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Wanas H, Kamel MH, William EA, Fayad T, Abdelfattah ME, Elbadawy HM, Mikhael ES. The impact of CYP3A4 and CYP3A5 genetic variations on tacrolimus treatment of living-donor Egyptian kidney transplanted patients. J Clin Lab Anal 2023; 37:e24969. [PMID: 37789683 PMCID: PMC10681408 DOI: 10.1002/jcla.24969] [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: 01/18/2023] [Revised: 08/21/2023] [Accepted: 09/20/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Tacrolimus (TAC) is the mainstay of immunosuppressive regimen for kidney transplantations. Its clinical use is complex due to high inter-individual variations which can be partially attributed to genetic variations at the metabolizing enzymes CYP3A4 and CYP3A5. Two single nucleotide polymorphisms (SNPs), CYP3A4*22 and CYP3A5*3, have been reported as important causes of differences in pharmacokinetics that can affect efficacy and/or toxicity of TAC. OBJECTIVE Investigating the effect of CYP3A4*22 and CYP3A5*3 SNPs individually and in combination on the TAC concentration in Egyptian renal recipients. METHODS Overall, 72 Egyptian kidney transplant recipients were genotyped for CYP3A4*22 G>A and CYP3A5*3 T>C. According to the functional defect associated with CYP3A variants, patients were clustered into: poor (PM) and non-poor metabolizers (Non-PM). The impact on dose adjusted through TAC concentrations (C0) and daily doses at different time points after transplantation was evaluated. RESULTS Cyp3A4*1/*22 and PM groups require significantly lower dose of TAC (mg/kg) at different time points with significantly higher concentration/dose (C0/D) ratio at day 10 in comparison to Cyp3A4*1/*1 and Non-PM groups respectively. However, CyP3A5*3 heterozygous individuals did not show any significant difference in comparison to CyP3A5*1/*3 individuals. By comparing between PM and Non-PM, the PM group had a significantly lower rate of recipients not reaching target C0 at day 14. CONCLUSION This is the first study on Egyptian population to investigate the impact of CYP3A4*22 and CYP3A5*3 SNPs individually and in combination on the TAC concentration. This study and future multicenter studies can contribute to the individualization of TAC dosing in Egyptian patients.
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Affiliation(s)
- Hanaa Wanas
- Medical Pharmacology DepartmentFaculty of Medicine Cairo UniversityCairoEgypt
- Pharmacology and Toxicology Department, Faculty of PharmacyTaibah UniversityMadinahSaudi Arabia
| | - Mai Hamed Kamel
- Clinical and Chemical Pathology DepartmentFaculty of Medicine Cairo UniversityCairoEgypt
| | - Emad Adel William
- National Research Centre, Medical Research and Clinical Studies InstituteCairoEgypt
| | - Tarek Fayad
- Internal Medicine DepartmentFaculty of Medicine Cairo UniversityCairoEgypt
| | | | | | - Emily Samir Mikhael
- Clinical and Chemical Pathology DepartmentFaculty of Medicine Cairo UniversityCairoEgypt
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2
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Cui YF, Pan Y, Zhu MF, Jiao Z. Pharmacokinetic Evaluation of Tacrolimus in Chinese Adult Patients during the Early Stages Post-Lung Transplantation. J Pers Med 2023; 13:jpm13040656. [PMID: 37109042 PMCID: PMC10145266 DOI: 10.3390/jpm13040656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/27/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Although tacrolimus has been widely used in patients undergoing lung transplantation, few studies have reported the pharmacokinetics of tacrolimus in Chinese patients after lung transplantation. Thus, we aimed to investigate the pharmacokinetics and influential factors in this patient cohort in the early stage after lung transplantation. METHODS We enrolled 14 adult lung transplant recipients who were treated with tacrolimus and then intensively collected blood samples within a 12-h dosing interval. The pharmacokinetic parameters of tacrolimus were calculated using non-compartmental analysis, and the influence of pathophysiological characteristics and CYP3A5*3 and CYP3A4*1G genotypes on the pharmacokinetics of tacrolimus was assessed. Using linear regression analysis, we investigated the correlation between tacrolimus concentration at different sampling points and measured the area under the time-concentration curve (AUC0-12h). RESULTS Geometric mean of apparent clearance (CL/F) was 18.13 ± 1.65 L/h in non-CYP3A5*3/*3 carriers, five times higher than that in CYP3A5*3/*3 carriers (p < 0.001). Furthermore, the tacrolimus concentration 4 h after administration had the strongest correlation with AUC0-12h (R2 = 0.979). CONCLUSION The pharmacokinetics of tacrolimus varied largely between patients during the early stage post-transplantation, which could be partially explained by CYP3A5*3 genetic polymorphisms.
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Affiliation(s)
- Yi-Fan Cui
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Yan Pan
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Min-Fang Zhu
- Department of Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
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3
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Shen G, Moua KTY, Perkins K, Johnson D, Li A, Curtin P, Gao W, McCune JS. Precision sirolimus dosing in children: The potential for model-informed dosing and novel drug monitoring. Front Pharmacol 2023; 14:1126981. [PMID: 37021042 PMCID: PMC10069443 DOI: 10.3389/fphar.2023.1126981] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 02/14/2023] [Indexed: 04/07/2023] Open
Abstract
The mTOR inhibitor sirolimus is prescribed to treat children with varying diseases, ranging from vascular anomalies to sporadic lymphangioleiomyomatosis to transplantation (solid organ or hematopoietic cell). Precision dosing of sirolimus using therapeutic drug monitoring (TDM) of sirolimus concentrations in whole blood drawn at the trough (before the next dose) time-point is the current standard of care. For sirolimus, trough concentrations are only modestly correlated with the area under the curve, with R 2 values ranging from 0.52 to 0.84. Thus, it should not be surprising, even with the use of sirolimus TDM, that patients treated with sirolimus have variable pharmacokinetics, toxicity, and effectiveness. Model-informed precision dosing (MIPD) will be beneficial and should be implemented. The data do not suggest dried blood spots point-of-care sampling of sirolimus concentrations for precision dosing of sirolimus. Future research on precision dosing of sirolimus should focus on pharmacogenomic and pharmacometabolomic tools to predict sirolimus pharmacokinetics and wearables for point-of-care quantitation and MIPD.
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Affiliation(s)
- Guofang Shen
- Department of Hematologic Malignancies Translational Sciences, City of Hope, and Department of Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, CA, United States
| | - Kao Tang Ying Moua
- Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, United States
| | - Kathryn Perkins
- Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, United States
| | - Deron Johnson
- Clinical Informatics, City of Hope Medical Center, Duarte, CA, United States
| | - Arthur Li
- Division of Biostatistics, City of Hope, Duarte, CA, United States
| | - Peter Curtin
- Department of Hematologic Malignancies Translational Sciences, City of Hope, and Department of Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, CA, United States
| | - Wei Gao
- Division of Engineering and Applied Science, Andrew and Peggy Cherng Department of Medical Engineering, California Institute of Technology, Pasadena, CA, United States
| | - Jeannine S. McCune
- Department of Hematologic Malignancies Translational Sciences, City of Hope, and Department of Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, CA, United States
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4
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Catić‐Đorđević A, Stefanović N, Pavlović I, Pavlović D, Živanović S, Kundalić A, Veličković‐Radovanović R, Mitić B. Utility of salivary mycophenolic acid concentration monitoring: Modeling and Monte Carlo validation approach. Pharmacol Res Perspect 2022; 10:e01034. [PMID: 36440680 PMCID: PMC9703583 DOI: 10.1002/prp2.1034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/20/2022] [Accepted: 11/06/2022] [Indexed: 11/29/2022] Open
Abstract
The results of the previous studies demonstrated an association between mycophenolic acid (MPA) exposure, serum albumin level (ALB), and adverse effects in kidney transplant patients. The aim was the identification of mathematical correlation and association between both, total and unbound MPA concentration in relation to ALB, body mass (BM), age and estimated glomerular filtration rate (eGFR) in stable kidney transplant recipients. Furthermore, investigation was conducted with the aim to clarify the role of salivary concentration (CSAL ) of MPA in adverse effect profile. In order to analyze the association between total and salivary concentration of MPA in relation to ALB, BM, age and eGFR, a least squares method for determining the correlation between these parameters was performed. In addition, derived mathematical model based on experimental data can also be performed and simulated through the Monte Carlo (MC) approach. Adverse effects were grouped according to the nature of symptoms and scored by a previously published validated system. Numerically calculated values of CSAL from the models [CSAL = f(ALB, BM, age, eGFR, CP ) = a00 + a10 *(ALB, BM, age, eGFR) + a01 *CP ] were then compared with those from validation set of patients, where the best fitting model was for ALB [CSAL = 54.96-1.64*ALB +13.4*CP ]. Adverse effects estimation showed the difference in esthetic score, positively correlated with CSAL in the lower ALB group (145.41 ± 219.02 vs. 354.08 ± 262.19; with statistical significance p = .014) and almost significant for gastrointestinal score (167.69 ± 174.79 vs. 347.55 ± 320.95; p = .247). The study showed that CSAL MPA may contribute to management of adverse effects, but these findings require confirmation of clinical utility.
