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Wangchinda W, Pogue JM, Thamlikitkul V, Leelawattanachai P, Koomanachai P, Pai MP. Population pharmacokinetic/pharmacodynamic target attainment analysis of IV fosfomycin for the treatment of MDR Gram-negative bacterial infections. J Antimicrob Chemother 2024:dkae111. [PMID: 38597137 DOI: 10.1093/jac/dkae111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/22/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND IV fosfomycin is used against MDR Gram-negative bacilli (GNB) but has dose-limiting side effects, especially in patients with impaired kidney function. OBJECTIVES To determine the optimal dosage of IV fosfomycin for patients with varying degrees of kidney function. METHODS Adult patients receiving IV fosfomycin for treatment of GNB were eligible. Five serial blood samples were collected after at least three doses of fosfomycin; plasma was assayed by LC-MS/MS and modelled by population pharmacokinetic analysis. The PTA for AUC24/MIC of 98.9 for Escherichia coli and Klebsiella pneumoniae, and 40.8 for Pseudomonas aeruginosa were computed by Monte Carlo simulations. Cumulative fractions of response (CFR) were analysed for each pathogen using EUCAST MIC distributions. RESULTS A total of 24 patients were included. Creatinine clearance (CLCR) and gender significantly influenced fosfomycin clearance. The kidney function-adjusted dosing regimens are proposed by using the lowest dose that can achieve ≥90% PTA for AUC24/MIC of 98.9 at an MIC of ≤32 mg/L (EUCAST v.13 susceptibility breakpoint for Enterobacterales). For patients with normal kidney function (CLCR 91-120 mL/min), a dosage of 15 g/day is suggested. This regimen achieved 97.1% CFR against E. coli, whereas CFR was 72.9% for K. pneumoniae and 76.7% for P. aeruginosa. CONCLUSIONS A fosfomycin dosage of 15 g/day with adjustment according to kidney function provided high PTA and CFR when treating E. coli. This dosage is lower than that used in current practice and may improve tolerability. Higher dosages may be needed for P. aeruginosa; however, safety data are limited.
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Affiliation(s)
- Walaiporn Wangchinda
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA
- Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jason M Pogue
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA
| | | | - Pannee Leelawattanachai
- Department of Pharmacy, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | | | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA
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Cojutti PG, Pai MP, Tonetti T, Siniscalchi A, Viale P, Pea F. Balancing the scales: achieving the optimal beta-lactam to beta-lactamase inhibitor ratio with continuous infusion piperacillin/tazobactam against extended spectrum beta-lactamase producing Enterobacterales. Antimicrob Agents Chemother 2024; 68:e0140423. [PMID: 38411995 PMCID: PMC10994818 DOI: 10.1128/aac.01404-23] [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: 10/28/2023] [Accepted: 02/02/2024] [Indexed: 02/28/2024] Open
Abstract
Piperacillin/tazobactam (TZP) is administered intravenously in a fixed ratio (8:1) with the potential for inadequate tazobactam exposure to ensure piperacillin activity against Enterobacterales. Adult patients receiving continuous infusion (CI) of TZP and therapeutic drug monitoring (TDM) of both agents were evaluated. Demographic variables and other pertinent laboratory data were collected retrospectively. A population pharmacokinetic approach was used to select the best kidney function model predictive of TZP clearance (CL). The probability of target attainment (PTA), cumulative fraction of response (CFR) and the ratio between piperacillin and tazobactam were computed to identify optimal dosage regimens by continuous infusion across kidney function. This study included 257 critically ill patients (79.3% male) with intra-abdominal, bloodstream, and hospital-acquired pneumonia infections in 89.5% as the primary indication. The median (min-max range) age, body weight, and estimated glomerular filtration rate (eGFR) were 66 (23-93) years, 75 (39-310) kg, and 79.2 (6.4-234) mL/min, respectively. Doses of up to 22.5 g/day were used to optimize TZP based on TDM. The 2021 chronic kidney disease epidemiology equation in mL/min best modeled TZP CL. The ratio of piperacillin:tazobactam increased from 6:1 to 10:1 between an eGFR of <20 mL/min and >120 mL/min. At conventional doses, the PTA is below 90% when eGFR is ≥100 mL/min. Daily doses of 18 g/day and 22.5 g/day by CI are expected to achieve a >80% CFR when eGFR is 100-120 mL/min and >120-160 mL/min, respectively. Inadequate piperacillin and tazobactam exposure is likely in patients with eGFR ≥ 100 mL/min. Dose regimen adjustments informed by TDM should be evaluated in this specific population.
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Affiliation(s)
- Pier Giorgio Cojutti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero—Universitaria di Bologna, Bologna, Italy
| | - Manjunath P. Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Tommaso Tonetti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Anesthesiology and Intensive Care Medicine, IRCCS Azienda Ospedaliero—Universitaria di Bologna, Bologna, Italy
| | - Antonio Siniscalchi
- Division of Anesthesiology, Department of Anesthesia and Intensive Care, IRCCS Azienda Ospedaliero—Universitaria di Bologna, Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero—Universitaria di Bologna, Bologna, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero—Universitaria di Bologna, Bologna, Italy
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Leino AD, Magee JC, Kershaw DB, Pai MP, Park JM. A Comprehensive Mixed-Method Approach to Characterize the Source of Diurnal Tacrolimus Exposure Variability in Children: Systematic Review, Meta-analysis, and Application to an Existing Data Set. J Clin Pharmacol 2024; 64:334-344. [PMID: 37740566 DOI: 10.1002/jcph.2352] [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: 06/29/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023]
Abstract
Tacrolimus is widely reported to display diurnal variation in pharmacokinetic parameters with twice-daily dosing. However, the contribution of chronopharmacokinetics versus food intake is unclear, with even less evidence in the pediatric population. The objectives of this study were to summarize the existing literature by meta-analysis and evaluate the impact of food composition on 24-hour pharmacokinetics in pediatric kidney transplant recipients. For the meta-analysis, 10 studies involving 253 individuals were included. The pooled effect sizes demonstrated significant differences in area under the concentration-time curve from time 0 to 12 hours (standardized mean difference [SMD], 0.27; 95% confidence interval [CI], 0.03-0.52) and maximum concentration (SMD, 0.75; 95% CI, 0.35-1.15) between morning and evening dose administration. However, there was significant between-study heterogeneity that was explained by food exposure. The effect size for minimum concentration was not significantly different overall (SMD, -0.09; 95% CI, -0.27 to 0.09) or across the food exposure subgroups. A 2-compartment model with a lag time, linear clearance, and first-order absorption best characterized the tacrolimus pharmacokinetics in pediatric participants. As expected, adding the time of administration and food composition covariates reduced the unexplained within-subject variability for the first-order absorption rate constant, but only caloric composition significantly reduced variability for lag time. The available data suggest food intake is the major driver of diurnal variation in tacrolimus exposure, but the associated changes are not reflected by trough concentrations alone.
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Affiliation(s)
- Abbie D Leino
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - John C Magee
- Department of Surgery, Medical School, University of Michigan, Ann Arbor, MI, USA
| | - David B Kershaw
- Department of Pediatrics, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Jeong M Park
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
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Koschmann C, Al-Holou WN, Alonso MM, Anastas J, Bandopadhayay P, Barron T, Becher O, Cartaxo R, Castro MG, Chung C, Clausen M, Dang D, Doherty R, Duchatel R, Dun M, Filbin M, Franson A, Galban S, Garcia Moure M, Garton H, Gowda P, Marques JG, Hawkins C, Heath A, Hulleman E, Ji S, Jones C, Kilburn L, Kline C, Koldobskiy MA, Lim D, Lowenstein PR, Lu QR, Lum J, Mack S, Magge S, Marini B, Martin D, Marupudi N, Messinger D, Mody R, Morgan M, Mota M, Muraszko K, Mueller S, Natarajan SK, Nazarian J, Niculcea M, Nuechterlein N, Okada H, Opipari V, Pai MP, Pal S, Peterson E, Phoenix T, Prensner JR, Pun M, Raju GP, Reitman ZJ, Resnick A, Rogawski D, Saratsis A, Sbergio SG, Souweidane M, Stafford JM, Tzaridis T, Venkataraman S, Vittorio O, Wadden J, Wahl D, Wechsler-Reya RJ, Yadav VN, Zhang X, Zhang Q, Venneti S. A road map for the treatment of pediatric diffuse midline glioma. Cancer Cell 2024; 42:1-5. [PMID: 38039965 DOI: 10.1016/j.ccell.2023.11.002] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/04/2023] [Accepted: 11/04/2023] [Indexed: 12/03/2023]
Abstract
Recent clinical trials for H3K27-altered diffuse midline gliomas (DMGs) have shown much promise. We present a consensus roadmap and identify three major barriers: (1) refinement of experimental models to include immune and brain-specific components; (2) collaboration among researchers, clinicians, and industry to integrate patient-derived data through sharing, transparency, and regulatory considerations; and (3) streamlining clinical efforts including biopsy, CNS-drug delivery, endpoint determination, and response monitoring. We highlight the importance of comprehensive collaboration to advance the understanding, diagnostics, and therapeutics for DMGs.
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Affiliation(s)
| | | | | | | | | | - Tara Barron
- Stanford University, Stanford, CA 94305, USA
| | - Oren Becher
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | | | | | - Chan Chung
- Daegu Gyeongbuk Institute of Science & Technology, Daegu, South Korea
| | | | - Derek Dang
- University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Ryan Duchatel
- University of Newcastle, Callaghan, NSW 2308, Australia
| | - Matthew Dun
- University of Newcastle, Callaghan, NSW 2308, Australia
| | | | | | | | | | - Hugh Garton
- University of Michigan, Ann Arbor, MI 48109, USA
| | | | | | | | - Allison Heath
- Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | | | - Sunjong Ji
- University of Michigan, Ann Arbor, MI 48109, USA
| | - Chris Jones
- Division of Molecular Pathology, Institute for Cancer Research, London SM2 5NG, UK
| | | | - Cassie Kline
- Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | | | - Daniel Lim
- University of California, San Francisco, San Francisco, CA 94143, USA
| | | | - Q Richard Lu
- Cincinnati Children's Hospital Medical Center, and University of Cincinnati, Cincinnati, OH 45229, USA
| | - Joanna Lum
- University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Suresh Magge
- University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Donna Martin
- University of Michigan, Ann Arbor, MI 48109, USA
| | | | | | - Rajen Mody
- University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Mateus Mota
- University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Sabine Mueller
- University of California, San Francisco, San Francisco, CA 94143, USA; Parker Institute for Cancer Immunotherapy, University of Zurich, Zurich, Switzerland
| | | | - Javad Nazarian
- Children's National, Washington, DC 20010, USA; University of Zurich, Zurich, Switzerland
| | | | - Nicholas Nuechterlein
- University of Michigan, Ann Arbor, MI 48109, USA; National Institutes of Health, Bethesda, MD, USA
| | - Hideho Okada
- University of California, San Francisco, San Francisco, CA 94143, USA
| | | | | | | | | | - Timothy Phoenix
- Cincinnati Children's Hospital Medical Center, and University of Cincinnati, Cincinnati, OH 45229, USA
| | | | - Matthew Pun
- University of Michigan, Ann Arbor, MI 48109, USA
| | - G Praveen Raju
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | | | - Adam Resnick
- Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | | | | | | | - Mark Souweidane
- Weill Cornell Medicine, New York Presbyterian and Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - James M Stafford
- Weill Cornell Medicine, New York Presbyterian and Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Theophilos Tzaridis
- Herbert Irving Comprehensive Cancer Center and Department of Neurology, Columbia University Medical Center, New York, NY 10032, USA
| | | | - Orazio Vittorio
- School of Biomedical Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Jack Wadden
- University of Michigan, Ann Arbor, MI 48109, USA
| | - Daniel Wahl
- University of Michigan, Ann Arbor, MI 48109, USA
| | | | | | - Xu Zhang
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Qiang Zhang
- University of Michigan, Ann Arbor, MI 48109, USA
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Takyi-Williams J, Leino AD, Li R, Downes KJ, Zuppa AF, Bwint A, Wen B, Sun D, Scheetz MH, Pai MP. Bioanalysis of six antibiotics from volumetric microsamples: a new tool for precision dosing in critically ill children. Bioanalysis 2024; 16:19-31. [PMID: 37991215 PMCID: PMC10718164 DOI: 10.4155/bio-2023-0171] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/02/2023] [Indexed: 11/23/2023] Open
Abstract
Background: Volumetric absorptive microsamples (VAMS) can support pharmacokinetic / pharmacodynamic studies. We present the bioanalytical method development for the simultaneous quantification of ampicillin, cefepime, ceftriaxone, meropenem, piperacillin, tazobactam, and vancomycin from VAMS. Methods & results: Optimal extraction, chromatographic, and mass spectrometry conditions were identified. Maximum extraction recoveries included 100 μl of water for rehydration and methanol for protein precipitation. Chromatographic separation used Phenomenex Kinetex™ Polar C18 column with a mobile phase comprising water/acetonitrile with formic acid and was fully validated. Hematocrit effects were only observed for vancomycin. Samples were stable for 90 days at -80°C except for meropenem, which was stable for 60 days. Conclusion: Multiple antibiotics can be assayed from a single VAMS sample to facilitate pharmacokinetic/pharmacodynamic studies.
