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Falkenhagen U, Cavallari LH, Duarte JD, Kloft C, Schmidt S, Huisinga W. Leveraging QSP Models for MIPD: A Case Study for Warfarin/INR. Clin Pharmacol Ther 2024. [PMID: 38655898 DOI: 10.1002/cpt.3274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/05/2024] [Indexed: 04/26/2024]
Abstract
Warfarin dosing remains challenging due to substantial inter-individual variability, which can lead to unsafe or ineffective therapy with standard dosing. Model-informed precision dosing (MIPD) can help individualize warfarin dosing, requiring the selection of a suitable model. For models developed from clinical data, the dependence on the study design and population raises questions about generalizability. Quantitative system pharmacology (QSP) models promise better extrapolation abilities; however, their complexity and lack of validation on clinical data raise questions about applicability in MIPD. We have previously derived a mechanistic warfarin/international normalized ratio (INR) model from a blood coagulation QSP model. In this article, we evaluated the predictive performance of the warfarin/INR model in the context of MIPD using an external dataset with INR data from patients starting warfarin treatment. We assessed the accuracy and precision of model predictions, benchmarked against an empirically based reference model. Additionally, we evaluated covariate contributions and assessed the predictive performance separately in the more challenging outpatient data. The warfarin/INR model performed comparably to the reference model across various measures despite not being calibrated with warfarin initiation data. Including CYP2C9 and/or VKORC1 genotypes as covariates improved the prediction quality of the warfarin/INR model, even after assimilating 4 days of INR data. The outpatient INR exhibited higher unexplained variability, and predictions slightly exceeded observed values, suggesting that model adjustments might be necessary when transitioning from an inpatient to an outpatient setting. Overall, this research underscores the potential of QSP-derived models for MIPD, offering a complementary approach to empirical model development.
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Affiliation(s)
- Undine Falkenhagen
- PharMetrX Graduate Research Training Program, Berlin/Potsdam, Germany
- Institute of Mathematics, Mathematical Modelling and Systems Biology, University of Potsdam, Potsdam, Germany
| | - Larisa H Cavallari
- College of Pharmacy, Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida, USA
| | - Julio D Duarte
- College of Pharmacy, Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida, USA
| | - Charlotte Kloft
- Institute of Pharmacy, Department of Clinical Pharmacy and Biochemistry, Freie Universität Berlin, Berlin, Germany
| | - Stephan Schmidt
- College of Pharmacy, Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, University of Florida, Orlando, Florida, USA
| | - Wilhelm Huisinga
- Institute of Mathematics, Mathematical Modelling and Systems Biology, University of Potsdam, Potsdam, Germany
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Colombo I, Koster KL, Holer L, Haefliger S, Rabaglio M, Bastian S, Schwitter M, Eckhardt K, Hayoz S, Mc Laughlin AM, Kloft C, Klose M, Halbherr S, Baumgartner C, Sessa C, Stathis A, Hess D, Joerger M. TLD-1, a novel liposomal doxorubicin, in patients with advanced solid tumors: Dose escalation and expansion part of a multicenter open-label phase I trial (SAKK 65/16). Eur J Cancer 2024; 201:113588. [PMID: 38377773 DOI: 10.1016/j.ejca.2024.113588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/23/2024] [Accepted: 01/26/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND TLD-1 is a novel liposomal doxorubicin that compared favorably to conventional doxorubicin liposomal formulations in preclinical models. This phase I first-in-human study aimed to define the maximum tolerated dose (MTD), recommended phase 2 dose (RP2D), safety and preliminary activity of TLD-1 in patients with advanced solid tumors. PATIENTS AND METHODS We recruited patients with advanced solid tumors who failed standard therapy and received up to 3 prior lines of palliative systemic chemotherapy. TLD-1 was administered intravenously every 3 weeks up to a maximum of 9 cycles (6 for patients with prior anthracyclines) from a starting dose of 10 mg/m2, according to an accelerated titration design followed by a modified continual reassessment method. RESULTS 30 patients were enrolled between November 2018 and May 2021. No dose-limiting toxicities (DLT) were observed. Maximum administered dose of TLD-1 was 45 mg/m2, RP2D was defined at 40 mg/m2. Most frequent treatment-related adverse events (TRAE) of any grade included palmar-plantar erythrodysesthesia (PPE) (50% of patients), oral mucositis (50%), fatigue (30%) and skin rash (26.7%). Most common G3 TRAE included PPE in 4 patients (13.3%) and oral mucositis in 2 (6.7%). Overall objective response rate was 10% in the whole population and 23.1% among 13 patients with breast cancer; median time-to-treatment failure was 2.7 months. TLD-1 exhibit linear pharmacokinetics, with a median terminal half-life of 95 h. CONCLUSIONS The new liposomal doxorubicin formulation TLD-1 showed a favourable safety profile and antitumor activity, particularly in breast cancer. RP2D was defined at 40 mg/m2 administered every 3 weeks. (NCT03387917).
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Affiliation(s)
- Ilaria Colombo
- Oncology Institute of Southern Switzerland, EOC, 6500 Bellinzona, Switzerland
| | - Kira-Lee Koster
- Department of Medical Oncology and Hematology, Cantonal Hospital, 9007 St.Gallen, Switzerland
| | - Lisa Holer
- Competence Center of SAKK, 3008 Bern, Switzerland
| | - Simon Haefliger
- Department of Medical Oncology, Inselspital, 3010 Bern, Switzerland
| | - Manuela Rabaglio
- Department of Medical Oncology, Inselspital, 3010 Bern, Switzerland
| | - Sara Bastian
- Department of Medical Oncology and Hematology, Cantonal Hospital, 7000 Chur, Switzerland
| | - Michael Schwitter
- Department of Medical Oncology and Hematology, Cantonal Hospital, 7000 Chur, Switzerland
| | | | | | - Anna M Mc Laughlin
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie aet Berlin, 12169 Berlin, Germany; PharMetrX Graduate Research Training Program, Berlin/Postdam, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie aet Berlin, 12169 Berlin, Germany
| | - Marian Klose
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie aet Berlin, 12169 Berlin, Germany; PharMetrX Graduate Research Training Program, Berlin/Postdam, Germany
| | | | | | - Cristiana Sessa
- Oncology Institute of Southern Switzerland, EOC, 6500 Bellinzona, Switzerland
| | - Anastasios Stathis
- Oncology Institute of Southern Switzerland, EOC, 6500 Bellinzona, Switzerland
| | - Dagmar Hess
- Department of Medical Oncology and Hematology, Cantonal Hospital, 9007 St.Gallen, Switzerland
| | - Markus Joerger
- Department of Medical Oncology and Hematology, Cantonal Hospital, 9007 St.Gallen, Switzerland; Medical faculty, University of Basel, 4056 Basel, Switzerland.
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Boulet S, Ursino M, Michelet R, Aulin LB, Kloft C, Comets E, Zohar S. Bayesian framework for multi-source data integration-Application to human extrapolation from preclinical studies. Stat Methods Med Res 2024; 33:574-588. [PMID: 38446999 DOI: 10.1177/09622802241231493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
In preclinical investigations, for example, in in vitro, in vivo, and in silico studies, the pharmacokinetic, pharmacodynamic, and toxicological characteristics of a drug are evaluated before advancing to first-in-man trial. Usually, each study is analyzed independently and the human dose range does not leverage the knowledge gained from all studies. Taking into account all preclinical data through inferential procedures can be particularly interesting in obtaining a more precise and reliable starting dose and dose range. Our objective is to propose a Bayesian framework for multi-source data integration, customizable, and tailored to the specific research question. We focused on preclinical results extrapolated to humans, which allowed us to predict the quantities of interest (e.g. maximum tolerated dose, etc.) in humans. We build an approach, divided into four steps, based on a sequential parameter estimation for each study, extrapolation to human, commensurability checking between posterior distributions and final information merging to increase the precision of estimation. The new framework is evaluated via an extensive simulation study, based on a real-life example in oncology. Our approach allows us to better use all the information compared to a standard framework, reducing uncertainty in the predictions and potentially leading to a more efficient dose selection.
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Affiliation(s)
- Sandrine Boulet
- Inria, HeKA, Paris, France
- INSERM, Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Paris, France
| | - Moreno Ursino
- Inria, HeKA, Paris, France
- INSERM, Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Paris, France
- Unit of Clinical Epidemiology, Assistance Publique - Hopitaux de Paris, CHU Robert Debré, INSERM CIC-EC 1426, Paris, France
| | - Robin Michelet
- Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Linda Bs Aulin
- Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Emmanuelle Comets
- INSERM, Univ Rennes, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMRS 1085, Rennes, France
- INSERM, Université Paris Cité, IAME, Paris, France Sandrine Boulet and Moreno Ursino made equal contributions and are co-first authors. Emmanuelle Comets and Sarah Zohar made equal contributions and are co-last authors
| | - Sarah Zohar
- Inria, HeKA, Paris, France
- INSERM, Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Paris, France
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Lehmann A, Geburek I, Hessel-Pras S, Enge AM, Mielke H, Müller-Graf C, Kloft C, Hethey C. PBTK model-based analysis of CYP3A4 induction and the toxicokinetics of the pyrrolizidine alkaloid retrorsine in man. Arch Toxicol 2024:10.1007/s00204-024-03698-2. [PMID: 38528153 DOI: 10.1007/s00204-024-03698-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/31/2024] [Indexed: 03/27/2024]
Abstract
Cytochrome P450 (CYP)3A4 induction by drugs and pesticides plays a critical role in the enhancement of pyrrolizidine alkaloid (PA) toxicity as it leads to increased formation of hepatotoxic dehydro-PA metabolites. Addressing the need for a quantitative analysis of this interaction, we developed a physiologically-based toxicokinetic (PBTK) model. Specifically, the model describes the impact of the well-characterized CYP3A4 inducer rifampicin on the kinetics of retrorsine, which is a prototypic PA and contaminant in herbal teas. Based on consumption data, the kinetics after daily intake of retrorsine were simulated with concomitant rifampicin treatment. Strongest impact on retrorsine kinetics (plasma AUC24 and C max reduced to 67% and 74% compared to the rifampicin-free reference) was predicted directly after withdrawal of rifampicin. At this time point, the competitive inhibitory effect of rifampicin stopped, while CYP3A4 induction was still near its maximum. Due to the impacted metabolism kinetics, the cumulative formation of intestinal retrorsine CYP3A4 metabolites increased to 254% (from 10 to 25 nmol), while the cumulative formation of hepatic CYP3A4 metabolites was not affected (57 nmol). Return to baseline PA toxicokinetics was predicted 14 days after stop of a 14-day rifampicin treatment. In conclusion, the PBTK model showed to be a promising tool to assess the dynamic interplay of enzyme induction and toxification pathways.
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Affiliation(s)
- Anja Lehmann
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169, Berlin, Germany
| | - Ina Geburek
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
| | - Stefanie Hessel-Pras
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
| | - Anne-Margarethe Enge
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
| | - Hans Mielke
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany.
| | - Christine Müller-Graf
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169, Berlin, Germany
| | - Christoph Hethey
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
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Mc Laughlin AM, Helland T, Klima F, Koolen SLW, van Schaik RHN, Mathijssen RHJ, Neven P, Swen JJ, Guchelaar HJ, Dalenc F, White-Koning M, Michelet R, Mikus G, Schroth W, Mürdter T, Brauch H, Schwab M, Søiland H, Mellgren G, Thomas F, Kloft C, Hertz DL. Nonlinear Mixed-Effects Model of Z-Endoxifen Concentrations in Tamoxifen-Treated Patients from the CEPAM Cohort. Clin Pharmacol Ther 2024. [PMID: 38494911 DOI: 10.1002/cpt.3238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/08/2024] [Indexed: 03/19/2024]
Abstract
Tamoxifen is widely used in patients with hormone receptor-positive breast cancer. The polymorphic enzyme CYP2D6 is primarily responsible for metabolic activation of tamoxifen, resulting in substantial interindividual variability of plasma concentrations of its most important metabolite, Z-endoxifen. The Z-endoxifen concentration thresholds below which tamoxifen treatment is less efficacious have been proposed but not validated, and prospective trials of individualized tamoxifen treatment to achieve Z-endoxifen concentration thresholds are considered infeasible. Therefore, we aim to validate the association between Z-endoxifen concentration and tamoxifen treatment outcomes, and identify a Z-endoxifen concentration threshold of tamoxifen efficacy, using pharmacometric modeling and simulation. As a first step, the CYP2D6 Endoxifen Percentage Activity Model (CEPAM) cohort was created by pooling data from 28 clinical studies (> 7,000 patients) with measured endoxifen plasma concentrations. After cleaning, data from 6,083 patients were used to develop a nonlinear mixed-effect (NLME) model for tamoxifen and Z-endoxifen pharmacokinetics that includes a conversion factor to allow inclusion of studies that measured total endoxifen but not Z-endoxifen. The final parent-metabolite NLME model confirmed the primary role of CYP2D6, and contributions from body weight, CYP2C9 phenotype, and co-medication with CYP2D6 inhibitors, on Z-endoxifen pharmacokinetics. Future work will use the model to simulate Z-endoxifen concentrations in patients receiving single agent tamoxifen treatment within large prospective clinical trials with long-term survival to identify the Z-endoxifen concentration threshold below which tamoxifen is less efficacious. Identification of this concentration threshold would allow personalized tamoxifen treatment to improve outcomes in patients with hormone receptor-positive breast cancer.
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Affiliation(s)
- Anna M Mc Laughlin
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
- PharMetrX Graduate Research Training Program, Berlin/Potsdam, Germany
| | - Thomas Helland
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Fenja Klima
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
- PharMetrX Graduate Research Training Program, Berlin/Potsdam, Germany
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Patrick Neven
- Department of Gynecological Oncology and Multidisciplinary Breast Center, University Hospitals Leuven, Leuven, Belgium
| | - Jesse J Swen
- Department Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Henk-Jan Guchelaar
- Department Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Florence Dalenc
- Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
- Cancer Research Center of Toulouse (CRCT), Inserm U1037, Université Paul Sabatier, Toulouse, France
| | - Melanie White-Koning
- Cancer Research Center of Toulouse (CRCT), Inserm U1037, Université Paul Sabatier, Toulouse, France
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Werner Schroth
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- University Tübingen, Tübingen, Germany
| | - Thomas Mürdter
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- University Tübingen, Tübingen, Germany
| | - Hiltrud Brauch
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- University Tübingen, Tübingen, Germany
- iFIT Cluster of Excellence, University of Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Partner Site Tübingen, Tübingen, Germany
| | - Matthias Schwab
- University Tübingen, Tübingen, Germany
- iFIT Cluster of Excellence, University of Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Partner Site Tübingen, Tübingen, Germany
- Departments of Clinical Pharmacology, and of Biochemistry and Pharmacy, University of Tübingen, Tübingen, Germany
| | - Håvard Søiland
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Research, Stavanger University Hospital, Stavanger, Norway
| | - Gunnar Mellgren
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Fabienne Thomas
- Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
- Cancer Research Center of Toulouse (CRCT), Inserm U1037, Université Paul Sabatier, Toulouse, France
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
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Steenholdt C, Lorentsen RD, Petersen PN, Widigson ES, Kloft C, Klaasen RA, Brynskov J. Therapeutic drug monitoring of vedolizumab therapy in inflammatory bowel disease. J Gastroenterol Hepatol 2024. [PMID: 38380724 DOI: 10.1111/jgh.16518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/01/2024] [Accepted: 02/03/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Therapeutic drug monitoring is effective for optimizing anti-tumor necrosis factor therapies in inflammatory bowel disease, but for vedolizumab, a gut-selective leucocyte migration inhibitor, data are scarce. METHODS Observational cohort study including 116 bio-experienced inflammatory bowel disease patients treated with vedolizumab for active luminal disease. Biobanked trough blood samples (n = 676) covering 96% of patients were analyzed using a drug-binding immunofluorometric assay. Steroid-free treatment outcomes were classified by clinical disease activity indices and objective findings, primarily endoscopy. RESULTS Patients with clinical remission to vedolizumab induction therapy (37%) had significantly higher trough levels than those without at weeks 6 (mean 34.1 vs 28.0 μg/mL, P = 0.03) and 10 (34.8 vs 27.5 μg/mL, P = 0.01). Optimal thresholds for discrimination were 32.4 μg/mL (AUCROC 0.66, P = 0.04) and 23.5 (AUCROC 0.67, P = 0.01), respectively. This positive association persisted during maintenance phase with 11.9 μg/mL (AUCROC 0.69, P < 0.01) associated with clinical remission (37%) and 15.3 (AUCROC 0.74, P < 0.001) for objective remission (46%). Stratification by temporal evolution of treatment effects revealed higher induction and maintenance vedolizumab levels in persistent and slow responders as compared to secondary or persistent failures. Pharmacokinetics was influenced by rare formation of anti-vedolizumab antibodies (2%), and to a lesser extent gender and albumin during induction, but not disease severity, concomitant steroids, or thiopurine metabolites. Switching to subcutaneous administrations resulted in 2.3-fold increase in steady-state trough levels. CONCLUSION Our study supports maintaining adequate drug exposure being essential for sustained positive outcomes of vedolizumab and emphasizes individualized, therapeutic drug monitoring-based treatment regimens. Controlled trials and pharmacokinetic modeling are, however, needed.
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Affiliation(s)
- Casper Steenholdt
- Department of Gastroenterology, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Ruben Due Lorentsen
- Department of Gastroenterology, Herlev and Gentofte Hospital, Herlev, Denmark
| | | | - Ella Sk Widigson
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität, Berlin, Germany
| | - Rolf Anton Klaasen
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Jørn Brynskov
- Department of Gastroenterology, Herlev and Gentofte Hospital, Herlev, Denmark
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Knöchel J, Kloft C, Huisinga W. Index analysis: An approach to understand signal transduction with application to the EGFR signalling pathway. PLoS Comput Biol 2024; 20:e1011777. [PMID: 38315738 PMCID: PMC10868873 DOI: 10.1371/journal.pcbi.1011777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/15/2024] [Accepted: 12/21/2023] [Indexed: 02/07/2024] Open
Abstract
In systems biology and pharmacology, large-scale kinetic models are used to study the dynamic response of a system to a specific input or stimulus. While in many applications, a deeper understanding of the input-response behaviour is highly desirable, it is often hindered by the large number of molecular species and the complexity of the interactions. An approach that identifies key molecular species for a given input-response relationship and characterises dynamic properties of states is therefore highly desirable. We introduce the concept of index analysis; it is based on different time- and state-dependent quantities (indices) to identify important dynamic characteristics of molecular species. All indices are defined for a specific pair of input and response variables as well as for a specific magnitude of the input. In application to a large-scale kinetic model of the EGFR signalling cascade, we identified different phases of signal transduction, the peculiar role of Phosphatase3 during signal activation and Ras recycling during signal onset. In addition, we discuss the challenges and pitfalls of interpreting the relevance of molecular species based on knock-out simulation studies, and provide an alternative view on conflicting results on the importance of parallel EGFR downstream pathways. Beyond the applications in model interpretation, index analysis is envisioned to be a valuable tool in model reduction.