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Affiliation(s)
| | - Nikola Stefanović
- Faculty of Medicine, Department of PharmacyUniversity of NisNisSerbia
| | - Ivan Pavlović
- Faculty of Mechanical EngineeringUniversity of NisNisSerbia
| | - Dragana Pavlović
- Faculty of Medicine, Department of PharmacyUniversity of NisNisSerbia
| | - Slavoljub Živanović
- Faculty of Medicine, Research Center for BiomedicineUniversity of NisNisSerbia
| | - Ana Kundalić
- Faculty of Medicine, Department of PharmacyUniversity of NisNisSerbia
| | | | - Branka Mitić
- Faculty of MedicineUniversity of NisNisSerbia
- Clinic of NephrologyUniversity Clinical Center NisNisSerbia
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Jeon K. Critical Care Management Following Lung Transplantation. J Chest Surg 2022; 55:325-331. [PMID: 35924541 PMCID: PMC9358155 DOI: 10.5090/jcs.22.067] [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: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
Postoperative critical care management for lung transplant recipients in the intensive care unit (ICU) has expanded in recent years due to its complexity and impact on clinical outcomes. The practical aspects of post-transplant critical care management, especially regarding ventilation and hemodynamic management during the early postoperative period in the ICU, are discussed in this brief review. Monitoring in the ICU provides information on the patient’s clinical status, diagnostic assessment of complications, and future management plans since lung transplantation involves unique pathophysiological conditions and risk factors for complications. After lung transplantation, the grafts should be appropriately ventilated with lung protective strategies to prevent ventilator-induced lung injury, as well as to promote graft function and maintain adequate gas exchange. Hypotension and varying degrees of pulmonary edema are common in the immediate postoperative lung transplantation setting. Ventricular dysfunction in lung transplant recipients should also be considered. Therefore, adequate volume and hemodynamic management with vasoactive agents based on their physiological effects and patient response are critical in the early postoperative lung transplantation period. Integrated management provided by a professional multidisciplinary team is essential for the critical care management of lung transplant recipients in the ICU.
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Affiliation(s)
- Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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6
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Kotecha S, Ivulich S, Snell G. Review: immunosuppression for the lung transplant patient. J Thorac Dis 2022; 13:6628-6644. [PMID: 34992841 PMCID: PMC8662512 DOI: 10.21037/jtd-2021-11] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 02/16/2021] [Indexed: 12/19/2022]
Abstract
Lung transplantation (LTx) has evolved significantly since its inception and the improvement in LTx outcomes over the last three decades has predominantly been driven by advances in immunosuppression management. Despite the lack of new classes of immunosuppression medications, immunosuppressive strategies have evolved significantly from a universal method to a more targeted approach, reflecting a greater understanding of the need for individualized therapy and careful consideration of all factors that are influenced by immunosuppression choice. This has become increasingly important as the demographics of lung transplant recipients have changed over time, with older and more medically complex candidates being accepted and undergoing LTx. Furthermore, improved survival post lung transplant has translated into more immunosuppression related comorbidities long-term, predominantly chronic kidney disease (CKD) and malignancy, which has required further nuanced management approaches. This review provides an update on current traditional lung transplant immunosuppression strategies, with modifications based on pre-existing recipient factors and comorbidities, peri-operative challenges and long term complications, balanced against the perpetual challenge of chronic lung allograft dysfunction (CLAD). As we continue to explore and understand the complexity of LTx immunology and the interplay of different factors, immunosuppression strategies will require ongoing critical evaluation and personalization in order to continue to improve lung transplant outcomes.
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Affiliation(s)
- Sakhee Kotecha
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
| | - Steven Ivulich
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
| | - Gregory Snell
- Lung Transplant Service, Alfred Hospital and Monash University, Melbourne, Australia
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Al-Kofahi M, Oetting WS, Schladt DP, Remmel RP, Guan W, Wu B, Dorr CR, Mannon RB, Matas AJ, Israni AK, Jacobson PA. Precision Dosing for Tacrolimus Using Genotypes and Clinical Factors in Kidney Transplant Recipients of European Ancestry. J Clin Pharmacol 2021; 61:1035-1044. [PMID: 33512723 PMCID: PMC11240873 DOI: 10.1002/jcph.1823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/26/2021] [Indexed: 12/14/2022]
Abstract
Genetic variation in the CYP3A4 and CYP3A5 (CYP3A4/5) genes, which encode the key enzymes in tacrolimus metabolism, is associated with tacrolimus clearance and dose requirements. Tacrolimus has a narrow therapeutic index with high intra- and intersubject variability, in part because of genetic variation. High tacrolimus clearance and low trough concentration are associated with a greater risk for rejection, whereas high troughs are associated with calcineurin-induced toxicity. The objective of this study was to develop a model of tacrolimus clearance with a dosing equation accounting for genotypes and clinical factors in adult kidney transplant recipients of European ancestry that could preemptively guide dosing. Recipients receiving immediate-release tacrolimus for maintenance immunosuppression from 2 multicenter studies were included. Participants in the GEN03 study were used for tacrolimus model development (n = 608 recipients) and was validated by prediction performance in the DeKAF Genomics study (n = 1361 recipients). Nonlinear mixed-effects modeling was used to develop the apparent oral tacrolimus clearance (CL/F) model. CYP3A4/5 genotypes and clinical covariates were tested for their influence on CL/F. The predictive performance of the model was determined by assessing the bias (median prediction error [ME] and median percentage error [MPE]) and the precision (root median squared error [RMSE]) of the model. CYP3A5*3, CYP3A4*22, corticosteroids, calcium channel blocker and antiviral drug use, age, and diabetes significantly contributed to the interindividual variability of oral tacrolimus apparent clearance. The bias (ME, MPE) and precision (RMSE) of the final model was good, 0.49 ng/mL, 6.5%, and 3.09 ng/mL, respectively. Prospective testing of this equation is warranted.
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Affiliation(s)
- Mahmoud Al-Kofahi
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - William S Oetting
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - David P Schladt
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
| | - Rory P Remmel
- Department of Medicinal Chemistry, University of Minnesota, Minneapolis, Minnesota, USA
| | - Weihua Guan
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Baolin Wu
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Casey R Dorr
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Roslyn B Mannon
- Division of Nephrology, University of Nebraska, Omaha, Nebraska, USA
| | - Arthur J Matas
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ajay K Israni
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
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8
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Duwez M, Chanoine S, Lepelley M, Vo TH, Pluchart H, Mazet R, Allenet B, Pison C, Briault A, Saint-Raymond C, Camara B, Claustre J, Bedouch P. Clinical evaluation of pharmacists' interventions on multidisciplinary lung transplant outpatients' management: results of a 7-year observational study. BMJ Open 2020; 10:e041563. [PMID: 33247028 PMCID: PMC7703423 DOI: 10.1136/bmjopen-2020-041563] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Lung transplant (LT) recipients require multidisciplinary care because of the complexity of therapeutic management. Pharmacists are able to detect drug-related problems and provide recommendations to physicians through pharmacists' interventions (PIs). We aimed at assessing the clinical impact of PIs on therapeutic management in LT outpatients. DESIGN Data were collected prospectively from an LT recipients cohort during 7 years. A multidisciplinary committee assessed retrospectively the clinical impact of accepted PIs. SETTING French University Hospital. PARTICIPANTS LT outpatients followed from 2009 to 2015. PRIMARY OUTCOME MEASURES Clinical impact of PIs performed by pharmacists using the CLEO tool and the Pareto chart. RESULTS 1449 PIs led to a change in patient therapeutic management and were mainly related to wrong dosage (39.6%) and untreated indication (19.6%). The clinical impact of PIs was 'avoids fatality', 'major' and 'moderate', in 0.1%, 7.0% and 57.9%, respectively. Immunosuppressants, antimycotics for systemic use and antithrombotic agents had the greatest clinical impact according to the Pareto chart. PIs related to drug-drug interactions (10%) mainly had a moderate and major clinical impact (82.3%, p<0.0001). CONCLUSION Clinical pharmacists play a key role for detecting drug-related problems mostly leading to a change in therapeutic management among LT outpatients. Our study provides a new insight to analyse the clinical impact of PIs in order to target PIs which have most value and contribute to patient care through interdisciplinary approach.
