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Cocanougher BT, Liu SW, Francescatto L, Behura A, Anneling M, Jackson DG, Deak KL, Hornik CD, ElMallah MK, Pizoli CE, Smith EC, Tan KGQ, McDonald MT. The severity of MUSK pathogenic variants is predicted by the protein domain they disrupt. HGG Adv 2024; 5:100288. [PMID: 38566418 PMCID: PMC11070630 DOI: 10.1016/j.xhgg.2024.100288] [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: 11/28/2023] [Revised: 03/27/2024] [Accepted: 03/27/2024] [Indexed: 04/04/2024] Open
Abstract
Biallelic loss-of-function variants in the MUSK gene result in two allelic disorders: (1) congenital myasthenic syndrome (CMS; OMIM: 616325), a neuromuscular disorder that has a range of severity from severe neonatal-onset weakness to mild adult-onset weakness, and (2) fetal akinesia deformation sequence (OMIM: 208150), a form of pregnancy loss characterized by severe muscle weakness in the fetus. The MUSK gene codes for muscle-specific kinase (MuSK), a receptor tyrosine kinase involved in the development of the neuromuscular junction. Here, we report a case of neonatal-onset MUSK-related CMS in a patient harboring compound heterozygous deletions in the MUSK gene, including (1) a deletion of exons 2-3 leading to an in-frame MuSK protein lacking the immunoglobulin 1 (Ig1) domain and (2) a deletion of exons 7-11 leading to an out-of-frame, truncated MuSK protein. Individual domains of the MuSK protein have been elucidated structurally; however, a complete MuSK structure generated by machine learning algorithms has clear inaccuracies. We modify a predicted AlphaFold structure and integrate previously reported domain-specific structural data to suggest a MuSK protein that dimerizes in two locations (Ig1 and the transmembrane domain). We analyze known pathogenic variants in MUSK to discover domain-specific genotype-phenotype correlations; variants that lead to a loss of protein expression, disruption of the Ig1 domain, or Dok-7 binding are associated with the most severe phenotypes. A conceptual model is provided to explain the severe phenotypes seen in Ig1 variants and the poor response of our patient to pyridostigmine.
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Affiliation(s)
- Benjamin T Cocanougher
- Department of Pediatrics, Duke University, Durham, NC, USA; Division of Medical Genetics, Duke University, Durham, NC, USA.
| | - Samuel W Liu
- Department of Pediatrics, Duke University, Durham, NC, USA; Division of Medical Genetics, Duke University, Durham, NC, USA
| | | | - Alexander Behura
- Department of Pediatrics, Duke University, Durham, NC, USA; Division of Medical Genetics, Duke University, Durham, NC, USA
| | - Mariele Anneling
- Department of Pediatrics, Duke University, Durham, NC, USA; Division of Medical Genetics, Duke University, Durham, NC, USA
| | - David G Jackson
- Department of Pediatrics, Duke University, Durham, NC, USA; Division of Medical Genetics, Duke University, Durham, NC, USA
| | - Kristen L Deak
- Department of Pathology, Duke University, Durham, NC, USA
| | - Chi D Hornik
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - Mai K ElMallah
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - Carolyn E Pizoli
- Department of Pediatrics, Duke University, Durham, NC, USA; Division of Pediatric Neurology, Duke University, Durham, NC, USA
| | - Edward C Smith
- Department of Pediatrics, Duke University, Durham, NC, USA; Division of Pediatric Neurology, Duke University, Durham, NC, USA
| | - Khoon Ghee Queenie Tan
- Department of Pediatrics, Duke University, Durham, NC, USA; Division of Medical Genetics, Duke University, Durham, NC, USA
| | - Marie T McDonald
- Department of Pediatrics, Duke University, Durham, NC, USA; Division of Medical Genetics, Duke University, Durham, NC, USA.
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Thompson EJ, Zimmerman KO, Gonzalez D, Foote HP, Park S, Hill KD, Hurst JH, Hornik CD, Chamberlain RC, Gbadegesin RA, Hornik CP. Population Pharmacokinetics of Caffeine in Neonates with Congenital Heart Disease and Associations with Acute Kidney Injury. J Clin Pharmacol 2024; 64:300-311. [PMID: 37933788 PMCID: PMC10898646 DOI: 10.1002/jcph.2382] [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: 07/14/2023] [Accepted: 11/03/2023] [Indexed: 11/08/2023]
Abstract
Cardiac surgery-associated acute kidney injury (CS-AKI) occurs in approximately 65% of neonates undergoing cardiac surgery on cardiopulmonary bypass and contributes to morbidity and mortality. Caffeine may reduce CS-AKI by counteracting adenosine receptor upregulation after bypass, but pharmacokinetics (PK) in this population are unknown. The goal of our analysis is to address knowledge gaps in age-, disease-, and bypass-related effects on caffeine disposition and explore preliminary associations between caffeine exposure and CS-AKI using population PK modeling techniques and an opportunistic, electronic health record-integrated trial design. We prospectively enrolled neonates receiving preoperative caffeine per standard of care and collected PK samples. We retrospectively identified neonates without caffeine exposure undergoing surgery on bypass as a control cohort. We followed US Food and Drug Administration guidance for population PK model development using NONMEM. Effects of clinical covariates on PK parameters were evaluated. We simulated perioperative exposures and used multivariable logistic regression to evaluate the association between caffeine exposure and CS-AKI. Twenty-seven neonates were included in model development. A 1-compartment model with bypass time as a covariate on clearance and volume of distribution best fit the data. Twenty-three neonates with caffeine exposure and 109 controls were included in the exposure-response analysis. Over half of neonates developed CS-AKI. On multivariable analysis, there were no significant differences between CS-AKI with and without caffeine exposure. Neonates with single-ventricle heart disease without CS-AKI had consistently higher simulated caffeine exposures. Our results highlight areas for further study to better understand disease- and bypass-specific effects on drug disposition and identify populations where caffeine may be beneficial.
