1
|
Le Merdy M, Szeto KX, Perrier J, Bolger MB, Lukacova V. PBPK Modeling Approach to Predict the Behavior of Drugs Cleared by Metabolism in Pregnant Subjects and Fetuses. Pharmaceutics 2024; 16:96. [PMID: 38258106 PMCID: PMC10820132 DOI: 10.3390/pharmaceutics16010096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 01/24/2024] Open
Abstract
This study aimed to develop a physiologically based pharmacokinetic (PBPK) model that simulates metabolically cleared compounds' pharmacokinetics (PK) in pregnant subjects and fetuses. This model accounts for the differences in tissue sizes, blood flow rates, enzyme expression levels, plasma protein binding, and other physiological factors affecting the drugs' PK in both the pregnant woman and the fetus. The PBPKPlus™ module in GastroPlus® was used to model the PK of metoprolol, midazolam, and metronidazole for both non-pregnant and pregnant groups. For each of the three compounds, the model was first developed and validated against PK data in healthy non-pregnant volunteers and then applied to predict the PK in the pregnant groups. The model accurately described the PK in both the non-pregnant and pregnant groups and explained well the differences in the plasma concentration due to pregnancy. When available, the fetal plasma concentration, placenta, and fetal tissue concentrations were also predicted reasonably well at different stages of pregnancy. The work described the use of a PBPK approach for drug development and demonstrates the ability to predict differences in PK in pregnant subjects and fetal exposure for metabolically cleared compounds.
Collapse
Affiliation(s)
- Maxime Le Merdy
- Simulations Plus, Inc., 42505 10th Street West, Lancaster, CA 93534, USA
| | - Ke Xu Szeto
- Simulations Plus, Inc., 42505 10th Street West, Lancaster, CA 93534, USA
| | - Jeremy Perrier
- PhinC Development, 36 Rue Victor Basch, 91300 Massy, France
| | - Michael B Bolger
- Simulations Plus, Inc., 42505 10th Street West, Lancaster, CA 93534, USA
| | - Viera Lukacova
- Simulations Plus, Inc., 42505 10th Street West, Lancaster, CA 93534, USA
| |
Collapse
|
2
|
Coppola P, Kerwash E, Cole S. Use of Physiologically Based Pharmacokinetic Modeling for Hepatically Cleared Drugs in Pregnancy: Regulatory Perspective. J Clin Pharmacol 2023; 63 Suppl 1:S62-S80. [PMID: 37317504 DOI: 10.1002/jcph.2266] [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: 11/29/2022] [Accepted: 04/18/2023] [Indexed: 06/16/2023]
Abstract
Physiologically based pharmacokinetic modeling could be used to predict changes in exposure during pregnancy and possibly inform medicine use in pregnancy in situations in which there is currently limited or no available clinical PK data. The Medicines and Healthcare Product Regulatory Agency has been evaluating the available models for a number of medicines cleared by hepatic clearance mechanisms. Models were evaluated for metoprolol, tacrolimus, clindamycin, ondansetron, phenytoin, caffeine, fluoxetine, clozapine, carbamazepine, metronidazole, and paracetamol. The hepatic metabolism through cytochrome P450 (CYP) contributes significantly to the elimination of these drugs, and available knowledge of CYP changes during pregnancy has been implemented in the existing pregnancy physiology models. In general, models were able to capture trends in exposure changes in pregnancy to some extent, but the magnitude of pharmacokinetic change for these hepatically cleared drugs was not captured in each case, nor were models always able to capture overall exposure in the populations. A thorough evaluation was hampered by the lack of clinical data for drugs cleared by a specific clearance pathway. The limited clinical data, as well as complex elimination pathways involving CYPs, uridine 5'-diphospho-glucuronosyltransferase and active transporter for many drugs, currently limit the confidence in the prospective use of the models. Pregnancy-related changes in uridine 5'-diphospho-glucuronosyltransferase and transport functions are emerging, and incorporation of such changes in current physiologically based pharmacokinetic modeling software is in progress. Filling this gap is expected to further enhance predictive performance of models and increase the confidence in predicting PK changes in pregnant women for hepatically cleared drugs.
