy Tissue. Front Pharmacol 2021; 12:733285. [PMID: 34764868 PMCID: PMC8576179 DOI: 10.3389/fphar.2021.733285] [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: 07/01/2021] [Accepted: 09/23/2021] [Indexed: 12/16/2022] Open
Abstract
Tacrolimus is an essential immunosuppressant for the prevention of rejection in solid organ transplantation. Its low therapeutic index and high pharmacokinetic variability necessitates therapeutic drug monitoring (TDM) to individualise dose. However, rejection and toxicity still occur in transplant recipients with blood tacrolimus trough concentrations (C0) within the target ranges. Peripheral blood mononuclear cells (PBMC) have been investigated as surrogates for tacrolimus's site of action (lymphocytes) and measuring allograft tacrolimus concentrations has also been explored for predicting rejection or nephrotoxicity. There are relatively weak correlations between blood and PBMC or graft tacrolimus concentrations. Haematocrit is the only consistent significant (albeit weak) determinant of tacrolimus distribution between blood and PBMC in both liver and renal transplant recipients. In contrast, the role of ABCB1 pharmacogenetics is contradictory. With respect to distribution into allograft tissue, studies report no, or poor, correlations between blood and graft tacrolimus concentrations. Two studies observed no effect of donor ABCB1 or CYP3A5 pharmacogenetics on the relationship between blood and renal graft tacrolimus concentrations and only one group has reported an association between donor ABCB1 polymorphisms and hepatic graft tacrolimus concentrations. Several studies describe significant correlations between in vivo PBMC tacrolimus concentrations and ex vivo T-cell activation or calcineurin activity. Older studies provide evidence of a strong predictive value of PBMC C0 and allograft tacrolimus C0 (but not blood C0) with respect to rejection in liver transplant recipients administered tacrolimus with/without a steroid. However, these results have not been independently replicated in liver or other transplants using current triple maintenance immunosuppression. Only one study has reported a possible association between renal graft tacrolimus concentrations and acute tacrolimus nephrotoxicity. Thus, well-designed and powered prospective clinical studies are still required to determine whether measuring tacrolimus PBMC or graft concentrations offers a significant benefit compared to current TDM.
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Affiliation(s)
- Benedetta C Sallustio
- Department of Clinical Pharmacology, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, SA, Australia.,Discipline of Pharmacology, School of Medicine, University of Adelaide, Adelaide, SA, Australia
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31
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Cerfon MA, Vernaudon J, Gervais F, Morelon E, Coste MH, Krolak-Salmon P, Mouchoux C, Novais T. Drug-related problems in older patients with advanced chronic kidney disease identified during pretransplant comprehensive geriatric assessment. Nephrol Ther 2021; 18:45-51. [PMID: 34756826 DOI: 10.1016/j.nephro.2021.08.006] [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: 01/06/2021] [Revised: 07/26/2021] [Accepted: 08/17/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Older patients with advanced chronic kidney disease may be exposed to a higher risk of adverse drug events due to chronic kidney disease and aging. The integration of clinical pharmacist into pretransplant comprehensive geriatric assessment is an opportunity to perform medication optimization. OBJECTIVE The aim was to describe drug-related problems in older patients with advanced chronic kidney disease. METHODS Observational study was conducted with retrospective data from July 2017 to April 2019. Patients≥65 years with advanced chronic kidney disease, referred by nephrologists for pretransplant comprehensive geriatric assessment were included. During medication optimization, the pharmacist evaluated the appropriateness of each medication prescribed and identified drug-related problems. Any drug-related problem identified lead to a pharmaceutical intervention. RESULTS In total, 103 patients were included (74.5±2.9 years, 26.2% female, 47.6% on dialysis). Overall, 394 drug-related problems were identified in 93.2% of patients (3.8±2.4 drug-related problems per patient) during the medication optimization. Cardiovascular medications (25.1%), antithrombotics (13.5%) and drugs for peptic ulcer and reflux disease (10.2%) were the most involved drugs in drug-related problems. Drug-related problems mainly concerned drugs without indication (27.1%), inappropriate method of administration (24.4%) and non-conformity to guidelines (20.1%). CONCLUSION A high prevalence of drug-related problems in older patients with advanced chronic kidney disease was identified during medication optimization. The systematic integration of a clinical pharmacist in the multidisciplinary team performing pretransplant comprehensive geriatric assessment may be relevant to detect inappropriate prescriptions and to prevent from adverse drug events.
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Affiliation(s)
- Marie-Anne Cerfon
- Pharmaceutical Unit, Charpennes Hospital, University Hospital of Lyon, 69100 Villeurbanne, France
| | - Julien Vernaudon
- Day-care unit, Charpennes Hospital, University Hospital of Lyon, 69100 Villeurbanne, France
| | - Frédéric Gervais
- Pharmaceutical Unit, Charpennes Hospital, University Hospital of Lyon, 69100 Villeurbanne, France
| | - Emmanuel Morelon
- Department of transplantation, nephrology and clinical immunology, Edouard-Herriot Hospital, University Hospital of Lyon, 69003 Lyon, France; University Lyon 1, 69008 Lyon, France
| | - Marie-Hélène Coste
- Day-care unit, Charpennes Hospital, University Hospital of Lyon, 69100 Villeurbanne, France
| | - Pierre Krolak-Salmon
- Day-care unit, Charpennes Hospital, University Hospital of Lyon, 69100 Villeurbanne, France; University Lyon 1, 69008 Lyon, France; Inserm U1028, CNRS UMR5292; Lyon neuroscience research center, brain dynamics and cognition team, 69675 Bron, France
| | - Christelle Mouchoux
- Pharmaceutical Unit, Charpennes Hospital, University Hospital of Lyon, 69100 Villeurbanne, France; University Lyon 1, 69008 Lyon, France; Inserm U1028, CNRS UMR5292; Lyon neuroscience research center, brain dynamics and cognition team, 69675 Bron, France
| | - Teddy Novais
- Pharmaceutical Unit, Charpennes Hospital, University Hospital of Lyon, 69100 Villeurbanne, France; University Lyon 1, 69008 Lyon, France; Inserm U1290, Research on Healthcare Performance (RESHAPE), University Lyon 1, 69008. Lyon, France.