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Affiliation(s)
- Jane Knöchel
- Institute of Mathematics, Universität Potsdam, Potsdam, Germany
- Graduate Research Training Program PharMetrX: Pharmacometrics & Computational Disease Modeling, Freie Universität Berlin and Universität Potsdam, Berlin/Potsdam, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
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Minichmayr IK, Wicha SG, Matzneller P, Kloft C, Zeitlinger M. Impact of Key Components of Intensified Ceftaroline Dosing on Pharmacokinetic/Pharmacodynamic Target Attainment. Clin Pharmacokinet 2024; 63:121-131. [PMID: 38007714 PMCID: PMC10786958 DOI: 10.1007/s40262-023-01325-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND AND OBJECTIVE Ceftaroline fosamil is a β-lactam antibiotic approved as a 600 mg twice daily dose (≤1 h infusion, 'standard dosing') or a 600 mg thrice daily dose (2 h infusion) to treat complicated skin and soft tissue infections caused by Staphylococcus aureus (minimum inhibitory concentration [MIC] 2-4 mg/L). We sought to systematically evaluate the relative impact of the three key components of the intensified dosing regimen (i.e. shortened dosing interval, prolonged infusion duration and increased total daily dose [TDD]) on the pharmacokinetic/pharmacodynamic (PK/PD) target attainment given different grades of bacterial susceptibility. METHODS A population PK model was developed using data from 12 healthy volunteers (EudraCT-2012-005134-11) receiving standard or intensified dosing. PK/PD target attainment (ƒT>MIC = 35% and 100%) after 24 h was compared following systematically varied combinations of the (1) dosing interval (every 12 h [q12h]→ every 8 h [q8h]); (2) infusion duration (1 h→2 h); and (3) individual and total daily dose (400→900 mg, i.e. TDD 1200→1800 mg), as well as for varying susceptibility of S. aureus (MIC 0.032-8 mg/L). RESULTS A two-compartment model with linear elimination adequately described ceftaroline concentrations (n = 274). The relevance of the dosing components dosing interval/infusion duration/TDD for ƒT>MIC systematically changed with pathogen susceptibility. For susceptible pathogens with MIC ≤1 mg/L, shortened dosing intervals appeared as the main driver of the improved target attainment associated with the intensified dosing regimen, followed by increased TDD and infusion duration. For less susceptible pathogens, the advantage of q8h dosing and 2 h infusions declined, and increased TDD improved ƒT>MIC the most. CONCLUSION The analysis calls to mind consideration of dose increases when prolonging the infusion duration in the case of low bacterial susceptibility.
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Affiliation(s)
- Iris K Minichmayr
- Department of Clinical Pharmacology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, 20146, Hamburg, Germany
| | - Peter Matzneller
- Department of Clinical Pharmacology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Service of Rheumatology, Hospital of Merano (SABES-ASDAA), Via Rossini 5, 39012, Merano, Italy
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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Nassar YM, Ojara FW, Pérez-Pitarch A, Geiger K, Huisinga W, Hartung N, Michelet R, Holdenrieder S, Joerger M, Kloft C. C-Reactive Protein as an Early Predictor of Efficacy in Advanced Non-Small-Cell Lung Cancer Patients: A Tumor Dynamics-Biomarker Modeling Framework. Cancers (Basel) 2023; 15:5429. [PMID: 38001689 PMCID: PMC10670607 DOI: 10.3390/cancers15225429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
In oncology, longitudinal biomarkers reflecting the patient's status and disease evolution can offer reliable predictions of the patient's response to treatment and prognosis. By leveraging clinical data in patients with advanced non-small-cell lung cancer receiving first-line chemotherapy, we aimed to develop a framework combining anticancer drug exposure, tumor dynamics (RECIST criteria), and C-reactive protein (CRP) concentrations, using nonlinear mixed-effects models, to evaluate and quantify by means of parametric time-to-event models the significance of early longitudinal predictors of progression-free survival (PFS) and overall survival (OS). Tumor dynamics was characterized by a tumor size (TS) model accounting for anticancer drug exposure and development of drug resistance. CRP concentrations over time were characterized by a turnover model. An x-fold change in TS from baseline linearly affected CRP production. CRP concentration at treatment cycle 3 (day 42) and the difference between CRP concentration at treatment cycles 3 and 2 were the strongest predictors of PFS and OS. Measuring longitudinal CRP allows for the monitoring of inflammatory levels and, along with its reduction across treatment cycles, presents a promising prognostic marker. This framework could be applied to other treatment modalities such as immunotherapies or targeted therapies allowing the timely identification of patients at risk of early progression and/or short survival to spare them unnecessary toxicities and provide alternative treatment decisions.
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Affiliation(s)
- Yomna M. Nassar
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, 12169 Berlin, Germany; (Y.M.N.)
- Graduate Research Training Program PharMetrX, Berlin/Potsdam, Germany
| | - Francis Williams Ojara
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, 12169 Berlin, Germany; (Y.M.N.)
- Graduate Research Training Program PharMetrX, Berlin/Potsdam, Germany
- Department of Pharmacology, Faculty of Medicine, Gulu University, Gulu P.O. Box 166, Uganda
| | - Alejandro Pérez-Pitarch
- Translational Medicine & Clinical Pharmacology, Boehringer Ingelheim Pharma GmbH & Co. KG, 55216 Ingelheim am Rhein, Germany
| | - Kimberly Geiger
- Institute of Laboratory Medicine, German Heart Centre Munich of the Free State of Bavaria, Technical University Munich, 80636 Munich, Germany
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, 14476 Potsdam, Germany; (W.H.); (N.H.)
| | - Niklas Hartung
- Institute of Mathematics, University of Potsdam, 14476 Potsdam, Germany; (W.H.); (N.H.)
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, 12169 Berlin, Germany; (Y.M.N.)
| | - Stefan Holdenrieder
- Institute of Laboratory Medicine, German Heart Centre Munich of the Free State of Bavaria, Technical University Munich, 80636 Munich, Germany
| | - Markus Joerger
- Department of Medical Oncology and Hematology, Cantonal Hospital, CH-9007 St. Gallen, Switzerland
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, 12169 Berlin, Germany; (Y.M.N.)
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10
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Ojara FW, Henrich A, Frances N, Nassar YM, Huisinga W, Hartung N, Geiger K, Holdenrieder S, Joerger M, Kloft C. A prognostic baseline blood biomarker and tumor growth kinetics integrated model in paclitaxel/platinum treated advanced non-small cell lung cancer patients. CPT Pharmacometrics Syst Pharmacol 2023; 12:1714-1725. [PMID: 36782356 PMCID: PMC10681433 DOI: 10.1002/psp4.12937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 01/11/2023] [Indexed: 02/15/2023] Open
Abstract
Paclitaxel/platinum chemotherapy, the backbone of standard first-line treatment of advanced non-small cell lung cancer (NSCLC), exhibits high interpatient variability in treatment response and high toxicity burden. Baseline blood biomarker concentrations and tumor size (sum of diameters) at week 8 relative to baseline (RS8) are widely investigated prognostic factors. However, joint analysis of data on demographic/clinical characteristics, blood biomarker levels, and chemotherapy exposure-driven early tumor response for improved prediction of overall survival (OS) is clinically not established. We developed a Weibull time-to-event model to predict OS, leveraging data from 365 patients receiving paclitaxel/platinum combination chemotherapy once every three weeks for ≤six cycles. A developed tumor growth inhibition model, combining linear tumor growth and first-order paclitaxel area under the concentration-time curve-induced tumor decay, was used to derive individual RS8. The median model-derived RS8 in all patients was a 20.0% tumor size reduction (range from -78% to +15%). Whereas baseline carcinoembryonic antigen, cytokeratin fragments, and thyroid stimulating hormone levels were not significantly associated with OS in a subset of 221 patients, and lactate dehydrogenase, interleukin-6 and neutrophil-to-lymphocyte ratio levels were significant only in univariate analyses (p value < 0.05); C-reactive protein (CRP) in combination with RS8 most significantly affected OS (p value < 0.01). Compared to the median population OS of 11.3 months, OS was 128% longer at the 5th percentile levels of both covariates and 60% shorter at their 95th percentiles levels. The combined paclitaxel exposure-driven RS8 and baseline blood CRP concentrations enables early individual prognostic predictions for different paclitaxel dosing regimens, forming the basis for treatment decision and optimizing paclitaxel/platinum-based advanced NSCLC chemotherapy.
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Affiliation(s)
- Francis Williams Ojara
- Department of Clinical Pharmacy and Biochemistry, Institute of PharmacyFreie Universitaet BerlinBerlinGermany
- Graduate Research Training Program PharMetrXBerlin/PotsdamGermany
| | - Andrea Henrich
- Department of Clinical Pharmacy and Biochemistry, Institute of PharmacyFreie Universitaet BerlinBerlinGermany
- Graduate Research Training Program PharMetrXBerlin/PotsdamGermany
| | - Nicolas Frances
- Department of Translational Modeling and Simulation, Roche Pharma Research and Early Development, Roche Innovation Center BaselF. Hoffmann‐La Roche LtdBaselSwitzerland
| | - Yomna M. Nassar
- Department of Clinical Pharmacy and Biochemistry, Institute of PharmacyFreie Universitaet BerlinBerlinGermany
- Graduate Research Training Program PharMetrXBerlin/PotsdamGermany
| | | | - Niklas Hartung
- Institute of MathematicsUniversity of PotsdamPotsdamGermany
| | - Kimberly Geiger
- Munich Biomarker Research Center, Institute of Laboratory Medicine, German Heart CenterTechnical University of MunichMunichGermany
| | - Stefan Holdenrieder
- Munich Biomarker Research Center, Institute of Laboratory Medicine, German Heart CenterTechnical University of MunichMunichGermany
| | - Markus Joerger
- Department of Oncology and HematologyCantonal Hospital St. GallenSt. GallenSwitzerland
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of PharmacyFreie Universitaet BerlinBerlinGermany
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11
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Kluwe F, Michelet R, Huisinga W, Zeitlinger M, Mikus G, Kloft C. Towards Model-Informed Precision Dosing of Voriconazole: Challenging Published Voriconazole Nonlinear Mixed-Effects Models with Real-World Clinical Data. Clin Pharmacokinet 2023; 62:1461-1477. [PMID: 37603216 PMCID: PMC10520167 DOI: 10.1007/s40262-023-01274-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Model-informed precision dosing (MIPD) frequently uses nonlinear mixed-effects (NLME) models to predict and optimize therapy outcomes based on patient characteristics and therapeutic drug monitoring data. MIPD is indicated for compounds with narrow therapeutic range and complex pharmacokinetics (PK), such as voriconazole, a broad-spectrum antifungal drug for prevention and treatment of invasive fungal infections. To provide guidance and recommendations for evidence-based application of MIPD for voriconazole, this work aimed to (i) externally evaluate and compare the predictive performance of a published so-called 'hybrid' model for MIPD (an aggregate model comprising features and prior information from six previously published NLME models) versus two 'standard' NLME models of voriconazole, and (ii) investigate strategies and illustrate the clinical impact of Bayesian forecasting for voriconazole. METHODS A workflow for external evaluation and application of MIPD for voriconazole was implemented. Published voriconazole NLME models were externally evaluated using a comprehensive in-house clinical database comprising nine voriconazole studies and prediction-/simulation-based diagnostics. The NLME models were applied using different Bayesian forecasting strategies to assess the influence of prior observations on model predictivity. RESULTS The overall best predictive performance was obtained using the aggregate model. However, all NLME models showed only modest predictive performance, suggesting that (i) important PK processes were not sufficiently implemented in the structural submodels, (ii) sources of interindividual variability were not entirely captured, and (iii) interoccasion variability was not adequately accounted for. Predictive performance substantially improved by including the most recent voriconazole observations in MIPD. CONCLUSION Our results highlight the potential clinical impact of MIPD for voriconazole and indicate the need for a comprehensive (pre-)clinical database as basis for model development and careful external model evaluation for compounds with complex PK before their successful use in MIPD.
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Affiliation(s)
- Franziska Kluwe
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin/Potsdam, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Karl-Liebknecht-Str. 24/25, 14476 Potsdam, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Gerd Mikus
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 419, 69120 Heidelberg, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
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12
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Lehmann A, Geburek I, These A, Hessel-Pras S, Hengstler JG, Albrecht W, Mielke H, Müller-Graf C, Yang X, Kloft C, Hethey C. PBTK modeling of the pyrrolizidine alkaloid retrorsine to predict liver toxicity in mouse and rat. Arch Toxicol 2023; 97:1319-1333. [PMID: 36906727 PMCID: PMC10110657 DOI: 10.1007/s00204-023-03453-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 02/02/2023] [Indexed: 03/13/2023]
Abstract
Retrorsine is a hepatotoxic pyrrolizidine alkaloid (PA) found in herbal supplements and medicines, food and livestock feed. Dose-response studies enabling the derivation of a point of departure including a benchmark dose for risk assessment of retrorsine in humans and animals are not available. Addressing this need, a physiologically based toxicokinetic (PBTK) model of retrorsine was developed for mouse and rat. Comprehensive characterization of retrorsine toxicokinetics revealed: both the fraction absorbed from the intestine (78%) and the fraction unbound in plasma (60%) are high, hepatic membrane permeation is dominated by active uptake and not by passive diffusion, liver metabolic clearance is 4-fold higher in rat compared to mouse and renal excretion contributes to 20% of the total clearance. The PBTK model was calibrated with kinetic data from available mouse and rat studies using maximum likelihood estimation. PBTK model evaluation showed convincing goodness-of-fit for hepatic retrorsine and retrorsine-derived DNA adducts. Furthermore, the developed model allowed to translate in vitro liver toxicity data of retrorsine to in vivo dose-response data. Resulting benchmark dose confidence intervals (mg/kg bodyweight) are 24.1-88.5 in mice and 79.9-104 in rats for acute liver toxicity after oral retrorsine intake. As the PBTK model was built to enable extrapolation to different species and other PA congeners, this integrative framework constitutes a flexible tool to address gaps in the risk assessment of PA.
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Affiliation(s)
- Anja Lehmann
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169, Berlin, Germany
| | - Ina Geburek
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
| | - Anja These
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
| | - Stefanie Hessel-Pras
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
| | - Jan G Hengstler
- Leibniz Research Centre for Working Environment and Human Factors (IfADo), Technical University of Dortmund, 44139, Dortmund, Germany
| | - Wiebke Albrecht
- Leibniz Research Centre for Working Environment and Human Factors (IfADo), Technical University of Dortmund, 44139, Dortmund, Germany
| | - Hans Mielke
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany.
| | - Christine Müller-Graf
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
| | - Xiaojing Yang
- Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, 110016, Liaoning, People's Republic of China
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169, Berlin, Germany
| | - Christoph Hethey
- German Federal Institute for Risk Assessment (BfR), Max-Dohrn-Str. 8-10, 10589, Berlin, Germany
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13
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Michelet R, Aulin LBS, Borghardt JM, Costa TD, Denti P, Ibarra M, Ma G, Meibohm B, Pillai GC, Schmidt S, Hennig S, Kloft C. Barriers to global pharmacometrics: educational challenges and opportunities across the globe. CPT Pharmacometrics Syst Pharmacol 2023. [PMID: 36960632 DOI: 10.1002/psp4.12940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/23/2022] [Accepted: 02/08/2023] [Indexed: 03/25/2023] Open
Affiliation(s)
- Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
- qPharmetra LLC, Nijmegen, The Netherlands
| | - Linda B S Aulin
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Jens M Borghardt
- Research DMPK, Drug Discovery Sciences, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Teresa Dalla Costa
- Pharmaceutical Sciences Graduate Program, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Manuel Ibarra
- Department of Pharmaceutical Sciences, Faculty of Chemistry, Universidad de la República, Montevideo, Uruguay
| | - Guangda Ma
- Department of Pharmacology & Clinical Pharmacology, The University of Auckland, Auckland, New Zealand
| | - Bernd Meibohm
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Goonaseelan Colin Pillai
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- CP+ Associates GmbH, Basel, Switzerland
- Phamacometrics Africa NPC, Cape Town, South Africa
| | - Stephan Schmidt
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Stefanie Hennig
- Certara, Inc., Princeton, New Jersey, USA
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Department of Clinical Pharmacy, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
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14
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Stachanow V, Neumann U, Blankenstein O, Alder-Baerens N, Bindellini D, Hindmarsh P, Ross RJ, Whitaker MJ, Melin J, Huisinga W, Michelet R, Kloft C. Model-Informed Target Morning 17α-Hydroxyprogesterone Concentrations in Dried Blood Spots for Pediatric Congenital Adrenal Hyperplasia Patients. Pharmaceuticals (Basel) 2023; 16:ph16030464. [PMID: 36986563 PMCID: PMC10051286 DOI: 10.3390/ph16030464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
Monitoring cortisol replacement therapy in congenital adrenal hyperplasia (CAH) patients is vital to avoid serious adverse events such as adrenal crises due to cortisol underexposure or metabolic consequences due to cortisol overexposure. The less invasive dried blood spot (DBS) sampling is an advantageous alternative to traditional plasma sampling, especially in pediatric patients. However, target concentrations for important disease biomarkers such as 17α-hydroxyprogesterone (17-OHP) are unknown using DBS. Therefore, a modeling and simulation framework, including a pharmacokinetic/pharmacodynamic model linking plasma cortisol concentrations to DBS 17-OHP concentrations, was used to derive a target morning DBS 17-OHP concentration range of 2-8 nmol/L in pediatric CAH patients. Since either capillary or venous DBS sampling is becoming more common in the clinics, the clinical applicability of this work was shown by demonstrating the comparability of capillary and venous cortisol and 17-OHP concentrations collected by DBS sampling, using a Bland-Altman and Passing-Bablok analysis. The derived target morning DBS 17-OHP concentration range is a first step towards providing improved therapy monitoring using DBS sampling and adjusting hydrocortisone (synthetic cortisol) dosing in children with CAH. In the future, this framework can be used to assess further research questions, e.g., target replacement ranges for the entire day.