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Affiliation(s)
| | - Sébastien Chanoine
- Pharmacy, CHUGA, Grenoble, France
- TIMC-IMAG UMR5525, CNRS, Grenoble, France
| | | | - Thi Ha Vo
- Pharmacy Faculty, Pham Ngoc Thach Medical University, Hochiminh, Viet Nam
| | | | | | - Benoit Allenet
- Pharmacy, CHUGA, Grenoble, France
- TIMC-IMAG UMR5525, CNRS, Grenoble, France
| | - Christophe Pison
- Service Hospitalier Universitaire Pneumologie Physiologie, CHUGA, Grenoble, France
| | - Amandine Briault
- Service Hospitalier Universitaire Pneumologie Physiologie, CHUGA, Grenoble, France
| | | | - Boubou Camara
- Service Hospitalier Universitaire Pneumologie Physiologie, CHUGA, Grenoble, France
| | - Johanna Claustre
- Service Hospitalier Universitaire Pneumologie Physiologie, CHUGA, Grenoble, France
| | - Pierrick Bedouch
- Pharmacy, CHUGA, Grenoble, France
- TIMC-IMAG UMR5525, CNRS, Grenoble, France
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Yabuki H, Matsuda Y, Watanabe T, Eba S, Hoshi F, Hirama T, Oishi H, Sado T, Noda M, Sakurada A, Kikuchi M, Yamaguchi H, Mano N, Okada Y. Plasma mycophenolic acid concentration and the clinical outcome after lung transplantation. Clin Transplant 2020; 34:e14088. [DOI: 10.1111/ctr.14088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Hiroshi Yabuki
- Department of Thoracic Surgery Tohoku University Hospital Sendai Japan
| | - Yasushi Matsuda
- Department of Thoracic Surgery Tohoku University Hospital Sendai Japan
| | - Tatsuaki Watanabe
- Department of Thoracic Surgery Tohoku University Hospital Sendai Japan
| | - Shunsuke Eba
- Department of Thoracic Surgery Tohoku University Hospital Sendai Japan
| | - Fumihiko Hoshi
- Department of Thoracic Surgery Tohoku University Hospital Sendai Japan
| | - Takashi Hirama
- Department of Thoracic Surgery Tohoku University Hospital Sendai Japan
| | - Hisashi Oishi
- Department of Thoracic Surgery Tohoku University Hospital Sendai Japan
| | - Tetsu Sado
- Department of Thoracic Surgery Tohoku University Hospital Sendai Japan
| | - Masafumi Noda
- Department of Thoracic Surgery Tohoku University Hospital Sendai Japan
| | - Akira Sakurada
- Department of Thoracic Surgery Tohoku University Hospital Sendai Japan
| | - Masafumi Kikuchi
- Department of Pharmaceutical Sciences Tohoku University Hospital Sendai Japan
| | - Hiroaki Yamaguchi
- Department of Pharmaceutical Sciences Tohoku University Hospital Sendai Japan
| | - Nariyasu Mano
- Department of Pharmaceutical Sciences Tohoku University Hospital Sendai Japan
| | - Yoshinori Okada
- Department of Thoracic Surgery Tohoku University Hospital Sendai Japan
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Report from the 2018 consensus conference on immunomodulating agents in thoracic transplantation: Access, formulations, generics, therapeutic drug monitoring, and special populations. J Heart Lung Transplant 2020; 39:1050-1069. [DOI: 10.1016/j.healun.2020.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 06/29/2020] [Indexed: 01/06/2023] Open
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11
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Leino AD, Pai MP. Maintenance Immunosuppression in Solid Organ Transplantation: Integrating Novel Pharmacodynamic Biomarkers to Inform Calcineurin Inhibitor Dose Selection. Clin Pharmacokinet 2020; 59:1317-1334. [PMID: 32720300 DOI: 10.1007/s40262-020-00923-w] [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
Calcineurin inhibitors, the primary immunosuppressive therapy used to prevent alloreactivity of transplanted organs, have a narrow therapeutic index. Currently, treatment is individualized based on clinical assessment of the risk of rejection or toxicity guided by trough concentration monitoring. Advances in immune monitoring have identified potential markers that may have value in understanding calcineurin inhibitor pharmacodynamics. Integration of these markers has the potential to complement therapeutic drug monitoring. Existing pharmacokinetic-pharmacodynamic (PK-PD) data is largely limited to correlation between the biomarker and trough concentrations at single time points. Immune related gene expression currently has the most evidence supporting PK-PD integration. Novel biomarker-based approaches to pharmacodynamic monitoring including development of enhanced PK-PD models are proposed to realize the full clinical benefit.
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Affiliation(s)
- Abbie D Leino
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Rm 3569, Ann Arbor, MI, 48109, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Rm 3569, Ann Arbor, MI, 48109, USA.
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12
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Therapeutic Drug Monitoring of Tacrolimus-Personalized Therapy: Second Consensus Report. Ther Drug Monit 2019; 41:261-307. [DOI: 10.1097/ftd.0000000000000640] [Citation(s) in RCA: 227] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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13
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Brunet M, van Gelder T, Åsberg A, Haufroid V, Hesselink DA, Langman L, Lemaitre F, Marquet P, Seger C, Shipkova M, Vinks A, Wallemacq P, Wieland E, Woillard JB, Barten MJ, Budde K, Colom H, Dieterlen MT, Elens L, Johnson-Davis KL, Kunicki PK, MacPhee I, Masuda S, Mathew BS, Millán O, Mizuno T, Moes DJAR, Monchaud C, Noceti O, Pawinski T, Picard N, van Schaik R, Sommerer C, Vethe NT, de Winter B, Christians U, Bergan S. Therapeutic Drug Monitoring of Tacrolimus-Personalized Therapy: Second Consensus Report. Ther Drug Monit 2019. [DOI: 10.1097/ftd.0000000000000640
expr 845143713 + 809233716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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14
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Darley DR, Carlos L, Hennig S, Liu Z, Day R, Glanville AR. Tacrolimus exposure early after lung transplantation and exploratory associations with acute cellular rejection. Eur J Clin Pharmacol 2019; 75:879-888. [PMID: 30859243 DOI: 10.1007/s00228-019-02658-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 02/27/2019] [Indexed: 12/18/2022]
Abstract
AIMS To (i) describe tacrolimus (TAC) pre-dose concentrations (C0), (ii) calculate apparent oral TAC clearance (CL/FHCT) adjusted for measured haematocrit (HCTi) and standardised to a HCT of 45%, across three observation time points and (iii) explore if low TAC C0 or high mean CL/FHCT are associated with an increased risk of rejection episodes early after lung transplantation. METHODS TAC whole blood concentration-time profiles and transbronchial biopsies were performed prospectively at weeks 3, 6 and 12 after lung transplantation. The TAC pre-dose concentration (C0) was measured, and CL/FHCT was determined using non-compartmental analysis. The associations between TAC C0 and CL/FHCT and rejection status were explored using repeated measures logistic regression. RESULTS Eighteen patients provided 377 TAC whole blood concentrations. Considerable variability around the median (IQR) CL/FHCT 6.8 (4.2-15.9) L h-1, and the median C0 12.7 (9.9-16.6) μg L-1 was noted. Despite adjustment for haematocrit, a significant decrease was observed in CL/FHCT in all patients over time: CL/FHCT 14 (5.4-23) at week 3, CL/FHCT 7.7 (4.5-12) at week 6 and CL/FHCT 3.9 (2.4-11) L h-1 at week 12 (p < 0.01). Seven (38.9%) patients experienced a single grade 2 rejection, whilst 11 (61.1%) patients experienced no rejection. Higher TAC C0 were associated with a reduced risk of rejection OR 0.68 (95% CI 0.51-0.91, p = 0.02), and greater mean CL/FHCT was associated with an increased risk of rejection OR 1.34 (95% CI 1.01-1.81 p = 0.04). CONCLUSION Monitoring TAC C0, HCT and CL/FHCT in patients after lung transplantation may assist clinicians in detecting patients at risk of acute rejection and may guide future research into TAC and HCT monitoring after lung transplantation.