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32
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Park Y, Lee H, Eum SH, Kim HD, Ko EJ, Yang CW, Chung BH. Intrapatient Variability in Tacrolimus Trough Levels Over 2 Years Affects Long-Term Allograft Outcomes of Kidney Transplantation. Front Immunol 2021; 12:746013. [PMID: 34659243 PMCID: PMC8514869 DOI: 10.3389/fimmu.2021.746013] [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: 07/23/2021] [Accepted: 09/09/2021] [Indexed: 11/13/2022] Open
Abstract
This study aimed to determine the impact of tacrolimus (TAC) trough level (C0) intrapatient variability (IPV) over a period of 2 years after kidney transplantation (KT) on allograft outcomes. In total, 1,143 patients with low immunologic risk were enrolled. The time-weighted coefficient variability (TWCV) of TAC-C0 was calculated, and patients were divided into tertile groups (T1: < 24.6%, T2: 24.6%–33.7%, T3: ≥ 33.7%) according to TAC-C0-TWCV up to post-transplant 1st year. They were classified into the low/low, low/high, high/low, and high/high groups based on a TAC-C0-TWCV value of 33.7% during post-transplant 0–1st and 1st–2nd years. The allograft outcomes among the three tertile and four TAC-C0-TWCV groups were compared. The T3 group had the highest rate of death-censored allograft loss (DCGL), and T3 was considered an independent risk factor for DCGL. The low/low group had the lowest and the high/high group had the highest risk for DCGL. Moreover, patients with a mean TAC-C0 of ≥5 ng/ml in the high/high group were at the highest risk for DCGL. Thus, TAC-IPV can significantly affect allograft outcomes even with a high mean TAC-C0. Furthermore, to improve allograft outcomes, a low TAC-IPV should be maintained even after the first year of KT.
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Affiliation(s)
- Yohan Park
- Division of Nephrology, Department of Internal Medicine, Konyang University Hospital, College of Medicine, Konyang University, Daejeon, South Korea.,Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hanbi Lee
- Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sang Hun Eum
- Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hyung Duk Kim
- Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Eun Jeong Ko
- Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chul Woo Yang
- Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Byung Ha Chung
- Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Chen D, Lu H, Sui W, Li L, Xu J, Yang T, Yang S, Zheng P, Chen Y, Chen J, Xue W, Li Q, Zheng Q, Ye D, Sadee W, Wang D, Qian W, Lai L, Li C, Li L. Functional CYP3A variants affecting tacrolimus trough blood concentrations in Chinese renal transplant recipients. THE PHARMACOGENOMICS JOURNAL 2021; 21:376-389. [PMID: 33649515 DOI: 10.1038/s41397-021-00216-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 01/07/2021] [Accepted: 01/27/2021] [Indexed: 01/31/2023]
Abstract
The aim of this study was to identify novel genetic variants affecting tacrolimus trough blood concentrations. We analyzed the association between 58 single nucleotide polymorphisms (SNPs) across the CYP3A gene cluster and the log-transformed tacrolimus concentration/dose ratio (log (C0/D)) in 819 renal transplant recipients (Discovery cohort). Multivariate linear regression was used to test for associations between tacrolimus log (C0/D) and clinical factors. Luciferase reporter gene assays were used to evaluate the functions of select SNPs. Associations of putative functional SNPs with log (C0/D) were further tested in 631 renal transplant recipients (Replication cohort). Nine SNPs were significantly associated with tacrolimus log (C0/D) after adjustment for CYP3A5*3 and clinical factors. Dual luciferase reporter assays indicated that the rs4646450 G allele and rs3823812 T allele were significantly associated with increased normalized luciferase activity ratios (p < 0.01). Moreover, CYP3A7*2 was associated with higher TAC log(C0/D) in the group of CYP3A5 expressers. Age, serum creatinine and hematocrit were significantly associated with tacrolimus log (C0/D). CYP3A7*2, rs4646450, and rs3823812 are proposed as functional SNPs affecting tacrolimus trough blood concentrations in Chinese renal transplant recipients. Clinical factors also significantly affect tacrolimus metabolism.
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Affiliation(s)
- Dina Chen
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China
| | - Huijie Lu
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China
| | - Weiguo Sui
- Guangxi Key laboratory of Metabolic Diseases Research, Nephrology Department of Guilin NO. 924 Hospital, Guilin, Guangxi, China
| | - Liqing Li
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China
| | - Jian Xu
- Department of Organ Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Tengfei Yang
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China
| | - Siyao Yang
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China
| | - Ping Zheng
- Department of Pharmacy, Nanfang hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yan Chen
- Department of Pharmacy, Nanfang hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jiejing Chen
- Guangxi Key laboratory of Metabolic Diseases Research, Nephrology Department of Guilin NO. 924 Hospital, Guilin, Guangxi, China
| | - Wen Xue
- Guangxi Key laboratory of Metabolic Diseases Research, Nephrology Department of Guilin NO. 924 Hospital, Guilin, Guangxi, China
| | - Qingping Li
- Department of Hepatobiliary Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Que Zheng
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China
| | - Demei Ye
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China
| | - Wolfgang Sadee
- Center for Pharmacogenomics, Department of Cancer Biology and Genetics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Danxin Wang
- Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Wanying Qian
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China
| | - Liusheng Lai
- Guangxi Key laboratory of Metabolic Diseases Research, Nephrology Department of Guilin NO. 924 Hospital, Guilin, Guangxi, China
| | - Chuanjiang Li
- Department of Hepatobiliary Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.
| | - Liang Li
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China.