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Affiliation(s)
- Viktoria Stachanow
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr 31, 12169 Berlin, Germany
- Graduate Research Training Program, PharMetrX, 12169 Berlin, Germany
| | - Uta Neumann
- Charité-Universitätsmedizin, Freie Universität Berlin, 13353 Berlin, Germany
| | - Oliver Blankenstein
- Charité-Universitätsmedizin, Freie Universität Berlin, 13353 Berlin, Germany
- Labor Berlin, Charité Vivantes GmbH, 13353 Berlin, Germany
| | | | - Davide Bindellini
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr 31, 12169 Berlin, Germany
- Graduate Research Training Program, PharMetrX, 12169 Berlin, Germany
| | - Peter Hindmarsh
- Developmental Endocrinology Research Group, UCL Institute of Child Health, London WC1E 6BT, UK
| | - Richard J Ross
- Department of Oncology and Metabolism, University of Sheffield, Sheffield S10 2TN, UK
| | - Martin J Whitaker
- Department of Oncology and Metabolism, University of Sheffield, Sheffield S10 2TN, UK
| | - Johanna Melin
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr 31, 12169 Berlin, Germany
- Graduate Research Training Program, PharMetrX, 12169 Berlin, Germany
| | - Wilhelm Huisinga
- Institute of Mathematics, Universität Potsdam, 14476 Potsdam, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr 31, 12169 Berlin, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr 31, 12169 Berlin, Germany
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15
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Falkenhagen U, Knöchel J, Kloft C, Huisinga W. Deriving mechanism-based pharmacodynamic models by reducing quantitative systems pharmacology models: An application to warfarin. CPT Pharmacometrics Syst Pharmacol 2023; 12:432-443. [PMID: 36866520 PMCID: PMC10088086 DOI: 10.1002/psp4.12903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/18/2022] [Accepted: 11/29/2022] [Indexed: 03/04/2023] Open
Abstract
Quantitative systems pharmacology (QSP) models integrate comprehensive qualitative and quantitative knowledge about pharmacologically relevant processes. We previously proposed a first approach to leverage the knowledge in QSP models to derive simpler, mechanism-based pharmacodynamic (PD) models. Their complexity, however, is typically still too large to be used in the population analysis of clinical data. Here, we extend the approach beyond state reduction to also include the simplification of reaction rates, elimination of reactions, and analytic solutions. We additionally ensure that the reduced model maintains a prespecified approximation quality not only for a reference individual but also for a diverse virtual population. We illustrate the extended approach for the warfarin effect on blood coagulation. Using the model-reduction approach, we derive a novel small-scale warfarin/international normalized ratio model and demonstrate its suitability for biomarker identification. Due to the systematic nature of the approach in comparison with empirical model building, the proposed model-reduction algorithm provides an improved rationale to build PD models also from QSP models in other applications.
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Affiliation(s)
- Undine Falkenhagen
- Institute of Mathematics, University of Potsdam, Potsdam, Germany.,Graduate Research Training Program PharMetrX: Pharmacometrics & Computational Disease Modelling, Freie Universität Berlin and University of Potsdam, Potsdam, Germany
| | - Jane Knöchel
- Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Potsdam, Germany
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16
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Gehrke-Beck S, Petersen M, Herrmann WJ, Zimmermann N, Daub E, Seeger J, Schulz J, Czimmeck C, Lauterbach N, Peters H, Kloft C, Schulz M, Siebenbrodt I, Behrend R. Development of a project for interprofessional collaboration between medical and pharmacy students to improve medication safety in polypharmacy (PILLE). GMS J Med Educ 2023; 40:Doc3. [PMID: 36923317 PMCID: PMC10010767 DOI: 10.3205/zma001585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/18/2022] [Accepted: 10/31/2022] [Indexed: 06/18/2023]
Abstract
AIM Interprofessional collaboration is particularly relevant to patient safety in outpatient care with polypharmacy. The educational project "PILLE" is meant to give medical and pharmacy students an understanding of the roles and competencies needed for cooperation in the provision of healthcare and to enable interprofessional learning. METHOD The curriculum is aimed at pharmacy and medical students and was developed in six steps according to the Kern cycle. It is comprised of an interprofessional seminar, a joint practical training in a simulated pharmacy, and a tandem job shadowing at a primary care practice. The project was implemented in three stages due to the pandemic: The interprofessional online seminar based on the ICAP model and the digital inverted classroom was held in the 2020 winter semester; the interprofessional practical training was added in the 2021 summer semester; and the interprofessional tandem job shadowing at a primary care practice in the 2021 winter semester. Attitudes toward interprofessional learning, among other things, was measured in the evaluation using the SPICE-2D questionnaire (Student Perceptions of Physician-Pharmacist Interprofessional Clinical Education). RESULTS In the first three semesters, a total of 105 students (46 pharmacy, 59 medicine) participated in the project, of which 78 participated in the evaluation (74% response rate). The students stated, in particular, that they had learned about the competencies and roles of the other profession and desired additional and more specific preparatory materials for the course sessions. The SPICE-2D questionnaire showed high values for both groups of students already in the pre-survey and these increased further as a result of the project. CONCLUSION Joint case-based learning could be implemented under the conditions imposed by the pandemic. Online teaching is a low-threshold means to enable interprofessional exchange.
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Affiliation(s)
- Sabine Gehrke-Beck
- Charité - Universitätsmedizin Berlin, Charité Campus Mitte, Institut für Allgemeinmedizin, Berlin, Germany
| | - Maike Petersen
- Freie Universität Berlin, Institut für Pharmazie, Berlin, Germany
- ABDA - Bundesvereinigung Deutscher Apothekerverbände e. V., Berlin, Germany
| | - Wolfram J. Herrmann
- Charité - Universitätsmedizin Berlin, Charité Campus Mitte, Institut für Allgemeinmedizin, Berlin, Germany
| | | | - Eva Daub
- Charité - Universitätsmedizin Berlin, Charité Campus Mitte, Institut für Allgemeinmedizin, Berlin, Germany
| | - Johanna Seeger
- Freie Universität Berlin, Institut für Pharmazie, Berlin, Germany
| | - Josefine Schulz
- Freie Universität Berlin, Institut für Pharmazie, Berlin, Germany
| | | | - Noemi Lauterbach
- Freie Universität Berlin, Institut für Pharmazie, Berlin, Germany
| | - Harm Peters
- Charité - Universitätsmedizin Berlin, Dieter Scheffner Fachzentrum für medizinische Hochschullehre und evidenzbasierte Ausbildungsforschung, Berlin, Germany
| | - Charlotte Kloft
- Freie Universität Berlin, Institut für Pharmazie, Berlin, Germany
| | - Martin Schulz
- Freie Universität Berlin, Institut für Pharmazie, Berlin, Germany
- ABDA - Bundesvereinigung Deutscher Apothekerverbände e. V., Berlin, Germany
| | - Ingo Siebenbrodt
- Freie Universität Berlin, Institut für Pharmazie, Berlin, Germany
| | - Ronja Behrend
- Charité - Universitätsmedizin Berlin, Prodekanat für Studium und Lehre, Semesterkoordination Modellstudiengang Medizin, Berlin, Germany
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17
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Stübler S, Kloft C, Huisinga W. Cell-level systems biology model to study inflammatory bowel diseases and their treatment options. CPT Pharmacometrics Syst Pharmacol 2023; 12:690-705. [PMID: 36727252 DOI: 10.1002/psp4.12932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/20/2022] [Accepted: 01/20/2023] [Indexed: 02/03/2023] Open
Abstract
To help understand the complex and therapeutically challenging inflammatory bowel diseases (IBDs), we developed a systems biology model of the intestinal immune system that is able to describe main aspects of IBD and different treatment modalities thereof. The model, including key cell types and processes of the mucosal immune response, compiles a large amount of isolated experimental findings from literature into a larger context and allows for simulations of different inflammation scenarios based on the underlying data and assumptions. In the context of a large and diverse virtual IBD population, we characterized the patients based on their phenotype (in contrast to healthy individuals, they developed persistent inflammation after a trigger event) rather than on a priori assumptions on parameter differences to a healthy individual. This allowed to reproduce the enormous diversity of predispositions known to lead to IBD. Analyzing different treatment effects, the model provides insight into characteristics of individual drug therapy. We illustrate for anti-TNF-α therapy, how the model can be used (i) to decide for alternative treatments with best prospects in the case of nonresponse, and (ii) to identify promising combination therapies with other available treatment options.
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Affiliation(s)
- Sabine Stübler
- Institute of Biochemistry and Biology, University of Potsdam, Potsdam, Germany.,Graduate Research Training Program PharMetrX: Pharmacometrics & Computational Disease Modelling, Freie Universität Berlin & University of Potsdam, Berlin, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
| | - Wilhelm Huisinga
- Institute of Biochemistry and Biology, University of Potsdam, Potsdam, Germany.,Institute of Mathematics, University of Potsdam, Potsdam/Golm, Germany
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Michelet R, Bindellini D, Melin J, Neumann U, Blankenstein O, Huisinga W, Johnson TN, Whitaker MJ, Ross R, Kloft C. Insights in the maturational processes influencing hydrocortisone pharmacokinetics in congenital adrenal hyperplasia patients using a middle-out approach. Front Pharmacol 2023; 13:1090554. [PMID: 36712688 PMCID: PMC9877293 DOI: 10.3389/fphar.2022.1090554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 12/23/2022] [Indexed: 01/15/2023] Open
Abstract
Introduction: Hydrocortisone is the standard of care in cortisol replacement therapy for congenital adrenal hyperplasia patients. Challenges in mimicking cortisol circadian rhythm and dosing individualization can be overcome by the support of mathematical modelling. Previously, a non-linear mixed-effects (NLME) model was developed based on clinical hydrocortisone pharmacokinetic (PK) pediatric and adult data. Additionally, a physiologically-based pharmacokinetic (PBPK) model was developed for adults and a pediatric model was obtained using maturation functions for relevant processes. In this work, a middle-out approach was applied. The aim was to investigate whether PBPK-derived maturation functions could provide a better description of hydrocortisone PK inter-individual variability when implemented in the NLME framework, with the goal of providing better individual predictions towards precision dosing at the patient level. Methods: Hydrocortisone PK data from 24 adrenal insufficiency pediatric patients and 30 adult healthy volunteers were used for NLME model development, while the PBPK model and maturation functions of clearance and cortisol binding globulin (CBG) were developed based on previous studies published in the literature. Results: Clearance (CL) estimates from both approaches were similar for children older than 1 year (CL/F increasing from around 150 L/h to 500 L/h), while CBG concentrations differed across the whole age range (CBGNLME stable around 0.5 μM vs. steady increase from 0.35 to 0.8 μM for CBG PBPK). PBPK-derived maturation functions were subsequently included in the NLME model. After inclusion of the maturation functions, none, a part of, or all parameters were re-estimated. However, the inclusion of CL and/or CBG maturation functions in the NLME model did not result in improved model performance for the CL maturation function (ΔOFV > -15.36) and the re-estimation of parameters using the CBG maturation function most often led to unstable models or individual CL prediction bias. Discussion: Three explanations for the observed discrepancies could be postulated, i) non-considered maturation of processes such as absorption or first-pass effect, ii) lack of patients between 1 and 12 months, iii) lack of correction of PBPK CL maturation functions derived from urinary concentration ratio data for the renal function relative to adults. These should be investigated in the future to determine how NLME and PBPK methods can work towards deriving insights into pediatric hydrocortisone PK.
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Affiliation(s)
- Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany,*Correspondence: Robin Michelet,
| | - Davide Bindellini
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany,Graduate Research Training Program, Berlin, Germany
| | - Johanna Melin
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany,Graduate Research Training Program, Berlin, Germany
| | - Uta Neumann
- Clinic for Pediatric Endocrinology and Diabetology, Charité-Universitätsmedizin, Berlin, Germany
| | - Oliver Blankenstein
- Clinic for Pediatric Endocrinology and Diabetology, Charité-Universitätsmedizin, Berlin, Germany
| | | | | | - Martin J. Whitaker
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Richard Ross
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom,Diurnal Limited, Cardiff, United Kingdom
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
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Schulz J, Michelet R, Zeitlinger M, Mikus G, Kloft C. Microdialysis of Drug and Drug Metabolite: a Comprehensive In Vitro Analysis for Voriconazole and Voriconazole N-oxide. Pharm Res 2022; 39:2991-3003. [PMID: 36171344 PMCID: PMC9633485 DOI: 10.1007/s11095-022-03292-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
Purpose Voriconazole is a therapeutically challenging antifungal drug associated with high interindividual pharmacokinetic variability. As a prerequisite to performing clinical trials using the minimally-invasive sampling technique microdialysis, a comprehensive in vitro microdialysis characterization of voriconazole (VRC) and its potentially toxic N-oxide metabolite (NO) was performed. Methods The feasibility of simultaneous microdialysis of VRC and NO was explored in vitro by investigating the relative recovery (RR) of both compounds in the absence and presence of the other. The dependency of RR on compound combination, concentration, microdialysis catheter and study day was evaluated and quantified by linear mixed-effects modeling. Results Median RR of VRC and NO during individual microdialysis were high (87.6% and 91.1%). During simultaneous microdialysis of VRC and NO, median RR did not change (87.9% and 91.1%). The linear mixed-effects model confirmed the absence of significant differences between RR of VRC and NO during individual and simultaneous microdialysis as well as between the two compounds (p > 0.05). No concentration dependency of RR was found (p = 0.284). The study day was the main source of variability (46.3%) while the microdialysis catheter only had a minor effect (4.33%). VRC retrodialysis proved feasible as catheter calibration for both compounds. Conclusion These in vitro microdialysis results encourage the application of microdialysis in clinical trials to assess target-site concentrations of VRC and NO. This can support the generation of a coherent understanding of VRC pharmacokinetics and its sources of variability. Ultimately, a better understanding of human VRC pharmacokinetics might contribute to the development of personalized dosing strategies.
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Affiliation(s)
- Josefine Schulz
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Gerd Mikus
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
- Department Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
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Berlak M, Tucker E, Dorel M, Winkler A, McGearey A, Rodriguez-Fos E, da Costa BM, Barker K, Fyle E, Calton E, Eising S, Ober K, Hughes D, Koutroumanidou E, Carter P, Stankunaite R, Proszek P, Jain N, Rosswog C, Dorado-Garcia H, Molenaar JJ, Hubank M, Barone G, Anderson J, Lang P, Deubzer HE, Künkele A, Fischer M, Eggert A, Kloft C, Henssen AG, Boettcher M, Hertwig F, Blüthgen N, Chesler L, Schulte JH. Mutations in ALK signaling pathways conferring resistance to ALK inhibitor treatment lead to collateral vulnerabilities in neuroblastoma cells. Mol Cancer 2022; 21:126. [PMID: 35689207 PMCID: PMC9185889 DOI: 10.1186/s12943-022-01583-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 04/22/2022] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Development of resistance to targeted therapies has tempered initial optimism that precision oncology would improve poor outcomes for cancer patients. Resistance mechanisms, however, can also confer new resistance-specific vulnerabilities, termed collateral sensitivities. Here we investigated anaplastic lymphoma kinase (ALK) inhibitor resistance in neuroblastoma, a childhood cancer frequently affected by activating ALK alterations. METHODS Genome-wide forward genetic CRISPR-Cas9 based screens were performed to identify genes associated with ALK inhibitor resistance in neuroblastoma cell lines. Furthermore, the neuroblastoma cell line NBLW-R was rendered resistant by continuous exposure to ALK inhibitors. Genes identified to be associated with ALK inhibitor resistance were further investigated by generating suitable cell line models. In addition, tumor and liquid biopsy samples of four patients with ALK-mutated neuroblastomas before ALK inhibitor treatment and during tumor progression under treatment were genomically profiled. RESULTS Both genome-wide CRISPR-Cas9-based screens and preclinical spontaneous ALKi resistance models identified NF1 loss and activating NRASQ61K mutations to confer resistance to chemically diverse ALKi. Moreover, human neuroblastomas recurrently developed de novo loss of NF1 and activating RAS mutations after ALKi treatment, leading to therapy resistance. Pathway-specific perturbations confirmed that NF1 loss and activating RAS mutations lead to RAS-MAPK signaling even in the presence of ALKi. Intriguingly, NF1 loss rendered neuroblastoma cells hypersensitive to MEK inhibition. CONCLUSIONS Our results provide a clinically relevant mechanistic model of ALKi resistance in neuroblastoma and highlight new clinically actionable collateral sensitivities in resistant cells.