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Affiliation(s)
- Elizabeth J Thompson
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Kanecia O Zimmerman
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Henry P Foote
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | | | - Kevin D Hill
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | - Jillian H Hurst
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | - Chi D Hornik
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Christoph P Hornik
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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Zimmerman KO, Wu H, Maharaj A, Turner A, Chen JY, Hornik CD, Arnold S, Muller W, Al-Uzri A, Meyer M, Shiloh-Malawsky Y, Taravath S, Lakhotia A, Joshi C, Jackman J, Hornik CP. Pharmacokinetics and Proposed Dosing of Levetiracetam in Children With Obesity. J Pediatr Pharmacol Ther 2023; 28:693-703. [PMID: 38094673 PMCID: PMC10715382 DOI: 10.5863/1551-6776-28.8.693] [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: 11/03/2022] [Accepted: 01/26/2023] [Indexed: 02/01/2024]
Abstract
OBJECTIVE Characterize levetiracetam pharmacokinetics (PK) in children with obesity to inform dosing. METHODS Children 2 to <21 years old receiving standard of care oral levetiracetam across two opportunistic studies provided blood samples. Levetiracetam plasma PK data were analyzed with a nonlinear mixed-effects modeling approach. Indirect measures for body size and covariates were tested for model inclusion. Individual empirical Bayesian estimates using the final model parameters were compared by obesity status. Monte Carlo simulation using total body weight was performed in children with normal estimated glomerular filtration rate to identify dosing for children with obesity that resulted in comparable exposures to normal weight adults and children after receiving label dosing. RESULTS The population PK model was developed from 341 plasma concentrations from 169 children. A 1-compartment model best fit the data with fat-free mass as a significant covariate. Compared with children with normal weight, children with obesity had significantly lower body weight-normalized clearance (median [range], 4.77 [1.49-10.44] and 3.71 [0.86-13.55] L/h/70 kg, respectively). After label dosing with the oral formulation in children with obesity 4 to <16 years old, maximum and minimum steady-state concentrations were higher (25% and 41%, respectively [oral solution] and 27% and 19%, respectively [tablet]) compared with children with normal weight. Comparable exposures between children with and without obesity were achieved with weight-tiered dosing regimens of <75 kg or ≥75 kg. CONCLUSIONS Weight-tiered dosing for levetiracetam oral solution and tablets for children with obesity 4 to <16 years old results in more comparable exposures to children of normal weight.
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Affiliation(s)
- Kanecia O. Zimmerman
- Department of Pediatrics (KOZ, CDH, CPH), Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute (KOZ, HW, CDH, JJ, CPH), Duke University, Durham, NC
| | - Huali Wu
- Duke Clinical Research Institute (KOZ, HW, CDH, JJ, CPH), Duke University, Durham, NC
| | - Anil Maharaj
- Pharmaceutical Sciences (AM), The University of British Columbia, Vancouver, British Columbia, Canada
| | - Alex Turner
- Undergraduate Student (AT), North Carolina State University, Raleigh, NC
| | - Jia-Yuh Chen
- Senior Biostatistician (JYC), The EMMES Corporation, Rockville, MD
| | - Chi D. Hornik
- Department of Pediatrics (KOZ, CDH, CPH), Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute (KOZ, HW, CDH, JJ, CPH), Duke University, Durham, NC
| | - Susan Arnold
- Department of Neurology and Neurotherapeutics (SA), University of Texas Southwestern Medical Center Dallas, Dallas, TX
| | - William Muller
- Infectious Disease (WM), Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Amira Al-Uzri
- Pediatric Nephrology (AA-U), Oregon Health and Science University, Portland, OR
| | - Marisa Meyer
- Pediatric Critical Care (MM), Nemours Children’s Health, Wilmington, DE
| | - Yael Shiloh-Malawsky
- Department of Neurology (YS-M), University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Arpita Lakhotia
- Pediatric Neurology (AL), Norton Children’s Hospital and University of Louisville, Louisville, KY
| | - Charuta Joshi
- Pediatric Neurology (CJ), The Children’s Hospital Colorado, Aurora, CO
| | - Jennifer Jackman
- Duke Clinical Research Institute (KOZ, HW, CDH, JJ, CPH), Duke University, Durham, NC
| | - Christoph P. Hornik
- Department of Pediatrics (KOZ, CDH, CPH), Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute (KOZ, HW, CDH, JJ, CPH), Duke University, Durham, NC
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Boutzoukas AE, Olson R, Sellers MA, Fischer G, Hornik CD, Alibrahim O, Iheagwara K, Abulebda K, Bass AL, Irby K, Subbaswamy A, Zivick EE, Sweney J, Stormorken AG, Barker EE, Lutfi R, McCrory MC, Costello JM, Ackerman KG, Munoz Pareja JC, Dean JM, Abdelsamad N, Hanley DF, Mould WA, Lane K, Stroud M, Feger BJ, Greenberg RG, Smith PB, Benjamin DK, Hornik CP, Zimmerman KO, Becker ML. Mechanisms to expedite pediatric clinical trial site activation: The DOSE trial experience. Contemp Clin Trials 2023; 125:107067. [PMID: 36577492 PMCID: PMC9918704 DOI: 10.1016/j.cct.2022.107067] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 11/02/2022] [Revised: 12/17/2022] [Accepted: 12/22/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Timely trial start-up is a key determinant of trial success; however, delays during start-up are common and costly. Moreover, data on start-up metrics in pediatric clinical trials are sparse. To expedite trial start-up, the Trial Innovation Network piloted three novel mechanisms in the trial titled Dexmedetomidine Opioid Sparing Effect in Mechanically Ventilated Children (DOSE), a multi-site, randomized, double-blind, placebo-controlled trial in the pediatric intensive care setting. METHODS The three novel start-up mechanisms included: 1) competitive activation; 2) use of trial start-up experts, called site navigators; and 3) supplemental funds earned for achieving pre-determined milestones. After sites were activated, they received a web-based survey to report perceptions of the DOSE start-up process. In addition to perceptions, metrics analyzed included milestones met, time to start-up, and subsequent enrollment of subjects. RESULTS Twenty sites were selected for participation, with 19 sites being fully activated. Across activated sites, the median (quartile 1, quartile 3) time from receipt of regulatory documents to site activation was 82 days (68, 113). Sites reported that of the three novel mechanisms, the most motivating factor for expeditious activation was additional funding available for achieving start-up milestones, followed by site navigator assistance and then competitive site activation. CONCLUSION Study start-up is a critical time for the success of clinical trials, and innovative methods to minimize delays during start-up are needed. Milestone-based funds and site navigators were preferred mechanisms by sites participating in the DOSE study and may have contributed to the expeditious start-up timeline achieved. CLINICALTRIALS gov #: NCT03938857.