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Affiliation(s)
| | - Abbie D Leino
- College of Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA
| | - Ruiting Li
- College of Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA
| | - Kevin J Downes
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Athena F Zuppa
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Amanda Bwint
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Bo Wen
- College of Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA
| | - Duxin Sun
- College of Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA
| | - Marc H Scheetz
- College of Pharmacy, Midwestern University, Downers Grove, IL 60515, USA
| | - Manjunath P Pai
- College of Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA
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Liu S, Matvekas A, Naimi T, Ghanem A, Li R, Rajanayake K, Derstine B, Ross B, Sullivan J, Yun HG, Regenbogen S, Byrn J, Su G, Wang S, Pai MP. Morphomics-informed population pharmacokinetic and physiologically-based pharmacokinetic modeling to optimize cefazolin surgical prophylaxis. Pharmacotherapy 2024; 44:77-86. [PMID: 37728152 PMCID: PMC10841046 DOI: 10.1002/phar.2878] [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: 04/14/2023] [Revised: 08/09/2023] [Accepted: 08/13/2023] [Indexed: 09/21/2023]
Abstract
INTRODUCTION Cefazolin is the leading antibiotic used to prevent surgical site infections worldwide. Consensus guidelines recommend adjustment of the cefazolin dose above and below 120 kg without regard to body composition. Algorithms exist to repurpose radiologic data into body composition (morphomics) and inform dosing decisions in obesity. OBJECTIVES To compare the current standard of body weight to morphomic measurements as covariates of cefazolin pharmacokinetics and aid dose stratification of cefazolin in patients with obesity undergoing colorectal surgery. METHODS This prospective study measured cefazolin plasma, fat, and colon tissue concentrations in colorectal surgery patients in order to develop a morphomics-informed population pharmacokinetic (PopPK) model to guide dose adjustments. A physiologically-based pharmacokinetic (PBPK) model was also constructed to inform tissue partitioning in morbidly obese patients (n = 21, body mass index ≥35 kg/m2 with one or more co-morbid conditions). RESULTS Morphomics and pharmacokinetic data were available in 58 patients with a median [min, max] weight and age of 95.9 [68.5, 148.8] kg and 55 [25, 79] years, respectively. The plasma-to-subcutaneous fat partition coefficient was predicted to be 0.072 and 0.060 by the PopPK and PBPK models, respectively. The estimated creatinine clearance (eCLcr ) and body depth at the third lumbar vertebra (body depth_L3) were identified as covariates of cefazolin exposure. The probability of maintaining subcutaneous fat concentrations above 2 μg/mL for 100% of a 4-h surgical period was below 90% when eCLcr ≥105 mL/min and body depth_L3 ≥ 300 mm and less sensitive to the rate of infusion between 5 and 60 min. CONCLUSIONS Kidney function and morphomics were more informative than body weight as covariates of cefazolin target site exposure. Data from more diverse populations, consensus on target cefazolin exposure, and comparative studies are needed before a change in practice can be implemented.
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Affiliation(s)
- Shuhan Liu
- University of Michigan, College of Pharmacy, Ann Arbor, Michigan, USA
| | - Aleksas Matvekas
- University of Michigan, College of Pharmacy, Ann Arbor, Michigan, USA
| | - Tamara Naimi
- University of Michigan, College of Pharmacy, Ann Arbor, Michigan, USA
| | - Aws Ghanem
- University of Michigan, College of Pharmacy, Ann Arbor, Michigan, USA
| | - Ruiting Li
- University of Michigan, College of Pharmacy, Ann Arbor, Michigan, USA
| | | | - Brian Derstine
- University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Brian Ross
- University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - June Sullivan
- University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Hyun Gi Yun
- University of Michigan, College of Pharmacy, Ann Arbor, Michigan, USA
| | - Scott Regenbogen
- University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - John Byrn
- University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Grace Su
- University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Stewart Wang
- University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Manjunath P. Pai
- University of Michigan, College of Pharmacy, Ann Arbor, Michigan, USA
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Jennaro TS, Puskarich MA, Flott TL, McLellan LA, Jones AE, Pai MP, Stringer KA. Kidney function as a key driver of the pharmacokinetic response to high-dose L-carnitine in septic shock. Pharmacotherapy 2023; 43:1240-1250. [PMID: 37775945 PMCID: PMC10841498 DOI: 10.1002/phar.2882] [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: 05/12/2023] [Revised: 08/22/2023] [Accepted: 08/31/2023] [Indexed: 10/01/2023]
Abstract
STUDY OBJECTIVE Levocarnitine (L-carnitine) has shown promise as a metabolic-therapeutic for septic shock, where mortality approaches 40%. However, high-dose (≥ 6 grams) intravenous supplementation results in a broad range of serum concentrations. We sought to describe the population pharmacokinetics (PK) of high-dose L-carnitine, test various estimates of kidney function, and assess the correlation of PK parameters with pre-treatment metabolites in describing drug response for patients with septic shock. DESIGN Population PK analysis was done with baseline normalized concentrations using nonlinear mixed effect models in the modeling platform Monolix. Various estimates of kidney function, patient demographics, dose received, and organ dysfunction were tested as population covariates. DATA SOURCE We leveraged serum samples and metabolomics data from a phase II trial of L-carnitine in vasopressor-dependent septic shock. Serum was collected at baseline (T0); end-of-infusion (T12); and 24, 48, and 72 h after treatment initiation. PATIENTS AND INTERVENTION Patients were adaptively randomized to receive intravenous L-carnitine (6 grams, 12 grams, or 18 grams) or placebo. MEASUREMENTS AND MAIN RESULTS The final dataset included 542 serum samples from 130 patients randomized to L-carnitine. A two-compartment model with linear elimination and a fixed volume of distribution (17.1 liters) best described the data and served as a base structural model. Kidney function estimates as a covariate on the elimination rate constant (k) reliably improved model fit. Estimated glomerular filtration rate (eGFR), based on the 2021 Chronic Kidney Disease Epidemiology collaboration (CKD-EPI) equation with creatinine and cystatin C, outperformed creatinine clearance (Cockcroft-Gault) and older CKD-EPI equations that use an adjustment for self-identified race. CONCLUSIONS High-dose L-carnitine supplementation is well-described by a two-compartment population PK model in patients with septic shock. Kidney function estimates that leverage cystatin C provided superior model fit. Future investigations into high-dose L-carnitine supplementation should consider baseline metabolic status and dose adjustments based on renal function over a fixed or weight-based dosing paradigm.
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Affiliation(s)
- Theodore S. Jennaro
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael A. Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Thomas L. Flott
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Laura A. McLellan
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Alan E. Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Manjunath P. Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Kathleen A. Stringer
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Hall, RG, Liu S, Putnam WC, Kallem R, Gumbo T, Pai MP. Optimizing anidulafungin exposure across a wide adult body size range. Antimicrob Agents Chemother 2023; 67:e0082023. [PMID: 37850741 PMCID: PMC10649049 DOI: 10.1128/aac.00820-23] [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: 06/20/2023] [Accepted: 09/06/2023] [Indexed: 10/19/2023] Open
Abstract
Echinocandins like anidulafungin are first-line therapies for candidemia and invasive candidiasis, but their dosing may be suboptimal in obese patients. Our objective was to quantify anidulafungin exposure in a cohort of adults across a wide body size range to test if body size affects anidulafungin pharmacokinetics (PK). We enrolled 20 adults between the ages of 18 and 80 years, with an equal distribution of patients above and below a body mass index of 30 kg/m2. A single 100-mg dose of anidulafungin was administered, followed by intensive sampling over 72 h. Population PK analysis was used to identify and compare covariates of anidulafungin PK parameters. Monte Carlo simulations were performed to compute the probability of target attainment (PTA) based on alternative dosing regimens. Participants (45% males) had a median (range) age of 45 (21-78) years and a median (range) weight of 82.7 (42.4-208.3) kg. The observed median (range) of AUC0-∞ was 106.4 (51.9, 138.4) mg∙h/L. Lean body weight (LBW) and adjusted body weight (AdjBW) were more influential than weight as covariates of anidulafungin PK parameters. The conventional 100 mg daily maintenance is predicted to have a PTA below 90% in adults with an LBW > 55 kg or an AdjBW > 75 kg. A daily maintenance dose of 150-200 mg is predicted in these heavier adults. Anidulafungin AUC0-∞ declines with increasing body size. A higher maintenance dose will increase the PTA compared to the current approach in obese patients.
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Affiliation(s)
- Ronald G. Hall,
- Jerry H. Hodge School of Pharmacy, Texas Tech University Health Sciences Center, Dallas, Texas, USA
| | - Shuhan Liu
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - William C. Putnam
- Jerry H. Hodge School of Pharmacy, Texas Tech University Health Sciences Center, Dallas, Texas, USA
| | - Rajareddy Kallem
- Jerry H. Hodge School of Pharmacy, Texas Tech University Health Sciences Center, Dallas, Texas, USA
| | | | - Manjunath P. Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
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Alikhani R, Pai MP. Reconsideration of the current models of estimated kidney function-based drug dose adjustment in older adults: The role of biological age. Clin Transl Sci 2023; 16:2095-2105. [PMID: 37702349 PMCID: PMC10651638 DOI: 10.1111/cts.13643] [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: 07/24/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/14/2023] Open
Abstract
Human lifespan has increased from a median of 46.5 years in 1950 to 71.7 years in 2022. As people age, one of the inevitable consequences is a decline in kidney function and glomerular filtration rate (GFR) which can have direct or indirect effects on the pharmacokinetic and pharmacodynamic profiles of many drugs. Numerous equations have been developed to generate estimated GFR (eGFR) using the two principal biomarkers: serum creatinine and serum cystatin C. However, the trajectory of changes with aging is dissimilar in these equations. In addition, there is recognition that chronological age (lifespan) often does not reflect biological age (healthspan) as an essential parameter in kidney function equations. In the past decade, there has been an increasing interest in quantifying biological age and new commercially available assays have entered the marketplace. In this narrative review, we illustrate how dominant equations of eGFR model the fractional change in this parameter very differently across chronological age. In addition, we review various biological age indicators (aging clocks) and challenges to their application in clinical practice. Importantly, by comparing vancomycin's mean clearance as a drug with limited metabolism and unchanged elimination between two age milestones in some recent population pharmacokinetic models, we show how efforts to quantify kidney function in older adults optimally remain under-explored, particularly those at the upper end of their lifespan. We also propose considering new models that integrate biological age as a new pathway to improve precision drug dosing in older adults.
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Affiliation(s)
- Radin Alikhani
- Department of Clinical Pharmacy, College of PharmacyUniversity of MichiganAnn ArborMichiganUSA
| | - Manjunath P. Pai
- Department of Clinical Pharmacy, College of PharmacyUniversity of MichiganAnn ArborMichiganUSA
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Jin G, Ho JW, Keeney-Bonthrone TP, Pai MP, Wen B, Ober RA, Dimonte D, Chtraklin K, Joaquin TA, Latif Z, Vercruysse C, Alam HB. Prolonging the therapeutic window for valproic acid treatment in a swine model of traumatic brain injury and hemorrhagic shock. J Trauma Acute Care Surg 2023; 95:657-663. [PMID: 37314445 DOI: 10.1097/ta.0000000000004022] [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] [Indexed: 06/15/2023]
Abstract
BACKGROUND It has previously been shown that administration of valproic acid (VPA) can improve outcomes if given within an hour following traumatic brain injury (TBI). This short therapeutic window (TW) limits its use in real-life situations. Based upon its pharmacokinetic data, we hypothesized that TW can be extended to 3 hours if a second dose of VPA is given 8 hours after the initial dose. METHOD Yorkshire swine (40-45 kg; n = 10) were subjected to TBI (controlled cortical impact) and 40% blood volume hemorrhage. After 2 hours of shock, they were randomized to either (1) normal saline resuscitation (control) or (2) normal saline-VPA (150 mg/kg × two doses). First dose of VPA was started 3 hours after the TBI, with a second dose 8 hours after the first dose. Neurologic severity scores (range, 0-36) were assessed daily for 14 days, and brain lesion size was measured via magnetic resonance imaging on postinjury day 3. RESULTS Hemodynamic and laboratory parameters of shock were similar in both groups. Valproic acid-treated animals had significantly less neurologic impairment on days 2 (16.3 ± 2.0 vs. 7.3 ± 2.8) and 3 (10.9 ± 3.6 vs. 2.8 ± 1.1) postinjury and returned to baseline levels 54% faster. Magnetic resonance imaging showed no differences in brain lesion size on day 3. Pharmacokinetic data confirmed neuroprotective levels of VPA in the circulation. CONCLUSION This is the first study to demonstrate that VPA can be neuroprotective even when given 3 hours after TBI. This expanded TW has significant implications for the design of the clinical trial.