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Affiliation(s)
- Mareike Berlak
- Department of Pediatric Oncology/Hematology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin School of Integrative Oncology (BSIO), Augustenburger Platz 1, 13353, Berlin, Germany
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr.31, 12169, Berlin, Germany
| | - Elizabeth Tucker
- Paediatric Solid Tumour Biology and Therapeutics Team, Clinical Division and Cancer Therapeutics Division, The Institute of Cancer Research, 15 Cotswold Road, Sutton, Surrey, SM2 5NG, UK
| | - Mathurin Dorel
- Otto Warburg Laboratory Gene Regulation and Systems Biology of Cancer, Max Planck Institute for Molecular Genetics, Berlin, Germany
- Institute of Pathology, Charité-Universitätsmedizin Berlin, 10117, Berlin, Germany
- IRI Life Sciences, Humboldt University Berlin, 10115, Berlin, Germany
| | - Annika Winkler
- Department of Pediatric Oncology/Hematology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Aleixandria McGearey
- Department of Pediatric Oncology/Hematology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Elias Rodriguez-Fos
- Department of Pediatric Oncology/Hematology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Experimental and Clinical Research Center (ECRC) of the Charité and Max-Delbrück-Center for Molecular Medicine (MDC) in the Helmholtz Association, 13125, Berlin, Germany
| | - Barbara Martins da Costa
- Paediatric Solid Tumour Biology and Therapeutics Team, Clinical Division and Cancer Therapeutics Division, The Institute of Cancer Research, 15 Cotswold Road, Sutton, Surrey, SM2 5NG, UK
| | - Karen Barker
- Paediatric Solid Tumour Biology and Therapeutics Team, Clinical Division and Cancer Therapeutics Division, The Institute of Cancer Research, 15 Cotswold Road, Sutton, Surrey, SM2 5NG, UK
| | - Elicia Fyle
- Paediatric Solid Tumour Biology and Therapeutics Team, Clinical Division and Cancer Therapeutics Division, The Institute of Cancer Research, 15 Cotswold Road, Sutton, Surrey, SM2 5NG, UK
| | - Elizabeth Calton
- Paediatric Solid Tumour Biology and Therapeutics Team, Clinical Division and Cancer Therapeutics Division, The Institute of Cancer Research, 15 Cotswold Road, Sutton, Surrey, SM2 5NG, UK
| | - Selma Eising
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Kim Ober
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Deborah Hughes
- Molecular Diagnostics Department, The Institute of Cancer Research and Clinical Genomics, The Royal Marsden NHS Foundation, London, UK
| | - Eleni Koutroumanidou
- Molecular Diagnostics Department, The Institute of Cancer Research and Clinical Genomics, The Royal Marsden NHS Foundation, London, UK
| | - Paul Carter
- Molecular Diagnostics Department, The Institute of Cancer Research and Clinical Genomics, The Royal Marsden NHS Foundation, London, UK
| | - Reda Stankunaite
- Molecular Diagnostics Department, The Institute of Cancer Research and Clinical Genomics, The Royal Marsden NHS Foundation, London, UK
| | - Paula Proszek
- Molecular Diagnostics Department, The Institute of Cancer Research and Clinical Genomics, The Royal Marsden NHS Foundation, London, UK
| | - Neha Jain
- Cancer Section, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Carolina Rosswog
- Department of Experimental Pediatric Oncology, Center for Molecular Medicine Cologne, 50931, Cologne, Germany
| | - Heathcliff Dorado-Garcia
- Department of Pediatric Oncology/Hematology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jan Jasper Molenaar
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of pharmaceutical sciences, Utrecht University, Utrecht, The Netherlands
| | - Mike Hubank
- Molecular Diagnostics Department, The Institute of Cancer Research and Clinical Genomics, The Royal Marsden NHS Foundation, London, UK
| | - Giuseppe Barone
- Cancer Section, UCL Great Ormond Street Institute of Child Health, London, UK
| | - John Anderson
- Cancer Section, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Peter Lang
- Department of Pediatric Oncology/Hematology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Department of Pediatric Hematology and Oncology, University Hospital, Tübingen, Germany
| | - Hedwig Elisabeth Deubzer
- Department of Pediatric Oncology/Hematology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Experimental and Clinical Research Center (ECRC) of the Charité and Max-Delbrück-Center for Molecular Medicine (MDC) in the Helmholtz Association, 13125, Berlin, Germany
- German Cancer Consortium (DKTK), Berlin, Germany
- German Cancer Research Center (DKFZ), 69120, Heidelberg, Germany
| | - Annette Künkele
- Department of Pediatric Oncology/Hematology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- German Cancer Consortium (DKTK), Berlin, Germany
- German Cancer Research Center (DKFZ), 69120, Heidelberg, Germany
- Berlin Institute of Health (BIH) at Charité-Universitätsmedizin Berlin, 10117, Berlin, Germany
| | - Matthias Fischer
- Department of Experimental Pediatric Oncology, Center for Molecular Medicine Cologne, 50931, Cologne, Germany
| | - Angelika Eggert
- Department of Pediatric Oncology/Hematology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- German Cancer Consortium (DKTK), Berlin, Germany
- German Cancer Research Center (DKFZ), 69120, Heidelberg, Germany
- Berlin Institute of Health (BIH) at Charité-Universitätsmedizin Berlin, 10117, Berlin, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr.31, 12169, Berlin, Germany
| | - Anton George Henssen
- Department of Pediatric Oncology/Hematology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Experimental and Clinical Research Center (ECRC) of the Charité and Max-Delbrück-Center for Molecular Medicine (MDC) in the Helmholtz Association, 13125, Berlin, Germany
- German Cancer Consortium (DKTK), Berlin, Germany
- German Cancer Research Center (DKFZ), 69120, Heidelberg, Germany
- Berlin Institute of Health (BIH) at Charité-Universitätsmedizin Berlin, 10117, Berlin, Germany
| | - Michael Boettcher
- Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), 06120, Halle, Germany
| | - Falk Hertwig
- Department of Pediatric Oncology/Hematology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Nils Blüthgen
- Institute of Pathology, Charité-Universitätsmedizin Berlin, 10117, Berlin, Germany
- IRI Life Sciences, Humboldt University Berlin, 10115, Berlin, Germany
- German Cancer Consortium (DKTK), Berlin, Germany
- German Cancer Research Center (DKFZ), 69120, Heidelberg, Germany
- Berlin Institute of Health (BIH) at Charité-Universitätsmedizin Berlin, 10117, Berlin, Germany
| | - Louis Chesler
- Paediatric Solid Tumour Biology and Therapeutics Team, Clinical Division and Cancer Therapeutics Division, The Institute of Cancer Research, 15 Cotswold Road, Sutton, Surrey, SM2 5NG, UK
| | - Johannes Hubertus Schulte
- Department of Pediatric Oncology/Hematology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
- German Cancer Consortium (DKTK), Berlin, Germany.
- German Cancer Research Center (DKFZ), 69120, Heidelberg, Germany.
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Weinelt FA, Stegemann MS, Theloe A, Pfäfflin F, Achterberg S, Weber F, Dübel L, Mikolajewska A, Uhrig A, Kiessling P, Huisinga W, Michelet R, Hennig S, Kloft C. Evaluation of a Meropenem and Piperacillin Monitoring Program in Intensive Care Unit Patients Calls for the Regular Assessment of Empirical Targets and Easy-to-Use Dosing Decision Tools. Antibiotics (Basel) 2022; 11:antibiotics11060758. [PMID: 35740164 PMCID: PMC9219867 DOI: 10.3390/antibiotics11060758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/25/2022] [Accepted: 05/29/2022] [Indexed: 02/01/2023] Open
Abstract
The drug concentrations targeted in meropenem and piperacillin/tazobactam therapy also depend on the susceptibility of the pathogen. Yet, the pathogen is often unknown, and antibiotic therapy is guided by empirical targets. To reliably achieve the targeted concentrations, dosing needs to be adjusted for renal function. We aimed to evaluate a meropenem and piperacillin/tazobactam monitoring program in intensive care unit (ICU) patients by assessing (i) the adequacy of locally selected empirical targets, (ii) if dosing is adequately adjusted for renal function and individual target, and (iii) if dosing is adjusted in target attainment (TA) failure. In a prospective, observational clinical trial of drug concentrations, relevant patient characteristics and microbiological data (pathogen, minimum inhibitory concentration (MIC)) for patients receiving meropenem or piperacillin/tazobactam treatment were collected. If the MIC value was available, a target range of 1–5 × MIC was selected for minimum drug concentrations of both drugs. If the MIC value was not available, 8–40 mg/L and 16–80 mg/L were selected as empirical target ranges for meropenem and piperacillin, respectively. A total of 356 meropenem and 216 piperacillin samples were collected from 108 and 96 ICU patients, respectively. The vast majority of observed MIC values was lower than the empirical target (meropenem: 90.0%, piperacillin: 93.9%), suggesting empirical target value reductions. TA was found to be low (meropenem: 35.7%, piperacillin 50.5%) with the lowest TA for severely impaired renal function (meropenem: 13.9%, piperacillin: 29.2%), and observed drug concentrations did not significantly differ between patients with different targets, indicating dosing was not adequately adjusted for renal function or target. Dosing adjustments were rare for both drugs (meropenem: 6.13%, piperacillin: 4.78%) and for meropenem irrespective of TA, revealing that concentration monitoring alone was insufficient to guide dosing adjustment. Empirical targets should regularly be assessed and adjusted based on local susceptibility data. To improve TA, scientific knowledge should be translated into easy-to-use dosing strategies guiding antibiotic dosing.
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Affiliation(s)
- Ferdinand Anton Weinelt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
- Graduate Research Training Program PharMetrX, Freie Universitaet Berlin/Universität Potsdam, 12169 Berlin, Germany
| | - Miriam Songa Stegemann
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany; (M.S.S.); (F.P.); (S.A.); (A.M.); (A.U.)
- Antimicrobial Stewardship, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany
| | - Anja Theloe
- Pharmacy Department, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany;
| | - Frieder Pfäfflin
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany; (M.S.S.); (F.P.); (S.A.); (A.M.); (A.U.)
- Antimicrobial Stewardship, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany
| | - Stephan Achterberg
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany; (M.S.S.); (F.P.); (S.A.); (A.M.); (A.U.)
| | - Franz Weber
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
- Graduate Research Training Program PharMetrX, Freie Universitaet Berlin/Universität Potsdam, 12169 Berlin, Germany
| | - Lucas Dübel
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
| | - Agata Mikolajewska
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany; (M.S.S.); (F.P.); (S.A.); (A.M.); (A.U.)
| | - Alexander Uhrig
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany; (M.S.S.); (F.P.); (S.A.); (A.M.); (A.U.)
| | | | - Wilhelm Huisinga
- Institute of Mathematics, Universität Potsdam, Karl-Liebknecht-Str. 24-25, 14476 Potsdam, Germany;
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
| | - Stefanie Hennig
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD 4000, Australia
- Certara, Inc., Princeton, NJ 08540, USA
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
- Correspondence: ; Tel.: +49-30-838-50676
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Hess D, Colombo I, Haefliger S, Rabaglio M, Bastian S, Schwitter M, Eckhardt K, Garzon JG, Hayoz S, Kopp C, Holer L, Mc Laughlin A, Kloft C, Sessa C, Stathis A, Halbherr S, Baumgartner C, Joerger M. TLD-1, a novel liposomal doxorubicin, in patients (pts) with advanced solid tumors: Dose escalation and expansion part of a multicenter open-label phase I trial (SAKK 65/16). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.3027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
3027 Background: TLD-1 is a novel liposomal doxorubicin that compared favorably to conventional liposomal formulations of doxorubicin in preclinical in vivo mouse breast cancer models. This phase I first-in-human trial is aiming to determine the recommended phase II dose (RP2D), toxicity profile, pharmacokinetics and preliminary activity. Methods: Patients with a maximum of 3 prior lines of systemic chemotherapy and preferably anthracycline-sensitive disease were eligible. TLD-1 was administered on day 1 iv over 60-90 minutes (depending on individual dose) q 21 days, for up to 6 or 9 cycles (according to prior anthracycline-exposure) with premedication of 8mg dexamethasone. Dose escalation with dose levels (DL) 1-7 of 10, 16, 23, 30, 35, 40 and 45mg/m2 started with an accelerated titration design, treating one pt at each DL up to DL6 (40mg/m2) followed by a modified continual reassessment method at DL7 due to observed toxicity. Results: 30 pts (F:M = 24:6) have been treated, one each at DLs 1-6, 15 pts at DL7 and an additional 9 pts at DL6. Most frequent tumor types included breast (n = 13), ovarian (n = 6), cervical cancer (n = 2) and cholangiocarcinoma (n = 2). Median age was 67.5 years (range:38-83), 13 pts were exposed to prior anthracyclines. The median number of cycles was 4 (range:1-9). No dose-limiting toxicities (DLT) occurred during cycle 1. At DLs 1 to 5, no treatment-related G3 AEs (TRAE) were observed. At DL6, there was one case of mucositis G3, one of palmar-plantar-erythrodysesthesia (PPE) G3 and one of anemia and neutropenia G3 each. One patient with pre-existing valvular cardiopathy developed symptoms of heart-failure G3 after 8 cycles. Echocardiography showed severe mitral regurgitation with normal LV-EF. In addition one case of urinary-tract infection G3 was seen. Dose-modifications or -delays due to AEs occurred in 7/50 cycles. At DL7, one case of mucositis G3, 3 events of PPE G3 and one case of fatigue G3 were reported. In addition, one case of infection with shingles occurred. Dose-modifications or -delays due to AEs occurred in 12/61 cycles. Shingles and heart failure were reported as SAEs. All toxicities listed above were categorized as TRAE. 29/30 pts were evaluable for response. Three breast cancer pts had a partial response, 2 at DL7 and 1 at DL6, 14 pts had stable disease. Conclusions: No DLT was observed up to DL7. RP2D was defined at 40mg/m2 due to cumulative PPE G3 at DL7. The trial is ongoing with a comparative PK-part evaluating the two iv liposomal formulations of doxorubicin TLD-1 and Caelyx. Clinical trial information: NCT03387917.
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Affiliation(s)
- Dagmar Hess
- Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Ilaria Colombo
- Istituto Oncologico della Svizzera Italiana, Bellinzona, Switzerland
| | | | | | | | | | | | | | - Stefanie Hayoz
- Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | - Christoph Kopp
- Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | - Lisa Holer
- Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | - Anna Mc Laughlin
- Freie Universität Berlin, Institute of Pharmacy, Berlin, Germany
| | - Charlotte Kloft
- Freie Universität Berlin, Institut für Pharmazie, Berlin, Germany
| | - Cristiana Sessa
- IOSI-Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Anastasios Stathis
- IOSI-Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | | | | | - Markus Joerger
- Department of Oncology/Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
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Scharf C, Weinelt F, Schroeder I, Paal M, Weigand M, Zoller M, Irlbeck M, Kloft C, Briegel J, Liebchen U. Does the cytokine adsorber CytoSorb ® reduce vancomycin exposure in critically ill patients with sepsis or septic shock? a prospective observational study. Ann Intensive Care 2022; 12:44. [PMID: 35599248 PMCID: PMC9124739 DOI: 10.1186/s13613-022-01017-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 05/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemadsorption of cytokines is used in critically ill patients with sepsis or septic shock. Concerns have been raised that the cytokine adsorber CytoSorb® unintentionally adsorbs vancomycin. This study aimed to quantify vancomycin elimination by CytoSorb®. METHODS Critically ill patients with sepsis or septic shock receiving continuous renal replacement therapy and CytoSorb® treatment during a prospective observational study were included in the analysis. Vancomycin pharmacokinetics was characterized using population pharmacokinetic modeling. Adsorption of vancomycin by the CytoSorb® was investigated as linear or saturable process. The final model was used to derive dosing recommendations based on stochastic simulations. RESULTS 20 CytoSorb® treatments in 7 patients (160 serum samples/24 during CytoSorb®-treatment, all continuous infusion) were included in the study. A classical one-compartment model, including effluent flow rate of the continuous hemodialysis as linear covariate on clearance, best described the measured concentrations (without CytoSorb®). Significant adsorption with a linear decrease during CytoSorb® treatment was identified (p < 0.0001) and revealed a maximum increase in vancomycin clearance of 291% (initially after CytoSorb® installation) and a maximum adsorption capacity of 572 mg. For a representative patient of our cohort a reduction of the area under the curve (AUC) by 93 mg/L*24 h during CytoSorb® treatment was observed. The additional administration of 500 mg vancomycin over 2 h during CytoSorb® attenuated the effect and revealed a negligible reduction of the AUC by 4 mg/L*24 h. CONCLUSION We recommend the infusion of 500 mg vancomycin over 2 h during CytoSorb® treatment to avoid subtherapeutic concentrations. Trial registration NCT03985605. Registered 14 June 2019, https://clinicaltrials.gov/ct2/show/NCT03985605.
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Affiliation(s)
- Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Ferdinand Weinelt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169, Berlin, Germany.,Graduate Research Training Program PharMetrX, Freie Universität Berlin/Universität Potsdam, Berlin, Germany
| | - Ines Schroeder
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael Weigand
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169, Berlin, Germany
| | - Josef Briegel
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany. .,Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169, Berlin, Germany.
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Stachanow V, Neumann U, Blankenstein O, Bindellini D, Melin J, Ross R, Whitaker MJ, Huisinga W, Michelet R, Kloft C. Exploring Dried Blood Spot Cortisol Concentrations as an Alternative for Monitoring Pediatric Adrenal Insufficiency Patients: A Model-Based Analysis. Front Pharmacol 2022; 13:819590. [PMID: 35370666 PMCID: PMC8968419 DOI: 10.3389/fphar.2022.819590] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH) is the most common form of adrenal insufficiency in childhood; it requires cortisol replacement therapy with hydrocortisone (HC, synthetic cortisol) from birth and therapy monitoring for successful treatment. In children, the less invasive dried blood spot (DBS) sampling with whole blood including red blood cells (RBCs) provides an advantageous alternative to plasma sampling. Potential differences in binding/association processes between plasma and DBS however need to be considered to correctly interpret DBS measurements for therapy monitoring. While capillary DBS samples would be used in clinical practice, venous cortisol DBS samples from children with adrenal insufficiency were analyzed due to data availability and to directly compare and thus understand potential differences between venous DBS and plasma. A previously published HC plasma pharmacokinetic (PK) model was extended by leveraging these DBS concentrations. In addition to previously characterized binding of cortisol to albumin (linear process) and corticosteroid-binding globulin (CBG; saturable process), DBS data enabled the characterization of a linear cortisol association with RBCs, and thereby providing a quantitative link between DBS and plasma cortisol concentrations. The ratio between the observed cortisol plasma and DBS concentrations varies highly from 2 to 8. Deterministic simulations of the different cortisol binding/association fractions demonstrated that with higher blood cortisol concentrations, saturation of cortisol binding to CBG was observed, leading to an increase in all other cortisol binding fractions. In conclusion, a mathematical PK model was developed which links DBS measurements to plasma exposure and thus allows for quantitative interpretation of measurements of DBS samples.
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Affiliation(s)
- Viktoria Stachanow
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany.,Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Uta Neumann
- Pediatric Endocrinology, Charité-Universitätsmedizin, Berlin, Germany
| | - Oliver Blankenstein
- Pediatric Endocrinology, Charité-Universitätsmedizin, Berlin, Germany.,Labor Berlin, Charité Vivantes GmbH, Berlin, Germany
| | - Davide Bindellini
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany.,Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Johanna Melin
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany.,Graduate Research Training Program PharMetrX, Berlin, Germany
| | | | | | | | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
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25
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van Dyk M, Boylan C, Michelet R, Mc Laughlin AM, Kichenadasse G, May N, Ziesenitz V, Van Den Anker JN, Groenland SL, Huitema ADR, Steeghs N, Mikus G, Kloft C, Tapp H. Plasma concentration guided dosing of drugs used for the treatment of childhood leukaemias: protocol for a systematic review. BMJ Open 2022; 12:e053308. [PMID: 34980620 PMCID: PMC8724759 DOI: 10.1136/bmjopen-2021-053308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Childhood leukaemia is the most common type of cancer in children and represents among 25% of the diagnoses in children <15 years old. Childhood survival rates have significantly improved within the last 40 years due to a rapid advancement in therapeutic interventions. However, in high-risk groups, survival rates remain poor. Pharmacokinetic (PK) data of cancer medications in children are limited and thus current dosing regimens are based on studies with small sample sizes. In adults, large variability in PK is observed and dose individualisation (plasma concentration guided dosing) has been associated with improved clinical outcomes; whether this is true for children is still unknown. This provides an opportunity to explore this strategy in children to potentially reduce toxicities and ensure optimal dosing. This paper will provide a protocol to systematically review studies that have used dose individualisation of drugs used in the treatment of childhood leukaemias. METHODS AND ANALYSIS Systematic review methodology will be applied to identify, select and extract data from published plasma guided dosing studies conducted in a paediatric leukaemia cohort. Databases (eg, Ovid Embase, Ovid MEDLINE, Ovid Cochrane) and clinical trial registries (CENTRAL, ClinicalTrials.gov and ISRCTN) will be used to perform the systematic literature search (up until February 2021). Only full empirical studies will be included, with primary clinical outcomes (progression-free survival, toxicities, minimal residual disease status, complete cytogenetic response, partial cytogenetic response and major molecular response) being used to decide whether the study will be included. The quality of included studies will be undertaken, with a subgroup analysis where appropriate. ETHICS AND DISSEMINATION This systematic review will not require ethics approval as there will not be collection of primary data. Findings of this review will be made available through publications in peer-reviewed journals and conference presentations. Gaps will be identified in current literature to inform future-related research. PROSPERO REGISTRATION NUMBER CRD42021225045.