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34
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Clinical Pharmacokinetics and Impact of Hematocrit on Monitoring and Dosing of Tacrolimus Early After Heart and Lung Transplantation. Clin Pharmacokinet 2021; 59:403-408. [PMID: 31820394 PMCID: PMC7109168 DOI: 10.1007/s40262-019-00846-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The calcineurin inhibitor tacrolimus is an effective immunosuppressant and is extensively used in solid organ transplantation. In the first week after heart and lung transplantation, tacrolimus dosing is difficult due to considerable physiological changes because of clinical instability, and toxicity often occurs, even when tacrolimus concentrations are within the therapeutic range. The physiological and pharmacokinetic changes are outlined. Excessive variability in bioavailability may lead to higher interoccasion (dose-to-dose) variability than interindividual variability of pharmacokinetic parameters. Intravenous tacrolimus dosing may circumvent this high variability in bioavailability. Moreover, the interpretation of whole-blood concentrations is discussed. The unbound concentration is related to hematocrit, and changes in hematocrit may increase toxicity, even within the therapeutic range of whole-blood concentrations. Therefore, in clinically unstable patients with varying hematocrit, aiming at the lower therapeutic level is recommended and tacrolimus personalized dosing based on hematocrit-corrected whole-blood concentrations may be used to control the unbound tacrolimus plasma concentrations and subsequently reduce toxicity.
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35
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Fan Z, Zheng D, Wen X, Shen F, Lei L, Su S, Zhang S, Liu Q, Zhang X, Lu Y, Di L, Shen XM, Da Y. CYP3A5*3 polymorphism and age affect tacrolimus blood trough concentration in myasthenia gravis patients. J Neuroimmunol 2021; 355:577571. [PMID: 33866281 DOI: 10.1016/j.jneuroim.2021.577571] [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: 10/13/2020] [Revised: 04/04/2021] [Accepted: 04/05/2021] [Indexed: 12/12/2022]
Abstract
The study aims to identify clinical factors affecting tacrolimus blood trough concentration (C0) in myasthenia gravis (MG) patients and to optimize the initial dose of tacrolimus in MG treatment. A total of 103 MG patients participated in this study, and their clinical factors, medication regimens, C0 values and CYP3A5*3 polymorphisms were collected in detail. We used a linear mixed model to analyze the effect of multiple factors on the dosage-weighted C0 (C0:D) and performed subgroup analyses to investigate the consistency of correlations between influencing factors and the C0:D ratios. Among all factors, CYP3A5*3 polymorphism and age showed a strong positive correlation with C0:D ratios. The C0:D ratios (ng/ml·mg-1) were higher for CYP3A5*3/*3 than for CYP3A5*1 (mean difference: 1.038, 95% confidence interval [CI]: 0.820-1.256, P-value <0.001), and for age in the range of 45-64 and ≥ 65 years than for age < 45 years (mean difference [95% CI] and P-value: 0.531[0.257-0.805] and P-value <0.001, 0.703 [0.377-1.029] and P-value <0.001, respectively). The C0:D ratios were not related to corticosteroid dosage, body weight, sex, hematocrit or the concomitant use of calcium channel blockers. The consistencies of the correlations between C0:D ratios and CYP3A5*3 polymorphism or age were confirmed by subgroup analyses. Thus, CYP3A5*3 polymorphism and age should be considered in optimizing the initial dose of tacrolimus for MG treatment.
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Affiliation(s)
- Zhirong Fan
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Deqiang Zheng
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Xinmei Wen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Faxiu Shen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lin Lei
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shengyao Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shu Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qing Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xueping Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Lu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Li Di
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xin-Ming Shen
- Department of Neurology and Neuromuscular Research Laboratory, Mayo Clinic, Rochester, MN 55905, USA.
| | - Yuwei Da
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.
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36
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Johnston JP, Cohen EA, Casal GH, Asch WS, Reardon DP. Impact of Low-Dose Fluconazole on Tacrolimus Dosing in Renal Transplant. J Pharm Pract 2021; 35:701-706. [PMID: 33759619 DOI: 10.1177/08971900211000702] [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: 11/15/2022]
Abstract
BACKGROUND The interaction between azole antifungal therapy and immunosuppressant tacrolimus (TAC) is a barrier to use. OBJECTIVE This study quantified the drug interaction between low-dose fluconazole (LDF) and TAC to determine the appropriate TAC dose adjustment when used concurrently in renal transplant recipients. METHODS We conducted a single-center retrospective chart review of renal transplant patients >18 years who received LDF or nystatin (NYS), and TAC. The primary outcome was the difference in tacrolimus total daily dose (TAC TDD) for LDF versus NYS groups. Secondary outcomes included days with supratherapeutic, therapeutic and subtherapeutic tacrolimus levels, time to therapeutic level, incidence of adverse drug reactions and graft rejection. RESULTS We evaluated 94 patients and included 81. Low-dose fluconazole received a greater TAC TDD prior to post-operative day (POD) 10 (10.5 ± 4.7 mg vs. 7.1 ± 4.5 mg, p < 0.001), but a decreased TAC TDD POD 10 - 30 (8.6 ± 2.2 mg vs. 9.8 ± 0.8 mg, p < 0.001) and following LDF discontinuation (6.9 ± 0.1 mg vs. 9.0 ± 0.4 mg, p < 0.001). Low-dose fluconazole had more patient-days with supratherapeutic (17.9 ± 7.0 vs. 13.9 ± 8.5; p = 0.02) but fewer with subtherapeutic (6.7 ± 5.7 vs. 12.9 ± 7.2; p < 0.01) TAC levels. There was no difference in patient-days with therapeutic TAC levels (15.9 ± 5.8 vs. 14.4 ± 6.6, p = 0.28), meanwhile LDF required less patient-days to therapeutic TAC level (7.1 ± 2.7 vs. 11.5 ± 7.7; p < 0.01). There was no difference in adverse drug reactions between groups and no incidence of graft rejection. CONCLUSION A 20% reduction in TAC TDD is warranted in renal transplant patients when used concomitantly with LDF to achieve therapeutic levels.