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Affiliation(s)
- Guang Jin
- From the Department of Surgery (G.J., J.W.H., T.P.K.-B., K.C., T.A.J., Z.L., C.V., H.B.A.), Feinberg School of Medicine, Northwestern University, Chicago; Department of Clinical Pharmacy (M.P.P., B.W.), University of Michigan, Ann Arbor, Michigan; Center for Comparative Medicine (R.A.O.), Northwestern University, Chicago; and Electrical and Computer Engineering (D.D.), Robert R. McCormick School, Northwestern University, Evanston, Illinois
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11
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Yun HG, Smith AJF, DeBacker KC, Pai MP. Estimated glomerular filtration rate with and without race for drug dosing: Cystatin C vs. serum creatinine. Br J Clin Pharmacol 2023; 89:1207-1210. [PMID: 36367379 DOI: 10.1111/bcp.15592] [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: 08/26/2022] [Revised: 10/13/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022] Open
Abstract
The goal of this study was to use a model kidney function clearance-dependent drug (vancomycin) to understand the gain or loss of precision in dosing with use of serum creatinine (Scr ), serum cystatin C (Scys ) and race and nonrace-based equations of the estimated glomerular filtration rate (eGFR). In this study of hospitalized patients, we compared Scr , Scys and their combination to estimate kidney function and vancomycin clearance. The nonrace-based Scys eGFR model outperformed other clearance models and improved the probability of target attainment by 15%. When Scys is not available, we show that the new 2021 CKD-EPI eGFRcr equation (no race factor) performs as well as the current conventional approach. This improvement in model performance does not negate the need for individualized dosing but exemplifies the need to remove race as a factor of kidney-function dose adjustment.
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Affiliation(s)
- Hyun Gi Yun
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew J F Smith
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Kenneth C DeBacker
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
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12
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Pasternak AL, Park JM, Pai MP. Predictive Capacity of Population Pharmacokinetic Models for the Tacrolimus Dose Requirements of Pediatric Solid Organ Transplant Recipients. Ther Drug Monit 2023; 45:95-101. [PMID: 36624576 PMCID: PMC9832243 DOI: 10.1097/ftd.0000000000001002] [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: 01/11/2022] [Accepted: 04/01/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Transplant recipients require individualized tacrolimus doses to maximize graft survival. Multiple pediatric tacrolimus population pharmacokinetic (PopPK) models incorporating CYP3A5 genotype and other covariates have been developed. Identifying the optimal popPK model is necessary for clinical implementation in pediatric solid organ transplant. The primary objective was to compare the dose prediction capabilities of the developed models in pediatric kidney and heart transplant recipients. METHODS Pediatric kidney or heart transplant recipients treated with tacrolimus and available CYP3A5 genotype data were identified. The initial weight-based tacrolimus dose and first therapeutic tacrolimus dose were collected retrospectively. Three published popPK models were used to predict the tacrolimus dose required to achieve a tacrolimus trough concentration of 10 ng/mL. Model dose predictions were compared with the initial and first therapeutic doses using Friedman test. The first therapeutic dose was plotted against the model-predicted dose. RESULTS The median initial dose approximately 2-fold lower than the first therapeutic dose for CYP3A5 expressers. The Chen et al model provided the closest estimates to the first therapeutic dose for kidney transplant recipients; however, all 3 models tended to underpredict the observed therapeutic dose. For heart transplant recipients, Andrews et al model predicted doses that were higher than the initial dose but similar to the actual therapeutic dose. CONCLUSIONS Weight-based tacrolimus dosing appears to underestimate the tacrolimus dose requirements. The development of a separate popPK model is necessary for heart transplant recipients. A genotype-guided strategy based on the Chen et al model provided the best estimates for doses in kidney transplant recipients and should be prospectively evaluated.
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Affiliation(s)
- Amy L. Pasternak
- University of Michigan College of Pharmacy, Department of Clinical Pharmacy, 428 Church St. Ann Arbor, MI 48109
- University of Michigan Health, Michigan Medicine, Department of Pharmacy, 1500 East Medical Center Drive, UHB2D301 / 5008, Ann Arbor, MI 48109
| | - Jeong M. Park
- University of Michigan College of Pharmacy, Department of Clinical Pharmacy, 428 Church St. Ann Arbor, MI 48109
- University of Michigan Health, Michigan Medicine, Department of Pharmacy, 1500 East Medical Center Drive, UHB2D301 / 5008, Ann Arbor, MI 48109
| | - Manjunath P. Pai
- University of Michigan College of Pharmacy, Department of Clinical Pharmacy, 428 Church St. Ann Arbor, MI 48109
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Pai MP, Sitaruno S, Abdelnabi M. Removing race and body surface area indexation for estimated kidney function based drug dosing: Aminoglycosides as justification of these principles. Pharmacotherapy 2023; 43:35-42. [PMID: 36401789 PMCID: PMC10098929 DOI: 10.1002/phar.2746] [Citation(s) in RCA: 1] [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] [Received: 10/12/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE The use of race in medicine can contribute to health inequity. Updated equations for estimated glomerular filtration rate (eGFR) without race have been published. Likewise, de-indexation of eGFR to body surface area (BSA) has been recommended by regulatory guidance for drug dosing in renal impairment. Clinical data justifying these recommendations for drug dosing are sparse. We examined the gain or loss of precision in drug dosing with estimated creatinine clearance (eCLcr) and eGFR using serum creatinine (eGFRcr) with and without race and BSA indexation by evaluating the population pharmacokinetics of the aminoglycosides as a classic drug class to probe kidney function. DESIGN Medical records from adult patients treated with gentamicin or tobramycin over a 13-year period were queried. Population pharmacokinetic analyses were performed using a 1-compartment base structural model. Models compared body size descriptors as covariates of the volume of distribution (V). Estimated creatinine clearance and eGFRcr using multiple contemporary equations with and without BSA indexation were tested as covariates of clearance (CL). MAIN RESULTS The final data set included 2968 patients treated with either gentamicin (20.2%) or tobramycin (79.8%). Patients self-identified as Caucasian (82%), African-American (10%), or other. The median [5th, 95th percentile] weight and BSA were 80.5 [49.4, 136] kg and 1.94 [1.48, 2.56] m2 , respectively. Models of eCLcr and eGFRcr without indexation to BSA had a better model fit than eGFRcr indexed to BSA for aminoglycoside CL. The 2021 Chronic Kidney Disease Epidemiology collaboration (CKD-EPI) eGFRcr equation (no race, no BSA indexation) provided a comparable model fit to the 2009 CKD-EPI eGFRcr equation (with race, no BSA indexation) for aminoglycoside CL. CONCLUSIONS Race is not a relevant covariate of aminoglycoside CL. The 2021 CKD-EPI eGFR equation without race and BSA indexation is a better method for gentamicin and tobramycin CL estimation. Confirmation of these results for other drugs can support the harmonization of dosing by kidney function.
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Affiliation(s)
- Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Sirima Sitaruno
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla, Thailand
| | - Mohamed Abdelnabi
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
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14
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Pai MP, Cojutti PG, Gerussi V, Della Siega P, Tascini C, Pea F. Linezolid Population Pharmacokinetics to Improve Dosing in Cardiosurgical Patients: Factoring a New Drug-Drug Interaction Pathway. Clin Infect Dis 2022; 76:1173-1179. [PMID: 36424854 DOI: 10.1093/cid/ciac917] [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: 09/01/2022] [Revised: 11/07/2022] [Accepted: 11/23/2022] [Indexed: 11/27/2022] Open
Abstract
Abstract
Background
Linezolid-induced myelosuppression limits optimal therapy in cardiosurgical patients with deep-seated infections at current doses.
Methods
Adult patients who received a cardiac surgery intervention and linezolid for a documented or presumed serious Gram-positive infection were evaluated. Therapeutic monitoring data, dosing, concomitant medications, and other pertinent laboratory data were collected retrospectively. A population pharmacokinetic model was constructed to identify covariates and test potential drug-drug interactions that may account for interpatient variability. Simulations from the final model identified doses that achieve a target therapeutic trough concentration of 2-8 mg/L.
Results
This study included 150 patients (79.3% male) with sepsis and hospital acquired pneumonia in 71.7% as the primary indication. The population had a median (min-max) age, body weight and estimated glomerular filtration rate (eGFR) of 66 (30–85) years, 76 (45–130) kg and 46.8 (4.9–153.7) mL/min, respectively. The standard linezolid dosage regimen achieved the therapeutic range in only 54.7% of patients. Lower than standard doses were necessary in the majority of patients (77%). A two-compartment Michaellis-Menten clearance model with weight, kidney function, and the number of interacting drugs were identified as covariates that best fit the concentration-time data. Cyclosporine had the greatest effect on lowering the maximum elimination rate (Vmax) of linezolid. Empiric linezolid doses of 300 to 450 mg every 12 hours based on eGFR and the number of interacting medications is suggested by this analysis.
Conclusions
Lower empiric linezolid doses in cardiosurgical patients may avoid toxicities. Confirmatory studies are necessary to verify these potential drug interactions.
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Affiliation(s)
- Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan , Ann Arbor, Michigan , USA
| | - Pier Giorgio Cojutti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna , Bologna , Italy
| | - Valentina Gerussi
- Infectious Diseases Clinic, Santa Maria della Misericordia University Hospital of Udine , Udine , Italy
| | - Paola Della Siega
- Infectious Diseases Clinic, Santa Maria della Misericordia University Hospital of Udine , Udine , Italy
| | - Carlo Tascini
- Infectious Diseases Clinic, Santa Maria della Misericordia University Hospital of Udine , Udine , Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna , Bologna , Italy
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15
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Leino AD, Takyi-Williams J, Wen B, Sun D, Pai MP. Application of a new volumetric microsampling device for quantitative bioanalysis of immunosuppression. Bioanalysis 2022; 14:1141-1152. [PMID: 36208082 PMCID: PMC9644239 DOI: 10.4155/bio-2022-0155] [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: 07/22/2022] [Accepted: 09/22/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Volumetric absorptive microsampling may reduce the blood collection burden associated with therapeutic drug monitoring of immunosuppression to prevent organ transplant rejection. This work describes the development of a laboratory and analytical technique for quantifying tacrolimus and mycophenolic acid (MPA) from the Tasso-M20™ in human whole blood using bead-based impact-assisted extraction. Results: The sampled blood volume was accurate with estimated volumes within <2% of the expected 20 μl. Recovery using impact-assisted extraction was 73-87% for MPA and 100% for tacrolimus and was hematocrit-independent for both analytes. The LC-MS/MS assay is precise and accurate within the acceptance criteria of 15%. Conclusion: The sampling and extraction procedures allowed for accurate quantification of tacrolimus and MPA. Exploration of abuse scenarios identified important education points for patients conducting home-based sample collections in the future.
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Affiliation(s)
- Abbie D Leino
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA
| | - John Takyi-Williams
- Pharmacokinetic & Mass Spectrometry Core, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA
| | - Bo Wen
- Pharmacokinetic & Mass Spectrometry Core, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA
| | - Duxin Sun
- Pharmacokinetic & Mass Spectrometry Core, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA
- Pharmacokinetic & Mass Spectrometry Core, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA
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16
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Hertz DL, Chen L, Henry NL, Griggs JJ, Hayes DF, Derstine BA, Su GL, Wang SC, Pai MP. Muscle mass affects paclitaxel systemic exposure and may inform personalized paclitaxel dosing. Br J Clin Pharmacol 2022; 88:3222-3229. [PMID: 35083783 PMCID: PMC9197985 DOI: 10.1111/bcp.15244] [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: 09/17/2021] [Revised: 12/01/2021] [Accepted: 01/01/2022] [Indexed: 01/03/2023] Open
Abstract
AIMS Patients with low muscle mass have increased risk of paclitaxel-induced peripheral neuropathy, which is dependent on systemic paclitaxel exposure. Dose optimization may be feasible through the secondary use of radiologic data for body composition. The objective of this study was to interrogate morphomic parameters as predictors of paclitaxel pharmacokinetics to identify alternative dosing strategies that may improve treatment outcomes. METHODS This was a secondary analysis of female patients with breast cancer scheduled to receive 80 mg/m2 weekly paclitaxel infusions. Paclitaxel was measured at the end of initial infusion to estimate maximum concentration (Cmax ). Computed tomography (CT) scans were used to measure 29 body composition features for inclusion in pharmacokinetic modelling. Monte Carlo simulations were performed to identify infusion durations that limit the probability of exceeding Cmax > 2885 ng/mL, which was selected based on prior work linking this to an unacceptable risk of peripheral neuropathy. RESULTS Thirty-nine patients were included in the analysis. The optimal model was a two-compartment pharmacokinetic model with T11 skeletal muscle area as a covariate of paclitaxel volume of distribution (Vd). Simulations suggest that extending infusion of the standard paclitaxel dose from 1 hour to 2 and 3 hours in patients who have skeletal muscle area 4907-7080 mm2 and <4907 mm2 , respectively, would limit risk of Cmax > 2885 ng/mL to <50%, consequently reducing neuropathy, while marginally increasing overall systemic paclitaxel exposure. CONCLUSION Extending paclitaxel infusion duration in ~25% of patients who have low skeletal muscle area is predicted to reduce peripheral neuropathy while maintaining systemic exposure, suggesting that personalizing paclitaxel dosing based on body composition may improve treatment outcomes.