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Affiliation(s)
- Madelé van Dyk
- Flinders Health and Medical Research Institute - Cancer, Flinders University, Adelaide, South Australia, Australia
| | - Chelsea Boylan
- Flinders Health and Medical Research Institute - Cancer, Flinders University College of Medicine and Public Health, Bedford Park, South Australia, Australia
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
- PharMetrX Graduate Research Training Program, Postdam/Berlin, UK
| | - Anna M Mc Laughlin
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
- Postdam/Berlin, PharMetrX Graduate Research Training Program, Postdam/Berlin, Germany
| | - Ganessan Kichenadasse
- Flinders Health and Medical Research Institute - Cancer, Flinders University College of Medicine and Public Health, Bedford Park, South Australia, Australia
- Medical Oncology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Nikki May
- SA Health Library Service, Bedford Park, South Australia, Australia
| | - Victoria Ziesenitz
- Pediatric Cardiology & Congenital Heart Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Johannes N Van Den Anker
- Division of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Basel, Switzerland
- Division of Clinical Pharmacology, Children's National Hospital, Washington, District of Columbia, USA
| | - Stefanie L Groenland
- Antoni van Leeuwenhoek Netherlands Cancer Institute, Amsterdam, Noord-Holland, The Netherlands
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Noord-Holland, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Netherlands Cancer Institute, Amsterdam, Noord-Holland, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Neeltje Steeghs
- Antoni van Leeuwenhoek Netherlands Cancer Institute, Amsterdam, Noord-Holland, The Netherlands
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Noord-Holland, The Netherlands
| | - Gerd Mikus
- Clinical Pharmacology and Pharmacoepidemiology, UniversitatsKlinikum Heidelberg, Heidelberg, Baden-Württemberg, Germany
- Department of Clinical Pharmacy and Biochemistry, Free University of Berlin, Berlin, Germany
| | - Charlotte Kloft
- Freie Universitat Berlin Institut fur Pharmazie, Berlin, Germany
| | - Heather Tapp
- Haematology/Oncology Unit, Women's and Children's Hospital Adelaide, North Adelaide, South Australia, Australia
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26
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Schulz J, Michelet R, Zeitlinger M, Mikus G, Kloft C. Microdialysis of Voriconazole and its N-Oxide Metabolite: Amalgamating Knowledge of Distribution and Metabolism Processes in Humans. Pharm Res 2022; 39:3279-3291. [PMID: 36271205 PMCID: PMC9780129 DOI: 10.1007/s11095-022-03407-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/29/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE Voriconazole is an essential antifungal drug whose complex pharmacokinetics with high interindividual variability impedes effective and safe therapy. By application of the minimally-invasive sampling technique microdialysis, interstitial space fluid (ISF) concentrations of VRC and its potentially toxic N-oxide metabolite (NO) were assessed to evaluate target-site exposure for further elucidating VRC pharmacokinetics. METHODS Plasma and ISF samples of a clinical trial with an approved VRC dosing regimen were analyzed for VRC and NO concentrations. Concentration-time profiles, exposure assessed as area-under-the-curve (AUC) and metabolic ratios of four healthy adults in plasma and ISF were evaluated regarding the impact of multiple dosing and CYP2C19 genotype. RESULTS VRC and NO revealed distribution into ISF with AUC values being ≤2.82- and 17.7-fold lower compared to plasma, respectively. Intraindividual variability of metabolic ratios was largest after the first VRC dose administration while interindividual variability increased with multiple dosing. The CYP2C19 genotype influenced interindividual differences with a maximum 6- and 24-fold larger AUCNO/AUCVRC ratio between the intermediate and rapid metabolizer in plasma and ISF, respectively. VRC metabolism was saturated/auto-inhibited indicated by substantially decreasing metabolic concentration ratios with increasing VRC concentrations and after multiple dosing. CONCLUSION The feasibility of the simultaneous microdialysis of VRC and NO in vivo was demonstrated and provided new quantitative insights by leveraging distribution and metabolism processes of VRC in humans. The exploratory analysis suggested substantial dissimilarities of VRC and NO pharmacokinetics in plasma and ISF. Ultimately, a thorough understanding of target-site pharmacokinetics might contribute to the optimization of personalized VRC dosing regimens.
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Affiliation(s)
- Josefine Schulz
- grid.14095.390000 0000 9116 4836Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
| | - Robin Michelet
- grid.14095.390000 0000 9116 4836Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
| | - Markus Zeitlinger
- grid.22937.3d0000 0000 9259 8492Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Gerd Mikus
- grid.14095.390000 0000 9116 4836Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany ,grid.5253.10000 0001 0328 4908Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Charlotte Kloft
- grid.14095.390000 0000 9116 4836Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
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27
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Nassar YM, Hohmann N, Michelet R, Gottwalt K, Meid AD, Burhenne J, Huisinga W, Haefeli WE, Mikus G, Kloft C. Quantification of the Time Course of CYP3A Inhibition, Activation, and Induction Using a Population Pharmacokinetic Model of Microdosed Midazolam Continuous Infusion. Clin Pharmacokinet 2022; 61:1595-1607. [PMID: 36195807 PMCID: PMC9652212 DOI: 10.1007/s40262-022-01175-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cytochrome P450 (CYP) 3A contributes to the metabolism of many approved drugs. CYP3A perpetrator drugs can profoundly alter the exposure of CYP3A substrates. However, effects of such drug-drug interactions are usually reported as maximum effects rather than studied as time-dependent processes. Identification of the time course of CYP3A modulation can provide insight into when significant changes to CYP3A activity occurs, help better design drug-drug interaction studies, and manage drug-drug interactions in clinical practice. OBJECTIVE We aimed to quantify the time course and extent of the in vivo modulation of different CYP3A perpetrator drugs on hepatic CYP3A activity and distinguish different modulatory mechanisms by their time of onset, using pharmacologically inactive intravenous microgram doses of the CYP3A-specific substrate midazolam, as a marker of CYP3A activity. METHODS Twenty-four healthy individuals received an intravenous midazolam bolus followed by a continuous infusion for 10 or 36 h. Individuals were randomized into four arms: within each arm, two individuals served as a placebo control and, 2 h after start of the midazolam infusion, four individuals received the CYP3A perpetrator drug: voriconazole (inhibitor, orally or intravenously), rifampicin (inducer, orally), or efavirenz (activator, orally). After midazolam bolus administration, blood samples were taken every hour (rifampicin arm) or every 15 min (remaining study arms) until the end of midazolam infusion. A total of 1858 concentrations were equally divided between midazolam and its metabolite, 1'-hydroxymidazolam. A nonlinear mixed-effects population pharmacokinetic model of both compounds was developed using NONMEM®. CYP3A activity modulation was quantified over time, as the relative change of midazolam clearance encountered by the perpetrator drug, compared to the corresponding clearance value in the placebo arm. RESULTS Time course of CYP3A modulation and magnitude of maximum effect were identified for each perpetrator drug. While efavirenz CYP3A activation was relatively fast and short, reaching a maximum after approximately 2-3 h, the induction effect of rifampicin could only be observed after 22 h, with a maximum after approximately 28-30 h followed by a steep drop to almost baseline within 1-2 h. In contrast, the inhibitory impact of both oral and intravenous voriconazole was prolonged with a steady inhibition of CYP3A activity followed by a gradual increase in the inhibitory effect until the end of sampling at 8 h. Relative maximum clearance changes were +59.1%, +46.7%, -70.6%, and -61.1% for efavirenz, rifampicin, oral voriconazole, and intravenous voriconazole, respectively. CONCLUSIONS We could distinguish between different mechanisms of CYP3A modulation by the time of onset. Identification of the time at which clearance significantly changes, per perpetrator drug, can guide the design of an optimal sampling schedule for future drug-drug interaction studies. The impact of a short-term combination of different perpetrator drugs on the paradigm CYP3A substrate midazolam was characterized and can define combination intervals in which no relevant interaction is to be expected. CLINICAL TRIAL REGISTRATION The trial was registered at the European Union Drug Regulating Authorities for Clinical Trials (EudraCT-No. 2013-004869-14).
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Affiliation(s)
- Yomna M. Nassar
- grid.14095.390000 0000 9116 4836Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany ,grid.14095.390000 0000 9116 4836Graduate Research Training Program PharMetrX, Freie Universität Berlin/University of Potsdam, Berlin/Potsdam, Germany
| | - Nicolas Hohmann
- grid.7700.00000 0001 2190 4373Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Robin Michelet
- grid.14095.390000 0000 9116 4836Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany
| | - Katharina Gottwalt
- grid.7700.00000 0001 2190 4373Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Andreas D. Meid
- grid.7700.00000 0001 2190 4373Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Jürgen Burhenne
- grid.7700.00000 0001 2190 4373Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Wilhelm Huisinga
- grid.11348.3f0000 0001 0942 1117Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Walter E. Haefeli
- grid.7700.00000 0001 2190 4373Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Gerd Mikus
- grid.14095.390000 0000 9116 4836Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany ,grid.7700.00000 0001 2190 4373Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Charlotte Kloft
- grid.14095.390000 0000 9116 4836Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany
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Schulz J, Michelet R, Joseph JF, Zeitlinger M, Schumacher F, Mikus G, Kloft C. A versatile high-performance LC-MS/MS assay for the quantification of voriconazole and its N-oxide metabolite in small sample volumes of multiple human matrices for biomedical applications. J Pharm Biomed Anal 2021; 210:114551. [PMID: 34999435 DOI: 10.1016/j.jpba.2021.114551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 01/18/2023]
Abstract
Voriconazole (VRC) pharmacokinetics, in particular its complex metabolism, is still not fully understood which challenges its optimal therapeutic use. To increase knowledge on the pharmacokinetics of this antifungal drug, it is essential to broaden the perspective and expand in vitro and clinical in vivo investigations in particular to aspects such as unbound plasma, target-site and metabolite concentrations. Innovative sampling approaches such as microdialysis, a minimally-invasive technique for the analysis of compound concentrations in target-site human tissue fluids, are associated with bioanalytical challenges, i.e. small sample volumes and low concentrations. Thus, a bioanalytical LC-MS/MS assay for the simultaneous quantification of VRC and its main N-oxide (NO) metabolite in human plasma, ultrafiltrate and microdialysate was developed and validated according to the European Medicines Agency guideline. Quantification was rapid, simple and feasible for clinically relevant concentrations from 5 to 5000 ng/mL in plasma and ultrafiltrate as well as from 4 to 4000 ng/mL in microdialysate. Due to the high sensitivity of the assay, only 20 µL of plasma or ultrafiltrate and 5 µL of microdialysate were required. For VRC and NO in all matrices, between-run accuracy was high with a maximum mean deviation of 7.0% from the nominal value and between-run precision was demonstrated by ≤ 11.8% coefficient of variation. Both compounds proved stable under various conditions. The assay suitability was demonstrated by the application to a clinical study quantifying simultaneously VRC and NO concentrations in plasma, ultrafiltrate and microdialysate. Additionally, the assay was successfully adapted for pharmacokinetic analyses in human tissue-derived in vitro experiments. Overall, by reducing the required sample volume, the bioanalytical method allows for an increased number of plasma samples in vulnerable populations, e.g. infants, and enables the generation of concentration-time profiles with a higher temporal resolution in microdialysis studies. Consequently, the developed assay is apt to elucidate the complex pharmacokinetics of VRC in clinical settings as prerequisite for therapy optimisation.
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Affiliation(s)
- Josefine Schulz
- Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany.
| | - Robin Michelet
- Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany.
| | - Jan F Joseph
- Core Facility BioSupraMol PharmaMS, Institute of Pharmacy, Freie Universitaet Berlin, Koenigin-Luise-Straße 2+4, 14195 Berlin, Germany.
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Fabian Schumacher
- Core Facility BioSupraMol PharmaMS, Institute of Pharmacy, Freie Universitaet Berlin, Koenigin-Luise-Straße 2+4, 14195 Berlin, Germany; Department of Pharmacology & Toxicology, Institute of Pharmacy, Freie Universitaet Berlin, Koenigin-Luise-Straße 2+4, 14195 Berlin, Germany.
| | - Gerd Mikus
- Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany; Department Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany.
| | - Charlotte Kloft
- Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany.
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29
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Busse D, Simon P, Schmitt L, Petroff D, Dorn C, Dietrich A, Zeitlinger M, Huisinga W, Michelet R, Wrigge H, Kloft C. Comparative Plasma and Interstitial Tissue Fluid Pharmacokinetics of Meropenem Demonstrate the Need for Increasing Dose and Infusion Duration in Obese and Non-obese Patients. Clin Pharmacokinet 2021; 61:655-672. [PMID: 34894344 PMCID: PMC9095536 DOI: 10.1007/s40262-021-01070-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES A quantitative evaluation of the PK of meropenem, a broad-spectrum β-lactam antibiotic, in plasma and interstitial space fluid (ISF) of subcutaneous adipose tissue of obese patients is lacking as of date. The objective of this study was the characterisation of meropenem population pharmacokinetics in plasma and ISF in obese and non-obese patients for identification of adequate dosing regimens via Monte-Carlo simulations. METHODS We obtained plasma and microdialysate concentrations after administration of meropenem 1000 mg to 15 obese and 15 non-obese surgery patients from a prospective clinical trial. After characterizing plasma- and microdialysis-derived ISF pharmacokinetics via population pharmacokinetic analysis, we simulated thrice-daily (TID) meropenem short-term (0.5 h), prolonged (3.0 h), and continuous infusions. Adequacy of therapy was assessed by the probability of pharmacokinetic/pharmacodynamic (PK/PD) target attainment (PTA) analysis based on time unbound concentrations exceeded minimum inhibitory concentrations (MIC) on treatment day 1 (%fT > MIC) and the sum of PTA weighted by relative frequency of MIC values for infections by pathogens commonly treated with meropenem. To avoid interstitial tissue fluid concentrations below MIC for the entire dosing interval during continuous infusions, a more conservative PK/PD index was selected (%fT > 4 × MIC). RESULTS Adjusted body weight (ABW) and calculated creatinine clearance (CLCRCG_ABW) of all patients (body mass index [BMI] = 20.5-81.5 kg/m2) explained a considerable proportion of the between-patient pharmacokinetic variability (15.1-31.0% relative reduction). The ISF:plasma ratio of %fT > MIC was relatively similar for MIC ≤ 2 mg/L but decreased for MIC = 8 mg/L over ABW = 60-120 kg (0.50-0.20). Steady-state concentrations were 2.68 times (95% confidence interval [CI] = 2.11-3.37) higher in plasma than in ISF, supporting PK/PD targets related to four times the MIC during continuous infusions to avoid suspected ISF concentrations constantly below the MIC. A 3000 mg/24 h continuous infusion was sufficient at MIC = 2 mg/L for patients with CLCRCG_ABW ≤ 100 mL/min and ABW < 90 kg, whereas 2000 mg TID prolonged infusions were adequate for those with CLCRCG_ABW ≤ 100 mL/min and ABW > 90 kg. For MIC = 2 mg/L and %fT> MIC = 95, PTA was adequate in patients over the entire investigated range of body mass and renal function using a 6000 mg continuous infusion. A prolonged infusion of meropenem 2000 mg TID was sufficient for MIC ≤ 8 mg/L and all investigated ABW and CLCRCG_ABW when employing the PK/PD target %fT > MIC = 40. Short-term infusions of 1000 mg TID were sufficient for CLCRCG_ABW ≤ 130 mL/min and distributions of MIC values for Escherichia coli, Citrobacter freundii, and Klebsiella pneumoniae but not for Pseudomonas aeruginosa. CONCLUSIONS This analysis indicated a need for higher doses (≥ 2000 mg) and prolonged infusions (≥ 3 h) for obese and non-obese patients at MIC ≥ 2 mg/L. Higher PTA was achieved with prolonged infusions in obese patients and with continuous infusions in non-obese patients. TRIAL REGISTRATION EudraCT: 2012-004383-22.
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Affiliation(s)
- David Busse
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Philipp Simon
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
| | - Lisa Schmitt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin, Germany
| | - David Petroff
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Clinical Trial Centre Leipzig, University of Leipzig, Leipzig, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - Arne Dietrich
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
| | - Hermann Wrigge
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany.
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Weinelt FA, Stegemann MS, Theloe A, Pfäfflin F, Achterberg S, Schmitt L, Huisinga W, Michelet R, Hennig S, Kloft C. Development of a Model-Informed Dosing Tool to Optimise Initial Antibiotic Dosing-A Translational Example for Intensive Care Units. Pharmaceutics 2021; 13:pharmaceutics13122128. [PMID: 34959409 PMCID: PMC8708464 DOI: 10.3390/pharmaceutics13122128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 12/19/2022] Open
Abstract
The prevalence and mortality rates of severe infections are high in intensive care units (ICUs). At the same time, the high pharmacokinetic variability observed in ICU patients increases the risk of inadequate antibiotic drug exposure. Therefore, dosing tailored to specific patient characteristics has a high potential to improve outcomes in this vulnerable patient population. This study aimed to develop a tabular dosing decision tool for initial therapy of meropenem integrating hospital-specific, thus far unexploited pathogen susceptibility information. An appropriate meropenem pharmacokinetic model was selected from the literature and evaluated using clinical data. Probability of target attainment (PTA) analysis was conducted for clinically interesting dosing regimens. To inform dosing prior to pathogen identification, the local pathogen-independent mean fraction of response (LPIFR) was calculated based on the observed minimum inhibitory concentrations distribution in the hospital. A simple, tabular, model-informed dosing decision tool was developed for initial meropenem therapy. Dosing recommendations achieving PTA > 90% or LPIFR > 90% for patients with different creatinine clearances were integrated. Based on the experiences during the development process, a generalised workflow for the development of tabular dosing decision tools was derived. The proposed workflow can support the development of model-informed dosing tools for initial therapy of various drugs and hospital-specific conditions.