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Affiliation(s)
- David R Darley
- Lung Transplant Unit, St Vincent's Hospital Darlinghurst, Sydney, Australia. .,UNSW Medicine, St Vincent's Hospital Clinical School, Sydney, Australia.
| | - Lilibeth Carlos
- Department of Pharmacy, St Vincent's Hospital Darlinghurst, Sydney, Australia
| | - Stefanie Hennig
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Zhixin Liu
- Department of Statistics, University of New South Wales, Kensington, Australia
| | - Richard Day
- UNSW Medicine, St Vincent's Hospital Clinical School, Sydney, Australia.,Department of Clinical Pharmacology, St Vincent's Hospital Darlinghurst, Sydney, Australia
| | - Allan R Glanville
- Lung Transplant Unit, St Vincent's Hospital Darlinghurst, Sydney, Australia
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15
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Jia Y, Meng X, Li Y, Xu C, Zeng W, Jiao Y, Han W. Optimal sampling time-point for cyclosporin A concentration monitoring in heart transplant recipients. Exp Ther Med 2018; 16:4265-4270. [PMID: 30402164 DOI: 10.3892/etm.2018.6711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 07/13/2018] [Indexed: 11/05/2022] Open
Abstract
The present study was performed to determine an optimal time-point for monitoring the concentration of the immunosuppressive drug cyclosporin A (CsA) in heart transplant patients and its efficacy in the prevention of transplant rejection. A total of 32 transplant recipients were randomly assigned for three treatment approaches. Recipients in groups A (n=11), B (n=13) and C (n=8) received oral administration of CsA at doses of 3.2, 3.5 and 4.4 mg/kg, respectively. The plasma CsA concentrations were examined at 2 h intervals over 12 h. Furthermore, their correlation with the 4 h pharmacokinetic profiles as the area under the plasma CsA concentration vs. time curve (AUC0-4 h) were calculated The efficacy of CsA in inhibiting cardiac allograft rejection was assessed at 2 h after oral CsA intake (C2) and adverse events of the drug were examined in the C2-monitored recipients. The plasma CsA concentration rapidly increased in most recipients with a peak level detected at ~2 h after dosing. Regression analysis revealed that among all time-points assessed, the CsA had the highest correlation with the AUC0-4 h at C2. At C2, increasing CsA doses exhibited a positive association with the measure of AUC0-4 h. The efficacy of increasing CsA target levels at C2 in preventing heart transplant rejection was comparable, as the survival rate was 100% in all of the treatment groups. However, the proportion of recipients with side effects in group A was obviously lower than that in the other two groups. In conclusion, C2 is an ideal time-point for monitoring plasma CsA levels with a utility for individualising the next scheduled dose for each patient to ensure that target levels are maintained and achieve a high efficacy and safety of CsA therapy in heart transplant recipients (clinical trial no. 12002610).
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Affiliation(s)
- Yixin Jia
- Department of Cardiac Surgery, Capital Medical University Affiliated Anzhen Hospital, Beijing 100029, P.R. China
| | - Xu Meng
- Department of Cardiac Surgery, Capital Medical University Affiliated Anzhen Hospital, Beijing 100029, P.R. China
| | - Yan Li
- Department of Cardiac Surgery, Capital Medical University Affiliated Anzhen Hospital, Beijing 100029, P.R. China
| | - Chunlei Xu
- Department of Cardiac Surgery, Capital Medical University Affiliated Anzhen Hospital, Beijing 100029, P.R. China
| | - Wen Zeng
- Department of Cardiac Surgery, Capital Medical University Affiliated Anzhen Hospital, Beijing 100029, P.R. China
| | - Yuqing Jiao
- Department of Cardiac Surgery, Capital Medical University Affiliated Anzhen Hospital, Beijing 100029, P.R. China
| | - Wei Han
- Department of Cardiac Surgery, Capital Medical University Affiliated Anzhen Hospital, Beijing 100029, P.R. China
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16
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Calabrese DR, Florez R, Dewey K, Hui C, Torgerson D, Chong T, Faust H, Rajalingam R, Hays SR, Golden JA, Kukreja J, Singer JP, Greenland JR. Genotypes associated with tacrolimus pharmacokinetics impact clinical outcomes in lung transplant recipients. Clin Transplant 2018; 32:e13332. [PMID: 29920787 DOI: 10.1111/ctr.13332] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2018] [Indexed: 12/18/2022]
Abstract
Most lung transplantation immunosuppression regimens include tacrolimus. Single nucleotide polymorphisms (SNPs) in genes important to tacrolimus bioavailability and clearance (ABCB1, CYP3A4, and CYP3A5) are associated with differences in tacrolimus pharmacokinetics. We hypothesized that polymorphisms in these genes would impact immunosuppression-related outcomes. We categorized ABCB1, CYP3A4, and CYP3A5 SNPs for 321 lung allograft recipients. Genotype effects on time to therapeutic tacrolimus level, interactions with antifungal medications, concentration to dose (C0 /D), acute kidney injury, and rejection were assessed using linear models adjusted for subject characteristics and repeat measures. Compared with CYP3A poor metabolizers (PM), time to therapeutic tacrolimus trough was increased by 5.1 ± 1.6 days for CYP3A extensive metabolizers (EM, P < 0.001). In the post-operative period, CYP3A intermediate metabolizers spent 1.2 ± 0.5 days less (P = 0.01) and EM spent 2.1 ± 0.5 days less (P < 0.001) in goal tacrolimus range than CYP3A PM. Azole antifungals interacted with CYP3A genotype in predicting C0 /D (P < 0.001). Increased acute kidney injury rates were observed in subjects with high ABCB1 function (OR 3.0, 95% CI 1.1-8.6, P = 0.01). Lower rates of acute cellular rejection were observed in subjects with low ABCB1 function (OR 0.36, 95% CI 0.07-0.94, P = 0.02). Recipient genotyping may help inform tacrolimus dosing decisions and risk of adverse clinical outcomes.
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Affiliation(s)
- Daniel R Calabrese
- Department of Medicine, University of California, San Francisco, California
| | - Rebecca Florez
- Department of Clinical Pharmacy, University of California, San Francisco, California
| | - Katherine Dewey
- Department of Clinical Pharmacy, University of California, San Francisco, California
| | - Christine Hui
- Department of Clinical Pharmacy, University of California, San Francisco, California
| | - Dara Torgerson
- Department of Medicine, University of California, San Francisco, California
| | - Tiffany Chong
- Department of Medicine, University of California, San Francisco, California
| | - Hilary Faust
- Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raja Rajalingam
- Immunogenetics and Transplantation Laboratory, Department of Surgery, University of California, San Francisco, California
| | - Steven R Hays
- Department of Medicine, University of California, San Francisco, California
| | - Jeffrey A Golden
- Department of Medicine, University of California, San Francisco, California
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, California
| | - Jonathan P Singer
- Department of Medicine, University of California, San Francisco, California
| | - John R Greenland
- Department of Medicine, University of California, San Francisco, California.,Medical Service, Veterans Affairs Health Care System, San Francisco, California
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17
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18
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Abstract
Immunosuppression management after lung transplantation continues to evolve, with an increasing number of agents available for use in various combinations allowing for more choice and individualization of immunosuppressive therapy. Therapeutic developments have led to improved outcomes including lower acute rejection rates and improved survival. However, a one size fits all approach for any immunosuppressive strategy may not be best suited to the individual patient and ultimately patient specific factors must be considered when designing the immunosuppressive regimen. Recipient factors including age, race, co-morbidities, immunologic risk, genetic polymorphisms, concomitant and previous pharmacotherapy, and overall immunosuppression burden should be considered. There are several significant drug-drug interactions with select immunosuppressive agents utilized in lung transplant pharmacotherapy that must be considered when choosing and devising a dosing strategy for an individual immunosuppressive agent. Herein, considerations for immunosuppression management in the individual patient will be reviewed.
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Affiliation(s)
- Jennifer K McDermott
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health, Grand Rapids, Michigan.,Michigan State University College of Human Medicine, Grand Rapids, Michigan
| | - Reda E Girgis
- Michigan State University College of Human Medicine, Grand Rapids, Michigan
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19
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Ivulich S, Dooley M, Kirkpatrick C, Snell G. Clinical Challenges of Tacrolimus for Maintenance Immunosuppression Post–Lung Transplantation. Transplant Proc 2017; 49:2153-2160. [DOI: 10.1016/j.transproceed.2017.07.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 07/30/2017] [Indexed: 12/25/2022]
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20
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Abstract
Cystic fibrosis (CF) is a common indication for lung transplantation (LTx) in children and adults with severe and irreversible lung disease. In the setting of LTx in the CF population, immunosuppressive medications are used to prevent allograft rejection despite the majority of these patients being chronically infected with numerous, and often antibiotic-resistant, pathogens. There is limited evidence for the optimal post-LTx immunosuppression regimen in patients with CF, particularly in children. This article provides a review of immunosuppression regimens in the pediatric and adult CF post-LTx population, investigating drug dosing and monitoring, and medication combinations. Currently used immunosuppressive medications and related systemic adverse effects are reviewed. With limitations of data in the pediatric population, future research should address immunosuppression in these children to help guide pediatric drug management as a means to optimize clinical outcomes after LTx.