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Affiliation(s)
- Daniel L. Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, United States, 48109-1065
| | - Li Chen
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, United States, 48109-1065
| | - N. Lynn Henry
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI
| | - Jennifer J Griggs
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI
| | - Daniel F Hayes
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI
| | - Brian A. Derstine
- Morphomic Analysis Group, University of Michigan Medical School, Ann Arbor, MI
| | - Grace L. Su
- Morphomic Analysis Group, University of Michigan Medical School, Ann Arbor, MI
| | - Stewart C Wang
- Morphomic Analysis Group, University of Michigan Medical School, Ann Arbor, MI
| | - Manjunath P. Pai
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, United States, 48109-1065
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Sitaruno S, Santimaleeworagun W, Pattharachayakul S, DeBacker KC, Vattanavanit V, Binyala W, Pai MP. Comparison of Race and Non-Race Based Equations for Kidney Function Estimation in Critically Ill Thai Patients for Vancomycin Dosing. J Clin Pharmacol 2022; 62:1215-1226. [PMID: 35543614 PMCID: PMC9544596 DOI: 10.1002/jcph.2070] [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: 02/25/2022] [Accepted: 05/02/2022] [Indexed: 11/12/2022]
Abstract
Empiric antibiotic dosing frequently relies on an estimate of kidney function based on age, serum creatinine (SCr), sex, and race (on occasion). New non-Race based estimated glomerular filtration rate (eGFR) equations have been published but their role to support dosing is not known. Here, we report on a population pharmacokinetic model of vancomycin that serves as a useful probe substrate of eGFR in critically ill Thai patients. Data were obtained from medical records during a 10-year period. A nonlinear mixed-effects modeling approach was conducted to estimate vancomycin parameters. Data from 208 critically ill patients (58.2% male and 36.0% septic shock) with 398 vancomycin concentrations were collected. Twenty-three covariates including 12 kidney function estimates were tested and ranked based on the model performance. The median [min, max] age, weight, and SCr was 69 [18, 97] years, 60.0 [27, 120] kg, and 1.53 [0.18, 7.15] mg/dL. The best base model was a one-compartment linear with zero-order input and proportional error model. A Thai specific eGFR equation not indexed to body surface area (BSA) model best predicted vancomycin clearance (CL). The typical value for volume of distribution and CL was 67.5 L and 1.22 L/h, respectively. A loading dose of 2000 mg followed by maintenance dose regimens based on eGFR is suggested. The Thai-GFR not indexed to BSA model best predicts vancomycin CL and dosing in the critically ill Thai population. A 5-10% absolute gain in the vancomycin probability of target attainment is expected with the use of this population specific GFR equation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Sirima Sitaruno
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | | | - Sutthiporn Pattharachayakul
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Kenneth C DeBacker
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Veerapong Vattanavanit
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Wanrada Binyala
- Pharmacy Department, Songklanagarind Hospital, Hat Yai, Songkhla, Thailand
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
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18
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Liu S, Pai MP, Lester CA. Medication Use Among U.S. Adults After Bariatric Surgery: A Population-Based Analysis of NHANES 2015-2018. Diabetes Care 2022; 45:e54-e55. [PMID: 35045158 DOI: 10.2337/dc21-2285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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19
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Pai MP, Crass RL. Translation of Pharmacodynamic Biomarkers of Antibiotic Efficacy in Specific Populations to Optimize Doses. Antibiotics (Basel) 2021; 10:antibiotics10111368. [PMID: 34827306 PMCID: PMC8614818 DOI: 10.3390/antibiotics10111368] [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: 09/29/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 11/16/2022] Open
Abstract
Antibiotic efficacy determination in clinical trials often relies on non-inferiority designs because they afford smaller study sample sizes. These efficacy studies tend to exclude patients within specific populations or include too few patients to discern potential differences in their clinical outcomes. As a result, dosing guidance in patients with abnormal liver and kidney function, age across the lifespan, and other specific populations relies on drug exposure-matching. The underlying assumption for exposure-matching is that the disease course and the response to the antibiotic are similar in patients with and without the specific condition. While this may not be the case, clinical efficacy studies are underpowered to ensure this is true. The current paper provides an integrative review of the current approach to dose selection in specific populations. We review existing clinical trial endpoints that could be measured on a more continuous rather than a discrete scale to better inform exposure-response relationships. The inclusion of newer systemic biomarkers of efficacy can help overcome the current limitations. We use a modeling and simulation exercise to illustrate how an efficacy biomarker can inform dose selection better. Studies that inform response-matching rather than exposure-matching only are needed to improve dose selection in specific populations.
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Affiliation(s)
- Manjunath P. Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Rm 2568, 428 Church St., Ann Arbor, MI 48109, USA
- Correspondence: ; Tel.: +1-734-647-0006
| | - Ryan L. Crass
- Ann Arbor Pharmacometrics Group, Ann Arbor, MI 48108, USA;
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20
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Wakam GK, Biesterveld BE, Pai MP, Kemp MT, O’Connell RL, Rajanayake KK, Chtraklin K, Vercruysse CA, Alam HB. A single dose of valproic acid improves neurologic recovery and decreases brain lesion size in swine subjected to an isolated traumatic brain injury. J Trauma Acute Care Surg 2021; 91:867-871. [PMID: 34695064 PMCID: PMC8715863 DOI: 10.1097/ta.0000000000003136] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We lack specific treatments for traumatic brain injury (TBI), which remains the leading cause of trauma-related morbidity and mortality. Treatment with valproic acid (VPA) improves outcomes in models of severe TBI with concurrent hemorrhage. However, it is unknown if VPA will have similar benefits after isolated nonlethal TBI, which is the more common clinical scenario. The goal of this study was to evaluate the effect of VPA treatment in a preclinical isolated TBI swine model on neurologic outcomes and brain lesion size and to perform detailed pharmacokinetic analyses for a future clinical trial. METHODS Yorkshire swine (n = 10; 5/cohort) were subjected to TBI (8-mm controlled cortical impact). An hour later, we randomized them to receive VPA (150 mg/kg) or saline placebo (control). Neuroseverity scores were assessed daily (0 [normal] to 36 [comatose]), brain lesion size was measured on postinjury 3, and serial blood samples were collected for pharmacokinetic studies. RESULTS Physiologic parameters and laboratory values were similar in both groups. Valproic acid-treated animals demonstrated significantly better neuroseverity scores on postinjury 1 (control, 9.2 ± 4.4; VPA, 0 ± 0; p = 0.001). Valproic acid-treated animals had significantly smaller brain lesion sizes (mean volume in microliter: control, 3,130 ± 2,166; VPA, 764 ± 208; p = 0.02). Pharmacokinetic data confirmed adequate plasma and tissue levels of VPA. CONCLUSION In this clinically relevant model of isolated TBI, a single dose of VPA attenuates neurological impairment and decreases brain lesion size.
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Affiliation(s)
- Glenn K. Wakam
- Department of Surgery, University of Michigan, Ann Arbor, MI, 48109; USA
| | - Ben E. Biesterveld
- Department of Surgery, University of Michigan, Ann Arbor, MI, 48109; USA
| | - Manjunath P. Pai
- Department of Clinical Pharmacy, University of Michigan, Ann Arbor, MI, 48109; USA
| | - Michael T. Kemp
- Department of Surgery, University of Michigan, Ann Arbor, MI, 48109; USA
| | | | | | - Kiril Chtraklin
- Department of Surgery, Northwestern University, Chicago, IL, 60611; USA
| | | | - Hasan B. Alam
- Department of Surgery, Northwestern University, Chicago, IL, 60611; USA
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21
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Rybak MJ, Le J, Lodise TP, Levine DP, Bradley JS, Liu C, Mueller BA, Pai MP, Beringer AW, Rodvold KA, Maples HD. Validity of 2020 vancomycin consensus recommendations and further guidance for practical application. Am J Health Syst Pharm 2021; 78:1364-1367. [PMID: 33764403 DOI: 10.1093/ajhp/zxab123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael J Rybak
- Anti-Infective Research Laboratory Department of Pharmacy Practice Eugene Applebaum College of Pharmacy & Health Sciences Wayne State University Detroit, MI, USA.,School of Medicine Wayne State University Detroit, MI, USA
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences University of California San Diego La Jolla, CA, USA
| | - Thomas P Lodise
- Albany College of Pharmacy and Health Sciences Albany, NY, USA
| | - Donald P Levine
- School of Medicine Wayne State University Detroit, MI, USA.,Detroit Receiving Hospital Detroit, MI, USA
| | - John S Bradley
- Department of Pediatrics Division of Infectious Diseases University of California at San Diego La Jolla, CA, USA.,Rady Children's Hospital San Diego San Diego, CA, USA
| | - Catherine Liu
- Division of Allergy and Infectious Diseases University of Washington Seattle, WA, USA
| | - Bruce A Mueller
- University of Michigan College of Pharmacy Ann Arbor, MI, USA
| | - Manjunath P Pai
- University of Michigan College of Pharmacy Ann Arbor, MI, USA
| | | | | | - Holly D Maples
- University of Arkansas for Medical Sciences College of Pharmacy & Arkansas Children's Hospital Little Rock, AR, USA
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22
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Falcone M, Menichetti F, Cattaneo D, Tiseo G, Baldelli S, Galfo V, Leonildi A, Tagliaferri E, Di Paolo A, Pai MP. Pragmatic options for dose optimization of ceftazidime/avibactam with aztreonam in complex patients. J Antimicrob Chemother 2021; 76:1025-1031. [PMID: 33378458 DOI: 10.1093/jac/dkaa549] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/04/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Avibactam is a β-lactamase inhibitor that is combined with aztreonam against Enterobacterales co-expressing serine- and metallo-β-lactamases (MBL). Optimal dosing of aztreonam with avibactam is not well-defined in critically ill patients and contingent on ceftazidime/avibactam product labelling. OBJECTIVES To identify a pragmatic dosing strategy for aztreonam with avibactam to maximize the probability of target attainment (PTA). METHODS We conducted a prospective observational pharmacokinetic study. Five blood samples were collected around the fourth dose of aztreonam or ceftazidime/avibactam and assayed for all three drugs. Population pharmacokinetic (PK) analysis coupled with Monte Carlo simulations were used to create a dosing nomogram for aztreonam and ceftazidime/avibactam based on drug-specific pharmacodynamic (PD) targets. RESULTS A total of 41 participants (59% male) median age of 75 years (IQR 63-79 years) were enrolled. They were critically ill (46%) with multiple comorbidities and complications including burns (20%). Population PK analysis identified higher volume of distribution and lower clearance (CL) compared with typical value expectations for aztreonam and ceftazidime/avibactam. Estimated glomerular filtration (eGFR) rate using the CKD-EPI equation predicted CL for all three drugs. The need for high doses of aztreonam and ceftazidime/avibactam above those in the existing product labels are not predicted by this analysis with the exception of ceftazidime/avibactam for patients with eGFR of 6-15 mL/min, in whom suboptimal PTA of ≤71% is predicted. CONCLUSIONS Pragmatic and lower daily-dose options are predicted for aztreonam and ceftazidime/avibactam when the eGFR is <90 mL/min. These options should be tested prospectively.