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Affiliation(s)
- Angelique E Boutzoukas
- Duke Clinical Research Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | - Rachel Olson
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Gwenyth Fischer
- University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Chi D Hornik
- Duke Clinical Research Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | | | | | - Kamal Abulebda
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Andora L Bass
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | | | | | - Jill Sweney
- Primary Children's Medical Center, University of Utah, Salt Lake City, UT, USA
| | | | | | - Riad Lutfi
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | | | | | | | | | | | | | - Daniel F Hanley
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - W Andrew Mould
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen Lane
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mary Stroud
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | | | - Rachel G Greenberg
- Duke Clinical Research Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | - P Brian Smith
- Duke Clinical Research Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | - Daniel K Benjamin
- Duke Clinical Research Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | - Kanecia O Zimmerman
- Duke Clinical Research Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | - Mara L Becker
- Duke Clinical Research Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA.
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Karatza E, Ganguly S, Hornik CD, Muller WJ, Al-Uzri A, James L, Balevic SJ, Gonzalez D. External Evaluation of Risperidone Population Pharmacokinetic Models Using Opportunistic Pediatric Data. Front Pharmacol 2022; 13:817276. [PMID: 35370711 PMCID: PMC8969425 DOI: 10.3389/fphar.2022.817276] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/31/2022] [Indexed: 11/23/2022] Open
Abstract
Risperidone is approved to treat schizophrenia in adolescents and autistic disorder and bipolar mania in children and adolescents. It is also used off-label in younger children for various psychiatric disorders. Several population pharmacokinetic models of risperidone and 9-OH-risperidone have been published. The objectives of this study were to assess whether opportunistically collected pediatric data can be used to evaluate risperidone population pharmacokinetic models externally and to identify a robust model for precision dosing in children. A total of 103 concentrations of risperidone and 112 concentrations of 9-OH-risperidone, collected from 62 pediatric patients (0.16–16.8 years of age), were used in the present study. The predictive performance of five published population pharmacokinetic models (four joint parent-metabolite models and one parent only) was assessed for accuracy and precision of the predictions using statistical criteria, goodness of fit plots, prediction-corrected visual predictive checks (pcVPCs), and normalized prediction distribution errors (NPDEs). The tested models produced similarly precise predictions (Root Mean Square Error [RMSE]) ranging from 0.021 to 0.027 nmol/ml for risperidone and 0.053–0.065 nmol/ml for 9-OH-risperidone). However, one of the models (a one-compartment mixture model with clearance estimated for three subpopulations) developed with a rich dataset presented fewer biases (Mean Percent Error [MPE, %] of 1.0% vs. 101.4, 146.9, 260.4, and 292.4%) for risperidone. In contrast, a model developed with fewer data and a more similar population to the one used for the external evaluation presented fewer biases for 9-OH-risperidone (MPE: 17% vs. 69.9, 47.8, and 82.9%). None of the models evaluated seemed to be generalizable to the population used in this analysis. All the models had a modest predictive performance, potentially suggesting that sources of inter-individual variability were not entirely captured and that opportunistic data from a highly heterogeneous population are likely not the most appropriate data to evaluate risperidone models externally.
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Affiliation(s)
- Eleni Karatza
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Samit Ganguly
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Regeneron Pharmaceuticals, Inc., Tarrytown, NY, United States
| | - Chi D Hornik
- Duke Clinical Research Institute, Durham, NC, United States
| | - William J Muller
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Amira Al-Uzri
- Oregon Health and Science University, Portland, OR, United States
| | - Laura James
- Arkansas Children's Hospital Research Institute and the University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | | | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Aleem S, Walker LS, Hornik CD, Smith MJ, Grotegut CA, Weimer KED. Severe Congenital Syphilis in the Neonatal Intensive Care Unit: A Retrospective Case Series. Pediatr Infect Dis J 2022; 41:335-339. [PMID: 34620796 DOI: 10.1097/inf.0000000000003370] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There has been a 291% relative increase in congenital syphilis (CS) cases in the United States from 2015 to 2019. Although the majority of affected fetuses/infants are stillborn or are asymptomatic, a subset is born with severe clinical illness. We describe a series of severe CS cases in the neonatal intensive care unit. METHODS Retrospective review of infants with CS, admitted to the Duke Intensive Care Nursery from June 2016 to February 2020. We recorded birthweight, gestational age, medications, procedures, diagnoses, laboratory data and outcomes. Severe symptoms included: birth depression, hypoxic ischemic encephalopathy (HIE), disseminated intravascular coagulopathy and/or persistent pulmonary hypertension (PPHN). RESULTS Seven infants with CS were identified and 5 with severe presentations were included. Median gestational age was 35.1 weeks (range: 29-37 weeks, median: 35 weeks). All infants required intubation at birth, 2 required chest compressions and epinephrine in the delivery room. One had hydrops fetalis and died in the delivery room. All 4 surviving infants had HIE, severe PPHN, hepatitis and seizures. All infants had a positive rapid plasma reagin, and were treated with penicillin G. Maternal rapid plasma reagin was pending for 3 of 5 infants at delivery, and later returned positive; 2 were positive during pregnancy but not treated. Other infectious work-up was negative. Three infants survived to discharge. CONCLUSION CS can be associated with HIE, PPHN and disseminated intravascular coagulopathy in affected infants. Clinicians should have a high index of suspicion and include CS in their differential diagnoses. This study also highlights the importance of adequate treatment of identified cases and screening during the third trimester and at delivery.