Collapse
Affiliation(s)
- Paola Coppola
- Medicines and Healthcare Products Regulatory Agency (MHRA), London, UK
| | - Essam Kerwash
- Medicines and Healthcare Products Regulatory Agency (MHRA), London, UK
| | - Susan Cole
- Medicines and Healthcare Products Regulatory Agency (MHRA), London, UK
| |
Collapse
|
3
|
Understanding the pharmacokinetics of antibiotics in pregnancy: Is there a role for therapeutic drug monitoring? A narrative review. Ther Drug Monit 2021; 44:50-64. [PMID: 34897239 DOI: 10.1097/ftd.0000000000000950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/03/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Antibiotics are commonly used during pregnancy. However, physiological changes during pregnancy can affect the pharmacokinetics of drugs, including antibiotics, used during this period. Pharmacokinetic evaluations have shed light on how antibiotics are affected during pregnancy and have influenced dosing recommendations in this context. Methods: A narrative review was conducted and included reports providing data reflecting drug distribution and exposure in the context of pregnancy. Results: Pharmacokinetic parameters of antibiotics in pregnancy and transplacental passage of antibiotics are comprehensively presented. Conclusion: Knowledge about the impact on pharmacokinetics and fetal exposure is especially helpful for complicated or severe infections, including intra-amniotic infection and sepsis in pregnancy, where both mother and fetus are at risk. Further studies are warranted to consolidate the role of therapeutic drug monitoring in complicated or severe infections in pregnant patients.
Collapse
|
4
|
Ajiji P, Uzunali A, Ripoche E, Vittaz E, Vial T, Maison P. Investigating the efficacy and safety of metronidazole during pregnancy; A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol X 2021; 11:100128. [PMID: 34136799 PMCID: PMC8176309 DOI: 10.1016/j.eurox.2021.100128] [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: 03/16/2021] [Accepted: 05/12/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE We aimed to review and analyze studies focusing on the efficacy of metronidazole in reducing the risk of preterm birth and the safety of metronidazole taking into account the different doses, duration of treatment and routes of administration. STUDY DESIGNS Embase, Cochrane Library and PubMed were searched up to 29 July 2019 to identify studies assessing metronidazole exposure during pregnancy. Additional studies were identified from reference lists of retrieved papers. Measured outcomes were preterm births (<37 weeks of gestation) and associated delivery outcomes such as spontaneous abortions (≤ 20 weeks of gestation), stillbirths (≥20 weeks of gestation) and low birth weight (<2500 g) irrespective of the period of exposure and major malformations after first-trimester exposure. Overall effect estimates for RCTs and observational studies were calculated using the random-effects model and pooled using Risk Ratios (RR) and Odds Ratios (OR) respectively. ROB-2 and ROBINS-I tool were used to assess Risk of Bias for RCTs and observational studies, respectively. RESULTS Twenty-four studies (17 observational studies and 7 RCTs) were selected. Pooled RR was 1.10 (95 % CI 0.78-1.55; n = 7; I2 = 72 %) for preterm birth. Subgroup analysis found RR 1.67; 95 % CI 1.07-2.62; n = 3; I² = 32 %) for treatment duration of ≤3 days among women with a previous preterm delivery. Pooled OR for spontaneous abortion was 1.72 (95 % CI 1.40-2.12; n = 5; I2 = 72 %) and 1.15 (95 % CI 0.98-1.34; n = 12; I2 = 25 %) for major malformations. After exclusion of studies with critical risk of bias, pooled OR were 1.7 (1.42-2.04; n = 3; I2 = 19 %) and 1.13 (0.93-1.36; n = 9; I2 = 28 %) respectively. Among several specific malformations analyzed, only congenital hydrocephaly was significantly increased at 4.06 (95 % CI 1.75-9.42; n = 2; I² = 0%). CONCLUSIONS Data do not confirm the efficacy of metronidazole in reducing the risk of preterm birth and associated delivery outcomes. Further research is required to confirm the effect of high dose and short duration of metronidazole treatment on preterm birth among the high-risk group. Regarding the increased odds of spontaneous abortion, RCTs are required to assess the role of the underlying infection. The need for further studies to confirm the risk of congenital hydrocephaly is paramount.