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Affiliation(s)
- Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Francesco Menichetti
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Giusy Tiseo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Sara Baldelli
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Valentina Galfo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Alessandro Leonildi
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy.,Microbiology Unit, Azienda Ospedaliera Universitaria Pisana., Pisa, Italy
| | - Enrico Tagliaferri
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Antonello Di Paolo
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
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23
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Luan X, Yuan H, Song Y, Hu H, Wen B, He M, Zhang H, Li Y, Li F, Shu P, Burnett JP, Truchan N, Palmisano M, Pai MP, Zhou S, Gao W, Sun D. Reappraisal of anticancer nanomedicine design criteria in three types of preclinical cancer models for better clinical translation. Biomaterials 2021; 275:120910. [PMID: 34144373 DOI: 10.1016/j.biomaterials.2021.120910] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [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: 02/22/2021] [Revised: 05/14/2021] [Accepted: 05/20/2021] [Indexed: 12/13/2022]
Abstract
Anticancer nanomedicines are designed to improve anticancer efficacy by increasing drug accumulation in tumors through enhanced permeability retention (EPR) effect, and to reduce toxicity by decreasing drug accumulation in normal organs through long systemic circulation. However, the inconsistent efficacy/safety of nanomedicines in cancer patients versus preclinical cancer models have provoked debate for nanomedicine design criteria. In this study, we investigate nanomedicine design criteria in three types of preclinical cancer models using five clinically used nanomedicines, which identifies the factors for better clinical translations of their observed clinical efficacy/safety compared to free drug or clinical micelle formulation. When those nanomedicines were compared with drug solution or clinical micelle formulation in breast tumors, long and short-circulating nanomedicines did not enhance tumor accumulation by EPR effect in transgenic spontaneous breast cancer model regardless of their size or composition, although they improved tumor accumulations in subcutaneous and orthotopic breast cancer models. However, when tumors were compared to normal breast tissue, nanomedicines, drug solution and clinical micelle formulation showed enhanced tumor accumulation regardless of the breast cancer models. In addition, long-circulating nanomedicines did not further increase tumor accumulation in transgenic mouse spontaneous breast cancer nor universally decrease drug accumulations in normal organs; they decreased or increased accumulation in different organs, potentially changing the clinical efficacy/safety. In contrast, short-circulating nanomedicines decreased blood concentration and altered drug distribution in normal organs, which are correlated with their clinical efficacy/safety. A reappraisal of current nanomedicine design criteria is needed to ensure consistent clinical translation for improvement of their clinical efficacy/safety in cancer patients.
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Affiliation(s)
- Xin Luan
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 1600 Huron Parkway, North Campus Research Complex, Building 520, Ann Arbor, MI, 48109, USA
| | - Hebao Yuan
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 1600 Huron Parkway, North Campus Research Complex, Building 520, Ann Arbor, MI, 48109, USA
| | - Yudong Song
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 1600 Huron Parkway, North Campus Research Complex, Building 520, Ann Arbor, MI, 48109, USA
| | - Hongxiang Hu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 1600 Huron Parkway, North Campus Research Complex, Building 520, Ann Arbor, MI, 48109, USA
| | - Bo Wen
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 1600 Huron Parkway, North Campus Research Complex, Building 520, Ann Arbor, MI, 48109, USA
| | - Miao He
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 1600 Huron Parkway, North Campus Research Complex, Building 520, Ann Arbor, MI, 48109, USA
| | - Huixia Zhang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 1600 Huron Parkway, North Campus Research Complex, Building 520, Ann Arbor, MI, 48109, USA
| | - Yan Li
- Translational Development and Clinical Pharmacology, Bristol Myers Squibb, 86 Morris Avenue, Summit, NJ, 07920, USA
| | - Feng Li
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 1600 Huron Parkway, North Campus Research Complex, Building 520, Ann Arbor, MI, 48109, USA
| | - Pan Shu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 1600 Huron Parkway, North Campus Research Complex, Building 520, Ann Arbor, MI, 48109, USA
| | - Joseph P Burnett
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 1600 Huron Parkway, North Campus Research Complex, Building 520, Ann Arbor, MI, 48109, USA
| | - Nathan Truchan
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 1600 Huron Parkway, North Campus Research Complex, Building 520, Ann Arbor, MI, 48109, USA
| | - Maria Palmisano
- Translational Development and Clinical Pharmacology, Bristol Myers Squibb, 86 Morris Avenue, Summit, NJ, 07920, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 1600 Huron Parkway, North Campus Research Complex, Building 520, Ann Arbor, MI, 48109, USA
| | - Simon Zhou
- Translational Development and Clinical Pharmacology, Bristol Myers Squibb, 86 Morris Avenue, Summit, NJ, 07920, USA.
| | - Wei Gao
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 1600 Huron Parkway, North Campus Research Complex, Building 520, Ann Arbor, MI, 48109, USA.
| | - Duxin Sun
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 1600 Huron Parkway, North Campus Research Complex, Building 520, Ann Arbor, MI, 48109, USA.
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24
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Pai MP, Wilcox M, Chitra S, McGovern P. Safety and efficacy of omadacycline by body mass index in patients with community-acquired bacterial pneumonia: Subanalysis from a randomized controlled trial. Respir Med 2021; 184:106442. [PMID: 34058682 DOI: 10.1016/j.rmed.2021.106442] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To examine the safety and efficacy of omadacycline by body mass index (BMI) in adults with community-acquired bacterial pneumonia (CABP) from a Phase III trial. METHODS Patients hospitalized for suspected CABP were randomized 1:1 to receive intravenous omadacycline or moxifloxacin, with an optional transition to oral, for a total of 7-14 days. Early clinical response (ECR) was assessed 72-120 h after receipt of the first dose, and clinical success was assessed 5-10 days after the last dose (post-treatment evaluation [PTE]). ECR was defined as improvement in at least two CABP symptoms with no worsening of other symptoms or use of rescue antibacterial treatment; success at PTE was defined as resolution of signs and symptoms to the extent that further antibacterial therapy was unnecessary. Safety evaluations included treatment-emergent adverse events and laboratory measures. Between-treatment comparisons were made by World Health Organization BMI categories and by diabetes history. RESULTS Distribution of patients in the normal weight, overweight, and obese subgroups was fairly even. Clinical success for omadacycline-treated patients at ECR were similar across ascending BMI groups (OMC: 82.9%, 80.5%, 76.9%; MOX: 88.6%, 80.7%, 76.9%). Outcomes by diabetes status were generally similar in omadacycline- and moxifloxacin-treated patients. Patients who had clinical success or clinical stability at ECR generally showed continued clinical success at PTE. Safety profiles for omadacycline and moxifloxacin were largely similar across BMI subgroups and by diabetes history. CONCLUSION The omadacycline fixed-dosing strategy showed consistent safety and efficacy in patients with CABP of different body sizes.
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Affiliation(s)
- Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church St, Rm 3569, Ann Arbor, MI, 48109, USA.
| | - Mark Wilcox
- University of Leeds & Leeds Teaching Hospitals, Woodhouse, Leeds, LS2 9JT, UK
| | - Surya Chitra
- Paratek Pharmaceuticals, Inc., 1000 First Avenue, Suite 200, King of Prussia, PA, 19406, USA
| | - Paul McGovern
- Paratek Pharmaceuticals, Inc., 1000 First Avenue, Suite 200, King of Prussia, PA, 19406, USA
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25
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Rybak MJ, Le J, Lodise TP, Levine DP, Bradley JS, Liu C, Mueller BA, Pai MP, Wong-Beringer A, Rotschafer JC, Rodvold KA, Maples HD, Lomaestro B. Therapeutic Monitoring of Vancomycin for Serious Methicillin-resistant Staphylococcus aureus Infections: A Revised Consensus Guideline and Review by the American Society of Health-system Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Clin Infect Dis 2021; 71:1361-1364. [PMID: 32658968 DOI: 10.1093/cid/ciaa303] [Citation(s) in RCA: 128] [Impact Index Per Article: 42.7] [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: 03/12/2020] [Indexed: 11/14/2022] Open
Abstract
Recent clinical data on vancomycin pharmacokinetics and pharmacodynamics suggest a reevaluation of current dosing and monitoring recommendations. The previous 2009 vancomycin consensus guidelines recommend trough monitoring as a surrogate marker for the target area under the curve over 24 hours to minimum inhibitory concentration (AUC/MIC). However, recent data suggest that trough monitoring is associated with higher nephrotoxicity. This document is an executive summary of the new vancomycin consensus guidelines for vancomycin dosing and monitoring. It was developed by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists vancomycin consensus guidelines committee. These consensus guidelines recommend an AUC/MIC ratio of 400-600 mg*hour/L (assuming a broth microdilution MIC of 1 mg/L) to achieve clinical efficacy and ensure safety for patients being treated for serious methicillin-resistant Staphylococcus aureus infections.
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Affiliation(s)
- Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.,School of Medicine, Wayne State University, Detroit, Michigan, USA.,Detroit Receiving Hospital, Detroit, Michigan, USA
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California, USA
| | - Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Donald P Levine
- School of Medicine, Wayne State University, Detroit, Michigan, USA.,Detroit Receiving Hospital, Detroit, Michigan, USA
| | - John S Bradley
- Department of Pediatrics, Division of Infectious Diseases, University of California, San Diego, La Jolla, California, USA.,Rady Children's Hospital San Diego, San Diego, California, USA
| | - Catherine Liu
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Bruce A Mueller
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Manjunath P Pai
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Annie Wong-Beringer
- University of Southern California School of Pharmacy, Los Angeles, California, USA
| | - John C Rotschafer
- University of Minnesota College of Pharmacy, Minneapolis, Minnesota, USA
| | - Keith A Rodvold
- University of Illinois College of Pharmacy, Chicago, Illinois, USA
| | - Holly D Maples
- University of Arkansas for Medical Sciences College of Pharmacy and Arkansas Children's Hospital, Little Rock, Arkansas, USA
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26
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Pai MP, Wilcox MH, Chitra S, McGovern PC. Safety and efficacy of omadacycline by BMI categories and diabetes history in two Phase III randomized studies of patients with acute bacterial skin and skin structure infections. J Antimicrob Chemother 2021; 76:1315-1322. [PMID: 33458763 PMCID: PMC8050767 DOI: 10.1093/jac/dkaa558] [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] [Received: 09/14/2020] [Accepted: 12/10/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The objectives of this post-hoc analysis were to examine the safety and efficacy of omadacycline by BMI categories and diabetes history in adults with acute bacterial skin and skin structure infections (ABSSSI) from two pivotal Phase III studies. PATIENTS AND METHODS OASIS-1 (ClinicalTrials.gov identifier NCT02378480): patients were randomized 1:1 to IV omadacycline or linezolid for 7-14 days, with optional transition to oral medication. OASIS-2 (ClinicalTrials.gov identifier NCT02877927): patients received once-daily oral omadacycline or twice-daily oral linezolid for 7-14 days. Early clinical response (ECR) was defined as ≥20% reduction in lesion size 48-72 h after the first dose. Clinical success at post-treatment evaluation (PTE; 7-14 days after the last dose) was defined as symptom resolution such that antibacterial therapy was unnecessary. Safety was assessed by treatment-emergent adverse events and laboratory measures. Between-treatment comparisons were made with regard to WHO BMI categories and diabetes history. RESULTS Patients were evenly distributed among healthy weight, overweight and obese groups. Clinical success for omadacycline-treated patients at ECR and PTE was similar across BMI categories. Outcomes by diabetes status were similar in omadacycline- and linezolid-treated patients: at ECR, clinical success rates were lower for those with diabetes; at PTE, clinical success was similar between treatment groups regardless of diabetes history. The safety of omadacycline and linezolid was largely similar across BMI groups and by diabetes history. CONCLUSIONS Omadacycline efficacy in patients with higher BMI and in patients with diabetes was consistent with results from two pivotal Phase III ABSSSI trials. Fixed-dose omadacycline is an appropriate treatment for ABSSSI in adults regardless of BMI.