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Affiliation(s)
- Samia Aleem
- From the Department of Pediatrics, Duke University
| | | | - Chi D Hornik
- From the Department of Pediatrics, Duke University
- Duke Clinical Research Institute
| | | | - Chad A Grotegut
- Department of Obstetrics and Gynecology, Duke University, Durham
- Department of Obstetrics and Gynecology, Wake Forest Baptist Health, Winston-Salem, North Carolina
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Jackson W, Gonzalez D, Smith PB, Ambalavanan N, Atz AM, Sokol GM, Hornik CD, Stewart D, Mundakel G, Poindexter BB, Ahlfeld SK, Mills M, Cohen-Wolkowiez M, Martz K, Hornik CP, Laughon MM. Safety of sildenafil in extremely premature infants: a phase I trial. J Perinatol 2022; 42:31-36. [PMID: 34741102 PMCID: PMC8569839 DOI: 10.1038/s41372-021-01261-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/16/2021] [Accepted: 10/20/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To characterize the safety of sildenafil in premature infants. STUDY DESIGN A phase I, open-label trial of sildenafil in premature infants receiving sildenafil per usual clinical care (cohort 1) or receiving a single IV dose of sildenafil (cohort 2). Safety was evaluated based on adverse events (AEs), transaminase levels, and mean arterial pressure monitoring. RESULTS Twenty-four infants in cohort 1 (n = 25) received enteral sildenafil. In cohort 2, infants received a single IV sildenafil dose of 0.25 mg/kg (n = 7) or 0.125 mg/kg (n = 2). In cohort 2, there was one serious AE related to study drug involving hypotension associated with a faster infusion rate than specified by the protocol. There were no AEs related to elevated transaminases. CONCLUSION Sildenafil was well tolerated by the study population. Drug administration times and flush rates require careful attention to prevent infusion-related hypotension associated with faster infusions of IV sildenafil in premature infants. CLINICAL TRIAL ClinicalTrials.gov Identifier: NCT01670136.
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Affiliation(s)
- Wesley Jackson
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Namasivayam Ambalavanan
- Division of Neonatology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew M Atz
- Department of Pediatrics, Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Gregory M Sokol
- Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chi D Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Dan Stewart
- University of Louisville Norton Children's Hospital, Louisville, KY, USA
| | - Gratias Mundakel
- Kings County Hospital Center/SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Brenda B Poindexter
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Shawn K Ahlfeld
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mary Mills
- Duke Clinical Research Institute, Durham, NC, USA
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Christoph P Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Matthew M Laughon
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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8
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Stark A, Smith PB, Hornik CP, Zimmerman KO, Hornik CD, Pradeep S, Clark RH, Benjamin DK, Laughon M, Greenberg RG. Medication Use in the Neonatal Intensive Care Unit and Changes from 2010 to 2018. J Pediatr 2022; 240:66-71.e4. [PMID: 34481808 PMCID: PMC9394450 DOI: 10.1016/j.jpeds.2021.08.075] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To provide up-to-date medication prescribing patterns in US neonatal intensive care units (NICUs) and to examine trends in prescribing patterns over time. STUDY DESIGN We performed a cohort study of 799 016 infants treated in NICUs managed by the Pediatrix Medical Group from 2010 to 2018. We used 3 different methods to report counts of medication: exposure, courses, and days of use. We defined the change in frequency of medication administration by absolute change and relative change. We examined the Food and Drug Administration (FDA) package insert for each medication to determine whether a medication was labeled for use in infants and used PubMed to search for pharmacokinetics (PK) studies. RESULTS The most frequently prescribed medications included ampicillin, gentamicin, caffeine citrate, poractant alfa, morphine, vancomycin, furosemide, fentanyl, midazolam, and acetaminophen. Of the top 50 medications used in infants with extremely low birth weight, only 20 (40%) are FDA-labeled for use in infants; of the 30 that are not labeled for use in infants, 13 (43%) had at least 2 published PK studies. The medications with the greatest relative increase in use from 2010 to 2018 included dexmedetomidine, clonidine, rocuronium, levetiracetam, atropine, and diazoxide. The medications with the greatest relative decrease in use included tromethamine acetate, pancuronium, chloral hydrate, imipenem + cilastatin, and amikacin. CONCLUSION Trends of medication use in the NICU change substantially over time. It is imperative to identify changes in medication use in the NICU to better inform further prospective studies.
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Affiliation(s)
- Ashley Stark
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Christoph P Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Kanecia O Zimmerman
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Chi D Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | | | | | - Daniel K Benjamin
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Matthew Laughon
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
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9
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Moorthy GS, Greenberg RG, Hornik CD, Cassino C, Ghahramani P, Kumar KR, Fowler VG, Cohen-Wolkowiez M. Safety and Pharmacokinetics of Exebacase in an Infant With Disseminated Staphylococcus aureus Infection. Clin Infect Dis 2021; 75:338-341. [PMID: 34894129 PMCID: PMC9410717 DOI: 10.1093/cid/ciab1015] [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: 08/27/2021] [Indexed: 12/13/2022] Open
Abstract
Exebacase, an antistaphylococcal lysin produced from a bacteriophage-encoded gene, is a promising adjunctive therapy for severe methicillin-resistant Staphylococcus aureus infections. We describe the first infant to receive exebacase, dosing, and pharmacokinetics. Exebacase may be safe and efficacious in children; however, further clinical trials are needed to optimize dosing.
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Affiliation(s)
| | - Rachel G Greenberg
- Duke University Medical Center, Durham, North Carolina, USA,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Chi D Hornik
- Duke University Medical Center, Durham, North Carolina, USA,Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | | | - Karan R Kumar
- Duke University Medical Center, Durham, North Carolina, USA,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Vance G Fowler
- Duke University Medical Center, Durham, North Carolina, USA,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Correspondence: M. Cohen-Wolkowiez, Duke Clinical Research Institute, 300 W Morgan St, Box 3850, Durham, NC 27701 ()
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10
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Maharaj AR, Wu H, Zimmerman KO, Muller WJ, Sullivan JE, Sherwin CMT, Autmizguine J, Rathore MH, Hornik CD, Al-Uzri A, Payne EH, Benjamin DK, Hornik CP. Pharmacokinetics of Ceftazidime in Children and Adolescents with Obesity. Paediatr Drugs 2021; 23:499-513. [PMID: 34302290 PMCID: PMC9706343 DOI: 10.1007/s40272-021-00460-4] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The aim of this study was to evaluate ceftazidime pharmacokinetics (PK) in a cohort that includes a predominate number of children and adolescents with obesity and assess the efficacy of competing dosing strategies. METHODS A population PK model was developed using opportunistically collected plasma samples. For each dosing strategy, model-based probability of target attainment (PTA) estimates were computed for study participants using empirical Bayes estimates. In addition, the effects of body size and renal function on PTA were evaluated using stochastic model simulations with virtually generated subjects. RESULTS Twenty-nine participants, 24 of whom were obese, contributed data towards the analysis. The median (range) age, body weight, and body mass index of participants were 12.2 years (2.3-20.6), 59.2 kg (8.4-121), and 25.2 kg/m2 (13.8-42.9), respectively. Administration of 50 mg/kg intravenously (IV) every 8 hours (q8h; max 6 g/day) or 40 mg/kg IV q6h (max 6 g/day) resulted in PTA values of ≥ 90% (minimum inhibitory concentration 8 mg/L) for the subset of obese participants with estimated glomerular filtration rates (GFR) ≥ ~ 80 mL/min/1.73 m2. However, for both regimens, stochastic model simulations denoted lower PTA values (< 90%) with increasing body weight for virtual subjects with GFR ≥ 120 mL/min/1.73 m2. Alternatively, permitting for a maximum daily dose of 8 g/day using a 40 mg/kg IV q6h regimen provided PTA values that were near or above target (90%) for virtual subjects between 10 to 120 kg with GFR ≥ 80 mL/min/1.73 m2. CONCLUSION Our analysis suggests administration of 40 mg/kg IV q6h (max 8 g/day) maximizes PTA in children and adolescents with obesity and GFR ≥ 80 mL/min/1.73 m2. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT01431326.