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21
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Pharmacokinetics, Pharmacodynamics, and Pharmacogenomics of Immunosuppressants in Allogeneic Hematopoietic Cell Transplantation: Part II. Clin Pharmacokinet 2016; 55:551-93. [PMID: 26620047 DOI: 10.1007/s40262-015-0340-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Part I of this article included a pertinent review of allogeneic hematopoietic cell transplantation (alloHCT), the role of postgraft immunosuppression in alloHCT, and the pharmacokinetics, pharmacodynamics, and pharmacogenomics of the calcineurin inhibitors and methotrexate. In this article (Part II), we review the pharmacokinetics, pharmacodynamics, and pharmacogenomics of mycophenolic acid (MPA), sirolimus, and the antithymocyte globulins (ATG). We then discuss target concentration intervention (TCI) of these postgraft immunosuppressants in alloHCT patients, with a focus on current evidence for TCI and on how TCI may improve clinical management in these patients. Currently, TCI using trough concentrations is conducted for sirolimus in alloHCT patients. Several studies demonstrate that MPA plasma exposure is associated with clinical outcomes, with an increasing number of alloHCT patients needing TCI of MPA. Compared with MPA, there are fewer pharmacokinetic/dynamic studies of rabbit ATG and horse ATG in alloHCT patients. Future pharmacokinetic/dynamic research of postgraft immunosuppressants should include '-omics'-based tools: pharmacogenomics may be used to gain an improved understanding of the covariates influencing pharmacokinetics as well as proteomics and metabolomics as novel methods to elucidate pharmacodynamic responses.
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22
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Pharmacokinetics, Pharmacodynamics and Pharmacogenomics of Immunosuppressants in Allogeneic Haematopoietic Cell Transplantation: Part I. Clin Pharmacokinet 2016; 55:525-50. [PMID: 26563168 DOI: 10.1007/s40262-015-0339-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Although immunosuppressive treatments and target concentration intervention (TCI) have significantly contributed to the success of allogeneic haematopoietic cell transplantation (alloHCT), there is currently no consensus on the best immunosuppressive strategies. Compared with solid organ transplantation, alloHCT is unique because of the potential for bidirectional reactions (i.e. host-versus-graft and graft-versus-host). Postgraft immunosuppression typically includes a calcineurin inhibitor (cyclosporine or tacrolimus) and a short course of methotrexate after high-dose myeloablative conditioning, or a calcineurin inhibitor and mycophenolate mofetil after reduced-intensity conditioning. There are evolving roles for the antithymyocyte globulins (ATGs) and sirolimus as postgraft immunosuppression. A review of the pharmacokinetics and TCI of the main postgraft immunosuppressants is presented in this two-part review. All immunosuppressants are characterized by large intra- and interindividual pharmacokinetic variability and by narrow therapeutic indices. It is essential to understand immunosuppressants' pharmacokinetic properties and how to use them for individualized treatment incorporating TCI to improve outcomes. TCI, which is mandatory for the calcineurin inhibitors and sirolimus, has become an integral part of postgraft immunosuppression. TCI is usually based on trough concentration monitoring, but other approaches include measurement of the area under the concentration-time curve (AUC) over the dosing interval or limited sampling schedules with maximum a posteriori Bayesian personalization approaches. Interpretation of pharmacodynamic results is hindered by the prevalence of studies enrolling only a small number of patients, variability in the allogeneic graft source and variability in postgraft immunosuppression. Given the curative potential of alloHCT, the pharmacodynamics of these immunosuppressants deserves to be explored in depth. Development of sophisticated systems pharmacology models and improved TCI tools are needed to accurately evaluate patients' exposure to drugs in general and to immunosuppressants in particular. Sequential studies, first without and then with TCI, should be conducted to validate the clinical benefit of TCI in homogenous populations; randomized trials are not feasible, because there are higher-priority research questions in alloHCT. In Part I of this article, we review the alloHCT process to facilitate optimal design of pharmacokinetic and pharmacodynamics studies. We also review the pharmacokinetics and TCI of calcineurin inhibitors and methotrexate.
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23
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Gu L, Jin W, Kan L, Wang X, Shan C, Fan H. A retrospective study to compare the use of tacrolimus and cyclosporine in combination with adriamycin in post-transplant liver cancer patients. Cell Biochem Biophys 2016; 71:565-70. [PMID: 25287673 DOI: 10.1007/s12013-014-0235-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The aim of this study was to compare the clinical effect of tacrolimus (TAC) versus cyclosporine (CycA) in post-transplant hepatic cancer patients undergoing adriamycin hydrochloride (ADM) chemotherapy. Patients with advanced hepatic cancer who underwent liver transplant and subsequent therapy between March 2007 and March 2009 in our hospital were selected for this study. All of these patients were treated with chemotherapeutic agent adriamycin, with respect to immunosuppressant, whereas they received either TAC or CycA, and hence represented two groups, TAC and controls, respectively. The short- and long-term outcomes of two therapies, ADM + TAC and ADM + CsA, were compared. The TAC group patients showed improved remission compared to the control group (40 cases with 46.0 % versus 32 cases with 31.1 % remission, respectively). The 5-year survival in TAC group was significantly prolonged (20.7 %) compared to that of the controls (8.7 %). The short-term outcomes, such as serum levels of calcium, biomarkers of cardiac toxicity/functioning, and regulatory T lymphocytes counts (markers of immune functioning), were found to be significantly more auspicious with TAC treatment than with CycA. Our study showed that use of TAC plus ADM resulted in improved patient survival, tolerance of the graft, and remission compared to CycA combined with ADM. The serum levels of various markers in the short follow-up analysis indicated a better cardiac and immune functioning with TAC than with CycA treatment.
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Affiliation(s)
- Liangfeng Gu
- Department of Pharmacy, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310016, China
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24
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Burgel PR, Bergeron A, Knoop C, Dusser D. [Small airway diseases and immune deficiency]. Rev Mal Respir 2016; 33:145-55. [PMID: 26854188 DOI: 10.1016/j.rmr.2015.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 06/09/2015] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Innate or acquired immune deficiency may show respiratory manifestations, often characterized by small airway involvement. The purpose of this article is to provide an overview of small airway disease across the major causes of immune deficiency. BACKGROUND In patients with common variable immune deficiency, recurrent lower airway infections may lead to bronchiolitis and bronchiectasis. Follicular and/or granulomatous bronchiolitis of unknown origin may also occur. Bronchiolitis obliterans is the leading cause of death after the first year in patients with lung transplantation. Bronchiolitis obliterans also occurs in patients with allogeneic haematopoietic stem cell transplantation, especially in the context of systemic graft-versus-host disease. VIEWPOINT AND CONCLUSION Small airway diseases have different clinical expression and pathophysiology across various causes of immune deficiency. A better understanding of small airways disease pathogenesis in these settings may lead to the development of novel targeted therapies.
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Affiliation(s)
- P-R Burgel
- Université Paris Descartes, Sorbonne Paris Cité, 75005 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.
| | - A Bergeron
- Université Paris Diderot, Sorbonne Paris Cité, 75013 Paris, France; Service de pneumologie, hôpital Saint-Louis, AP-HP, 75010 Paris, France
| | - C Knoop
- Department of Chest Medicine, Erasme University Hospital, université libre de Bruxelles, Bruxelles, Belgique
| | - D Dusser
- Université Paris Descartes, Sorbonne Paris Cité, 75005 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
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25
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Sanghavi K, Brundage RC, Miller MB, Schladt DP, Israni AK, Guan W, Oetting WS, Mannon RB, Remmel RP, Matas AJ, Jacobson PA. Genotype-guided tacrolimus dosing in African-American kidney transplant recipients. THE PHARMACOGENOMICS JOURNAL 2015; 17:61-68. [PMID: 26667830 PMCID: PMC4909584 DOI: 10.1038/tpj.2015.87] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 10/07/2015] [Accepted: 11/02/2015] [Indexed: 12/11/2022]
Abstract
Tacrolimus is dependent on CYP3A5 enzyme for metabolism. Expression of the CYP3A5 enzyme is controlled by several alleles including CYP3A5*1, CYP3A5*3, CYP3A5*6 and CYP3A5*7. African Americans (AAs) have on average higher tacrolimus dose requirements than Caucasians; however, some have requirements similar to Caucasians. Studies in AAs have primarily evaluated the CYP3A5*3 variant; however, there are other common nonfunctional variants in AAs (CYP3A5*6 and CYP3A5*7) that do not occur in Caucasians. These variants are associated with lower dose requirements and may explain why some AAs are metabolically similar to Caucasians. We created a tacrolimus clearance model in 354 AAs using a development and validation cohort. Time after transplant, steroid and antiviral use, age and CYP3A5*1, *3, *6 and *7 alleles were significant toward clearance. This study is the first to develop an AA-specific genotype-guided tacrolimus dosing model to personalize therapy.