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Affiliation(s)
- Jackie P Johnston
- Department of Pharmacy Practice and Administration, 15484Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | - Elizabeth A Cohen
- Department of Transplant Surgery, 25047Yale-New Haven Hospital, New Haven, CT, USA
| | - Gianna H Casal
- Department of Pharmacy, 25047Yale New Haven Hospital, New Haven, CT, USA
| | - William S Asch
- Yale-New Haven Transplant Center, 25047Yale-New Haven Hospital, New Haven, CT, USA
| | - David P Reardon
- Pharmacy Networks, Vizient Pharmacy Member Services, 26560Vizient Inc, Irving, TX, USA
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37
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BK Polyomavirus Nephropathy in Kidney Transplantation: Balancing Rejection and Infection. Viruses 2021; 13:v13030487. [PMID: 33809472 PMCID: PMC7998398 DOI: 10.3390/v13030487] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/12/2021] [Accepted: 03/14/2021] [Indexed: 12/16/2022] Open
Abstract
BK polyomavirus nephropathy (BKVN) and allograft rejection are two closely-associated diseases on opposite ends of the immune scale in kidney transplant recipients. The principle of balancing the immune system remains the mainstay of therapeutic strategy. While patient outcomes can be improved through screening, risk factors identification, and rapid reduction of immunosuppressants, a lack of standard curative therapy is the primary concern during clinical practice. Additionally, difficulty in pathological differential diagnosis and clinicopathology’s dissociation pose problems for a definite diagnosis. This article discusses the delicate evaluation needed to optimize immunosuppression and reviews recent advances in molecular diagnosis and immunological therapy for BKVN patients. New biomarkers for BKVN diagnosis are under development. For example, measurement of virus-specific T cell level may play a role in steering immunosuppressants. The development of cellular therapy may provide prevention, even a cure, for BKVN, a complex post-transplant complication.
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38
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Sallustio BC, Noll BD, Hu R, Barratt DT, Tuke J, Coller JK, Russ GR, Somogyi AA. Tacrolimus dose, blood concentrations and acute nephrotoxicity, but not CYP3A5/ABCB1 genetics, are associated with allograft tacrolimus concentrations in renal transplant recipients. Br J Clin Pharmacol 2021; 87:3901-3909. [PMID: 33646566 DOI: 10.1111/bcp.14806] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 02/02/2021] [Accepted: 02/17/2021] [Indexed: 12/16/2022] Open
Abstract
AIMS Long-term use of the immunosuppressant tacrolimus is limited by nephrotoxicity. Following renal transplantation, the risk of nephrotoxicity may be determined more by allograft than by blood tacrolimus concentrations, and thus may be affected by donor CYP3A5 and ABCB1 genetics. Little is known regarding factors that determine tacrolimus intrarenal exposure. METHODS This study investigated the relationship between trough blood (C0Blood ) and allograft (CGraft ) tacrolimus concentrations and tacrolimus dose, haematocrit, genetics, acute nephrotoxicity, rejection status, delayed graft function, and time post-transplant. C0Blood and CGraft were quantified in 132 renal transplant recipients together with recipient and donor CYP3A5 (rs776746) and ABCB1 3435 (rs1045642) genotypes. RESULTS C0Blood ranged from 2.6 to 52.3 ng/mL and CGraft from 33 to 828 pg/mg tissue. Adjusting for dose, recipients who were CYP3A5 expressors had lower C0Blood compared to nonexpressors, whilst delayed graft function was associated with higher C0Blood . Linear regression showed that the significant predictors of CGraft were C0Blood (point-wise P = 7 × 10-10 ), dose (P = .004) acute nephrotoxicity (P = .002) and an interaction between C0Blood and acute tacrolimus nephrotoxicity (P = .0002), with an adjusted r2 = 0.35 and no contribution from donor or recipient CYP3A5 or ABCB1 genotype. The association between CGraft and acute nephrotoxicity depended on one very high CGraft (828 pg/mg tissue). CONCLUSIONS Recipient and donor CYP3A5 and ABCB1 3435C>T genotypes are not determinants of allograft tacrolimus exposure in kidney transplant recipients. However, tacrolimus dose and C0Blood were significant predictors of CGraft , and the relationship between C0Blood and CGraft appeared to differ in the presence or absence of acute nephrotoxicity.
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Affiliation(s)
- Benedetta C Sallustio
- Department of Clinical Pharmacology, Basil Hetzel Institute, The Queen Elizabeth Hospital, Woodville South, SA, 5011, Australia.,Discipline of Pharmacology, Adelaide Medical School, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Benjamin D Noll
- School of Pharmacy and Medical Sciences, University of South Australia, Australia, Adelaide, SA, 5000, Australia
| | - Rong Hu
- Department of Pharmacy, Guangzhou Women's and Children's Medical Centre, Guangzhou Medical University, Guangzhou, China
| | - Daniel T Barratt
- Discipline of Pharmacology, Adelaide Medical School, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Jonathan Tuke
- ARC Centre for Excellence for Mathematical and Statistical Frontiers, School of Mathematical Sciences, Adelaide, SA, 5000, Australia.,School of Mathematical Sciences, Adelaide, SA, 5000, Australia
| | - Janet K Coller
- Discipline of Pharmacology, Adelaide Medical School, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Graeme R Russ
- Central Northern Adelaide Renal and Transplantation Services, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
| | - Andrew A Somogyi
- Discipline of Pharmacology, Adelaide Medical School, University of Adelaide, Adelaide, SA, 5000, Australia
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Abstract
Tacrolimus was discovered in 1984 and entered clinical use shortly thereafter, contributing to successful solid organ transplantation across the globe. In this review, we cover development of tacrolimus, its evolving clinical utility, and issues affecting its current usage. Since earliest use of this class of immunosuppressant, concerns for calcineurin-inhibitor toxicity have led to efforts to minimize or eliminate these agents in clinical regimens but with limited success. Current understanding of the role of tacrolimus focuses more on its efficacy in preventing graft rejection and graft loss. As we enter the fourth decade of tacrolimus use, newer studies utilizing novel combinations (as with the mammalian target of rapamycin inhibitor, everolimus, and T-cell costimulation blockade with belatacept) offer potential for enhanced benefits.
