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Yeung CHT, Verstegen RHJ, Greenberg R, Lewis TR. Pharmacokinetic and pharmacodynamic principles: unique considerations for optimal design of neonatal clinical trials. Front Pediatr 2024; 11:1345969. [PMID: 38283405 PMCID: PMC10811156 DOI: 10.3389/fped.2023.1345969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
Core clinical pharmacology principles must be considered when designing and executing neonatal clinical trials. In this review, the authors discuss important aspects of drug dose selection, pharmacokinetics, pharmacogenetics and pharmacodynamics that stakeholders may consider when undertaking a neonatal or infant clinical trial.
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Affiliation(s)
- Cindy Hoi Ting Yeung
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ruud H. J. Verstegen
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Rachel Greenberg
- Duke Clinical Research Institute, Durham, NC, United States
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Tamorah Rae Lewis
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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Arachchige DL, Dwivedi SK, Jaeger S, Olowolagba AM, Mahmoud M, Tucker DR, Fritz DR, Werner T, Tanasova M, Luck RL, Liu H. Highly Sensitive Cyanine Dyes for Rapid Sensing of NAD(P)H in Mitochondria and First-Instar Larvae of Drosophila melanogaster. ACS APPLIED BIO MATERIALS 2023; 6:3199-3212. [PMID: 37556116 PMCID: PMC10584401 DOI: 10.1021/acsabm.3c00320] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
We have developed two highly sensitive cyanine dyes, which we refer to as probes A and B. These dyes are capable of quick and sensitive sensing of NAD(P)H. The dyes were fabricated by connecting benzothiazolium and 2,3-dimethylnaphtho[1,2-d]thiazol-3-ium units to 3-quinolinium through a vinyl bond. In the absence of NAD(P)H, both probes have low fluorescence and absorption peaks at 370 and 400 nm, correspondingly. This is because of their two electron-withdrawing acceptor systems with high charge densities. However, when NAD(P)H reduces the probes' electron-withdrawing 3-quinolinium units to electron-donating 1,4-dihydroquinoline units, the probes absorb at 533 and 535 nm and fluoresce at 572 and 586 nm for A and B correspondingly. This creates well-defined donor-π-acceptor cyanine dyes. We successfully used probe A to monitor NAD(P)H levels in live cells during glycolysis, under hypoxic conditions induced by CoCl2 treatment and after treatment with cancer drugs, including cisplatin, camptothecin, and gemcitabine. Probe A was also employed to visualize NAD(P)H in Drosophila melanogaster first-instar larvae. We observed an increase in NAD(P)H levels in A549 cancer cells both under hypoxic conditions and after treatment with cancer drugs, including cisplatin, camptothecin, and gemcitabine.
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Affiliation(s)
- Dilka Liyana Arachchige
- Department of Chemistry, Michigan Technological University, Houghton, Michigan 49931, United States
- Department of Chemistry, and Health Research Institute, Michigan Technological University, Houghton, Michigan 49931, United States
| | - Sushil K Dwivedi
- Department of Chemistry, Michigan Technological University, Houghton, Michigan 49931, United States
- Department of Chemistry, and Health Research Institute, Michigan Technological University, Houghton, Michigan 49931, United States
| | - Sophia Jaeger
- Department of Chemistry, Michigan Technological University, Houghton, Michigan 49931, United States
- Department of Chemistry, and Health Research Institute, Michigan Technological University, Houghton, Michigan 49931, United States
| | - Adenike Mary Olowolagba
- Department of Chemistry, Michigan Technological University, Houghton, Michigan 49931, United States
- Department of Chemistry, and Health Research Institute, Michigan Technological University, Houghton, Michigan 49931, United States
| | - Mohamed Mahmoud
- Department of Chemistry, Michigan Technological University, Houghton, Michigan 49931, United States
- Department of Chemistry, and Health Research Institute, Michigan Technological University, Houghton, Michigan 49931, United States
| | - Daniel R Tucker
- Department of Chemistry, Michigan Technological University, Houghton, Michigan 49931, United States
| | - Delaney Raine Fritz
- Department of Biological Sciences, and Health Research Institute, Michigan Technological University, Houghton, Michigan 49931, United States
| | - Thomas Werner
- Department of Biological Sciences, and Health Research Institute, Michigan Technological University, Houghton, Michigan 49931, United States
| | - Marina Tanasova
- Department of Chemistry, Michigan Technological University, Houghton, Michigan 49931, United States
| | - Rudy L Luck
- Department of Chemistry, Michigan Technological University, Houghton, Michigan 49931, United States
| | - Haiying Liu
- Department of Chemistry, Michigan Technological University, Houghton, Michigan 49931, United States
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Association between Vancomycin Pharmacokinetic Parameters and Clinical and Microbiological Efficacy in a Cohort of Neonatal Patients. Antimicrob Agents Chemother 2022; 66:e0110922. [PMID: 36222533 PMCID: PMC9664865 DOI: 10.1128/aac.01109-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Vancomycin pharmacokinetic/pharmacodynamic (PK/PD) targets have not been validated in the neonatal population as no specifically designed studies are available. The main goal of this study was to analyze the therapeutic vancomycin regimen, the 24-h area under the curve (AUC24), and the trough plasma concentration (Ct) obtained that achieved clinical and microbiological effectiveness in a cohort of neonates. This was an observational, prospective, single-center study covering a period of 2 years. Eligible patients were neonates and young infants who were undergoing treatment with intravenous vancomycin for ≥72 h with ≥1 Ct available. The primary outcome was the association of Ct and AUC24 with clinical and microbiological efficacy at the beginning (early clinical evolution [ECE]) and the end (late clinical evolution [LCE]) of treatment with vancomycin. A total of 43 patients were included, 88.4% of whom were cured. In ECE, the cutoff points of the receiver operating characteristic (ROC) curve were 238 mg · h/L (sensitivity of 61% and specificity of 88%) for AUC24 and 6.8 μg/mL (sensitivity of 61% and specificity of 92%) for Ct. In LCE, the Ct value was 11 μg/mL, with a sensitivity of 80% and a specificity of 92%. In this analysis, AUC24 was not considered a good predictor. Logistic regression showed that a vancomycin Ct of ≤6.8 μg/mL was associated with an unfavorable ECE (P = 0.001), being 18 times more likely to progress poorly compared to those with higher levels. AUC24 and Ct are good predictors of ECE in this population. Concentrations close to 7 μg/mL and an AUC24 of around 240 mg · h/L 48 h after antibiotic initiation seem to be sufficient to achieve clinical cure in most cases.