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Affiliation(s)
- Anil R Maharaj
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, Canada
- Duke Clinical Research Institute, Duke University School of Medicine, 300 West Morgan Street, Box 3850, Durham, NC, 27701, USA
| | - Huali Wu
- Duke Clinical Research Institute, Duke University School of Medicine, 300 West Morgan Street, Box 3850, Durham, NC, 27701, USA
| | - Kanecia O Zimmerman
- Duke Clinical Research Institute, Duke University School of Medicine, 300 West Morgan Street, Box 3850, Durham, NC, 27701, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - William J Muller
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University, Chicago, IL, USA
| | - Janice E Sullivan
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, OH, USA
| | - Julie Autmizguine
- Department of Pharmacology and Pediatrics, Research Center, CHU Sainte-Justine, Montreal, QC, Canada
| | - Mobeen H Rathore
- Division of Pediatric Infectious Diseases and Immunology, University of Florida Center for HIV/AIDS Research, Education, and Service, Wolfson Children's Hospital, Jacksonville, FL, USA
| | - Chi D Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, 300 West Morgan Street, Box 3850, Durham, NC, 27701, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Amira Al-Uzri
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | | | - Daniel K Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, 300 West Morgan Street, Box 3850, Durham, NC, 27701, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, 300 West Morgan Street, Box 3850, Durham, NC, 27701, USA.
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
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11
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Miller LE, DeRienzo C, Smith PB, Bose C, Clark RH, Cotten CM, Benjamin DK, Hornik CD, Greenberg RG. Association between neonatal intensive care unit medication safety practices, adverse events, and death. J Perinatol 2021; 41:1739-1744. [PMID: 33033390 DOI: 10.1038/s41372-020-00857-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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/15/2020] [Accepted: 09/26/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Determine the associations between neonatal intensive care unit (NICU) medication safety practices, laboratory-based adverse events (lab-AEs), and death. STUDY DESIGN We combined data from a 2016 survey of Pediatrix NICUs on use of medication safety practices with 2014-2016 infant data. We grouped NICUs based on the number of safety practices used (≤5, 6-7, and 8-10) and evaluated the association between the number of safety practices used and lab-AEs and deaths using logistic regressions. RESULTS Of the 94 NICUs included, 17% used ≤5 medication safety practices, 51% used 6-7, and 32% used 8-10. NICUs with more safety practices did not have a difference in lab-AEs or death. CONCLUSION In this cohort, the use of more medication safety practices was not associated with fewer lab-AEs or decreased death.
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Affiliation(s)
- Laura E Miller
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Chris DeRienzo
- Department of Medicine, Division of Population Health, Stanford University, Stanford, CA, USA
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Carl Bose
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | | | - Chi D Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA. .,Duke Clinical Research Institute, Durham, NC, USA.
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12
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Hornik CD, Bondi DS, Greene NM, Cober MP, John B. Review of Fluconazole Treatment and Prophylaxis for Invasive Candidiasis in Neonates. J Pediatr Pharmacol Ther 2021; 26:115-122. [PMID: 33603574 PMCID: PMC7887891 DOI: 10.5863/1551-6776-26.2.115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/17/2020] [Indexed: 01/29/2023]
Abstract
Invasive candidiasis accounts for approximately 10% of nosocomial infections in preterm infants, with an incidence of 1% to 4% among neonatal intensive care unit (NICU) admissions and a mortality as high as 20% to 30%. These outcomes warrant improved treatment and prevention strategies for infants at highest risk. The Infectious Diseases Society of America provides guidelines on antifungal medications for the prophylaxis and treatment of candidiasis in NICUs; however, there are still variations in practice on the use of fluconazole for prophylaxis and treatment of invasive candidiasis. This review provides specific information regarding fluconazole activity, pharmacokinetics, and a literature evaluation of dosing strategies and comparisons to other treatments in the neonatal population.
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13
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Salerno SN, Edginton A, Gerhart JG, Laughon MM, Ambalavanan N, Sokol GM, Hornik CD, Stewart D, Mills M, Martz K, Gonzalez D. Physiologically-Based Pharmacokinetic Modeling Characterizes the CYP3A-Mediated Drug-Drug Interaction Between Fluconazole and Sildenafil in Infants. Clin Pharmacol Ther 2021; 109:253-262. [PMID: 32691891 PMCID: PMC8138939 DOI: 10.1002/cpt.1990] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [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] [Received: 04/08/2020] [Accepted: 07/05/2020] [Indexed: 12/12/2022]
Abstract
Physiologically-based pharmacokinetic (PBPK) modeling can potentially predict pediatric drug-drug interactions (DDIs) when clinical DDI data are limited. In infants for whom treatment of pulmonary hypertension and prevention or treatment of invasive candidiasis are indicated, sildenafil with fluconazole may be given concurrently. To account for developmental changes in cytochrome P450 (CYP) 3A, we determined and incorporated fluconazole inhibition constants (KI ) for CYP3A4, CYP3A5, and CYP3A7 into a PBPK model developed for sildenafil and its active metabolite, N-desmethylsildenafil. Pharmacokinetic (PK) data in preterm infants receiving sildenafil with and without fluconazole were used for model development and evaluation. The simulated PK parameters were comparable to observed values. Following fluconazole co-administration, differences in the fold change for simulated steady-state area under the plasma concentration vs. time curve from 0 to 24 hours (AUCss,0-24 ) were observed between virtual adults and infants (2.11-fold vs. 2.82-fold change). When given in combination with treatment doses of fluconazole (12 mg/kg i.v. daily), reducing the sildenafil dose by ~ 60% resulted in a geometric mean ratio of 1.01 for simulated AUCss,0-24 relative to virtual infants receiving sildenafil alone. This study highlights the feasibility of PBPK modeling to predict DDIs in infants and the need to include CYP3A7 parameters.