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Affiliation(s)
- K Sanghavi
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - R C Brundage
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - M B Miller
- Department of Psychology, University of Minnesota, Minneapolis, MN, USA
| | - D P Schladt
- Department of Nephrology and Chronic Disease Research Group, Minneapolis Medical Research Foundation, Hennepin County Medical Center, Minneapolis, MN, USA
| | - A K Israni
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - W Guan
- Department of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - W S Oetting
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - R B Mannon
- Department of Nephrology, University of Alabama, Birmingham, AL, USA
| | - R P Remmel
- Department of Medicinal Chemistry, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - A J Matas
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - P A Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
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26
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Erratic tacrolimus exposure, assessed using the standard deviation of trough blood levels, predicts chronic lung allograft dysfunction and survival. J Heart Lung Transplant 2015; 34:1442-8. [DOI: 10.1016/j.healun.2015.05.028] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 04/02/2015] [Accepted: 05/28/2015] [Indexed: 12/16/2022] Open
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27
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Wang JY, Fan H. P70S6 kinase phosphorylation: a new site to assess pharmacodynamy of sirolimus. Chin Med J (Engl) 2015; 128:664-9. [PMID: 25698201 PMCID: PMC4834780 DOI: 10.4103/0366-6999.151670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: The phosphorylation of p70S6 kinase (p70S6K) represents an important target for sensitive detection on pharmacodynamic effects of sirolimus, but the methods of assessing p70S6K phosphorylation are still unclear. The aim of this study was to investigate p70S6K phosphorylation located down-stream of the mammalian target of rapamycin (mTOR) pathway in peripheral blood mononuclear cells (PBMCs) of liver transplant patients through different methods. Methods: Seventy-five liver transplant recipients from Beijing Chaoyang Hospital of the Capital Medical University were analyzed in this study. Patients were divided into three groups, patient treated with sirolimus (n = 22), patient treated with tacrolimus (n = 30), patient treated with cyclosporine (n = 23). The p70S6K phosphorylation of PBMCs in patients and healthy control (HC, n = 12) were analyzed by phospho-flow cytometry and Western blotting. A correlation analysis of data from phospho-flow cytometry and Western blotting was performed. Intra-assay variability of p70S6K phosphorylation in HC and different patients were measured. Results: Intra-assay variability of p70S6K phosphorylation in phospho-flow cytometry was from 4.1% to 8.4% and in Western blotting was from 8.2% to 18%. The p70S6K phosphorylation in patients receiving a sirolimus (19.5 ± 7.7) was significantly lower than in HC (50.1 ± 11.3, P < 0.001), tacrolimus (37.7 ± 15.7, P < 0.001) or cyclosporine treated patients (41.7 ± 11.7, P < 0.001). The p70S6K phosphorylation in HC (50.1 ± 11.3) was significantly higher than in tacrolimus (37.7 ± 15.7, P < 0.01) or cyclosporine-treated patients (41.7 ± 11.7, P < 0.01). There was correlation between data from phospho-flow cytometry and data from Western blotting (r = 0.88, P < 0.001). Conclusions: The degree of mTOR inhibition by assessing p70S6K phosphorylation was established by phospho-flow cytometry and Western blotting. Assessment of p70S6K phosphorylation may play an adjunct role to on pharmacodynamically guide and individualize sirolimus based on immunosuppression.
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Affiliation(s)
| | - Hua Fan
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
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28
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Ruiz J, Herrero MJ, Bosó V, Megías JE, Hervás D, Poveda JL, Escrivá J, Pastor A, Solé A, Aliño SF. Impact of Single Nucleotide Polymorphisms (SNPs) on Immunosuppressive Therapy in Lung Transplantation. Int J Mol Sci 2015; 16:20168-82. [PMID: 26307985 PMCID: PMC4613195 DOI: 10.3390/ijms160920168] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 07/13/2015] [Accepted: 08/13/2015] [Indexed: 01/08/2023] Open
Abstract
Lung transplant patients present important variability in immunosuppressant blood concentrations during the first months after transplantation. Pharmacogenetics could explain part of this interindividual variability. We evaluated SNPs in genes that have previously shown correlations in other kinds of solid organ transplantation, namely ABCB1 and CYP3A5 genes with tacrolimus (Tac) and ABCC2, UGT1A9 and SLCO1B1 genes with mycophenolic acid (MPA), during the first six months after lung transplantation (51 patients). The genotype was correlated to the trough blood drug concentrations corrected for dose and body weight (C0/Dc). The ABCB1 variant in rs1045642 was associated with significantly higher Tac concentration, at six months post-transplantation (CT vs. CC). In the MPA analysis, CT patients in ABCC2 rs3740066 presented significantly lower blood concentrations than CC or TT, three months after transplantation. Other tendencies, confirming previously expected results, were found associated with the rest of studied SNPs. An interesting trend was recorded for the incidence of acute rejection according to NOD2/CARD15 rs2066844 (CT: 27.9%; CC: 12.5%). Relevant SNPs related to Tac and MPA in other solid organ transplants also seem to be related to the efficacy and safety of treatment in the complex setting of lung transplantation.
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Affiliation(s)
- Jesus Ruiz
- Unidad de Farmacogenética, Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe, Av. Fernando Abril Martorell 106, 46010 Valencia, Spain.
- Servicio de Farmacia, Hospital Universitario y Politécnico La Fe, Av. Fernando Abril Martorell 106, 46010 Valencia, Spain.
| | - María José Herrero
- Unidad de Farmacogenética, Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe, Av. Fernando Abril Martorell 106, 46010 Valencia, Spain.
- Departamento Farmacología, Facultad de Medicina, Universidad de Valencia, Av. Blasco Ibáñez 15, 46010 Valencia, Spain.
| | - Virginia Bosó
- Unidad de Farmacogenética, Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe, Av. Fernando Abril Martorell 106, 46010 Valencia, Spain.
- Servicio de Farmacia, Hospital Universitario y Politécnico La Fe, Av. Fernando Abril Martorell 106, 46010 Valencia, Spain.
| | - Juan Eduardo Megías
- Unidad de Farmacogenética, Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe, Av. Fernando Abril Martorell 106, 46010 Valencia, Spain.
- Servicio de Farmacia, Hospital Universitario y Politécnico La Fe, Av. Fernando Abril Martorell 106, 46010 Valencia, Spain.
| | - David Hervás
- Unidad de Bioestadística, Instituto Investigación Sanitaria La Fe. Av. Fernando Abril Martorell 106, 46010 Valencia, Spain.
| | - Jose Luis Poveda
- Servicio de Farmacia, Hospital Universitario y Politécnico La Fe, Av. Fernando Abril Martorell 106, 46010 Valencia, Spain.
| | - Juan Escrivá
- Unidad de Trasplante Pulmonar, Hospital Universitario y Politécnico La Fe, Av. Fernando Abril Martorell 106, 46010 Valencia, Spain.
| | - Amparo Pastor
- Unidad de Trasplante Pulmonar, Hospital Universitario y Politécnico La Fe, Av. Fernando Abril Martorell 106, 46010 Valencia, Spain.
| | - Amparo Solé
- Unidad de Trasplante Pulmonar, Hospital Universitario y Politécnico La Fe, Av. Fernando Abril Martorell 106, 46010 Valencia, Spain.
| | - Salvador Francisco Aliño
- Unidad de Farmacogenética, Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe, Av. Fernando Abril Martorell 106, 46010 Valencia, Spain.
- Departamento Farmacología, Facultad de Medicina, Universidad de Valencia, Av. Blasco Ibáñez 15, 46010 Valencia, Spain.
- Unidad de Farmacología Clínica, Área Clínica del Medicamento, Hospital Universitario y Politécnico La Fe, Av. Fernando Abril Martorell 106, 46010 Valencia, Spain.
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29
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CYP3A5*3 and POR*28 genetic variants influence the required dose of tacrolimus in heart transplant recipients. Ther Drug Monit 2015; 36:710-5. [PMID: 24739669 DOI: 10.1097/ftd.0000000000000080] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND After heart transplantation (HTx), the interindividual pharmacokinetic variability of immunosuppressive drugs represents a major therapeutic challenge due to the narrow therapeutic window between over-immunosuppression causing toxicity and under-immunosuppression leading to graft rejection. Although genetic polymorphisms have been shown to influence pharmacokinetics of immunosuppressants, data in the context of HTx are scarce. We thus assessed the role of genetic variation in CYP3A4, CYP3A5, POR, NR1I2, and ABCB1 acting jointly in immunosuppressive drug pathways in tacrolimus (TAC) and ciclosporin (CSA) dose requirement in HTx recipients. METHODS Associations between 7 functional genetic variants and blood dose-adjusted trough (C0) concentrations of TAC and CSA at 1, 3, 6, and 12 months after HTx were evaluated in cohorts of 52 and 45 patients, respectively. RESULTS Compared with CYP3A5 nonexpressors (*3/*3 genotype), CYP3A5 expressors (*1/*3 or *1/*1 genotype) required around 2.2- to 2.6-fold higher daily TAC doses to reach the targeted C0 concentration at all studied time points (P ≤ 0.003). Additionally, the POR*28 variant carriers showed higher dose-adjusted TAC-C0 concentrations at all time points resulting in significant differences at 3 (P = 0.025) and 6 months (P = 0.047) after HTx. No significant associations were observed between the genetic variants and the CSA dose requirement. CONCLUSIONS The CYP3A5*3 variant has a major influence on the required TAC dose in HTx recipients, whereas the POR*28 may additionally contribute to the observed variability. These results support the importance of genetic markers in TAC dose optimization after HTx.