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Affiliation(s)
- Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA
| | - Mark H Wilcox
- University of Leeds & Leeds Teaching Hospitals, Leeds LS2 9JT, UK
| | - Surya Chitra
- Paratek Pharmaceuticals, Inc., King of Prussia, PA 19406, USA
| | - Paul C McGovern
- Paratek Pharmaceuticals, Inc., King of Prussia, PA 19406, USA
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27
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Rybak MJ, Le J, Lodise TP, Levine DP, Bradley JS, Liu C, Mueller BA, Pai MP, Wong-Beringer A, Rotschafer JC, Rodvold KA, Maples HD, Lomaestro BM. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2021; 77:835-864. [PMID: 32191793 DOI: 10.1093/ajhp/zxaa036] [Citation(s) in RCA: 552] [Impact Index Per Article: 184.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI, School of Medicine, Wayne State University, Detroit, MI, and Detroit Receiving Hospital, Detroit, MI
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Albany, NY, and Stratton VA Medical Center, Albany, NY
| | - Donald P Levine
- School of Medicine, Wayne State University, Detroit, MI, and Detroit Receiving Hospital, Detroit, MI
| | - John S Bradley
- Department of Pediatrics, Division of Infectious Diseases, University of California at San Diego, La Jolla, CA, and Rady Children's Hospital San Diego, San Diego, CA
| | - Catherine Liu
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, and Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | | | | | | | | | - Holly D Maples
- University of Arkansas for Medical Sciences College of Pharmacy & Arkansas Children's Hospital, Little Rock, AR
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28
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Biesterveld BE, O'Connell R, Kemp MT, Wakam GK, Williams AM, Pai MP, Alam HB. Validation of intraosseous delivery of valproic acid in a swine model of polytrauma. Trauma Surg Acute Care Open 2021; 6:e000683. [PMID: 33791436 PMCID: PMC7978107 DOI: 10.1136/tsaco-2021-000683] [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: 01/20/2021] [Revised: 02/04/2021] [Accepted: 02/28/2021] [Indexed: 11/03/2022] Open
Abstract
Background Intraosseous (IO) drug delivery may be necessary in emergency situations when intravenous access is unattainable. Valproic acid (VPA) is a histone deacetylase inhibitor that has previously been shown to improve survival in preclinical models of lethal polytrauma. In this study, we sought to compare serum levels of intravenously and IO-delivered VPA, and to analyze the effect of IO-delivered VPA. Methods Swine were subjected to 40% blood volume hemorrhage, brain injury, femur fracture, rectus crush injury and liver laceration. After 1 hour of shock, animals were randomized (n=3/group) to receive normal saline resuscitation (control), normal saline+intravenous VPA 150 mg/kg (intravenous group) or normal saline +IO VPA 150 mg/kg (IO group). Serum levels of VPA were assessed between groups, and proteomics analyses were performed on IO and control groups on heart, lung and liver samples. Results Intravenous and IO serum VPA levels were similar at 1, 3, 5 and 7 hours after starting the infusion (p>0.05). IO-delivered VPA induced significant proteomics changes in the heart, lung and liver, which were most pronounced in the lung. Biologic processes affected included inflammation, metabolism and transcriptional & translational machinery. The control group had 0% survival, and the intravenous and IO group both had 100% survival to the end of the experiment (p<0.05). Discussion IO-delivered VPA is noninferior to intravenous administration and is a viable option in emergent situations when intravenous access is unattainable. Level of evidence Not applicable (animal study).
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Affiliation(s)
- Ben E Biesterveld
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Rachel O'Connell
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Surgery, Northwestern University, Evanston, Illinois, USA
| | - Michael T Kemp
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Glenn K Wakam
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Aaron M Williams
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Hasan B Alam
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Surgery, Northwestern University, Evanston, Illinois, USA
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29
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Ravi K, Franson A, Homan MJ, Roberts H, Pai MP, Miklja Z, He M, Wen B, Benitez LL, Perissinotti AJ, Bixby DL, Koschmann C, Marini BL. Comparative pharmacokinetic analysis of the blood-brain barrier penetration of dasatinib and ponatinib in mice. Leuk Lymphoma 2021; 62:1990-1994. [PMID: 33682631 DOI: 10.1080/10428194.2021.1894647] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Karthik Ravi
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Andrea Franson
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Morgan J Homan
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Holly Roberts
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Manjunath P Pai
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | | | - Miao He
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Bo Wen
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Lydia L Benitez
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | | | - Dale L Bixby
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Carl Koschmann
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
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30
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Pai MP. Antimicrobial Dosing in Specific Populations and Novel Clinical Methodologies: Kidney Function. Clin Pharmacol Ther 2021; 109:952-957. [PMID: 33523498 DOI: 10.1002/cpt.2179] [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: 11/04/2020] [Accepted: 01/04/2021] [Indexed: 12/26/2022]
Abstract
Kidney function is a common parameter used to define antimicrobial drug dosage and frequency of administration. Several methods exist to measure kidney function but for pragmatic reasons rely on estimated kidney function equations based on the endogenous biomarker serum creatinine and common clinical variables. Current regulatory guidance on the design of studies in patients with abnormal kidney function in the United States also recommend consideration of estimated kidney function for this reason. Over the past few decades, alternate endogenous biomarkers, administration of exogenous biomarkers for noninvasive measurement, use of probe substrates to characterize individual kidney drug clearance pathways, modifications to conventional equations to account for time-varying clearance, and improved clinical trial modeling and simulation to factor in these uncertainties have occurred. Furthermore, major changes to kidney replacement therapy delivery in the outpatient, inpatient, and at-home setting are occurring. Antimicrobial drug dose adjustment in this diverse population is complex and in a state of flux due to technical innovations. Over-reliance on kidney function estimates to guide drug dosing in patients with infectious diseases can bias underdosing especially among the acutely ill. A holistic approach to drug dose adjustment in patients with abnormal kidney function is necessary to optimize clinical outcomes.
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Affiliation(s)
- Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
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31
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Pai MP. Antimicrobial Dosing in Specific Populations and Novel Clinical Methodologies: Obesity. Clin Pharmacol Ther 2021; 109:942-951. [PMID: 33523485 DOI: 10.1002/cpt.2181] [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: 12/01/2020] [Accepted: 01/16/2021] [Indexed: 12/17/2022]
Abstract
Obesity and its related comorbidities can negatively influence the outcomes of certain infectious diseases. Specific dosing recommendations are often lacking in the product label for patients with obesity that leads to unclear guidance in practice. Higher rates of therapeutic failure have been reported with some fixed dose antibiotics and pragmatic approaches to dose modification are limited for orally administered agents. For i.v. antimicrobials dosed on weight, alternate body size descriptors (ABSDs) have been used to reduce the risk of overdosing. These ABSDs are mathematical transformations of height and weight that represent fat-free weight and follow the same principles as body surface area (BSA)-based dosing of cancer chemotherapy. However, ABSDs are rarely studied in pivotal phase III studies and so can risk the underdosing of antimicrobials in patients with obesity when incorrectly applied in the real-world setting. Specific case examples are presented to highlight these risks. Although general principles may be considered by clinicians, a universal approach to dose modification in obesity is unlikely. Studies that can better distinguish human body phenotypes may help reduce our reliance on height and weight to define dosing. Simple and complex technologies exist to quantify individual body composition that could improve upon our current approach. Early evidence suggests that body composition parameters repurposed from medical imaging data may improve upon height and weight as covariates of drug clearance and distribution. Clinical trials that can integrate human body phenotyping may help us identify new approaches to optimal dose selection of antimicrobials in patients with obesity.
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Affiliation(s)
- Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
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Wakam GK, Biesterveld BE, Pai MP, Kemp MT, O'Connell RL, Williams AM, Srinivasan A, Chtraklin K, Siddiqui AZ, Bhatti UF, Vercruysse CA, Alam HB. Administration of valproic acid in clinically approved dose improves neurologic recovery and decreases brain lesion size in swine subjected to hemorrhagic shock and traumatic brain injury. J Trauma Acute Care Surg 2021; 90:346-352. [PMID: 33230090 DOI: 10.1097/ta.0000000000003036] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) and hemorrhage remain the leading causes of death after trauma. We have previously shown that a dose of valproic acid (VPA) at (150 mg/kg) can decrease brain lesion size and hasten neurologic recovery. The current Food and Drug Administration-approved dose of VPA is 60 mg/kg. We evaluate neurologic outcomes and brain lesion size of a single dose of VPA at a level currently within Food and Drug Administration-approved dose in swine subjected to TBI and hemorrhagic shock. METHODS Swine (n = 5/group) were subjected to TBI and 40% blood volume hemorrhage. Animals remained in shock for 2 hours before randomization to normal saline (NS) resuscitation alone (control), NS-VPA 150 mg/kg (VPA 150), or NS-VPA 50 mg/kg (VPA 50). Neurologic severity scores (range, 0-32) were assessed daily for 14 days, and brain lesion size was measured via magnetic resonance imaging on postinjury day (PID) 3. RESULTS Shock severity and laboratory values were similar in all groups. Valproic acid-treated animals demonstrated significantly less neurologic impairment on PID 1 and returned to baseline faster (PID 1 mean neurologic severity score, control = 22 ± 3 vs. VPA 150 mg/kg = 8 ± 7 or VPA 50 mg/kg = 6 ± 6; p = 0.02 and 0.003). Valproic acid-treated animals had significantly smaller brain lesion sizes (mean volume in mm3, control = 1,268.0 ± 241.2 vs. VPA 150 mg/kg = 620.4 ± 328.0 or VPA 50 mg/kg = 438.6 ± 234.8; p = 0.007 and 0.001). CONCLUSION In swine subjected to TBI and hemorrhagic shock, VPA treatment, in a dose that is approved for clinical use, decreases brain lesion size and reduces neurologic impairment compared with resuscitation alone.
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Affiliation(s)
- Glenn K Wakam
- From the Department of Surgery (G.K.W., B.E.B., M.T.K., R.L.O., A.M.W., K.C., A.Z.S., U.F.B., C.A.V., H.B.A.), Department of Clinical Pharmacy (M.P.P.), and Section of Neuroradiology, Department of Radiology (A.S.), Michigan Medicine, University of Michigan, Ann Arbor, Michigan
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Morley VJ, Kinnear CL, Sim DG, Olson SN, Jackson LM, Hansen E, Usher GA, Showalter SA, Pai MP, Woods RJ, Read AF. An adjunctive therapy administered with an antibiotic prevents enrichment of antibiotic-resistant clones of a colonizing opportunistic pathogen. eLife 2020; 9:e58147. [PMID: 33258450 PMCID: PMC7707840 DOI: 10.7554/elife.58147] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 04/22/2020] [Accepted: 10/29/2020] [Indexed: 12/22/2022] Open
Abstract
A key challenge in antibiotic stewardship is figuring out how to use antibiotics therapeutically without promoting the evolution of antibiotic resistance. Here, we demonstrate proof of concept for an adjunctive therapy that allows intravenous antibiotic treatment without driving the evolution and onward transmission of resistance. We repurposed the FDA-approved bile acid sequestrant cholestyramine, which we show binds the antibiotic daptomycin, as an 'anti-antibiotic' to disable systemically-administered daptomycin reaching the gut. We hypothesized that adjunctive cholestyramine could enable therapeutic daptomycin treatment in the bloodstream, while preventing transmissible resistance emergence in opportunistic pathogens colonizing the gastrointestinal tract. We tested this idea in a mouse model of Enterococcus faecium gastrointestinal tract colonization. In mice treated with daptomycin, adjunctive cholestyramine therapy reduced the fecal shedding of daptomycin-resistant E. faecium by up to 80-fold. These results provide proof of concept for an approach that could reduce the spread of antibiotic resistance for important hospital pathogens.