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Affiliation(s)
- Sara N. Salerno
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Andrea Edginton
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada
| | - Jacqueline G. Gerhart
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Matthew M. Laughon
- Department of Pediatrics, UNC School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Namasivayam Ambalavanan
- Division of Neonatology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gregory M. Sokol
- Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Chi D. Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Dan Stewart
- University of Louisville Norton Children’s Hospital, Louisville, Kentucky, USA
| | - Mary Mills
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Karen Martz
- The Emmes Company, LLC, Rockville, Maryland, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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14
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Scott BL, Hornik CD, Zimmerman K. Pharmacokinetic, efficacy, and safety considerations for the use of antifungal drugs in the neonatal population. Expert Opin Drug Metab Toxicol 2020; 16:605-616. [PMID: 32508205 DOI: 10.1080/17425255.2020.1773793] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Invasive fungal infections are an important cause of morbidity and mortality in infants, particularly in extreme prematurity. Successful systemic treatment requires consideration of antifungal efficacy, safety, and pharmacokinetics, including optimization of dosing in this population. AREAS COVERED This review summarizes published pharmacokinetic data on four classes of antifungal agents used in the neonatal population. Alterations in absorption, distribution, drug metabolism and clearance in infants compared to adult populations are highlighted. Additionally, pharmacodynamics, safety, and therapeutic drug monitoring are discussed. Recent advancements in neonatal antifungal pharmacotherapies are examined, with emphasis on clinical application. EXPERT OPINION Over the last two decades, published studies have provided increased knowledge on pharmacokinetic considerations in the neonatal population. Future research should focus on filling in the knowledge gaps that remain regarding the benefits and risks of combination antifungal therapy, the rising use of micafungin for invasive candidiasis given its fungicidal activity against polyene and azole-resistant Candida species and its minimal adverse effect profile, and the need for pharmacokinetic and safety data of broad spectrum triazoles, like voriconazole and posaconazole, in infants. Furthermore, efforts should focus on well-designed trials, including population pharmacokinetic studies, to develop dosing recommendations with subsequent implementation into clinical practice.
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Affiliation(s)
- Briana L Scott
- Department of Pediatrics, Division of Critical Care Medicine, Duke University Medical Center , Durham, NC, USA
| | - Chi D Hornik
- Department of Pediatrics, Division of Critical Care Medicine, Duke University Medical Center , Durham, NC, USA.,Duke University School of Medicine, Duke Clinical Research Institute , Durham, NC, USA
| | - Kanecia Zimmerman
- Department of Pediatrics, Division of Critical Care Medicine, Duke University Medical Center , Durham, NC, USA.,Duke University School of Medicine, Duke Clinical Research Institute , Durham, NC, USA
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15
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Maharaj AR, Wu H, Hornik CP, Balevic SJ, Hornik CD, Smith PB, Gonzalez D, Zimmerman KO, Benjamin DK, Cohen-Wolkowiez M. Simulated Assessment of Pharmacokinetically Guided Dosing for Investigational Treatments of Pediatric Patients With Coronavirus Disease 2019. JAMA Pediatr 2020; 174:e202422. [PMID: 32501511 PMCID: PMC7275264 DOI: 10.1001/jamapediatrics.2020.2422] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE Children of all ages appear susceptible to severe acute respiratory syndrome coronavirus 2 infection. To support pediatric clinical studies for investigational treatments of coronavirus disease 2019 (COVID-19), pediatric-specific dosing is required. OBJECTIVE To define pediatric-specific dosing regimens for hydroxychloroquine and remdesivir for COVID-19 treatment. DESIGN, SETTING, AND PARTICIPANTS Pharmacokinetic modeling and simulation were used to extrapolate investigated adult dosages toward children (March 2020-April 2020). Physiologically based pharmacokinetic modeling was used to inform pediatric dosing for hydroxychloroquine. For remdesivir, pediatric dosages were derived using allometric-scaling with age-dependent exponents. Dosing simulations were conducted using simulated pediatric and adult participants based on the demographics of a white US population. INTERVENTIONS Simulated drug exposures following a 5-day course of hydroxychloroquine (400 mg every 12 hours × 2 doses followed by 200 mg every 12 hours × 8 doses) and a single 200-mg intravenous dose of remdesivir were computed for simulated adult participants. A simulation-based dose-ranging study was conducted in simulated children exploring different absolute and weight-normalized dosing strategies. MAIN OUTCOMES AND MEASURES The primary outcome for hydroxychloroquine was average unbound plasma concentrations for 5 treatment days. Additionally, unbound interstitial lung concentrations were simulated. For remdesivir, the primary outcome was plasma exposure (area under the curve, 0 to infinity) following single-dose administration. RESULTS For hydroxychloroquine, the physiologically based pharmacokinetic model analysis included 500 and 600 simulated white adult and pediatric participants, respectively, and supported weight-normalized dosing for children weighing less than 50 kg. Geometric mean-simulated average unbound plasma concentration values among children within different developmental age groups (32-35 ng/mL) were congruent to adults (32 ng/mL). Simulated unbound hydroxychloroquine concentrations in lung interstitial fluid mirrored those in unbound plasma and were notably lower than in vitro concentrations needed to mediate antiviral activity. For remdesivir, the analysis included 1000 and 6000 simulated adult and pediatric participants, respectively. The proposed pediatric dosing strategy supported weight-normalized dosing for participants weighing less than 60 kg. Geometric mean-simulated plasma area under the time curve 0 to infinity values among children within different developmental age-groups (4315-5027 ng × h/mL) were similar to adults (4398 ng × h/mL). CONCLUSIONS AND RELEVANCE This analysis provides pediatric-specific dosing suggestions for hydroxychloroquine and remdesivir and raises concerns regarding hydroxychloroquine use for COVID-19 treatment because concentrations were less than those needed to mediate an antiviral effect.