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Affiliation(s)
- Ferdinand Anton Weinelt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (F.A.W.); (L.S.); (R.M.); (S.H.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Miriam Songa Stegemann
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany; (M.S.S.); (F.P.); (S.A.)
- Antimicrobial Stewardship, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany
| | - Anja Theloe
- Pharmacy Department, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany;
| | - Frieder Pfäfflin
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany; (M.S.S.); (F.P.); (S.A.)
- Antimicrobial Stewardship, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany
| | - Stephan Achterberg
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany; (M.S.S.); (F.P.); (S.A.)
| | - Lisa Schmitt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (F.A.W.); (L.S.); (R.M.); (S.H.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, 14476 Potsdam, Germany;
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (F.A.W.); (L.S.); (R.M.); (S.H.)
| | - Stefanie Hennig
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (F.A.W.); (L.S.); (R.M.); (S.H.)
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane 4000, Australia
- Certara, Inc., Princeton, NJ 08540, USA
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (F.A.W.); (L.S.); (R.M.); (S.H.)
- Correspondence: ; Tel.: +49-30-838-50656
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Kloft C, Hoerr R. EGb 761 ® Does Not Affect Blood Coagulation and Bleeding Time in Patients with Probable Alzheimer's Dementia-Secondary Analysis of a Randomized, Double-Blind Placebo-Controlled Trial. Healthcare (Basel) 2021; 9:healthcare9121678. [PMID: 34946404 PMCID: PMC8701823 DOI: 10.3390/healthcare9121678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 11/16/2022] Open
Abstract
Following reports of bleeding upon Ginkgo intake, we assessed whether Ginkgo extract EGb 761® affects coagulation or platelet function or increases the risk of bleeding. In a double-blind, placebo-controlled trial, prothrombin time, activated partial thromboplastin time, international normalized ratio and bleeding time were measured in patients with Alzheimer’s dementia at baseline, weeks 6 and 26. A total of 513 patients were randomized to 120 mg (n = 169) or 240 mg EGb 761® (n = 170) or placebo (n = 174). No relevant changes were found for coagulation parameters and bleeding time. Numbers of bleeding-related adverse events were similar in all groups. Concomitant intake of acetylsalicylic acid was documented for 68 patients in the placebo group and 105 in the EGb 761® groups. Within these groups, the means at baseline and week 26 differed by less than 1 unit for prothrombin time and bleeding time and less than 0.1 unit for international normalized ratio. Data on warfarin treatment in nine patients each taking placebo or EGb 761® did not indicate enhancement of warfarin effects by EGb 761®. No evidence was found that EGb 761® affects hemostasis or increases the bleeding risk. No pharmacodynamic interactions with warfarin or acetylsalicylic acid were found.
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Affiliation(s)
- Charlotte Kloft
- Institute of Pharmacy, Freie Universität Berlin, 12169 Berlin, Germany;
| | - Robert Hoerr
- Research & Development, Dr. Willmar Schwabe GmbH & Co. KG, 76227 Karlsruhe, Germany
- Correspondence: ; Tel.: +49-721-4005-492
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Maier C, de Wiljes J, Hartung N, Kloft C, Huisinga W. A continued learning approach for model-informed precision dosing: updating models in clinical practice. CPT Pharmacometrics Syst Pharmacol 2021; 11:185-198. [PMID: 34779144 PMCID: PMC8846635 DOI: 10.1002/psp4.12745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/28/2021] [Accepted: 10/28/2021] [Indexed: 11/12/2022]
Abstract
Model-informed precision dosing (MIPD) is a quantitative dosing framework that combines prior knowledge on the drug-disease-patient system with patient data from therapeutic drug/biomarker monitoring (TDM) to support individualized dosing in ongoing treatment. Structural models and prior parameter distributions used in MIPD approaches typically build on prior clinical trials that involve only a limited number of patients selected according to some exclusion/inclusion criteria. Compared to the prior clinical trial population, the patient population in clinical practice can be expected to include also altered behavior and/or increased interindividual variability, the extent of which, however, is typically unknown. Here, we address the question of how to adapt and refine models on the level of the model parameters to better reflect this real-world diversity. We propose an approach for continued learning across patients during MIPD using a sequential hierarchical Bayesian framework. The approach builds on two stages to separate the update of the individual patient parameters from updating the population parameters. Consequently, it enables continued learning across hospitals or study centers, since only summary patient data (on the level of model parameters) need to be shared, but no individual TDM data. We illustrate this continued learning approach with neutrophil-guided dosing of paclitaxel. The present study constitutes an important step towards building confidence in MIPD and eventually establishing MIPD increasingly in everyday therapeutic use.
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Affiliation(s)
- Corinna Maier
- Institute of Mathematics, University of Potsdam, Germany.,Graduate Research Training Program PharMetrX: Pharmacometrics & Computational Disease Modelling, Freie Universität Berlin and University of Potsdam, Germany
| | - Jana de Wiljes
- Institute of Mathematics, University of Potsdam, Germany
| | - Niklas Hartung
- Institute of Mathematics, University of Potsdam, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Germany
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Busse D, Borghardt JM, Petroff D, Pevzner A, Dorn C, El-Najjar N, Huisinga W, Wrigge H, Simon P, Kloft C. Evaluating prediction methods for glomerular filtration to optimise drug doses in obese and nonobese patients. Br J Clin Pharmacol 2021; 88:2973-2981. [PMID: 34688225 DOI: 10.1111/bcp.15115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 08/19/2021] [Accepted: 10/03/2021] [Indexed: 01/02/2023] Open
Abstract
AIMS The most suitable method for predicting the glomerular filtration rate (GFR) in obesity is currently debated. Therefore, multiple GFR/creatinine clearance prediction methods were applied to (morbidly) obese and nonobese patients ranging from moderate renal impairment to glomerular hyperfiltration and their predictions were rated based on observed fosfomycin pharmacokinetics, as this model drug is exclusively eliminated via glomerular filtration. METHODS The GFR/creatinine clearance predictions via the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Modification of Diet in Renal Disease (MDRD; indexed and de-indexed by body surface area) and creatinine clearance via the Cockcroft-Gault formula (CLCRCG ) using different body size descriptors were compared to the fosfomycin clearance (CLFOF ) from 30 surgical patients (body mass index = 20.1-52.0 kg m-2 ), receiving 8000 mg as intravenous infusion. RESULTS The concordance between CLFOF and creatinine clearance predictions was highest for CLCRCG employing either ideal body weight or adjusted body weight (if body mass >1.3 ideal body weight; CLCRCG_ABW-Schwartz , concordance-correlation coefficient [95% confidence interval] = 0.474 [0.156; 0.703], CCC) and GFR predictions via the de-indexed MDRD equation (concordance-correlation coefficient = 0.452 [0.137; 0.685]). The proportion of predicted GFR values within ±30% of the observed CLFOF (P30 = 72.3-76.7%) was only marginally lower than the reported P30 in the original CKD-EPI and MDRD publications (P30 = 84.1-90.0%). CONCLUSION This analysis represents a successful proof-of-concept for evaluating GFR/creatinine clearance prediction methods: Across all body mass index classes CLCRCG_ABW-Schwartz or the de-indexed MDRD were most suitable for predicting creatinine clearance/GFR also in (morbidly) obese, CKD stage <3B individuals in therapeutic use. Their application is proposed in optimising doses for vital therapies in obese patients requiring monitoring of renal function (e.g. methotrexate dosing).
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Affiliation(s)
- David Busse
- Institute of Pharmacy, Department of Clinical Pharmacy and Biochemistry, Freie Universitaet Berlin, Berlin, Germany.,Graduate Research Training program PharMetrX, Berlin/Potsdam, Germany
| | - Jens Markus Borghardt
- Drug Discovery Sciences, Research DMPK, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - David Petroff
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.,Clinical Trial Centre Leipzig, University of Leipzig, Leipzig, Germany
| | - Alice Pevzner
- Institute of Pharmacy, Department of Clinical Pharmacy and Biochemistry, Freie Universitaet Berlin, Berlin, Germany
| | - Christoph Dorn
- University of Regensburg, Institute of Pharmacy, Regensburg, Germany
| | - Nahed El-Najjar
- Institute of Clinical Microbiology and Hygiene, Faculty of Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Wilhelm Huisinga
- University of Potsdam, Institute of Mathematics, Potsdam, Germany
| | - Hermann Wrigge
- Clinical Trial Centre Leipzig, University of Leipzig, Leipzig, Germany.,Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
| | - Philipp Simon
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Charlotte Kloft
- Institute of Pharmacy, Department of Clinical Pharmacy and Biochemistry, Freie Universitaet Berlin, Berlin, Germany
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Liebchen U, Scharf C, Zoller M, Weinelt F, Kloft C. No clinically relevant removal of meropenem by cytokine adsorber CytoSorb ® in critically ill patients with sepsis or septic shock. Intensive Care Med 2021; 47:1332-1333. [PMID: 34519848 PMCID: PMC8550492 DOI: 10.1007/s00134-021-06487-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.,Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169, Berlin, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Ferdinand Weinelt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169, Berlin, Germany.,Graduate Research Training Program PharMetrX, Freie Universität Berlin/Universität Potsdam, Berlin, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169, Berlin, Germany.
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Busse D, Simon P, Petroff D, Dorn C, Schmitt L, Bindellini D, Kratzer A, Dietrich A, Zeitlinger M, Huisinga W, Michelet R, Wrigge H, Kloft C. Similar Piperacillin/Tazobactam Target Attainment in Obese versus Nonobese Patients despite Differences in Interstitial Tissue Fluid Pharmacokinetics. Pharmaceutics 2021; 13:1380. [PMID: 34575456 PMCID: PMC8464843 DOI: 10.3390/pharmaceutics13091380] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/09/2021] [Accepted: 08/27/2021] [Indexed: 11/17/2022] Open
Abstract
Precision dosing of piperacillin/tazobactam in obese patients is compromised by sparse information on target-site exposure. We aimed to evaluate the appropriateness of current and alternative piperacillin/tazobactam dosages in obese and nonobese patients. Based on a prospective, controlled clinical trial in 30 surgery patients (15 obese/15 nonobese; 0.5-h infusion of 4 g/0.5 g piperacillin/tazobactam), piperacillin pharmacokinetics were characterized in plasma and at target-site (interstitial fluid of subcutaneous adipose tissue) via population analysis. Thereafter, multiple 3-4-times daily piperacillin/tazobactam short-term/prolonged (recommended by EUCAST) and continuous infusions were evaluated by simulation. Adequacy of therapy was assessed by probability of pharmacokinetic/pharmacodynamic target-attainment (PTA ≥ 90%) based on time unbound piperacillin concentrations exceed the minimum inhibitory concentration (MIC) during 24 h (%fT>MIC). Lower piperacillin target-site maximum concentrations in obese versus nonobese patients were explained by the impact of lean (approximately two thirds) and fat body mass (approximately one third) on volume of distribution. Simulated steady-state concentrations were 1.43-times, 95%CI = (1.27; 1.61), higher in plasma versus target-site, supporting targets of %fT>2×MIC instead of %fT>4×MIC during continuous infusion to avoid target-site concentrations constantly below MIC. In all obesity and renally impairment/hyperfiltration stages, at MIC = 16 mg/L, adequate PTA required prolonged (thrice-daily 4 g/0.5 g over 3.0 h at %fT>MIC = 50) or continuous infusions (24 g/3 g over 24 h following loading dose at %fT>MIC = 98) of piperacillin/tazobactam.
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Affiliation(s)
- David Busse
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (D.B.); (L.S.); (D.B.); (R.M.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Philipp Simon
- Department of Anesthesiology, Intensive Care, University of Leipzig Medical Centre, 04103 Leipzig, Germany; (P.S.); (A.D.)
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, 04103 Leipzig, Germany; (D.P.); (H.W.)
| | - David Petroff
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, 04103 Leipzig, Germany; (D.P.); (H.W.)
- Clinical Trial Centre Leipzig, University of Leipzig, 04109 Leipzig, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, 93053 Regensburg, Germany;
| | - Lisa Schmitt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (D.B.); (L.S.); (D.B.); (R.M.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Davide Bindellini
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (D.B.); (L.S.); (D.B.); (R.M.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Alexander Kratzer
- Hospital Pharmacy, University Hospital Regensburg, 93053 Regensburg, Germany;
| | - Arne Dietrich
- Department of Anesthesiology, Intensive Care, University of Leipzig Medical Centre, 04103 Leipzig, Germany; (P.S.); (A.D.)
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, University Medical University of Vienna, 1090 Vienna, Austria;
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, 14469 Potsdam, Germany;
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (D.B.); (L.S.); (D.B.); (R.M.)
| | - Hermann Wrigge
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, 04103 Leipzig, Germany; (D.P.); (H.W.)
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, 06112 Halle, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (D.B.); (L.S.); (D.B.); (R.M.)
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van Dyk M, Bulamu N, Boylan C, Mc Laughlin AM, Kichenadasse G, May N, Michelet R, Kloft C, Kaambwa B. Cost-effectiveness of oral anticancer drugs and associated individualised dosing approaches in patients with cancer: protocol for a systematic review. BMJ Open 2021; 11:e047173. [PMID: 34404700 PMCID: PMC8372804 DOI: 10.1136/bmjopen-2020-047173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Oral anticancer drugs (OADs) have rapidly expanded with more than 70 OADs targeting several molecular targets. Many of the OADs exert an exposure-response relationship but still, a 'one-size fits-all' dose is used, ignoring interindividual variability. Several of these OADs share similar mechanisms of actions and thus target the same cancer and has resulted in a substantial research focus on comparing the health benefit of each. However, significantly less is known about the cost-benefit associated with OADs. This paper will provide a protocol to systematically review studies that have evaluated the cost-effectiveness of OADs and their associated individualised dosing interventions. METHODS AND ANALYSIS Systematic review methodology will be applied to identify, select and extract data from published economic evaluation (costs and outcomes/benefits) studies of OADs and their associated individualised dosing interventions. Bibliographic databases (eg, Ovid EMBASE, Ovid MEDLINE) will be used to perform the systematic literature search (between 1 January 2000 and October 2020). Only full economic evaluations will be included, but no restrictions on study outcomes will be applied. The quality of included primary studies will be assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist for reporting economic evaluations. Studies with low-quality evidence will be excluded. A narrative synthesis of the results from the included studies will be undertaken, with a subgroup analysis where appropriate. ETHICS AND DISSEMINATION This systematic review will not require ethics approval as there will not be any collection of primary data. Findings of this review will be disseminated through publications in peer-reviewed journals, presentations at workshops or conferences and sharing through a media release. Findings from this review will provide evidence to direct and inform policy-makers where cost-neutral strategies may be effective or where dose individualising strategies may be economically beneficial. Additionally, gaps will be identified in the current literature to inform future-related research. PROSPERO REGISTRATION NUMBER CRD42020218170. ELECTRONIC SUPPLEMENTAL MATERIAL The online version of this article contains supplemental material, which is available to authorised users.
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Affiliation(s)
- Madelé van Dyk
- Flinders Health & Medical Research Institute- Cancer, Flinders University College of Medicine and Public Health, Bedford Park, South Australia, Australia
- Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Bedford Park, South Australia, Australia
| | - Norma Bulamu
- Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Bedford Park, South Australia, Australia
- Health Economics, Flinders University College of Medicine and Public Health, Bedford Park, South Australia, Australia
| | - Chelsea Boylan
- Flinders Health & Medical Research Institute- Cancer, Flinders University College of Medicine and Public Health, Bedford Park, South Australia, Australia
- Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Bedford Park, South Australia, Australia
| | - Anna M Mc Laughlin
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
- Postdam/Berlin, PharMetrX Graduate Research Training Program, Postdam/Berlin, Germany
| | - Ganessan Kichenadasse
- Flinders Health & Medical Research Institute- Cancer, Flinders University College of Medicine and Public Health, Bedford Park, South Australia, Australia
- Medical Oncology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Nikki May
- SA Health Library Service, Bedford Park, South Australia, Australia
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
- PharMetrX Graduate Research Training Program, Postdam/Berlin, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
- PharMetrX Graduate Research Training Program, Postdam/Berlin, Germany
| | - Billingsley Kaambwa
- Health Economics, Flinders University College of Medicine and Public Health, Bedford Park, South Australia, Australia
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Seeger J, Michelet R, Kloft C. Quantification of persister formation of Escherichia coli leveraging electronic cell counting and semi-mechanistic pharmacokinetic/pharmacodynamic modelling. J Antimicrob Chemother 2021; 76:2088-2096. [PMID: 33997902 DOI: 10.1093/jac/dkab146] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/07/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Persister formation of Escherichia coli under fluoroquinolone exposure causes treatment failure and promotes emergence of resistant strains. Semi-mechanistic pharmacokinetic/pharmacodynamic modelling of data obtained from in vitro infection model experiments comprehensively characterizes exposure-effect relationships, providing mechanistic insights. OBJECTIVES To quantify persister formation of E. coli under levofloxacin exposure and to explain the observed growth-kill behaviour, leveraging electronic cell counting and pharmacokinetic/pharmacodynamic modelling. METHODS Three fluoroquinolone-resistant clinical E. coli isolates were exposed to levofloxacin in static and dynamic in vitro infection model experiments. Complementary to plate counting, bacterial concentrations over time were quantified by electronic cell counting and amalgamated in a semi-mechanistic pharmacokinetic/pharmacodynamic model (1281 bacterial and 394 levofloxacin observations). RESULTS Bacterial regrowth was observed under exposure to clinically relevant dosing regimens in the dynamic in vitro infection model. Electronic cell counting facilitated identification of three bacterial subpopulations: persisters, viable cells and dead cells. Two strain-specific manifestations of the levofloxacin effect were identified: a killing effect, characterized as a sigmoidal Emax model, and an additive increase in persister formation under levofloxacin exposure. Significantly different EC50 values quantitatively discerned levofloxacin potency for two isolates displaying the same MIC value: 8 mg/L [EC50 = 17.2 (95% CI = 12.6-23.8) mg/L and 8.46 (95% CI = 6.86-10.3) mg/L, respectively]. Persister formation was most pronounced for the isolate with the lowest MIC value (2 mg/L). CONCLUSIONS The developed pharmacokinetic/pharmacodynamic model adequately characterized growth-kill behaviour of three E. coli isolates and unveiled strain-specific levofloxacin potencies and persister formation. The mimicked dosing regimens did not eradicate the resistant isolates and enhanced persister formation to a strain-specific extent.