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Affiliation(s)
- Valerie J Morley
- Center for Infectious Disease Dynamics, Department of Biology, The Pennsylvania State UniversityUniversity ParkUnited States
| | - Clare L Kinnear
- Division of Infectious Diseases, Department of Internal Medicine, University of MichiganAnn ArborUnited States
| | - Derek G Sim
- Center for Infectious Disease Dynamics, Department of Biology, The Pennsylvania State UniversityUniversity ParkUnited States
| | - Samantha N Olson
- Center for Infectious Disease Dynamics, Department of Biology, The Pennsylvania State UniversityUniversity ParkUnited States
| | - Lindsey M Jackson
- Center for Infectious Disease Dynamics, Department of Biology, The Pennsylvania State UniversityUniversity ParkUnited States
| | - Elsa Hansen
- Center for Infectious Disease Dynamics, Department of Biology, The Pennsylvania State UniversityUniversity ParkUnited States
| | - Grace A Usher
- Department of Biochemistry and Molecular Biology, The Pennsylvania State UniversityUniversity ParkUnited States
| | - Scott A Showalter
- Department of Biochemistry and Molecular Biology, The Pennsylvania State UniversityUniversity ParkUnited States
- Department of Chemistry, The Pennsylvania State UniversityUniversity ParkUnited States
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of MichiganAnn ArborUnited States
| | - Robert J Woods
- Division of Infectious Diseases, Department of Internal Medicine, University of MichiganAnn ArborUnited States
| | - Andrew F Read
- Center for Infectious Disease Dynamics, Department of Biology, The Pennsylvania State UniversityUniversity ParkUnited States
- Huck Institutes for the Life Sciences, The Pennsylvania State UniversityUniversity ParkUnited States
- Department of Entomology, The Pennsylvania State UniversityUniversity ParkUnited States
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Rybak MJ, Le J, Lodise TP, Levine DP, Bradley JS, Liu C, Mueller BA, Pai MP, Beringer AW, Rodvold KA, Maples HD. Questions on Vancomycin dosing. Clin Infect Dis 2020; 73:e1777-e1778. [PMID: 33238295 DOI: 10.1093/cid/ciaa1775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI.,School of Medicine, Wayne State University, Detroit, MI.,Detroit Receiving Hospital, Detroit, MI
| | - Jennife Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Albany, New York
| | - Donald P Levine
- School of Medicine, Wayne State University, Detroit, MI.,Detroit Receiving Hospital, Detroit, MI
| | - John S Bradley
- Albany Medical Center Hospital, Albany New York.,Department of Pediatrics, Division of Infectious Diseases, University of California at San Diego, La Jolla, CA.,Rady Children's Hospital San Diego, San Diego, CA
| | - Catherine Liu
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA
| | - Bruce A Mueller
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | | | | | - Holly D Maples
- University of Arkansas for Medical Sciences College of Pharmacy & Arkansas Children's Hospital, Little Rock, AR
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Miklja Z, Yadav VN, Cartaxo RT, Siada R, Thomas CC, Cummings JR, Mullan B, Stallard S, Paul A, Bruzek AK, Wierzbicki K, Yang T, Garcia T, Wolfe I, Leonard M, Robertson PL, Garton HJ, Wahl DR, Parmar H, Sarkaria JN, Kline C, Mueller S, Nicolaides T, Glasser C, Leary SE, Venneti S, Kumar-Sinha C, Chinnaiyan AM, Mody R, Pai MP, Phoenix TN, Marini BL, Koschmann C. Everolimus improves the efficacy of dasatinib in PDGFRα-driven glioma. J Clin Invest 2020; 130:5313-5325. [PMID: 32603316 PMCID: PMC7524471 DOI: 10.1172/jci133310] [Citation(s) in RCA: 24] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 06/24/2020] [Indexed: 12/26/2022] Open
Abstract
Pediatric and adult high-grade gliomas (HGGs) frequently harbor PDGFRA alterations. We hypothesized that cotreatment with everolimus may improve the efficacy of dasatinib in PDGFRα-driven glioma through combinatorial synergism and increased tumor accumulation of dasatinib. We performed dose-response, synergism, P-glycoprotein inhibition, and pharmacokinetic studies in in vitro and in vivo human and mouse models of HGG. Six patients with recurrent PDGFRα-driven glioma were treated with dasatinib and everolimus. We found that dasatinib effectively inhibited the proliferation of mouse and human primary HGG cells with a variety of PDGFRA alterations. Dasatinib exhibited synergy with everolimus in the treatment of HGG cells at low nanomolar concentrations of both agents, with a reduction in mTOR signaling that persisted after dasatinib treatment alone. Prolonged exposure to everolimus significantly improved the CNS retention of dasatinib and extended the survival of PPK tumor-bearing mice (mutant TP53, mutant PDGFRA, H3K27M). Six pediatric patients with glioma tolerated this combination without significant adverse events, and 4 patients with recurrent disease (n = 4) had a median overall survival of 8.5 months. Our results show that the efficacy of dasatinib treatment of PDGFRα-driven HGG was enhanced with everolimus and suggest a promising route for improving targeted therapy for this patient population.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Hemant Parmar
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jann N. Sarkaria
- Department of Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Cassie Kline
- Department of Pediatrics and
- Department of Neurology, UCSF, San Francisco, California, USA
| | - Sabine Mueller
- Department of Pediatrics and
- Department of Neurology, UCSF, San Francisco, California, USA
| | - Theodore Nicolaides
- Division of Pediatric Hematology/Oncology, NYU Langone Medical Center, New York, New York, USA
| | - Chana Glasser
- Division of Pediatric Hematology/Oncology, NYU Winthrop Hospital, Mineola, New York, USA
| | - Sarah E.S. Leary
- Seattle Children’s Hospital/University of Washington (UW), Seattle, Washington, USA
| | | | | | - Arul M. Chinnaiyan
- Department of Pathology
- Department of Urology
- Michigan Center for Translational Pathology
- Howard Hughes Medical Institute
- Rogel Cancer Center, and
| | | | - Manjunath P. Pai
- College of Pharmacy, Michigan Medicine, Ann Arbor, Michigan, USA
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Mehta RK, Pal S, Kondapi K, Sitto M, Dewar C, Devasia T, Schipper MJ, Thomas DG, Basrur V, Pai MP, Morishima Y, Osawa Y, Pratt WB, Lawrence TS, Nyati MK. Low-Dose Hsp90 Inhibitor Selectively Radiosensitizes HNSCC and Pancreatic Xenografts. Clin Cancer Res 2020; 26:5246-5257. [PMID: 32718999 PMCID: PMC7541797 DOI: 10.1158/1078-0432.ccr-19-3102] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 09/24/2019] [Revised: 04/21/2020] [Accepted: 07/21/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Treatment approaches using Hsp90 inhibitors at their maximum tolerated doses (MTDs) have not produced selective tumor toxicity. Inhibition of Hsp90 activity causes degradation of client proteins including those involved in recognizing and repairing DNA lesions. We hypothesized that if DNA repair proteins were degraded by concentrations of an Hsp90 inhibitor below those required to cause nonspecific cytotoxicity, significant tumor-selective radiosensitization might be achieved. EXPERIMENTAL DESIGN Tandem mass tagged-mass spectrometry was performed to determine the effect of a subcytotoxic concentration of the Hsp90 inhibitor, AT13387 (onalespib), on global protein abundance. The effect of AT13387 on in vitro radiosensitization was assessed using a clonogenic assay. Pharmacokinetics profiling was performed in mice bearing xenografts. Finally, the effect of low-dose AT13387 on the radiosensitization of three tumor models was assessed. RESULTS A subcytotoxic concentration of AT13387 reduced levels of DNA repair proteins, without affecting the majority of Hsp90 clients. The pharmacokinetics study using one-third of the MTD showed 40-fold higher levels of AT13387 in tumors compared with plasma. This low dose enhanced Hsp70 expression in peripheral blood mononuclear cells (PBMCs), which is a biomarker of Hsp90 inhibition. Low dose monotherapy was ineffective, but when combined with radiotherapy, produced significant tumor growth inhibition. CONCLUSIONS This study shows that a significant therapeutic ratio can be achieved by a low dose of Hsp90 inhibitor in combination with radiotherapy. Hsp90 inhibition, even at a low dose, can be monitored by measuring Hsp70 expression in PBMCs in human studies.
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Affiliation(s)
- Ranjit K Mehta
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Sanjima Pal
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Koushik Kondapi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Merna Sitto
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Cuyler Dewar
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Theresa Devasia
- School of Public Health, University of Michigan, Ann Arbor, Michigan
| | | | - Dafydd G Thomas
- Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - Venkatesha Basrur
- Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - Manjunath P Pai
- Department of Clinical Pharmacy, University of Michigan, Ann Arbor, Michigan
| | | | - Yoichi Osawa
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan
| | - William B Pratt
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan
| | - Theodore S Lawrence
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Mukesh K Nyati
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
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Crass RL, Pai MP. Optimizing Estimated Glomerular Filtration Rate to Support Adult to Pediatric Pharmacokinetic Bridging Studies in Patients with Cystic Fibrosis. Clin Pharmacokinet 2020; 58:1323-1332. [PMID: 30972695 DOI: 10.1007/s40262-019-00761-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The estimated glomerular filtration rate (eGFR) is often used to model drug clearance (CL) and scale doses across age and body size. Over their lifetime, patients with cystic fibrosis (CF) receive repeated courses of tobramycin, an antibiotic with eGFR-dependent CL, for the treatment of pulmonary exacerbations. Tobramycin population pharmacokinetic (PK) modeling can be used to decipher the best approach to define eGFR for pediatric bridging studies. METHODS Inpatients with CF who received intravenous tobramycin between 1 January 2006 and 30 May 2018 were eligible for inclusion. Encounters without tobramycin concentration measurement or missing covariate data were excluded. Population PK analysis was performed using NONMEM.Covariate models were built following identification of the base model, with specific emphasis on the effect of different methods of estimating renal function as a covariate of tobramycin CL. RESULTS A total of 296 CF patients contributed 1029 care encounters (420 pediatric, 609 adult) and 4352 tobramycin concentrations to this analysis. The median (minimum, maximum) age at encounter was 19 years (0.2, 60), with serum creatinine of 0.60 mg/dL (0.10, 3.41). A two-compartment model best described the observed data, with height and eGFR as significant covariates of tobramycin CL. eGFR was best modeled using a combination of the modified Schwartz and Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) equations expressed in absolute units. CONCLUSIONS The CKDEPI equation bridges PK data generated in adults to adolescents with CF better than the current regulatory standard. The eGFR should be expressed in absolute units (mL/min) for PK analyses.
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Affiliation(s)
- Ryan L Crass
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, MI, 48109, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, MI, 48109, USA.
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Jennaro TS, Puskarich MA, McCann MR, Gillies CE, Pai MP, Karnovsky A, Evans CR, Jones AE, Stringer KA. Using l-Carnitine as a Pharmacologic Probe of the Interpatient and Metabolic Variability of Sepsis. Pharmacotherapy 2020; 40:913-923. [PMID: 32688453 DOI: 10.1002/phar.2448] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 02/06/2023]
Abstract
OBJECTIVE The objective of this review is to discuss the therapeutic use and differential treatment response to Levo-carnitine (l-carnitine) treatment in septic shock, and to demonstrate common lessons learned that are important to the advancement of precision medicine approaches to sepsis. We propose that significant interpatient variability in the metabolic response to l-carnitine and clinical outcomes can be used to elucidate the mechanistic underpinnings that contribute to sepsis heterogeneity. METHODS A narrative review was conducted that focused on explaining interpatient variability in l-carnitine treatment response. Relevant biological and patient-level characteristics considered include genetic, metabolic, and morphomic phenotypes; potential drug interactions; and pharmacokinetics (PKs). MAIN RESULTS Despite promising results in a phase I study, a recent phase II clinical trial of l-carnitine treatment in septic shock showed a nonsignificant reduction in mortality. However, l-carnitine treatment induces significant interpatient variability in l-carnitine and acylcarnitine concentrations over time. In particular, administration of l-carnitine induces a broad, dynamic range of serum concentrations and measured peak concentrations are associated with mortality. Applied systems pharmacology may explain variability in drug responsiveness by using patient characteristics to identify pretreatment phenotypes most likely to derive benefit from l-carnitine. Moreover, provocation of sepsis metabolism with l-carnitine offers a unique opportunity to identify metabolic response signatures associated with patient outcomes. These approaches can unmask latent metabolic pathways deranged in the sepsis syndrome and offer insight into the pathophysiology, progression, and heterogeneity of the disease. CONCLUSIONS The compiled evidence suggests there are several potential explanations for the variability in carnitine concentrations and clinical response to l-carnitine in septic shock. These serve as important confounders that should be considered in interpretation of l-carnitine clinical studies and broadly holds lessons for future clinical trial design in sepsis. Consideration of these factors is needed if precision medicine in sepsis is to be achieved.
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Affiliation(s)
- Theodore S Jennaro
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael A Puskarich
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA.,Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Marc R McCann
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher E Gillies
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), School of Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Institute for Data Science, Office of Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Alla Karnovsky
- Department of Computational Medicine and Bioinformatics, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Charles R Evans
- Michigan Regional Comprehensive Metabolomics Resource Core (MRC2), University of Michigan, Ann Arbor, Michigan, USA.,Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Alan E Jones
- Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Kathleen A Stringer
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), School of Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Pai MP, DeBacker KC. Modeling Kinetic Glomerular Filtration Rate in Adults with Stable and Unstable Kidney Function: Vancomycin as the Motivating Example. Pharmacotherapy 2020; 40:872-879. [DOI: 10.1002/phar.2442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Manjunath P. Pai
- Department of Clinical Pharmacy College of Pharmacy University of Michigan Ann Arbor MichiganUSA
| | - Kenneth C. DeBacker
- Department of Clinical Pharmacy College of Pharmacy University of Michigan Ann Arbor MichiganUSA
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40
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Abstract
Oral and intravenous (IV) omadacycline formulations are approved in the United States for treating acute bacterial skin and skin structure infections and community-acquired bacterial pneumonia in adults. Oral omadacycline bioavailability is 34.5%; similar exposures are obtained following 300 mg oral and 100 mg IV doses. Oral administration should be in a fasted state, with dairy products, antacids, or multivitamins avoided for ≥4 hours after dosing. Low protein binding (21%), large volume of distribution (190 L), low systemic clearance (10 L/hour), and long elimination half-life (16-17 hours) support once-daily dosing. Omadacycline is excreted unchanged in feces (81.1%) and urine (14.4%), with low potential for drug-drug interactions. Dose adjustments are unnecessary for age, sex, and renal or hepatic impairment. Pharmacokinetic-pharmacodynamic studies identify fAUC0-24/MIC ratio as the parameter that correlates with in vivo efficacy. Systemic exposure of omadacycline in epithelial lining fluid is greater than/equal to plasma concentrations in healthy adults.