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Affiliation(s)
- Song C Ong
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
| | - Robert S Gaston
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
- CTI Clinical Trial and Consulting, Inc., Covington, KT
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40
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Sikma MA, Hunault CC, Van Maarseveen EM, Huitema ADR, Van de Graaf EA, Kirkels JH, Verhaar MC, Grutters JC, Kesecioglu J, De Lange DW. High Variability of Whole-Blood Tacrolimus Pharmacokinetics Early After Thoracic Organ Transplantation. Eur J Drug Metab Pharmacokinet 2020; 45:123-134. [PMID: 31745812 PMCID: PMC6994432 DOI: 10.1007/s13318-019-00591-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background and Objective Oral tacrolimus is initiated perioperatively in heart and lung transplantation patients. There have been few studies on oral tacrolimus pharmacokinetics early post-transplantation, even though tacrolimus-related toxicity may occur early, potentially leading to morbidity and mortality. Therefore, we aimed to study the pharmacokinetics of oral tacrolimus in thoracic organ recipients during the first days after transplantation. Methods We conducted a pharmacokinetic study in 30 thoracic organ transplants at intensive care at the University Medical Center Utrecht in the first week post-transplantation. Twelve-hour whole-blood tacrolimus profiles were examined using high-performance liquid chromatography tandem mass spectrometry (HPLC–MS/MS) and analysed via population pharmacokinetic modelling. Results The concentration–time profiles showed high variability. Concentrations at 12 h were outside the target range in 69% of the cases. A two-compartment model with mixed first-order and zero-order absorption adequately described tacrolimus concentrations. The typical value of the apparent clearance was 19.6 L/h (95% CI 16.2–22.9), and the apparent distribution volumes of central and peripheral compartments, V1 and V2, were 231 L (95% CI 199–267) and 521 L (95% CI 441–634), respectively. Inter-occasion (dose-to-dose) variability far exceeded the interindividual variability (IIV), with an estimated variability in relative bioavailability of 55% (95% CI 48.5–64.4). Conclusions The high variability of tacrolimus pharmacokinetics early after thoracic organ transplantation is largely due to excessive variability in bioavailability, making individualised dosing based on measured concentrations futile. To bypass this bioavailability issue, we suggest administering tacrolimus intravenously and aiming below the upper therapeutic range early post-transplantation. Clinical Trial Registraion: NTR 3912/EudraCT 2012-001909-24. Electronic supplementary material The online version of this article (10.1007/s13318-019-00591-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maaike A Sikma
- Department of Intensive Care and Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, F06.149, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Claudine C Hunault
- Dutch Poisons Information Center, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Erik M Van Maarseveen
- Department of Clinical Pharmacy, Princess Máxima Center, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands.,Department of Pharmacy and Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Ed A Van de Graaf
- Department of Lung Transplantation, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Johannes H Kirkels
- Department of Cardiology, Heart Transplantation, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Jan C Grutters
- Department of Lung Transplantation, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands.,Department of Pulmonology, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Jozef Kesecioglu
- Department of Intensive Care, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Dylan W De Lange
- Dutch Poisons Information Center and Department of Intensive Care, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
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Degraeve AL, Moudio S, Haufroid V, Chaib Eddour D, Mourad M, Bindels LB, Elens L. Predictors of tacrolimus pharmacokinetic variability: current evidences and future perspectives. Expert Opin Drug Metab Toxicol 2020; 16:769-782. [PMID: 32721175 DOI: 10.1080/17425255.2020.1803277] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION In kidney transplantation, tacrolimus (TAC) is at the cornerstone of current immunosuppressive strategies. Though because of its narrow therapeutic index, it is critical to ensure that TAC levels are maintained within this sharp window through reactive adjustments. This would allow maximizing efficiency while limiting drug-associated toxicity. However, TAC high intra- and inter-patient pharmacokinetic (PK) variability makes it more laborious to accurately predict the appropriate dosage required for a given patient. AREAS COVERED This review summarizes the state-of-the-art knowledge regarding drug interactions, demographic and pharmacogenetics factors as predictors of TAC PK. We provide a scoring index for each association to grade its relevance and we present practical recommendations, when possible for clinical practice. EXPERT OPINION The management of TAC concentration in transplanted kidney patients is as critical as it is challenging. Recommendations based on rigorous scientific evidences are lacking as knowledge of potential predictors remains limited outside of DDIs. Awareness of these limitations should pave the way for studies looking at demographic and pharmacogenetic factors as well as gut microbiota composition in order to promote tailored treatment plans. Therapeutic approaches considering patients' clinical singularities may help allowing to maintain appropriate concentration of TAC.