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Affiliation(s)
- Johanna Seeger
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
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Dorn C, Petroff D, Stoelzel M, Kees MG, Kratzer A, Dietrich A, Kloft C, Zeitlinger M, Kees F, Wrigge H, Simon P. Perioperative administration of cefazolin and metronidazole in obese and non-obese patients: a pharmacokinetic study in plasma and interstitial fluid. J Antimicrob Chemother 2021; 76:2114-2120. [PMID: 33969405 DOI: 10.1093/jac/dkab143] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/11/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To assess plasma and tissue pharmacokinetics of cefazolin and metronidazole in obese patients undergoing bariatric surgery and non-obese patients undergoing intra-abdominal surgery. PATIENTS AND METHODS Fifteen obese and 15 non-obese patients received an IV short infusion of 2 g cefazolin and 0.5 g metronidazole for perioperative prophylaxis. Plasma and microdialysate from subcutaneous tissue were sampled until 8 h after dosing. Drug concentrations were determined by HPLC-UV. Pharmacokinetic parameters were calculated non-compartmentally. RESULTS In obese patients (BMI 39.5-69.3 kg/m2) compared with non-obese patients (BMI 18.7-29.8 kg/m2), mean Cmax of total cefazolin in plasma was lower (115 versus 174 mg/L) and Vss was higher (19.4 versus 14.2 L). The mean differences in t½ (2.7 versus 2.4 h), CL (5.14 versus 4.63 L/h) and AUC∞ (402 versus 450 mg·h/L) were not significant. The influence of obesity on the pharmacokinetics of metronidazole was similar (Cmax 8.99 versus 14.7 mg/L, Vss 73.9 versus 51.8 L, t½ 11.9 versus 9.1 h, CL 4.62 versus 4.13 L/h, AUC∞ 116 versus 127 mg·h/L). Regarding interstitial fluid (ISF), mean concentrations of cefazolin remained >4 mg/L until 6 h in both groups, and those of metronidazole up to 8 h in the non-obese group. In obese patients, the mean ISF concentrations of metronidazole were between 3 and 3.5 mg/L throughout the measuring interval. CONCLUSIONS During the time of surgery, cefazolin concentrations in plasma and ISF of subcutaneous tissue were lower in obese patients, but not clinically relevant. Regarding metronidazole, the respective differences were higher, and may influence dosing of metronidazole for perioperative prophylaxis in obese patients.
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Affiliation(s)
- Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - David Petroff
- Clinical Trial Centre, University of Leipzig, Leipzig, Germany.,Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
| | - Melanie Stoelzel
- Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig Medical Centre, Leipzig, Germany
| | - Martin G Kees
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Alexander Kratzer
- Hospital Pharmacy, University Hospital Regensburg, Regensburg, Germany
| | - Arne Dietrich
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.,Department of Surgery, University of Leipzig, Leipzig, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Frieder Kees
- Department of Pharmacology, University of Regensburg, Regensburg, Germany
| | - Hermann Wrigge
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.,Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
| | - Philipp Simon
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig Medical Centre, Leipzig, Germany
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Stachanow V, Neumann U, Blankenstein O, Fuhr U, Huisinga W, Michelet R, Reisch N, Kloft C. Rationale of a lower dexamethasone dose in prenatal congenital adrenal hyperplasia therapy based on pharmacokinetic modelling. Eur J Endocrinol 2021; 185:365-374. [PMID: 34228630 DOI: 10.1530/eje-21-0395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/06/2021] [Indexed: 11/08/2022]
Abstract
CONTEXT Prenatal dexamethasone therapy is used in female foetuses with congenital adrenal hyperplasia to suppress androgen excess and prevent virilisation of the external genitalia. The traditional dexamethasone dose of 20 µg/kg/day has been used since decades without examination in clinical trials and is thus still considered experimental. OBJECTIVE As the traditional dexamethasone dose potentially causes adverse effects in treated mothers and foetuses, we aimed to provide a rationale of a reduced dexamethasone dose in prenatal congenital adrenal hyperplasia therapy based on a pharmacokinetics-based modelling and simulation framework. METHODS Based on a published dexamethasone dataset, a nonlinear mixed-effects model was developed describing maternal dexamethasone pharmacokinetics. In stochastic simulations (n = 1000), a typical pregnant population (n = 124) was split into two dosing arms receiving either the traditional 20 µg/kg/day dexamethasone dose or reduced doses between 5 and 10 µg/kg/day. Target maternal dexamethasone concentrations, identified from the literature, served as a threshold to be exceeded by 90% of mothers at a steady state to ensure foetal hypothalamic-pituitary-adrenal axis suppression. RESULTS A two-compartment dexamethasone pharmacokinetic model was developed and subsequently evaluated to be fit for purpose. The simulations, including a sensitivity analysis regarding the assumed foetal:maternal dexamethasone concentration ratio, resulted in 7.5 µg/kg/day to be the minimum effective dose and thus our suggested dose. CONCLUSIONS We conclude that the traditional dexamethasone dose is three-fold higher than needed, possibly causing harm in treated foetuses and mothers. The clinical relevance and appropriateness of our recommended dose should be tested in a prospective clinical trial.
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Affiliation(s)
- Viktoria Stachanow
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Uta Neumann
- Institute for Experimental Paediatric Endocrinology, Charité-Universitätsmedizin, Berlin, Germany
| | - Oliver Blankenstein
- Institute for Experimental Paediatric Endocrinology, Charité-Universitätsmedizin, Berlin, Germany
| | - Uwe Fuhr
- Department I of Pharmacology, Center for Pharmacology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | | | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Nicole Reisch
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
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Schroepf S, Burau D, Muench HG, Derendorf H, Zeitlinger M, Genzel-Boroviczény O, Adam D, Kloft C. Microdialysis sampling to monitor target-site vancomycin concentrations in septic infants: a feasible way to close the knowledge gap. Int J Antimicrob Agents 2021; 58:106405. [PMID: 34289402 DOI: 10.1016/j.ijantimicag.2021.106405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/24/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
This work is dedicated to the memory of Hartmut Derendorf (1953-2020), a pioneer of modern pharmacokinetics and valued mentor of this project. OBJECTIVES Septic infants/neonates need effective antibiotic exposure, but dosing recommendations are challenging as the pharmacokinetics in this age are highly variable. For vancomycin, which is used as a standard treatment, comprehensive pharmacokinetic knowledge especially at the infection site is lacking. Hence, an exploratory clinical study was conducted to assess the feasibility and safety of microdialysis sampling for vancomycin monitoring at the target site. METHODS Nine infants/neonates with therapeutic indications for vancomycin treatment were administered 15 mg/kg as 1-hour infusions every 8-24 hours. Microdialysis catheters were implanted in the subcutaneous interstitial space fluid of the lateral thigh. Samples were collected every 30 minutes over 24 hours, followed by retrodialysis for catheter calibration. Prior in vitro investigations have evaluated impact factors on relative recovery and retrodialysis. RESULTS In vitro investigations showed the applicability of microdialysis for vancomycin monitoring. Microdialysis sampling was well tolerated in all infants/neonates (23-255 days) without major bleeding or other adverse events. Pharmacokinetic profiles were obtained and showed plausible vancomycin concentration-time courses. CONCLUSIONS Microdialysis as a minimally invasive technique for continuous longer-term sampling is feasible and safe in infants/neonates. Interstitial space fluid profiles were plausible and showed substantial interpatient variation. Hence, a larger microdialysis trial is warranted to further characterise the pharmacokinetics and variability of vancomycin at the target site and ultimately improve vancomycin dosing in these vulnerable patients.
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Affiliation(s)
- Sebastian Schroepf
- Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Muenchen, Germany.
| | - Daniela Burau
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Hans-Georg Muench
- Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Muenchen, Germany
| | - Hartmut Derendorf
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Wien, Austria
| | | | | | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
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Casilag F, Matarazzo L, Franck S, Figeac M, Michelet R, Kloft C, Carnoy C, Sirard JC. The Biosynthetic Monophosphoryl Lipid A Enhances the Therapeutic Outcome of Antibiotic Therapy in Pneumococcal Pneumonia. ACS Infect Dis 2021; 7:2164-2175. [PMID: 34260199 DOI: 10.1021/acsinfecdis.1c00176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Alternative treatment strategies against bacterial infections are required to decrease the use of antibiotics. This study tested the hypothesis that stimulation of the innate immune receptor Toll-like receptor 4 can be combined with antibiotics to improve the treatment of invasive pneumonia. The efficacy of the biosynthetic monophosphoryl lipid A (MPLA), a clinically approved Toll-like receptor 4 activator, was tested in a mouse model of Streptococcus pneumoniae respiratory infection. Interestingly, administration of amoxicillin or MPLA decreased 400- to 11 000-fold the bacterial load in the lungs and spleen but did not enhance survival compared to mock treatment. The single administration of a combination of MPLA and amoxicillin further reduced 10- to 18-fold the bacterial colonization and invasion and significantly improved protection against lethal disease. The combined administration of MPLA and amoxicillin in a context of infection was associated with transient increase of the serum concentrations of amoxicillin and pro-inflammatory cytokines and chemokines as well as the expression of immune genes in lung tissue. Remarkably, the systemic and lung immune activation extended beyond amoxicillin elimination, suggesting a two-step and cooperative anti-infective effect, i.e., rapid antibiotic-mediated alteration of bacteria and a long-lasting impact through mucosal and systemic immunity. Our proof-of-concept study demonstrated for the first time that boosting Toll-like receptor 4 signaling can synergize with antibiotics in order to increase the efficacy of therapy of bacterial pneumonia, thereby in fine reducing the dose or regimen of antibiotics.
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Affiliation(s)
- Fiordiligie Casilag
- Univ. Lille, CNRS, INSERM, CHU Lille, Institut Pasteur de Lille, U1019 - UMR9017 - CIIL - Center for Infection and Immunity of Lille, F-59000 Lille, France
| | - Laura Matarazzo
- Univ. Lille, CNRS, INSERM, CHU Lille, Institut Pasteur de Lille, U1019 - UMR9017 - CIIL - Center for Infection and Immunity of Lille, F-59000 Lille, France
| | - Sebastian Franck
- Freie Universitaet Berlin, Institute of Pharmacy, Department of Clinical Pharmacy & Biochemistry, D-12169 Berlin, Germany
| | - Martin Figeac
- Univ. Lille, Plateforme de Génomique Fonctionnelle et Structurale, F-59000 Lille, France
| | - Robin Michelet
- Freie Universitaet Berlin, Institute of Pharmacy, Department of Clinical Pharmacy & Biochemistry, D-12169 Berlin, Germany
| | - Charlotte Kloft
- Freie Universitaet Berlin, Institute of Pharmacy, Department of Clinical Pharmacy & Biochemistry, D-12169 Berlin, Germany
| | - Christophe Carnoy
- Univ. Lille, CNRS, INSERM, CHU Lille, Institut Pasteur de Lille, U1019 - UMR9017 - CIIL - Center for Infection and Immunity of Lille, F-59000 Lille, France
| | - Jean-Claude Sirard
- Univ. Lille, CNRS, INSERM, CHU Lille, Institut Pasteur de Lille, U1019 - UMR9017 - CIIL - Center for Infection and Immunity of Lille, F-59000 Lille, France
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Mueller-Schoell A, Puebla-Osorio N, Michelet R, Green MR, Künkele A, Huisinga W, Strati P, Chasen B, Neelapu SS, Yee C, Kloft C. Early Survival Prediction Framework in CD19-Specific CAR-T Cell Immunotherapy Using a Quantitative Systems Pharmacology Model. Cancers (Basel) 2021; 13:2782. [PMID: 34205020 PMCID: PMC8199881 DOI: 10.3390/cancers13112782] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/22/2021] [Accepted: 05/28/2021] [Indexed: 12/20/2022] Open
Abstract
Chimeric antigen receptor (CAR)-T cell therapy has revolutionized treatment of relapsed/refractory non-Hodgkin lymphoma (NHL). However, since 36-60% of patients relapse, early response prediction is crucial. We present a novel population quantitative systems pharmacology model, integrating literature knowledge on physiology, immunology, and adoptive cell therapy together with 133 CAR-T cell phenotype, 1943 cytokine, and 48 metabolic tumor measurements. The model well described post-infusion concentrations of four CAR-T cell phenotypes and CD19+ metabolic tumor volume over 3 months after CAR-T cell infusion. Leveraging the model, we identified a low expansion subpopulation with significantly lower CAR-T cell expansion capacities amongst 19 NHL patients. Together with two patient-/therapy-related factors (autologous stem cell transplantation, CD4+/CD8+ T cells), the low expansion subpopulation explained 2/3 of the interindividual variability in the CAR-T cell expansion capacities. Moreover, the low expansion subpopulation had poor prognosis as only 1/4 of the low expansion subpopulation compared to 2/3 of the reference population were still alive after 24 months. We translated the expansion capacities into a clinical composite score (CCS) of 'Maximum naïve CAR-T cell concentrations/Baseline tumor burden' ratio and propose a CCSTN-value > 0.00136 (cells·µL-1·mL-1 as predictor for survival. Once validated in a larger cohort, the model will foster refining survival prediction and solutions to enhance NHL CAR-T cell therapy response.
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Affiliation(s)
- Anna Mueller-Schoell
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Nahum Puebla-Osorio
- Department of Lymphoma and Myeloma, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (N.P.-O.); (M.R.G.); (P.S.)
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.)
| | - Michael R. Green
- Department of Lymphoma and Myeloma, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (N.P.-O.); (M.R.G.); (P.S.)
| | - Annette Künkele
- Department of Pediatric Oncology and Hematology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt–Universität zu Berlin, Augustenburger Platz 1, 1335 Berlin, Germany;
- German Cancer Consortium (DKTK), Partner Site Berlin, CCC (Campus Mitte), 10178 Berlin, Germany
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, 14476 Potsdam, Germany;
| | - Paolo Strati
- Department of Lymphoma and Myeloma, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (N.P.-O.); (M.R.G.); (P.S.)
| | - Beth Chasen
- Department of Nuclear Medicine, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Sattva S. Neelapu
- Department of Lymphoma and Myeloma, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (N.P.-O.); (M.R.G.); (P.S.)
| | - Cassian Yee
- Department of Melanoma Medical Oncology, UT MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Immunology, UT MD Anderson Cancer Center, Houston, TX 70030, USA
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.)
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Boulet S, Ursino M, Michelet R, Kloft C, Comets E, Zohar S. Extrapolation bayésienne de la préclinique à la clinique. Rev Epidemiol Sante Publique 2021. [DOI: 10.1016/j.respe.2021.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Seeger J, Guenther S, Schaufler K, Heiden SE, Michelet R, Kloft C. Novel Pharmacokinetic/Pharmacodynamic Parameters Quantify the Exposure-Effect Relationship of Levofloxacin against Fluoroquinolone-Resistant Escherichia coli. Antibiotics (Basel) 2021; 10:antibiotics10060615. [PMID: 34063980 PMCID: PMC8224043 DOI: 10.3390/antibiotics10060615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 11/30/2022] Open
Abstract
Minimal inhibitory concentration-based pharmacokinetic/pharmacodynamic (PK/PD) indices are commonly applied to antibiotic dosing optimisation, but their informative value is limited, as they do not account for bacterial growth dynamics over time. We aimed to comprehensively characterise the exposure–effect relationship of levofloxacin against Escherichia coli and quantify strain-specific characteristics applying novel PK/PD parameters. In vitro infection model experiments were leveraged to explore the exposure–effect relationship of three clinical Escherichia coli isolates, harbouring different genomic fluoroquinolone resistance mechanisms, under constant levofloxacin concentrations or human concentration–time profiles (≤76 h). As an exposure metric, the ‘cumulative area under the levofloxacin–concentration time curve’ was determined. The antibiotic effect was assessed as the ‘cumulative area between the growth control and the bacterial-killing and -regrowth curve’. PK/PD modelling was applied to characterise the exposure–effect relationship and derive novel PK/PD parameters. A sigmoidal Emax model with an inhibition term best characterised the exposure–effect relationship and allowed for discrimination between two isolates sharing the same MIC value. Strain- and exposure-pattern-dependent differences were captured by the PK/PD parameters and elucidated the contribution of phenotypic adaptation to bacterial regrowth. The novel exposure and effect metrics and derived PK/PD parameters allowed for comprehensive characterisation of the isolates and could be applied to overcome the limitations of the MIC in clinical antibiotic dosing decisions, drug research and preclinical development.
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Affiliation(s)
- Johanna Seeger
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (J.S.); (R.M.)
| | - Sebastian Guenther
- Department of Pharmaceutical Biology, Institute of Pharmacy, Universitaet Greifswald, Friedrich-Ludwig-Jahn-Straße 17, 17489 Greifswald, Germany;
| | - Katharina Schaufler
- Department of Pharmaceutical Microbiology, Institute of Pharmacy, Universitaet Greifswald, Friedrich-Ludwig-Jahn-Straße 17, 17489 Greifswald, Germany; (K.S.); (S.E.H.)
| | - Stefan E. Heiden
- Department of Pharmaceutical Microbiology, Institute of Pharmacy, Universitaet Greifswald, Friedrich-Ludwig-Jahn-Straße 17, 17489 Greifswald, Germany; (K.S.); (S.E.H.)
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (J.S.); (R.M.)
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (J.S.); (R.M.)
- Correspondence: ; Tel.: +49-30-838-50656
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Mueller-Schoell A, Michelet R, Klopp-Schulze L, van Dyk M, Mürdter TE, Schwab M, Joerger M, Huisinga W, Mikus G, Kloft C. Computational Treatment Simulations to Assess the Need for Personalized Tamoxifen Dosing in Breast Cancer Patients of Different Biogeographical Groups. Cancers (Basel) 2021; 13:cancers13102432. [PMID: 34069810 PMCID: PMC8157244 DOI: 10.3390/cancers13102432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/10/2021] [Accepted: 05/13/2021] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Tamoxifen is a drug often used to treat the most common type of breast cancer. Its metabolite endoxifen is formed by the liver enzyme CYP2D6, whose activity is variable and depends on a patient’s genetic profile. The frequency of CYP2D6 variants with different functional enzymatic activity varies largely between populations. To ensure sufficient efficacy of tamoxifen, a certain target concentration of endoxifen is needed, and 20% of White breast cancer patients have been shown not to reach this target concentration. However, little is known about the risk of not attaining the endoxifen target amongst other ethnic populations. This study investigated the risk for suboptimal endoxifen concentration in nine different biogeographical populations based on their distinct CYP2D6 genetic profile. The variability between the populations was high (up to three-fold), and East Asian breast cancer patients were identified as the population with the highest need for personalized tamoxifen dosing. Abstract Tamoxifen is used worldwide to treat estrogen receptor-positive breast cancer. It is extensively metabolized, and minimum steady-state concentrations of its metabolite endoxifen (CSS,min ENDX) >5.97 ng/mL have been associated with favorable outcome. Endoxifen formation is mediated by the enzyme CYP2D6, and impaired CYP2D6 function has been associated with lower CSS,min ENDX. In the Women’s Healthy Eating and Living (WHEL) study proposing the target concentration, 20% of patients showed subtarget CSS,min ENDX at tamoxifen standard dosing. CYP2D6 allele frequencies vary largely between populations, and as 87% of the patients in the WHEL study were White, little is known about the risk for subtarget CSS,min ENDX in other populations. Applying pharmacokinetic simulations, this study investigated the risk for subtarget CSS,min ENDX at tamoxifen standard dosing and the need for dose individualization in nine different biogeographical groups with distinct CYP2D6 allele frequencies. The high variability in CYP2D6 allele frequencies amongst the biogeographical groups resulted in an up to three-fold difference in the percentages of patients with subtarget CSS,min ENDX. Based on their CYP2D6 allele frequencies, East Asian breast cancer patients were identified as the population for which personalized, model-informed precision dosing would be most beneficial (28% of patients with subtarget CSS,min ENDX).