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Alrahahleh D, Xu S, Zhu Z, Toufaili H, Luig M, Kim HY, Alffenaar JW. An Audit to Evaluate Vancomycin Therapeutic Drug Monitoring in a Neonatal Intensive Care Unit. Ther Drug Monit 2022; 44:651-658. [PMID: 35383737 DOI: 10.1097/ftd.0000000000000986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/14/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) is routinely used for optimization of vancomycin therapy, because of exposure-related efficacy and toxicity, in addition to significant variability in pharmacokinetics, which leads to unpredictable drug exposure. OBJECTIVE The aim of this study was to evaluate target attainment and TDM of vancomycin in neonates. METHODS The authors conducted a retrospective study and collected data from medical records of all neonates who received vancomycin therapy in the neonatal intensive care unit between January 2019 and December 2019. The primary outcome was the proportion of vancomycin courses that reached target trough concentrations of 10-20 mg/L based on appropriate TDM samples collection. Secondary outcomes included proportion of courses with appropriate dose and dose frequency, and proportion of patients who achieved target concentrations after the first dose adjustment. RESULTS In total, 69 patients were included, with 129 vancomycin courses. The median initial vancomycin trough concentration was 12 (range: 4-36) mg/L. The target trough concentration was achieved in 75% of courses after the initial dose with appropriate TDM, and 84% of courses after TDM-guided dose adjustments. Patients were dosed appropriately in 121/129 courses and TDM was performed correctly according to protocol in 51/93 courses. A dose adjustment was performed in 18/29 courses, to increase target attainment. CONCLUSIONS This study showed that there is a need for an increase in dose to improve target attainment. There is also a need to explore more effective TDM strategies to increase the proportion of neonatal patients attaining vancomycin target trough concentrations.
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Affiliation(s)
- Dua'a Alrahahleh
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
| | - Sophia Xu
- Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia
| | - Zhaowen Zhu
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Hassan Toufaili
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Melissa Luig
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia ; and
| | - Hannah Yejin Kim
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Camperdown, NSW, Australia
| | - Jan-Willem Alffenaar
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Camperdown, NSW, Australia
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Chen Q, Wan J, Shen W, Lin W, Lin X, Huang Z, Lin M, Chen Y. Optimal exposure targets for vancomycin in the treatment of neonatal coagulase-negative Staphylococcus infection: A retrospective study based on electronic medical records. Pediatr Neonatol 2022; 63:247-254. [PMID: 35190273 DOI: 10.1016/j.pedneo.2021.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/12/2021] [Accepted: 11/26/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND The currently advocated ratio of area under the curve (AUC) over 24 h to minimum inhibitory concentration (AUC/MIC) > 400 and AUC < 600 mg h/L as the therapeutic drug monitoring (TDM) target of vancomycin is based on data from multiple observational studies in adult patients with methicillin-resistant Staphylococcus aureus (MRSA) infection. It may not be applicable to newborns with coagulase-negative Staphylococcus (CoNS) infection. We conducted a retrospective study to identify the optimal exposure targets for vancomycin in the treatment of neonatal CoNS infection. METHODS Based on the inclusion and exclusion criteria, serum vancomycin concentration, demographics, clinical data, and related laboratory data of newborns who received vancomycin intravenous infusion from June 1, 2016 to February 1, 2021 were collected retrospectively. The AUC was calculated using the maximum a posteriori Bayesian (MAPB) method. The vancomycin exposure threshold of AUC/MIC for efficacy and AUC for toxicity (acute kidney injury, AKI) were determined based on receiver operating characteristic (ROC) curve analysis. The correlation between vancomycin exposure and both clinical effect and nephrotoxicity was analyzed using logistic multivariate regression. RESULTS In total, 153 patients and 245 vancomycin concentrations (160 trough and 85 peak concentrations) were included. The ROC curve analysis showed that the exposure thresholds of AUC/MIC for clinical efficacy and AUC for nephrotoxicity were 281 and 602 mg h/L, respectively. The multivariate regression analysis showed that AUC/MIC > 280 was a predictor of efficacy (OR: 13.960, 95% CI: 1.891-103.078, P < 0.05) and AUC > 600 mg h/L was associated with AKI (OR: 9.008, 95% CI: 2.706-29.983, P < 0.05). The vancomycin AUC/MIC threshold for treating neonatal CoNS infection with vancomycin is lower than the currently advocated AUC/MIC >400. CONCLUSION The optimal exposure targets for vancomycin in neonatal CoNS infection were AUC/MIC > 280 and AUC < 600 mg h/L.
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Affiliation(s)
- Quanyao Chen
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Jun Wan
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Wei Shen
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Wanlong Lin
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Xiuxian Lin
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Zhiyi Huang
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Min Lin
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China.
| | - Yao Chen
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China.
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