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Affiliation(s)
| | - Huali Wu
- Duke Clinical Research Institute, Durham, North
Carolina
| | - Christoph P. Hornik
- Duke Clinical Research Institute, Durham, North
Carolina,Department of Pediatrics, Duke University School of
Medicine, Durham, North Carolina
| | - Stephen J. Balevic
- Duke Clinical Research Institute, Durham, North
Carolina,Department of Pediatrics, Duke University School of
Medicine, Durham, North Carolina
| | - Chi D. Hornik
- Duke Clinical Research Institute, Durham, North
Carolina,Department of Pediatrics, Duke University School of
Medicine, Durham, North Carolina,Department of Pharmacy, Duke University Medical
Center, Durham, North Carolina
| | - P. Brian Smith
- Duke Clinical Research Institute, Durham, North
Carolina,Department of Pediatrics, Duke University School of
Medicine, Durham, North Carolina
| | - Daniel Gonzalez
- University of North Carolina Eshelman School of
Pharmacy, Division of Pharmacotherapy and Experimental Therapeutics, University of North
Carolina at Chapel Hill
| | - Kanecia O. Zimmerman
- Duke Clinical Research Institute, Durham, North
Carolina,Department of Pediatrics, Duke University School of
Medicine, Durham, North Carolina
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Durham, North
Carolina,Department of Pediatrics, Duke University School of
Medicine, Durham, North Carolina
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Durham, North
Carolina,Department of Pediatrics, Duke University School of
Medicine, Durham, North Carolina
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16
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Gonzalez D, Laughon MM, Smith PB, Ge S, Ambalavanan N, Atz A, Sokol GM, Hornik CD, Stewart D, Mundakel G, Poindexter BB, Gaedigk R, Mills M, Cohen‐Wolkowiez M, Martz K, Hornik CP. Population pharmacokinetics of sildenafil in extremely premature infants. Br J Clin Pharmacol 2019; 85:2824-2837. [PMID: 31475367 PMCID: PMC6955411 DOI: 10.1111/bcp.14111] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 03/26/2019] [Revised: 08/06/2019] [Accepted: 08/22/2019] [Indexed: 11/30/2022] Open
Abstract
AIMS To characterize the population pharmacokinetics (PK) of sildenafil and its active metabolite, N-desmethyl sildenafil (DMS), in premature infants. METHODS We performed a multicentre, open-label trial to characterize the PK of sildenafil in infants ≤28 weeks gestation and < 365 postnatal days (cohort 1) or < 32 weeks gestation and 3-42 postnatal days (cohort 2). In cohort 1, we obtained PK samples from infants receiving sildenafil as ordered per the local standard of care (intravenous [IV] or enteral). In cohort 2, we administered a single IV dose of sildenafil and performed PK sampling. We performed a population PK analysis and dose-exposure simulations using the software NONMEM®. RESULTS We enrolled 34 infants (cohort 1 n = 25; cohort 2 n = 9) and collected 109 plasma PK samples. Sildenafil was given enterally (0.42-2.09 mg/kg) in 24 infants in cohort 1 and via IV (0.125 or 0.25 mg/kg) in all infants in cohort 2. A 2-compartment PK model for sildenafil and 1-compartment model for DMS, with presystemic conversion of sildenafil to DMS, characterized the data well. Coadministration of fluconazole (n = 4), a CYP3A inhibitor, resulted in an estimated 59% decrease in sildenafil clearance. IV doses of 0.125, 0.5 and 1 mg/kg every 8 hours (in the absence of fluconazole) resulted in steady-state maximum sildenafil concentrations that were generally within the range of those reported to inhibit phosphodiesterase type 5 activity in vitro. CONCLUSIONS We successfully characterized the PK of sildenafil and DMS in premature infants and applied the model to inform dosing for a follow-up, phase II study.
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MESH Headings
- Administration, Oral
- Cohort Studies
- Cytochrome P-450 CYP3A/blood
- Cytochrome P-450 CYP3A/genetics
- Fluconazole/administration & dosage
- Fluconazole/pharmacokinetics
- Gestational Age
- Humans
- Hypertension, Pulmonary/blood
- Hypertension, Pulmonary/drug therapy
- Infant
- Infant, Newborn
- Infant, Premature/blood
- Infant, Premature, Diseases/blood
- Infant, Premature, Diseases/drug therapy
- Injections, Intravenous
- Models, Biological
- Phosphodiesterase 5 Inhibitors/administration & dosage
- Phosphodiesterase 5 Inhibitors/blood
- Phosphodiesterase 5 Inhibitors/pharmacokinetics
- Phosphodiesterase 5 Inhibitors/therapeutic use
- Sildenafil Citrate/administration & dosage
- Sildenafil Citrate/blood
- Sildenafil Citrate/pharmacokinetics
- Sildenafil Citrate/therapeutic use
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Affiliation(s)
- Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of PharmacyThe University of North Carolina at Chapel HillChapel HillNCUSA
| | - Matthew M. Laughon
- Department of Pediatrics, School of MedicineThe University of North Carolina at Chapel HillChapel HillNCUSA
| | - P. Brian Smith
- Department of PediatricsDuke University School of MedicineDurhamNCUSA
- Duke Clinical Research InstituteDurhamNCUSA
| | - Shufan Ge
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of PharmacyThe University of North Carolina at Chapel HillChapel HillNCUSA
| | - Namasivayam Ambalavanan
- Division of Neonatology, School of MedicineUniversity of Alabama at BirminghamBirminghamALUSA
| | - Andrew Atz
- Department of PediatricsMedical University of South Carolina Children's HospitalCharlestonSCUSA
| | - Gregory M. Sokol
- Section of Neonatal‐Perinatal MedicineIndiana University School of MedicineIndianapolisINUSA
| | - Chi D. Hornik
- Department of PediatricsDuke University School of MedicineDurhamNCUSA
- Duke Clinical Research InstituteDurhamNCUSA
- Department of PharmacyDuke University Medical CenterDurhamNCUSA
| | - Dan Stewart
- University of Louisville Norton Children's HospitalLouisvilleKYUSA
| | - Gratias Mundakel
- Kings County Hospital Center/SUNY Downstate Medical CenterBrooklynNYUSA
| | | | - Roger Gaedigk
- Department of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy‐Kansas CityUniversity of Missouri‐Kansas City School of MedicineKansas CityMOUSA
| | - Mary Mills
- Duke Clinical Research InstituteDurhamNCUSA
| | - Michael Cohen‐Wolkowiez
- Department of PediatricsDuke University School of MedicineDurhamNCUSA
- Duke Clinical Research InstituteDurhamNCUSA
| | | | - Christoph P. Hornik
- Department of PediatricsDuke University School of MedicineDurhamNCUSA
- Duke Clinical Research InstituteDurhamNCUSA
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17