Collapse
Affiliation(s)
- Priscilla Ajiji
- Agence Nationale de Sécurité du Médicament et des Produits de santé (ANSM), France
- EA 7379, EpiDermE Faculté de Santé, Université Paris-Est Créteil, France
| | - Anil Uzunali
- Agence Nationale de Sécurité du Médicament et des Produits de santé (ANSM), France
| | - Emmanuelle Ripoche
- Agence Nationale de Sécurité du Médicament et des Produits de santé (ANSM), France
| | - Emilie Vittaz
- Agence Nationale de Sécurité du Médicament et des Produits de santé (ANSM), France
| | - Thierry Vial
- Service Hospitalo-Universitaire de Pharmacotoxicologie, CHU-Lyon, Lyon, France
| | - Patrick Maison
- Agence Nationale de Sécurité du Médicament et des Produits de santé (ANSM), France
- EA 7379, EpiDermE Faculté de Santé, Université Paris-Est Créteil, France
| |
Collapse
|
5
|
Ren Z, Bremer AA, Pawlyk AC. Drug development research in pregnant and lactating women. Am J Obstet Gynecol 2021; 225:33-42. [PMID: 33887238 DOI: 10.1016/j.ajog.2021.04.227] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/08/2021] [Accepted: 04/11/2021] [Indexed: 12/15/2022]
Abstract
Pregnant and lactating women are considered "therapeutic orphans" because they generally have been excluded from clinical drug research and the drug development process owing to legal, ethical, and safety concerns. Most medications prescribed for pregnant and lactating women are used "off-label" because most of the clinical approved medications do not have appropriate drug labeling information for pregnant and lactating women. Medications that lack human safety data on use during pregnancy and lactation may pose potential risks for adverse effects in pregnant and lactating women as well as risks of teratogenic effects to their unborn and newborn babies. Federal policy requiring the inclusion of women in clinical research and trials led to considerable changes in research design and practice. Despite more women being included in clinical research and trials, the inclusion of pregnant and lactating women in drug research and clinical trials remains limited. A recent revision to the "Common Rule" that removed pregnant women from the classification as a "vulnerable" population may change the culture of drug research and drug development in pregnant and lactating women. This review article provides an overview of medications studied by the Obstetric-Fetal Pharmacology Research Units Network and Centers and describes the challenges in current obstetrical pharmacology research and alternative strategies for future research in precision therapeutics in pregnant and lactating women. Implementation of the recommendations of the Task Force on Research Specific to Pregnant Women and Lactating Women can provide legislative requirements and opportunities for research focused on pregnant and lactating women.
Collapse
Affiliation(s)
- Zhaoxia Ren
- Obstetric and Pediatric Pharmacology and Therapeutics Branch, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD.
| | - Andrew A Bremer
- Pediatric Growth and Nutrition Branch, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD; Pregnancy and Perinatology Branch, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Aaron C Pawlyk
- Obstetric and Pediatric Pharmacology and Therapeutics Branch, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| |
Collapse
|
6
|
Hazenberg P, Navaratnam K, Busuulwa P, Waitt C. Anti-Infective Dosing in Special Populations: Pregnancy. Clin Pharmacol Ther 2021; 109:977-986. [PMID: 33548055 DOI: 10.1002/cpt.2192] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/28/2021] [Indexed: 12/29/2022]
Abstract
Substantial anatomical and physiological changes occur during pregnancy and labor, which impact on drug absorption, distribution, metabolism, and elimination. Reduced maternal concentrations may have a clinically important impact on the efficacy of anti-infectives for mother, fetus, and neonate, with potential dosing implications. However, there is a paucity of pregnancy-specific data examining this. Existing data on the pharmacokinetics of anti-infectives in pregnancy are summarized and evaluated, with emphasis on agents that are used in treatment of HIV, tuberculosis, malaria, and common bacterial infections. Limitations and challenges in achieving ideal study designs in pregnant populations are highlighted, and key quality considerations for the generation of the highest quality evidence are outlined. PubMed was searched for each chosen anti-infective. Pharmacokinetic studies which either compared pharmacokinetics from pregnant women against nonpregnant controls, or which assessed concentrations against a known minimum inhibitory concentration were included. Two independent reviewers extracted data from each study and appraised them using the 24-point ClinPK Checklist. The main finding was that there is a lack of published data for anti-infectives in pregnancy, despite their clinical importance. Of the studies identified, only those investigating cobicistat-boosted antiretroviral regimens firmly concluded that these should not be used in pregnancy. Most studies concluded either that further research was needed, or that there were significant pharmacokinetic differences between pregnant and nonpregnant participants which had uncertain clinical significance. Challenges in applying existing quality grading systems to these studies were noted, suggesting a development of a refined system for appraisal of pharmacokinetic studies in "special populations" may be warranted.