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Affiliation(s)
- Anna Mueller-Schoell
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.); (L.K.-S.); (G.M.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.); (L.K.-S.); (G.M.)
| | - Lena Klopp-Schulze
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.); (L.K.-S.); (G.M.)
| | - Madelé van Dyk
- College of Medicine and Public Health, Flinders University, Adelaide, SA 5042, Australia;
| | - Thomas E. Mürdter
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, and University Tübingen, 70376 Tübingen, Germany;
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, 70376 Stuttgart, Germany;
- German Cancer Consortium (DKTK), Partner Site Tübingen, German Cancer Research, 69120 Heidelberg, Germany
- Departments of Clinical Pharmacology, Pharmacy and Biochemistry, University Tübingen, 72076 Tübingen, Germany
| | - Markus Joerger
- Department of Medical Oncology and Hematology, Cantonal Hospital, 9007 St. Gallen, Switzerland;
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, 14476 Potsdam, Germany;
| | - Gerd Mikus
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.); (L.K.-S.); (G.M.)
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, 53113 Bonn, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (A.M.-S.); (R.M.); (L.K.-S.); (G.M.)
- Correspondence:
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Michelet R, Ursino M, Boulet S, Franck S, Casilag F, Baldry M, Rolff J, van Dyk M, Wicha SG, Sirard JC, Comets E, Zohar S, Kloft C. The Use of Translational Modelling and Simulation to Develop Immunomodulatory Therapy as an Adjunct to Antibiotic Treatment in the Context of Pneumonia. Pharmaceutics 2021; 13:601. [PMID: 33922017 PMCID: PMC8143524 DOI: 10.3390/pharmaceutics13050601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 11/16/2022] Open
Abstract
The treatment of respiratory tract infections is threatened by the emergence of bacterial resistance. Immunomodulatory drugs, which enhance airway innate immune defenses, may improve therapeutic outcome. In this concept paper, we aim to highlight the utility of pharmacometrics and Bayesian inference in the development of immunomodulatory therapeutic agents as an adjunct to antibiotics in the context of pneumonia. For this, two case studies of translational modelling and simulation frameworks are introduced for these types of drugs up to clinical use. First, we evaluate the pharmacokinetic/pharmacodynamic relationship of an experimental combination of amoxicillin and a TLR4 agonist, monophosphoryl lipid A, by developing a pharmacometric model accounting for interaction and potential translation to humans. Capitalizing on this knowledge and associating clinical trial extrapolation and statistical modelling approaches, we then investigate the TLR5 agonist flagellin. The resulting workflow combines expert and prior knowledge on the compound with the in vitro and in vivo data generated during exploratory studies in order to construct high-dimensional models considering the pharmacokinetics and pharmacodynamics of the compound. This workflow can be used to refine preclinical experiments, estimate the best doses for human studies, and create an adaptive knowledge-based design for the next phases of clinical development.
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Affiliation(s)
- Robin Michelet
- Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (S.F.); (C.K.)
| | - Moreno Ursino
- Unit of Clinical Epidemiology, Assistance Publique-Hôpitaux de Paris, CHU Robert Debré, Université de Paris, Sorbonne Paris-Cité, Inserm U1123 and CIC-EC 1426, F-75019 Paris, France;
- INSERM, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, F-75006 Paris, France; (S.B.); (S.Z.)
| | - Sandrine Boulet
- INSERM, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, F-75006 Paris, France; (S.B.); (S.Z.)
- HeKA, Inria, F-75006 Paris, France
| | - Sebastian Franck
- Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (S.F.); (C.K.)
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany;
| | - Fiordiligie Casilag
- CNRS, Inserm, CHU Lille, Institute Pasteur de Lille, U1019-UMR9017-CIIL-Centre for Infection and Immunity of Lille, Université de Lille, F-59000 Lille, France; (F.C.); (M.B.); (J.-C.S.)
| | - Mara Baldry
- CNRS, Inserm, CHU Lille, Institute Pasteur de Lille, U1019-UMR9017-CIIL-Centre for Infection and Immunity of Lille, Université de Lille, F-59000 Lille, France; (F.C.); (M.B.); (J.-C.S.)
| | - Jens Rolff
- Department of Evolutionary Biology, Institute of Biology, Freie Universitaet Berlin, 14195 Berlin, Germany;
| | - Madelé van Dyk
- Flinders Centre for Innovation in Cancer, College of Medicine and Public Health, Flinders University, Adelaide 5042, Australia;
| | - Sebastian G. Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany;
| | - Jean-Claude Sirard
- CNRS, Inserm, CHU Lille, Institute Pasteur de Lille, U1019-UMR9017-CIIL-Centre for Infection and Immunity of Lille, Université de Lille, F-59000 Lille, France; (F.C.); (M.B.); (J.-C.S.)
| | - Emmanuelle Comets
- INSERM, University Rennes-1, CIC 1414, F-35000 Rennes, France;
- INSERM, IAME, Université de Paris, F-75006 Paris, France
| | - Sarah Zohar
- INSERM, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, F-75006 Paris, France; (S.B.); (S.Z.)
- HeKA, Inria, F-75006 Paris, France
| | - Charlotte Kloft
- Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (S.F.); (C.K.)
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Mueller-Schoell A, Groenland SL, Scherf-Clavel O, van Dyk M, Huisinga W, Michelet R, Jaehde U, Steeghs N, Huitema ADR, Kloft C. Therapeutic drug monitoring of oral targeted antineoplastic drugs. Eur J Clin Pharmacol 2021; 77:441-464. [PMID: 33165648 PMCID: PMC7935845 DOI: 10.1007/s00228-020-03014-8] [Citation(s) in RCA: 102] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/01/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE This review provides an overview of the current challenges in oral targeted antineoplastic drug (OAD) dosing and outlines the unexploited value of therapeutic drug monitoring (TDM). Factors influencing the pharmacokinetic exposure in OAD therapy are depicted together with an overview of different TDM approaches. Finally, current evidence for TDM for all approved OADs is reviewed. METHODS A comprehensive literature search (covering literature published until April 2020), including primary and secondary scientific literature on pharmacokinetics and dose individualisation strategies for OADs, together with US FDA Clinical Pharmacology and Biopharmaceutics Reviews and the Committee for Medicinal Products for Human Use European Public Assessment Reports was conducted. RESULTS OADs are highly potent drugs, which have substantially changed treatment options for cancer patients. Nevertheless, high pharmacokinetic variability and low treatment adherence are risk factors for treatment failure. TDM is a powerful tool to individualise drug dosing, ensure drug concentrations within the therapeutic window and increase treatment success rates. After reviewing the literature for 71 approved OADs, we show that exposure-response and/or exposure-toxicity relationships have been established for the majority. Moreover, TDM has been proven to be feasible for individualised dosing of abiraterone, everolimus, imatinib, pazopanib, sunitinib and tamoxifen in prospective studies. There is a lack of experience in how to best implement TDM as part of clinical routine in OAD cancer therapy. CONCLUSION Sub-therapeutic concentrations and severe adverse events are current challenges in OAD treatment, which can both be addressed by the application of TDM-guided dosing, ensuring concentrations within the therapeutic window.
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Affiliation(s)
- Anna Mueller-Schoell
- Dept. of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
- Graduate Research Training Program, PharMetrX, Berlin/Potsdam, Germany
| | - Stefanie L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Oliver Scherf-Clavel
- Institute of Pharmacy and Food Chemistry, Julius-Maximilians-Universität Würzburg, Würzburg, Germany
| | - Madelé van Dyk
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Robin Michelet
- Dept. of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Ulrich Jaehde
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany
| | - Neeltje Steeghs
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Charlotte Kloft
- Dept. of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany.
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48
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Franck S, Michelet R, Casilag F, Sirard JC, Wicha SG, Kloft C. A Model-Based Pharmacokinetic/Pharmacodynamic Analysis of the Combination of Amoxicillin and Monophosphoryl Lipid A Against S. pneumoniae in Mice. Pharmaceutics 2021; 13:469. [PMID: 33808396 PMCID: PMC8065677 DOI: 10.3390/pharmaceutics13040469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/24/2021] [Accepted: 03/25/2021] [Indexed: 11/16/2022] Open
Abstract
Combining amoxicillin with the immunostimulatory toll-like receptor 4 agonist monophosphoryl lipid A (MPLA) represents an innovative approach for enhancing antibacterial treatment success. Exploiting pharmacokinetic and pharmacodynamic data from an infection model of Streptococcus pneumoniae infected mice, we aimed to evaluate the preclinical exposure-response relationship of amoxicillin with MPLA coadministration and establish a link to survival. Antibiotic serum concentrations, bacterial numbers in lung and spleen and survival data of mice being untreated or treated with amoxicillin (four dose levels), MPLA, or their combination were analyzed by nonlinear mixed-effects modelling and time-to-event analysis using NONMEM® to characterize these treatment regimens. On top of a pharmacokinetic interaction, regarding the pharmacodynamic effects the combined treatment was superior to both monotherapies: The amoxicillin efficacy at highest dose was increased by a bacterial reduction of 1.74 log10 CFU/lung after 36 h and survival was increased 1.35-fold to 90.3% after 14 days both compared to amoxicillin alone. The developed pharmacometric pharmacokinetic/pharmacodynamic disease-treatment-survival models provided quantitative insights into a novel treatment option against pneumonia revealing a pharmacokinetic interaction and enhanced activity of amoxicillin and the immune system stimulator MPLA in combination. Further development of this drug combination flanked with pharmacometrics towards the clinical setting seems promising.
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Affiliation(s)
- Sebastian Franck
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (S.F.); (R.M.)
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany;
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (S.F.); (R.M.)
| | - Fiordiligie Casilag
- CNRS, INSERM, CHU Lille, Institut Pasteur de Lille, U1019-UMR8204-CIIL-Center of Infection and Immunity of Lille, University Lille, 59019 Lille, France; (F.C.); (J.-C.S.)
| | - Jean-Claude Sirard
- CNRS, INSERM, CHU Lille, Institut Pasteur de Lille, U1019-UMR8204-CIIL-Center of Infection and Immunity of Lille, University Lille, 59019 Lille, France; (F.C.); (J.-C.S.)
| | - Sebastian G. Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany;
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (S.F.); (R.M.)
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49
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Saafan H, Alahdab A, Michelet R, Gohlke L, Ziemann J, Holdenrieder S, McLaughlin KM, Wass MN, Cinatl J, Michaelis M, Kloft C, Ritter CA. Constitutive Cell Proliferation Regulating Inhibitor of Protein Phosphatase 2A (CIP2A) Mediates Drug Resistance to Erlotinib in an EGFR Activating Mutated NSCLC Cell Line. Cells 2021; 10:716. [PMID: 33804833 PMCID: PMC8103245 DOI: 10.3390/cells10040716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 11/21/2022] Open
Abstract
Exploring mechanisms of drug resistance to targeted small molecule drugs is critical for an extended clinical benefit in the treatment of non-small cell lung cancer (NSCLC) patients carrying activating epidermal growth factor receptor (EGFR) mutations. Here, we identified constitutive cell proliferation regulating inhibitor of protein phosphatase 2A (CIP2A) in the HCC4006rErlo0.5 NSCLC cell line adapted to erlotinib as a model of acquired drug resistance. Constitutive CIP2A resulted in a constitutive activation of Akt signaling. The proteasome inhibitor bortezomib was able to reduce CIP2A levels, which resulted in an activation of protein phosphatase 2A and deactivation of Akt. Combination experiments with erlotinib and bortezomib revealed a lack of interaction between the two drugs. However, the effect size of bortezomib was higher in HCC4006rErlo0.5, compared to the erlotinib-sensitive HCC4006 cells, as indicated by an increase in Emax (0.911 (95%CI 0.867-0.954) vs. 0.585 (95%CI 0.568-0.622), respectively) and decrease in EC50 (52.4 µM (95%CI 46.1-58.8 µM) vs. 73.0 µM (95%CI 60.4-111 µM), respectively) in the concentration-effect model, an earlier onset of cell death induction, and a reduced colony surviving fraction (0.38 ± 0.18 vs. 0.95 ± 0.25, respectively, n = 3, p < 0.05). Therefore, modulation of CIP2A with bortezomib could be an interesting approach to overcome drug resistance to erlotinib treatment in NSCLC.
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Affiliation(s)
- Hisham Saafan
- Institute of Pharmacy, Clinical Pharmacy, University of Greifswald, Friedrich-Ludwig-Jahn-Str. 17, 17489 Greifswald, Germany; (H.S.); (A.A.); (L.G.)
| | - Ahmad Alahdab
- Institute of Pharmacy, Clinical Pharmacy, University of Greifswald, Friedrich-Ludwig-Jahn-Str. 17, 17489 Greifswald, Germany; (H.S.); (A.A.); (L.G.)
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 14195 Berlin, Germany; (R.M.); (C.K.)
| | - Linus Gohlke
- Institute of Pharmacy, Clinical Pharmacy, University of Greifswald, Friedrich-Ludwig-Jahn-Str. 17, 17489 Greifswald, Germany; (H.S.); (A.A.); (L.G.)
| | - Janine Ziemann
- Central Unit for Infection Prevention and Control, University Medicine Greifswald, 17475 Greifswald, Germany;
| | - Stefan Holdenrieder
- Institute of Laboratory Medicine, German Heart Center, Munich Technical University, 80636 Munich, Germany;
| | - Katie-May McLaughlin
- Industrial Biotechnology Centre, School of Biosciences, University of Kent, Canterbury CT2 7NJ, UK; (K.-M.M.); (M.N.W.); (M.M.)
| | - Mark N. Wass
- Industrial Biotechnology Centre, School of Biosciences, University of Kent, Canterbury CT2 7NJ, UK; (K.-M.M.); (M.N.W.); (M.M.)
| | - Jindrich Cinatl
- Institute of Medical Virology, Goethe-University, 60596 Frankfurt am Main, Germany;
| | - Martin Michaelis
- Industrial Biotechnology Centre, School of Biosciences, University of Kent, Canterbury CT2 7NJ, UK; (K.-M.M.); (M.N.W.); (M.M.)
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 14195 Berlin, Germany; (R.M.); (C.K.)
| | - Christoph A Ritter
- Institute of Pharmacy, Clinical Pharmacy, University of Greifswald, Friedrich-Ludwig-Jahn-Str. 17, 17489 Greifswald, Germany; (H.S.); (A.A.); (L.G.)
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50
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Busse D, Schaeftlein A, Solms A, Ilia L, Michelet R, Zeitlinger M, Huisinga W, Kloft C. Which Analysis Approach Is Adequate to Leverage Clinical Microdialysis Data? A Quantitative Comparison to Investigate Exposure and Reponse Exemplified by Levofloxacin. Pharm Res 2021; 38:381-395. [PMID: 33723793 PMCID: PMC7994214 DOI: 10.1007/s11095-021-02994-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/05/2020] [Indexed: 01/22/2023]
Abstract
Purpose Systematic comparison of analysis methods of clinical microdialysis data for impact on target-site drug exposure and response. Methods 39 individuals received a 500 mg levofloxacin short-term infusion followed by 24-h dense sampling in plasma and microdialysate collection in interstitial space fluid (ISF). ISF concentrations were leveraged using non-compartmental (NCA) and compartmental analysis (CA) via (ii) relative recovery correction at midpoint of the collection interval (midpoint-NCA, midpoint-CA) and (ii) dialysate-based integrals of time (integral-CA). Exposure and adequacy of community-acquired pneumonia (CAP) therapy via pharmacokinetic/pharmacodynamic target-attainment (PTA) analysis were compared between approaches. Results Individual AUCISF estimates strongly varied for midpoint-NCA and midpoint-CA (≥52.3%CV) versus integral-CA (≤32.9%CV) owing to separation of variability in PK parameters (midpoint-CA = 46.5%–143%CVPK, integral-CA = 26.4%–72.6%CVPK) from recovery-related variability only in integral-CA (41.0%–50.3%CVrecovery). This also led to increased variability of AUCplasma for midpoint-CA (56.0%CV) versus midpoint-NCA and integral-CA (≤33.0%CV), and inaccuracy of predictive model performance of midpoint-CA in plasma (visual predictive check). PTA analysis translated into 33% of evaluated patient cases being at risk of incorrectly rejecting recommended dosing regimens at CAP-related epidemiological cut-off values. Conclusions Integral-CA proved most appropriate to characterise clinical pharmacokinetics- and microdialysis-related variability. Employing this knowledge will improve the understanding of drug target-site PK for therapeutic decision-making. Supplementary Information The online version contains supplementary material available at 10.1007/s11095-021-02994-1.
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Affiliation(s)
- David Busse
- Institute of Pharmacy, Department of Clinical Pharmacy and Biochemistry, Freie Universitaet Berlin, Berlin, Germany.,Graduate Research Training program PharMetrX, Berlin/Potsdam, Germany
| | | | - Alexander Solms
- Institute of Mathematics, University of Potsdam, Potsdam, Germany.,Clinical Pharmacometrics, Bayer AG, Berlin, Germany
| | - Luis Ilia
- Institute of Pharmacy, Department of Clinical Pharmacy and Biochemistry, Freie Universitaet Berlin, Berlin, Germany
| | - Robin Michelet
- Institute of Pharmacy, Department of Clinical Pharmacy and Biochemistry, Freie Universitaet Berlin, Berlin, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Charlotte Kloft
- Institute of Pharmacy, Department of Clinical Pharmacy and Biochemistry, Freie Universitaet Berlin, Berlin, Germany.
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