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Ku LC, Simmons C, Smith PB, Greenberg RG, Fisher K, Hornik CD, Cotten CM, Goldberg RN, Bidegain M. Intranasal midazolam and fentanyl for procedural sedation and analgesia in infants in the neonatal intensive care unit. J Neonatal Perinatal Med 2019; 12:143-148. [PMID: 30562908 DOI: 10.3233/npm-17149] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 06/09/2023]
Abstract
BACKGROUND The intranasal route is a minimally invasive method for rapidly delivering midazolam and fentanyl to provide short-term analgesia and sedation in infants. However, intranasal use of midazolam and fentanyl is not labeled for infants and safety data are sparse. The objective of this study is to evaluate the safety of intranasal midazolam and intranasal fentanyl in infants admitted to the Neonatal Intensive Care Unit (NICU). METHODS We retrospectively identified all infants receiving intranasal midazolam or fentanyl in the NICU from 2009 to 2015. We recorded indication for use and vital signs and determined the proportion of infants experiencing the following adverse events: death within 24 hours, hypotension, bradycardia, worsening respiratory status, and chest wall rigidity. Vital signs 4 hours before and after each dose were compared using the Wilcoxon signed-rank test. RESULTS We identified 17 infants (gestational ages 23- 41 weeks) receiving 25 intranasal doses. None of the infants died or developed hypotension, bradycardia, or chest wall rigidity. Intranasal delivery was most commonly used for sedation during magnetic resonance imaging studies. Other indications include analgesia or sedation for retinopathy of prematurity surgery, intubation, and peripherally inserted central catheter placement. One infant receiving intranasal midazolam experienced worsening respiratory status. Vital signs before and after dosing were not significantly different. CONCLUSIONS Intranasal midazolam and fentanyl use in term and preterm infants appeared safe and well-tolerated in this small cohort of infants. Larger, prospective studies evaluating the safety and efficacy of intranasal midazolam and fentanyl use in infants are warranted.
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Affiliation(s)
- L C Ku
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - C Simmons
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Duke University Medical Center, Durham, NC, USA
| | - P B Smith
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - R G Greenberg
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - K Fisher
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Duke University Medical Center, Durham, NC, USA
| | - C D Hornik
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Duke University Medical Center, Durham, NC, USA
| | - C Michael Cotten
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Duke University Medical Center, Durham, NC, USA
| | - R N Goldberg
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Duke University Medical Center, Durham, NC, USA
- Jean and George Brumley Jr. Neonatal Perinatal Research Institute, Duke University Medical Center, Durham, NC, USA
| | - M Bidegain
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Duke University Medical Center, Durham, NC, USA
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18
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Abstract
Infant delirium is an under-recognized clinical entity in neonatal intensive care, and earlier identification and treatment could minimize morbidities associated with this condition. We describe a case of a 6-month-old former 32 weeks gestation infant undergoing a prolonged mechanical ventilation course diagnosed with delirium related to the combination of his underlying illness and the use of multiple sedative and analgesic medications. Initiation of the atypical antipsychotic risperidone allowed for weaning from continuous infusions of benzodiazepines and opiods, and lower dosages of bolus-dosed sedation and analgesics. The patient experienced no adverse side effects from use of this neuroleptic.
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Affiliation(s)
- L E Edwards
- Department of Pediatrics, Division of Neonatology, Duke University Medical Center, Durham, NC, USA
| | - L B Hutchison
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - C D Hornik
- Department of Pharmacy, Duke University Medical Center, Durham, NC, USA
| | - P B Smith
- Department of Pediatrics, Division of Neonatology, Duke University Medical Center, Durham, NC, USA
| | - C M Cotten
- Department of Pediatrics, Division of Neonatology, Duke University Medical Center, Durham, NC, USA
| | - M Bidegain
- Department of Pediatrics, Division of Neonatology, Duke University Medical Center, Durham, NC, USA
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19
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Edwards L, DeMeo S, Hornik CD, Cotten CM, Smith PB, Pizoli C, Hauer JM, Bidegain M. Gabapentin Use in the Neonatal Intensive Care Unit. J Pediatr 2016; 169:310-2. [PMID: 26578075 PMCID: PMC4729593 DOI: 10.1016/j.jpeds.2015.10.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 08/21/2015] [Accepted: 10/05/2015] [Indexed: 01/23/2023]
Abstract
Gabapentin was used for the treatment of term and preterm infants with suspected visceral hyperalgesia caused by a variety of neurologic and gastrointestinal morbidities. Improved feeding tolerance and decreased irritability were seen, as well as decreased usage of opioids and benzodiazepines. Adverse events occurred with abrupt discontinuation of this medication.
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Affiliation(s)
- Laura Edwards
- Department of Pediatrics, Division of Neonatology, Duke
University Medical Center, Durham NC
| | - Stephen DeMeo
- Department of Pediatrics, Division of Neonatology, Duke
University Medical Center, Durham NC
| | - Chi D. Hornik
- Department of Pharmacy, Duke University Medical Center,
Durham NC
| | - C. Michael Cotten
- Department of Pediatrics, Division of Neonatology, Duke
University Medical Center, Durham NC
| | - P. Brian Smith
- Department of Pediatrics, Division of Neonatology, Duke
University Medical Center, Durham NC
| | - Carolyn Pizoli
- Department of Pediatrics, Division of Pediatric Neurology,
Duke University Medical Center, Durham, NC
| | - Julie M. Hauer
- Department of Pediatrics, Children's Hospital Boston,
Boston, MA
| | - Margarita Bidegain
- Division of Neonatology, Department of Pediatrics, Duke University Medical Center, Durham, NC.
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