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Affiliation(s)
- Alexandra L Degraeve
- Integrated Pharmacometrics, Pharmacogenomics and Pharmacokinetics (PMGK), Louvain Drug Research Institute (LDRI), Université Catholique De Louvain , Brussels, Belgium.,Metabolism and Nutrition Research Group (Mnut), Louvain Drug Research Institute (LDRI), Université Catholique De Louvain , Brussels, Belgium
| | - Serge Moudio
- Integrated Pharmacometrics, Pharmacogenomics and Pharmacokinetics (PMGK), Louvain Drug Research Institute (LDRI), Université Catholique De Louvain , Brussels, Belgium.,Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut De Recherche Expérimentale Et Clinique (IREC), Université Catholique De Louvain , Brussels, Belgium
| | - Vincent Haufroid
- Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut De Recherche Expérimentale Et Clinique (IREC), Université Catholique De Louvain , Brussels, Belgium.,Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc , Brussels, Belgium
| | - Djamila Chaib Eddour
- Kidney and Pancreas Transplantation Unit, Cliniques Universitaires Saint-Luc , Brussels, Belgium
| | - Michel Mourad
- Kidney and Pancreas Transplantation Unit, Cliniques Universitaires Saint-Luc , Brussels, Belgium
| | - Laure B Bindels
- Metabolism and Nutrition Research Group (Mnut), Louvain Drug Research Institute (LDRI), Université Catholique De Louvain , Brussels, Belgium
| | - Laure Elens
- Integrated Pharmacometrics, Pharmacogenomics and Pharmacokinetics (PMGK), Louvain Drug Research Institute (LDRI), Université Catholique De Louvain , Brussels, Belgium.,Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut De Recherche Expérimentale Et Clinique (IREC), Université Catholique De Louvain , Brussels, Belgium
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Cai X, Song H, Jiao Z, Yang H, Zhu M, Wang C, Wei D, Shi L, Wu B, Chen J. Population pharmacokinetics and dosing regimen optimization of tacrolimus in Chinese lung transplant recipients. Eur J Pharm Sci 2020; 152:105448. [PMID: 32621968 DOI: 10.1016/j.ejps.2020.105448] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 06/24/2020] [Accepted: 06/30/2020] [Indexed: 01/16/2023]
Abstract
We aimed to (i) develop a population pharmacokinetic model of tacrolimus in Chinese lung transplant recipients and (ii) propose model-based dosing regimens for individualized treatment. We obtained 807 tacrolimus steady-state whole blood concentrations from 52 lung transplant patients and genotyped CYP3A5*3. Population pharmacokinetic analysis was performed using nonlinear mixed-effects modeling. Monte Carlo simulations were employed to determine the initial dosing regimens. Tacrolimus pharmacokinetics was described by a one-compartment model with first-order absorption and elimination processes. In CYP3A5*3/*3 70-kg patients with 30% hematocrit and voriconazole-free therapy, the mean estimated apparent clearance was 13.1 l h-1 with 20.1% between-subject variability, which was lower than that in Caucasian lung transplant patients (17.5-36.5 l h-1). Hematocrit, postoperative days, tacrolimus daily dose, voriconazole concomitant therapy, and CYP3A5*3 genotype were identified as significant covariates for tacrolimus clearance. To achieve target trough concentration (10-15 ng ml-1) on the 8th day post-transplant, a higher initial dosage than the current regimen of 0.04 mg kg-1 every 12 h is recommended for CYP3A5*1/*3 patients without voriconazole concomitant therapy. Given the nonlinear kinetics of tacrolimus and large variability, population pharmacokinetic model should be combined with therapeutic drug monitoring to optimize individualized therapy.
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Affiliation(s)
- Xiaojun Cai
- Department of Pharmacy, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, PR China; Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai 200040, PR China
| | - Huizhu Song
- Department of Pharmacy, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, PR China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, PR China.
| | - Hang Yang
- Lung Transplant Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, PR China
| | - Min Zhu
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, PR China; School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 211198, PR China
| | - Chengyu Wang
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, PR China
| | - Dong Wei
- Lung Transplant Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, PR China
| | - Lingzhi Shi
- Lung Transplant Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, PR China
| | - Bo Wu
- Lung Transplant Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, PR China.
| | - Jingyu Chen
- Lung Transplant Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, PR China.
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Abstract
Tacrolimus is an immunosuppressant agent utilized for solid organ transplantations. It has been associated with rare neurotoxic effects. This case highlights one possible delayed neurotoxic effect. A 52-year-old lady on tacrolimus (3mg daily) among her immunosuppressive regimen for her kidney transplant 16 year ago. She presented with unilateral left paracentral black dots progressing over a week, associated with periorbital and temporal pain. The patient was diagnosed with left papillitis. Tacrolimus was tapered and then changed to cyclosporine. However, patient did not show any improvement of any parameter. Reports have indicated such neurotoxic effects with Tacrolimus use. Here, the report emphasizes on the unilateral optic neuropathic effect of tacrolimus even after one decade.
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Affiliation(s)
- Muhannad A Alnahdi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia. E-mail:
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Tyson RJ, Park CC, Powell JR, Patterson JH, Weiner D, Watkins PB, Gonzalez D. Precision Dosing Priority Criteria: Drug, Disease, and Patient Population Variables. Front Pharmacol 2020; 11:420. [PMID: 32390828 PMCID: PMC7188913 DOI: 10.3389/fphar.2020.00420] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/19/2020] [Indexed: 12/12/2022] Open
Abstract
The administered dose of a drug modulates whether patients will experience optimal effectiveness, toxicity including death, or no effect at all. Dosing is particularly important for diseases and/or drugs where the drug can decrease severe morbidity or prolong life. Likewise, dosing is important where the drug can cause death or severe morbidity. Since we believe there are many examples where more precise dosing could benefit patients, it is worthwhile to consider how to prioritize drug-disease targets. One key consideration is the quality of information available from which more precise dosing recommendations can be constructed. When a new more precise dosing scheme is created and differs significantly from the approved label, it is important to consider the level of proof necessary to either change the label and/or change clinical practice. The cost and effort needed to provide this proof should also be considered in prioritizing drug-disease precision dosing targets. Although precision dosing is being promoted and has great promise, it is underutilized in many drugs and disease states. Therefore, we believe it is important to consider how more precise dosing is going to be delivered to high priority patients in a timely manner. If better dosing schemes do not change clinical practice resulting in better patient outcomes, then what is the use? This review paper discusses variables to consider when prioritizing precision dosing candidates while highlighting key examples of precision dosing that have been successfully used to improve patient care.