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A simple and robust LC-MS/MS method for measuring sirolimus and everolimus in whole blood. Bioanalysis 2015; 6:1597-604. [PMID: 25077621 DOI: 10.4155/bio.14.43] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Therapeutic drug monitoring of immunosuppressants sirolimus and everolimus is mandatory and liquid chromatography tandem mass spectrometry (LC-MS/MS) is the preferred technology for the measurement. Due to the high hydrophobicity these analytes bind to reverse-phase columns tightly and need column heating to elute. Column heating not only requires extra instrument preparation but also causes permanent column damage if the heater is left on while elution pumps stop by the end of the run. The primary improvement in the current method was to elute the analytes at room temperature using special buffers. This new LC-MS/MS method has been validated for clinical use and offers improved simplicity and robustness by eliminating column heating yet with high sensitivity, precision and accuracy.
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Fukuda A, Imadome KI, Sakamoto S, Shigeta T, Uchida H, Matsunami M, Sasaki K, Kanazawa H, Kawano F, Nakazawa A, Fujiwara S, Kasahara M. Evaluation of the immune function assay in pediatric living donor liver transplantation. Pediatr Transplant 2015; 19:144-52. [PMID: 25418834 DOI: 10.1111/petr.12402] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2014] [Indexed: 12/22/2022]
Abstract
The immune function (ImmuKnow) assay is a measure of cell-mediated immunity based on the peripheral CD4+ T cell ATP activity. The efficacy of ImmuKnow in pediatric LDLT is not well documented. The aim of this study was to assess the correlations between the ImmuKnow and the clinical status in pediatric LDLT recipients. A total of 716 blood samples were obtained from 60 pediatric LDLT recipients (one month to 16 yr of age). The recipient's status was classified as follows: stable, infection, or rejection. The ImmuKnow values in the pediatric LDLT recipients with a clinically stable status had a lower immune response (IQR 85-297 ATP ng/mL) than that previously reported in adults. Meanwhile, the ImmuKnow values of the stable patients were not correlated with age. Furthermore, a significant difference was found in the ImmuKnow values between the bacterial or fungal infection and stable groups, but not between the CMV or EBV infection and stable groups. The ImmuKnow levels in the pediatric LDLT were lower than those observed in the adult LDLT. The proposed reference value is between 85 and 297 ATP ng/mL in pediatric LDLT recipients. We conclude that the ImmuKnow assay could be helpful for monitoring pediatric LDLT recipients with bacterial or fungal infections.
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Affiliation(s)
- Akinari Fukuda
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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Proactive therapeutic concentration monitoring of infliximab may improve outcomes for patients with inflammatory bowel disease: results from a pilot observational study. Inflamm Bowel Dis 2014; 20:1996-2003. [PMID: 25192499 PMCID: PMC5557346 DOI: 10.1097/mib.0000000000000156] [Citation(s) in RCA: 176] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Infliximab (IFX) is effective in the treatment of inflammatory bowel disease; however, the effect is often not durable. It is unknown if proactive therapeutic concentration monitoring (TCM) of IFX improves outcomes. METHODS This is a retrospective observational study examining the use of proactive TCM and titration of IFX to a target concentration for patients with inflammatory bowel disease in clinical remission at a tertiary care center. The primary aim was to describe the clinical course of patients who had proactive TCM. A secondary analysis was done to assess if this strategy was superior to the standard of care. RESULTS Forty-eight patients were identified as having proactive TCM. Fifteen percent had an initial undetectable trough concentration. Twenty-five percent (12 of 48) of patients escalated IFX after the first proactive TCM while 15% (7 of 48) of patients de-escalated IFX therapy over the study period. A control group of 78 patients was identified. Patients who had proactive TCM had a greater probability of remaining on IFX than controls (hazard ratio, 0.3; 95% confidence interval, 0.1-0.6; log rank test; P = 0.0006). The probability of remaining on IFX was greatest for patients who achieved a trough concentration >5 μg/mL (hazard ratio, 0.03; 95% confidence interval, 0.01-0.1; P < 0.0001 versus trough <5 μg/mL). Fewer patients in the proactive TCM group stopped IFX (10% versus 31%, P = 0.009). CONCLUSIONS In this pilot observational study, proactive TCM of IFX frequently identified patients with low or undetectable trough concentrations and resulted in a greater probability of remaining on IFX.
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Vaughn BP, Martinez-Vazquez M, Patwardhan VR, Moss AC, Sandborn WJ, Cheifetz AS. Proactive therapeutic concentration monitoring of infliximab may improve outcomes for patients with inflammatory bowel disease: results from a pilot observational study. Inflamm Bowel Dis 2014. [PMID: 25192499 DOI: 10.1987/mib.0000000000000156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Infliximab (IFX) is effective in the treatment of inflammatory bowel disease; however, the effect is often not durable. It is unknown if proactive therapeutic concentration monitoring (TCM) of IFX improves outcomes. METHODS This is a retrospective observational study examining the use of proactive TCM and titration of IFX to a target concentration for patients with inflammatory bowel disease in clinical remission at a tertiary care center. The primary aim was to describe the clinical course of patients who had proactive TCM. A secondary analysis was done to assess if this strategy was superior to the standard of care. RESULTS Forty-eight patients were identified as having proactive TCM. Fifteen percent had an initial undetectable trough concentration. Twenty-five percent (12 of 48) of patients escalated IFX after the first proactive TCM while 15% (7 of 48) of patients de-escalated IFX therapy over the study period. A control group of 78 patients was identified. Patients who had proactive TCM had a greater probability of remaining on IFX than controls (hazard ratio, 0.3; 95% confidence interval, 0.1-0.6; log rank test; P = 0.0006). The probability of remaining on IFX was greatest for patients who achieved a trough concentration >5 μg/mL (hazard ratio, 0.03; 95% confidence interval, 0.01-0.1; P < 0.0001 versus trough <5 μg/mL). Fewer patients in the proactive TCM group stopped IFX (10% versus 31%, P = 0.009). CONCLUSIONS In this pilot observational study, proactive TCM of IFX frequently identified patients with low or undetectable trough concentrations and resulted in a greater probability of remaining on IFX.
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Affiliation(s)
- Byron P Vaughn
- *Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and †Division of Gastroenterology, University of California San Diego, La Jolla, California
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Current and Future Status of Therapeutic Drug Monitoring in the Treatment of IBD. ACTA ACUST UNITED AC 2014; 12:76-89. [DOI: 10.1007/s11938-013-0005-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Ciclosporin Population Pharmacokinetics and Bayesian Estimation in Thoracic Transplant Recipients. Clin Pharmacokinet 2013; 52:277-88. [DOI: 10.1007/s40262-013-0037-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Kunimoto Y, Yasui H, Touda N, Okazaki M, Nakata H, Noda N, Ikeda H, Hayashi T, Takahashi S, Shinomura Y, Ishida T, Miyamoto A. Coadministration of tenofovir decreased atazanavir plasma concentration after unilateral nephrectomy. J Infect Chemother 2013; 19:750-3. [DOI: 10.1007/s10156-012-0488-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 09/18/2012] [Indexed: 10/27/2022]
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Gao B, Yeap S, Clements A, Balakrishnar B, Wong M, Gurney H. Evidence for Therapeutic Drug Monitoring of Targeted Anticancer Therapies. J Clin Oncol 2012; 30:4017-25. [DOI: 10.1200/jco.2012.43.5362] [Citation(s) in RCA: 158] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Therapeutic drug monitoring (TDM) provides valuable guidance for dose adjustment of antibiotics, immunosuppressives, antiepileptics, and other drugs, but its use for traditional anticancer therapies has been limited. Perhaps the most important obstacle is the impractical requirement of multiple blood samples to adequately define systemic exposure of drugs that have a short elimination half-life and are given by intermittent intravenous injections. However, the newer targeted anticancer therapies have different pharmacokinetic (PK) and dosing characteristics compared with traditional cytotoxic drugs, making it possible to estimate the steady-state drug exposure with a single trough-level measurement. Recent evidence indicates that certain PK parameters, including trough levels, are correlated with clinical outcomes for many of these agents, including imatinib, sunitinib, rituximab, and cetuximab. Although the current evidence is insufficient to mandate TDM in routine practice, a concerted investigation should be encouraged to determine whether the steady-state trough measurements of targeted agents will have a practical place in the clinical care of patients with cancer.