Collapse
Affiliation(s)
- Phoebe Hazenberg
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Kate Navaratnam
- Centre for Women's Health Research, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Paula Busuulwa
- Centre for Women's Health Research, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Catriona Waitt
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular & Integrative Biology, University of Liverpool, Liverpool, UK.,Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| |
Collapse
|
7
|
Ansari J, Carvalho B, Shafer SL, Flood P. Pharmacokinetics and Pharmacodynamics of Drugs Commonly Used in Pregnancy and Parturition. Anesth Analg 2016; 122:786-804. [DOI: 10.1213/ane.0000000000001143] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
|
8
|
Padberg S. Anti-infective Agents. DRUGS DURING PREGNANCY AND LACTATION 2015. [PMCID: PMC7150338 DOI: 10.1016/b978-0-12-408078-2.00007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
|
9
|
Abstract
Pregnancy is associated with a variety of physiological changes that can alter the pharmacokinetics and pharmacodynamics of several drugs. However, limited data exists on the pharmacokinetics and pharmacodynamics of the majority of the medications used in pregnancy. In this article, we first describe basic concepts (drug absorption, bioavailability, distribution, metabolism, elimination, and transport) in pharmacokinetics. Then, we discuss several physiological changes that occur during pregnancy that theoretically affect absorption, distribution, metabolism, and elimination. Further, we provide a brief review of the literature on the clinical pharmacokinetic studies performed in pregnant women in recent years. In general, pregnancy increases the clearance of several drugs and correspondingly decreases drug exposure during pregnancy. Based on current drug exposure measurements during pregnancy, alterations in the dose or dosing regimen of certain drugs are essential during pregnancy. More pharmacological studies in pregnant women are needed to optimize drug therapy in pregnancy.
Collapse
Affiliation(s)
- Yang Zhao
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, 718 Salk Hall, 3501 Terrace St, Pittsburgh, PA 15261
| | - Mary F. Hebert
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA,Department of Obstetrics and Gynecology, School of Medicine University of Washington, Seattle, WA
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, 718 Salk Hall, 3501 Terrace St, Pittsburgh, PA 15261; Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA; Thomas Starzl Transplantation Institute, Pittsburgh, PA; McGovern Institute for Regenerative Medicine, Pittsburgh, PA; Magee Womens Research Institute, Pittsburgh, PA.
| |
Collapse
|
10
|
McCormack SA, Best BM. Obstetric Pharmacokinetic Dosing Studies are Urgently Needed. Front Pediatr 2014; 2:9. [PMID: 24575394 PMCID: PMC3920104 DOI: 10.3389/fped.2014.00009] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 01/26/2014] [Indexed: 12/28/2022] Open
Abstract
Use of pharmacotherapy during pregnancy is common and increasing. Physiologic changes during pregnancy may significantly alter the overall systemic drug exposure, necessitating dose changes. A search of PubMed for pharmacokinetic clinical trials showed 494 publications during pregnancy out of 35,921 total pharmacokinetic published studies (1.29%), from the late 1960s through August 31, 2013. Closer examination of pharmacokinetic studies in pregnant women published since 2008 (81 studies) revealed that about a third of the trials were for treatment of acute labor and delivery issues, a third included studies of infectious disease treatment during pregnancy, and the remaining third were for varied ante-partum indications. Approximately, two-thirds of these recent studies were primarily funded by government agencies worldwide, one-quarter were supported by private non-profit foundations or combinations of government and private funding, and slightly <10% were supported by pharmaceutical industry. As highlighted in this review, vast gaps exist in pharmacology information and evidence for appropriate dosing of medications in pregnant women. This lack of knowledge and understanding of drug disposition throughout pregnancy place both the mother and the fetus at risk for avoidable therapeutic misadventures - suboptimal efficacy or excess toxicity - with medication use in pregnancy. Increased efforts to perform and support obstetric dosing and pharmacokinetic studies are greatly needed.
Collapse
Affiliation(s)
- Shelley A McCormack
- Pediatrics Department, School of Medicine, Rady Children's Hospital San Diego, University of California San Diego , San Diego, CA , USA
| | - Brookie M Best
- Pediatrics Department, School of Medicine, Rady Children's Hospital San Diego, University of California San Diego , San Diego, CA , USA ; Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego , La Jolla, CA , USA
| |
Collapse
|
11
|
Spezielle Arzneimitteltherapie in der Schwangerschaft. ARZNEIMITTEL IN SCHWANGERSCHAFT UND STILLZEIT 2012. [PMCID: PMC7271212 DOI: 10.1016/b978-3-437-21203-1.10002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|