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Affiliation(s)
- Rachel J. Tyson
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Christine C. Park
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - J. Robert Powell
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - J. Herbert Patterson
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Daniel Weiner
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Paul B. Watkins
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Institute for Drug Safety Sciences, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Yin S, Song T, Li X, Xu H, Zhang X, Jiang Y, Lin T. Non-linear Relationship between Tacrolimus Blood Concentration and Acute Rejection After Kidney Transplantation: A Systematic Review and Dose-Response Meta-Analysis of Cohort Studies. Curr Pharm Des 2020; 25:2394-2403. [PMID: 31333109 DOI: 10.2174/1381612825666190717101941] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 06/28/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Maintaining the exposure of tacrolimus (Tac) after kidney transplantation (KT) must be necessary to prevent acute rejection (AR) and improve graft survival,but there is still no clear consensus on the optimal Tac target blood concentration and concentration-effect relationship is poorly defined. METHODS We conducted a dose-response meta-analysis to quantitatively assess the association between Tac blood concentration and (AR) or adverse effects after KT. A comprehensive search of PubMed, Embase and Cochrane library databases was conducted to find eligible studies up to 10th September 2018. Unpublished data from patients receiving KT in West China Hospital (Sichuan University, China) were also collected. Both twostage dose-response and one-stage dose-response meta-analysis models were used to improve the statistical power. RESULTS A total of 4967 individuals from 10 original studies and 1453 individuals from West China Hospital were eligible for the ultimate analysis. In the two-stage dose-response meta-analysis model, we observed a significant non-linear relationship between Tac blood concentration and AR (P < 0.001) with moderate heterogeneity (I2 = 46.0%, P = 0.08). Tac blood concentration at 8ng/ml was associated with the lowest risk of AR (RR: 0.26, 95%CI: 0.13 - 0.54) by reference to 2ng/ml. Tac concentration at 7.0 - 11.0 ng/ml reduced the risk of AR by at least 70%, 5-14 ng/ml by at least 60%, and 4.5 - 14 ng/ml at least 50%. In the one-stage dose-response model, we also found a strong non-linear relationship between Tac and AR (P < 0.001) with moderate heterogeneity (I2 = 41.2%, P = 0.10). Tac concentration of 7.5 ng/ml was associated with the lowest risk of AR (RR: 0.35, 95%CI: 0.16 - 0.77). The blood concentration at 5.5 - 9.5 ng/ml was associated with the reduced AR by at least 60% and 4.5 - 10.5 ng/ml by at least 50% by reference to 2 ng/ml. CONCLUSION Maintaining Tac blood concentration at 5 - 9.5 ng/ml within the first year may prevent AR most effectively.
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Affiliation(s)
- Saifu Yin
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Organ transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Turun Song
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Organ transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xingxing Li
- West China Hospital/West China school of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Hanyue Xu
- West China Hospital/West China school of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Xueling Zhang
- West China Hospital/West China school of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Yamei Jiang
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Organ transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tao Lin
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Organ transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Tacrolimus Intrapatient Variability, Time in Therapeutic Range, and Risk of De Novo Donor–Specific Antibodies. Transplantation 2020; 104:881-887. [DOI: 10.1097/tp.0000000000002913] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Cai X, Li R, Sheng C, Tao Y, Zhang Q, Zhang X, Li J, Shen C, Qiu X, Wang Z, Jiao Z. Systematic external evaluation of published population pharmacokinetic models for tacrolimus in adult liver transplant recipients. Eur J Pharm Sci 2020; 145:105237. [DOI: 10.1016/j.ejps.2020.105237] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 12/19/2022]
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Guo HL, Xu J, Sun JY, Li L, Guo HL, Jing X, Xu ZY, Hu YH, Xu ZJ, Sun F, Ding XS, Chen F, Zhao F. Tacrolimus treatment in childhood refractory nephrotic syndrome: A retrospective study on efficacy, therapeutic drug monitoring, and contributing factors to variable blood tacrolimus levels. Int Immunopharmacol 2020; 81:106290. [PMID: 32058933 DOI: 10.1016/j.intimp.2020.106290] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/03/2020] [Accepted: 02/04/2020] [Indexed: 12/21/2022]
Abstract
Tacrolimus, an immunosuppressive drug, was recommended by the 2012 KDIGO guidelines to treat nephrotic syndrome (NS) in children and adults. However, it has high interpatient pharmacokinetic variability and exposure levels should be monitored, although there are no specified target concentrations. This retrospective study aimed to review efficacy and safety after concomitant treatment with tacrolimus and prednisone, and to identify factors that contribute to the variable blood-trough-concentration-to-dose (C0/Dose) ratio in children with refractory NS (RNS). A 6-month therapy induced complete or partial remission in 95% of patients. One-year follow-up indicated a high remission rate and low nephrotoxicity. Under maintenance dosages, approximately 95% of the C0 values were 2-7 ng/mL. Body weight (BW), age, CYP3A5 polymorphisms were the factors affecting the C0/Dose ratio. The C0/Dose ratio in patients with a BW of <20 kg was 1.5-fold than that in patients with BW of ≥40 kg. Moreover, the C0/Dose ratio in patients aged 1-≤6 and 6-≤12 years was significantly lower than that in patients aged 12-≤18 years, by 25% and 48%, respectively. There were no significant association between CYP3A5 genotyping and C0/Dose ratio in younger children (1-≤6 years), rather than older children (6-≤18 years). In conclusion, routine CYP3A5 genotyping should be considered in children aged over 6 years and exposure levels (C0) of 2-7 ng/mL may be feasible when tacrolimus is combined with low-dose prednisone to treat childhood RNS.
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Affiliation(s)
- Hong-Li Guo
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Xu
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jie-Yu Sun
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Ling Li
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Hui-Lei Guo
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xia Jing
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ze-Yue Xu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Ya-Hui Hu
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ze-Jun Xu
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Fang Sun
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xuan-Sheng Ding
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Feng Chen
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.
| | - Fei Zhao
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China.