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Affiliation(s)
- Bo Gao
- Bo Gao, Arthur Clements, Bavanthi Balakrishnar, Mark Wong, and Howard Gurney, Westmead Hospital, Westmead; Bo Gao and Howard Gurney, University of Sydney, Sydney, New South Wales, Australia; and Shang Yeap, Johns Hopkins Hospital,Singapore
| | - Shang Yeap
- Bo Gao, Arthur Clements, Bavanthi Balakrishnar, Mark Wong, and Howard Gurney, Westmead Hospital, Westmead; Bo Gao and Howard Gurney, University of Sydney, Sydney, New South Wales, Australia; and Shang Yeap, Johns Hopkins Hospital,Singapore
| | - Arthur Clements
- Bo Gao, Arthur Clements, Bavanthi Balakrishnar, Mark Wong, and Howard Gurney, Westmead Hospital, Westmead; Bo Gao and Howard Gurney, University of Sydney, Sydney, New South Wales, Australia; and Shang Yeap, Johns Hopkins Hospital,Singapore
| | - Bavanthi Balakrishnar
- Bo Gao, Arthur Clements, Bavanthi Balakrishnar, Mark Wong, and Howard Gurney, Westmead Hospital, Westmead; Bo Gao and Howard Gurney, University of Sydney, Sydney, New South Wales, Australia; and Shang Yeap, Johns Hopkins Hospital,Singapore
| | - Mark Wong
- Bo Gao, Arthur Clements, Bavanthi Balakrishnar, Mark Wong, and Howard Gurney, Westmead Hospital, Westmead; Bo Gao and Howard Gurney, University of Sydney, Sydney, New South Wales, Australia; and Shang Yeap, Johns Hopkins Hospital,Singapore
| | - Howard Gurney
- Bo Gao, Arthur Clements, Bavanthi Balakrishnar, Mark Wong, and Howard Gurney, Westmead Hospital, Westmead; Bo Gao and Howard Gurney, University of Sydney, Sydney, New South Wales, Australia; and Shang Yeap, Johns Hopkins Hospital,Singapore
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Malesker MA, Morrow LE. Monitoring immunosuppressive medications for lung disease and lung transplantation: the time is now. Chest 2012; 142:1081-1082. [PMID: 23131927 DOI: 10.1378/chest.12-1656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Mark A Malesker
- Department of Pharmacy Practice and Medicine, Creighton University, Omaha, NE.
| | - Lee E Morrow
- Department of Pharmacy Practice and Medicine, Creighton University, Omaha, NE
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Harrison JJ, Wang J, Cervenko J, Jackson L, Munyal D, Hamandi B, Chernenko S, Dorosz J, Chaparro C, Singer LG. Pilot study of a pharmaceutical care intervention in an outpatient lung transplant clinic. Clin Transplant 2012; 26:E149-57. [PMID: 22507355 DOI: 10.1111/j.1399-0012.2012.01623.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Lung transplant recipients have complex drug regimens. Study objectives were to assess drug therapy problems (DTPs), pharmacist recommendations, and patient satisfaction with pharmacist services. METHODS Using a pharmaceutical care assessment process, pharmacists identified DTPs and made therapeutic recommendations. Number of DTPs identified per pharmacist visit was calculated and compared to standard care visits through retrospective chart review. Potential clinical impact of recommendations was evaluated by blinded clinicians. Patient satisfaction was assessed via survey. RESULTS Fifty-five DTPs were identified in 43 patients over 50 pharmacist visits (1.05 ± 1.34 DTPs per visit). In these same patients, rate of DTP identification was 0.51 ± 0.64 DTPs per standard visit in the preceding two-wk period (p = 0.018 vs. pharmacist visit). The most common DTPs identified by the pharmacist were adverse drug effect (27%) and untreated indication (25%). Overall, 62% of pharmacist recommendations were rated very significant or significant. Survey return rate was 58% and satisfaction scores ranged from 3 to 5 out of 5. Review of medications and teaching regarding the use of medications received the most "very satisfied" and "highly important" scores. CONCLUSIONS Pharmacists can make valuable contributions in a lung transplant clinic setting by identifying DTPs and making recommendations with a positive impact on patient outcomes and satisfaction.
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Affiliation(s)
- Jennifer J Harrison
- Department of Pharmacy Services, Toronto General Hospital, University Health Network, Toronto, ON, Canada.
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Monchaud C, de Winter BC, Knoop C, Estenne M, Reynaud-Gaubert M, Pison C, Stern M, Kessler R, Guillemain R, Marquet P, Rousseau A. Population Pharmacokinetic Modelling and Design of a Bayesian Estimator for Therapeutic Drug Monitoring of Tacrolimus in Lung Transplantation. Clin Pharmacokinet 2012; 51:175-86. [DOI: 10.2165/11594760-000000000-00000] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Söllner J, Mayer P, Heinzel A, Fechete R, Siehs C, Oberbauer R, Mayer B. Synthetic lethality for linking the mycophenolate mofetil mode of action with molecular disease and drug profiles. MOLECULAR BIOSYSTEMS 2012; 8:3197-207. [DOI: 10.1039/c2mb25256b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Dieterlen MT, Bittner HB, Klein S, von Salisch S, Mittag A, Tárnok A, Dhein S, Mohr FW, Barten MJ. Assay validation of phosphorylated S6 ribosomal protein for a pharmacodynamic monitoring of mTOR-inhibitors in peripheral human blood. CYTOMETRY PART B-CLINICAL CYTOMETRY 2011; 82:151-7. [DOI: 10.1002/cyto.b.21005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 11/24/2011] [Accepted: 11/30/2011] [Indexed: 11/10/2022]
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Abstract
Immunosuppressive therapy has contributed significantly to improved survival after solid organ transplantation. Nevertheless, treatment-related adverse events and persistently high risk of chronic graft rejection remain major obstacles to long-term survival after lung transplantation. The development of new agents, refinements in techniques to monitor immunosuppression, and enhanced understanding of transplant immunobiology are essential for further improvements in outcome. In this article, conventional immunosuppressive regimens, novel approaches to preventing graft rejection, and investigational agents for solid organ transplantation are reviewed.
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Affiliation(s)
- Timothy Floreth
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
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Knoop C, Dumonceaux M, Rondelet B, Estenne M. Complications de la transplantation pulmonaire : complications médicales. Rev Mal Respir 2010; 27:365-82. [DOI: 10.1016/j.rmr.2010.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2009] [Accepted: 12/16/2009] [Indexed: 02/06/2023]
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Knoop C, Rondelet B, Dumonceaux M, Estenne M. [Medical complications of lung transplantation]. REVUE DE PNEUMOLOGIE CLINIQUE 2010; 67:28-49. [PMID: 21353971 DOI: 10.1016/j.pneumo.2010.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Accepted: 08/15/2010] [Indexed: 05/30/2023]
Abstract
In 2010, lung transplantation is a valuable therapeutic option for a number of patients suffering from of end-stage non-neoplastic pulmonary diseases. The patients frequently regain a very good quality of life, however, long-term survival is often hampered by the development of complications such as the bronchiolitis obliterans syndrome, metabolic and infectious complications. As the bronchiolitis obliterans syndrome is the first cause of death in the medium and long term, an intense immunosuppressive treatment is maintained for life in order to prevent or stabilize this complication. The immunosuppression on the other hand induces a number of potentially severe complications including metabolic complications, infections and malignancies. The most frequent metabolic complications are arterial hypertension, chronic renal insufficiency, diabetes, hyperlipidemia and osteoporosis. Bacterial, viral and fungal infections are the second cause of mortality. They are to be considered as medical emergencies and require urgent assessment and targeted therapy after microbiologic specimens have been obtained. They should not, under any circumstances, be treated empirically and it has also to be kept in mind that the lung transplant recipient may present several concomitant infections. The most frequent malignancies are skin cancers, the post-transplant lymphoproliferative disorders, Kaposi's sarcoma and some types of bronchogenic carcinomas, head/neck and digestive cancers. Lung transplantation is no longer an exceptional procedure; thus, the pulmonologist will be confronted with such patients and should be able to recognize the symptoms and signs of the principal non-surgical complications. The goal of this review is to give a general overview of the most frequently encountered complications. Their assessment and treatment, though, will most often require the input of other specialists and a multidisciplinary and transversal approach.
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Affiliation(s)
- C Knoop
- Unité de transplantation cardiaque et pulmonaire (UTCP), service de pneumologie, hôpital universitaire Érasme, Bruxelles, Belgique.
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