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Cheung J, Wentzell J, Trinacty M, Giguère P, Patel P, Kekre N, Nguyen T. Efficacy, Safety, and Practicality of Tacrolimus Monitoring after Bone Marrow Transplant: Assessment of a Change in Practice. Can J Hosp Pharm 2020; 73:37-44. [PMID: 32109959 PMCID: PMC7023932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Currently, there is no standardized approach to the frequency of monitoring tacrolimus levels in patients who have undergone hematopoietic stem cell transplant (HSCT). Previously, the practice at the study hospital was to monitor tacrolimus levels daily throughout a patient's admission. A recent institutional study suggested that measurement of tacrolimus level is more frequent than needed to achieve consistent time in the therapeutic range (TTR), particularly after the first 7 days. As a result, tacrolimus monitoring was changed to daily measurement for the initial week of therapy, followed by measurements on Monday, Wednesday, and Friday in subsequent weeks. OBJECTIVE To confirm the safety and efficacy of the recent practice change. METHODS This retrospective chart review of HSCT patients admitted to The Ottawa Hospital involved 68 patients in the pre-practice change group and 43 patients in the post-practice change group. Data on tacrolimus measurement were collected for up to 21 days after initiation of this medication. The proportion of TTR was compared between the 2 groups. Differences in the incidence and severity of renal dysfunction and the incidence of acute graft versus host disease (GVHD) were determined and described. RESULTS In the pre-practice change cohort, the median proportion of TTR for tacrolimus was 40.5% for days 1-7, 65.1% for days 8-14, and 78.9% for days 15-21, similar to the values for the post-practice change group (46.6% [p = 0.09], 62.9% [p = 0.93], and 70.0% [p = 0.22], respectively, for the same periods). The incidence of acute GVHD within 100 days after HSCT was 24% and 33% for the pre- and post-practice change cohorts, respectively. The incidence and severity of renal dysfunction were similar between the 2 groups. CONCLUSION The proportion of TTR for tacrolimus was not significantly affected by the recent practice change. Similarly, the incidence and severity of renal dysfunction and the incidence of acute GVHD did not appear to differ between the pre- and post-practice change groups.
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Affiliation(s)
- Jacky Cheung
- , BSc, PharmD, ACPR, was, at the time of this study, a Pharmacy Resident with the Pharmacy Department of The Ottawa Hospital, Ottawa, Ontario. He is now a Clinical Pharmacist with The Ottawa Hospital
| | - Jason Wentzell
- , BScPharm, ACPR, BCOP, is a Clinical Pharmacist with the Pharmacy Department of The Ottawa Hospital, Ottawa, Ontario
| | - Melanie Trinacty
- , BSc, BScPharm, ACPR, is a Clinical Pharmacist with the Pharmacy Department of The Ottawa Hospital, Ottawa, Ontario
| | - Pierre Giguère
- , BPharm, MSc, is a Clinical Pharmacist with the Pharmacy Department of The Ottawa Hospital, Ottawa, Ontario
| | - Priya Patel
- , BSc, PharmD, ACPR, is a Clinical Pharmacist with the Pharmacy Department of the Princess Margaret Cancer Centre, Toronto, Ontario
| | - Natasha Kekre
- , BSc, MD, MPH, FRCPC, is a Staff Hematologist with the Blood and Marrow Transplant Program, The Ottawa Hospital, Ottawa, Ontario
| | - Tiffany Nguyen
- , BScPharm, ACPR, BCOP, is a Clinical Pharmacist with the Pharmacy Department of The Ottawa Hospital, Ottawa, Ontario
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50
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Nakazawa R, Yoshiike M, Nozawa S, Aida K, Katsuoka Y, Fujimoto E, Yazawa M, Kikuchi E, Shibagaki Y, Sasaki H. Clinically useful limited sampling strategy to estimate area under the concentration-time curve of once-daily tacrolimus in adult Japanese kidney transplant recipients. PLoS One 2019; 14:e0225878. [PMID: 31825991 PMCID: PMC6905578 DOI: 10.1371/journal.pone.0225878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 11/14/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND An extended-release, once-daily, oral formulation of tacrolimus is currently used after kidney transplantation as a substitute for the conventional twice-daily formulation. The purpose of this study was to provide a limited sampling strategy with minimum and optimum sampling points to predict the tacrolimus area under the concentration-time curve (AUC) after administration of once-daily tacrolimus in de novo adult kidney transplant patients. METHODS A total of 36 adult Japanese kidney transplant patients receiving once-daily tacrolimus were included: 31 were allocated to a study group to develop limited sampling strategy (LSS) model equations based on multiple stepwise linear regression analysis, and 5 were allocated to a validation group to estimate the precision of the LSS equations developed by the study group. Twelve-hour AUC (AUC0-12) was calculated by the trapezoidal rule, and the relationship between individual concentration points and AUC0-12 were determined by multiple linear regression analysis. The coefficient of determination (R2) was used to assess the goodness-of-fit of the regression models. Three error indices (mean error, mean absolute error, and root mean squared prediction error) were calculated to evaluate predictive bias, accuracy, and precision, respectively. Quality of the statistical models was compared with Akaike's information criterion (AIC). RESULTS A four-point model using C0, C2, C4 and C6 gave the best fit to predict AUC0-12 (R2 = 0.978). In the three- and two-point models, the best fits were at time points C2, C4, and C6 (R2 = 0.973), and C2 and C6 (R2 = 0.962), respectively. All three models reliably estimated tacrolimus AUC0-12, consistent with evaluations by the three error indices and Akaike's information criterion. Practically, the two-point model with C2 and C6 was considered to be the best combination, providing a highly accurate prediction and the lowest blood sampling frequency. CONCLUSIONS The two-point model with C2 and C6 may be valuable in reducing the burden on patients, as well as medical costs, for once-daily tacrolimus monitoring.
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Affiliation(s)
- Ryuto Nakazawa
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
- * E-mail:
| | - Miki Yoshiike
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Shiari Nozawa
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Koichiro Aida
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yuichi Katsuoka
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Eisuke Fujimoto
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masahiko Yazawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Eiji Kikuchi
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hideo Sasaki
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
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