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Affiliation(s)
- Keith A Rodvold
- University of Illinois at Chicago, Colleges of Pharmacy and Medicine
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41
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Leino AD, Pai MP. Maintenance Immunosuppression in Solid Organ Transplantation: Integrating Novel Pharmacodynamic Biomarkers to Inform Calcineurin Inhibitor Dose Selection. Clin Pharmacokinet 2020; 59:1317-1334. [PMID: 32720300 DOI: 10.1007/s40262-020-00923-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Calcineurin inhibitors, the primary immunosuppressive therapy used to prevent alloreactivity of transplanted organs, have a narrow therapeutic index. Currently, treatment is individualized based on clinical assessment of the risk of rejection or toxicity guided by trough concentration monitoring. Advances in immune monitoring have identified potential markers that may have value in understanding calcineurin inhibitor pharmacodynamics. Integration of these markers has the potential to complement therapeutic drug monitoring. Existing pharmacokinetic-pharmacodynamic (PK-PD) data is largely limited to correlation between the biomarker and trough concentrations at single time points. Immune related gene expression currently has the most evidence supporting PK-PD integration. Novel biomarker-based approaches to pharmacodynamic monitoring including development of enhanced PK-PD models are proposed to realize the full clinical benefit.
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Affiliation(s)
- Abbie D Leino
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Rm 3569, Ann Arbor, MI, 48109, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Rm 3569, Ann Arbor, MI, 48109, USA.
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Hsu CH, Tiba MH, McCracken BM, Colmenero CI, Pickell Z, Leander DC, Weitzel AM, Raghunayakula S, Liao J, Jinka T, Cummings BC, Pai MP, Alam HB, Ward KR, Sanderson TH, Neumar RW. Dose optimization of early high-dose valproic acid for neuroprotection in a swine cardiac arrest model. Resusc Plus 2020; 1-2:100007. [PMID: 34223294 PMCID: PMC8244526 DOI: 10.1016/j.resplu.2020.100007] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/01/2020] [Accepted: 05/11/2020] [Indexed: 10/31/2022] Open
Abstract
Aim High-dose valproic acid (VPA) improves the survival and neurologic outcomes after asphyxial cardiac arrest (CA) in rats. We characterized the pharmacokinetics, pharmacodynamics, and safety of high-dose VPA in a swine CA model to advance clinical translation. Methods After 8 min of untreated ventricular fibrillation CA, 20 male Yorkshire swine were resuscitated until return of spontaneous circulation (ROSC). They were block randomized to receive placebo, 75 mg/kg, 150 mg/kg, or 300 mg/kg VPA as 90-min intravenous infusion (n = 5/group) beginning at ROSC. Animals were monitored for 2 additional hours then euthanized. Experimental operators were blinded to treatments. Results The mean(SD) total CA duration was 14.8(1.2) minutes. 300 mg/kg VPA animals required more adrenaline to maintain mean arterial pressure ≥80 mmHg and had worse lactic acidosis. There was a strong linear correlation between plasma free VPA Cmax and brain total VPA (r2 = 0.9494; p < 0.0001). VPA induced dose-dependent increases in pan- and site-specific histone H3 and H4 acetylation in the brain. Plasma free VPA Cmax is a better predictor than peripheral blood mononuclear cell histone acetylation for brain H3 and H4 acetylation (r2 = 0.7189 for H3K27ac, r2 = 0.7189 for pan-H3ac, and r2 = 0.7554 for pan-H4ac; p < 0.0001). Conclusions Up to 150 mg/kg VPA can be safely tolerated as 90-min intravenous infusion in a swine CA model. High-dose VPA induced dose-dependent increases in brain histone H3 and H4 acetylation, which can be predicted by plasma free VPA Cmax as the pharmacodynamics biomarker for VPA target engagement after CA.
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Affiliation(s)
- Cindy H Hsu
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Mohamad H Tiba
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brendan M McCracken
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Carmen I Colmenero
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Zachary Pickell
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,College of Literature Science and the Arts, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Danielle C Leander
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Anne M Weitzel
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Sarita Raghunayakula
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jinhui Liao
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Tulasi Jinka
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brandon C Cummings
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Hasan B Alam
- Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kevin R Ward
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Biomedical Engineering, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Thomas H Sanderson
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Robert W Neumar
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI, USA
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Crass RL, Rodvold KA, Mueller BA, Pai MP. Renal Dosing of Antibiotics: Are We Jumping the Gun? Clin Infect Dis 2020; 68:1596-1602. [PMID: 30219824 DOI: 10.1093/cid/ciy790] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [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: 06/11/2018] [Accepted: 09/10/2018] [Indexed: 12/20/2022] Open
Abstract
Antibiotic renal dose adjustments are determined in patients with stable chronic kidney disease and may not translate to patients in late-phase trials and practice. Ceftolozane/tazobactam, ceftazidime/avibactam, and telavancin all carry precautionary statements for reduced clinical response in patients with baseline creatinine clearance of 30-50 mL/min, potentially due to unnecessary dose reduction in the setting of acute kidney injury (AKI). In this review, we discuss the regulatory landscape for antibiotics eliminated by the kidney and highlight the importance of the first 48 hours of therapy. Using a clinical database, we identified AKI on admission in a substantial proportion of patients with pneumonia (27.1%), intraabdominal (19.5%), urinary tract (20.0%), or skin and skin structure infections (9.7%) that resolved by 48 hours in 57.2% of cases. We suggest that deferred renal dose reduction of wide therapeutic index antibiotics could improve outcomes in patients with infectious diseases.
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Affiliation(s)
- Ryan L Crass
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor
| | - Keith A Rodvold
- Departments of Pharmacy Practice and Medicine, Colleges of Pharmacy and Medicine, University of Illinois at Chicago
| | - Bruce A Mueller
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor
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44
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Pai MP, Debacker KC, Derstine B, Sullivan J, Su GL, Wang SC. Comparison of Body Size, Morphomics, and Kidney Function as Covariates of High‐Dose Methotrexate Clearance in Obese Adults with Primary Central Nervous System Lymphoma. Pharmacotherapy 2020; 40:308-319. [DOI: 10.1002/phar.2379] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Manjunath P. Pai
- Department of Clinical Pharmacy College of Pharmacy University of Michigan Ann Arbor Michigan
| | - Kenneth C. Debacker
- Department of Clinical Pharmacy College of Pharmacy University of Michigan Ann Arbor Michigan
| | - Brian Derstine
- Department of Surgery Michigan Medicine University of Michigan Ann Arbor Michigan
| | - June Sullivan
- Department of Surgery Michigan Medicine University of Michigan Ann Arbor Michigan
| | - Grace L. Su
- Department of Surgery Michigan Medicine University of Michigan Ann Arbor Michigan
- Department of Medicine VA Ann Arbor Health System Ann Arbor Michigan
| | - Stewart C. Wang
- Department of Surgery Michigan Medicine University of Michigan Ann Arbor Michigan
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45
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Rybak MJ, Le J, Lodise TP, Levine DP, Bradley JS, Liu C, Mueller BA, Pai MP, Wong-Beringer A, Rotschafer JC, Rodvold KA, Maples HD, Lomaestro BM. Executive Summary: Therapeutic Monitoring of Vancomycin for Serious Methicillin-Resistant Staphylococcus aureus Infections: A Revised Consensus Guideline and Review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Pharmacotherapy 2020; 40:363-367. [PMID: 32227354 DOI: 10.1002/phar.2376] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [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: 11/07/2022]
Abstract
BACKGROUND Recent vancomycin PK/PD and toxicodynamic studies enable a reassessment of the current dosing and monitoring guideline in an attempt to further optimize the efficacy and safety of vancomycin therapy. The area-under-the-curve to minimum inhibitory concentration (AUC/MIC) has been identified as the most appropriate pharmacokinetic/pharmacodynamic (PK/PD) target for vancomycin. The 2009 vancomycin consenus guidelines recommended specific trough concentrations as a surrogate marker for AUC/MIC. However, more recent toxicodynamic studies have reported an increase in nephrotoxicity associated with trough monitoring. METHODS AND RESULTS This is the executive summary of the new vancomycin consensus guidelines for dosing and monitoring vancomycin therapy and was developed by the American Society of Health-Systems Pharmacists, Infectious Diseases Society of America, Pediatric Infectious Diseases Society and the Society of Infectious Diseases Pharmacists vancomycin consensus guidelines committee. CONCLUSIONS The recommendations provided in this document are intended to assist the clinician in optimizing vancomycin for the treatment of invasive MRSA infections in adult and pediatric patients. An AUC/MIC by broth microdilution (BMD) ratio of 400 to 600 (assuming MICBMD of 1 mg/L) should be advocated as the target to achieve clinical efficacy while improving patient safety for patients with serious MRSA infections. In such cases, AUC-guided dosing and monitoring is the most accurate and optimal way to manage vancomycin therapy.
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Affiliation(s)
- Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, Michigan.,School of Medicine, Wayne State University, Detroit, Michigan, United States.,Detroit Receiving Hospital, Detroit, Michigan
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California
| | - Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Albany, New York, United States.,Albany Medical Center Hospital, Albany, New York
| | - Donald P Levine
- School of Medicine, Wayne State University, Detroit, Michigan, United States.,Detroit Receiving Hospital, Detroit, Michigan
| | - John S Bradley
- Division of Infectious Diseases, Department of Pediatrics, University of California at San Diego, La Jolla, California.,Rady Children's Hospital San Diego, San Diego, California
| | - Catherine Liu
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Bruce A Mueller
- University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Manjunath P Pai
- University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Annie Wong-Beringer
- University of Southern California School of Pharmacy, Los Angeles, California
| | | | - Keith A Rodvold
- University of Illinois College of Pharmacy, Chicago, Illinois
| | - Holly D Maples
- College of Pharmacy & Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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46
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Wubben TJ, Pawar M, Weh E, Smith A, Sajjakulnukit P, Zhang L, Dai L, Hager H, Pai MP, Lyssiotis CA, Besirli CG. Small molecule activation of metabolic enzyme pyruvate kinase muscle isozyme 2, PKM2, circumvents photoreceptor apoptosis. Sci Rep 2020; 10:2990. [PMID: 32076076 PMCID: PMC7031539 DOI: 10.1038/s41598-020-59999-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 09/26/2019] [Accepted: 02/06/2020] [Indexed: 01/22/2023] Open
Abstract
Photoreceptor cell death is the ultimate cause of vision loss in many retinal disorders, and there is an unmet need for neuroprotective modalities to improve photoreceptor survival. Similar to cancer cells, photoreceptors maintain pyruvate kinase muscle isoform 2 (PKM2) expression, which is a critical regulator in aerobic glycolysis. Unlike PKM1, which has constitutively high catalytic activity, PKM2 is under complex regulation. Recently, we demonstrated that genetically reprogramming photoreceptor metabolism via PKM2-to-PKM1 substitution is a promising neuroprotective strategy. Here, we explored the neuroprotective effects of pharmacologically activating PKM2 via ML-265, a small molecule activator of PKM2, during acute outer retinal stress. We found that ML-265 increased PKM2 activity in 661 W cells and in vivo in rat eyes without affecting the expression of genes involved in glucose metabolism. ML-265 treatment did, however, alter metabolic intermediates of glucose metabolism and those necessary for biosynthesis in cultured cells. Long-term exposure to ML-265 did not result in decreased photoreceptor function or survival under baseline conditions. Notably, though, ML-265-treatment did reduce entrance into the apoptotic cascade in in vitro and in vivo models of outer retinal stress. These data suggest that reprogramming metabolism via activation of PKM2 is a novel, and promising, therapeutic strategy for photoreceptor neuroprotection.
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Affiliation(s)
- Thomas J Wubben
- University of Michigan, Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, Ann Arbor, USA
| | - Mercy Pawar
- University of Michigan, Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, Ann Arbor, USA
| | - Eric Weh
- University of Michigan, Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, Ann Arbor, USA
| | - Andrew Smith
- University of Michigan, Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, Ann Arbor, USA
| | - Peter Sajjakulnukit
- University of Michigan, Department of Molecular and Integrative Physiology, Ann Arbor, USA
| | - Li Zhang
- University of Michigan Biomedical Research Core Facilities, Metabolomics Core, Ann Arbor, USA
| | - Lipeng Dai
- University of Michigan, College of Pharmacy, Ann Arbor, USA
| | - Heather Hager
- University of Michigan, Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, Ann Arbor, USA
| | | | - Costas A Lyssiotis
- University of Michigan, Department of Molecular and Integrative Physiology, Ann Arbor, USA
| | - Cagri G Besirli
- University of Michigan, Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, Ann Arbor, USA.
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47
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Dunn RD, Crass RL, Hong J, Pai MP, Krop LC. Vancomycin volume of distribution estimation in adults with class III obesity. Am J Health Syst Pharm 2019; 76:2013-2018. [PMID: 31630155 DOI: 10.1093/ajhp/zxz241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 11/13/2022] Open
Abstract
PURPOSE To compare methods of estimating vancomycin volume of distribution (V) in adults with class III obesity. METHODS A retrospective, multicenter pharmacokinetic analysis of adults treated with vancomycin and monitored through measurement of peak and trough concentrations was performed. Individual pharmacokinetic parameter estimates were obtained via maximum a posteriori Bayesian analysis. The relationship between V and body weight was assessed using linear regression. Mean bias and root-mean-square error (RMSE) were calculated to assess the precision of multiple methods of estimating V. RESULTS Of 241 patients included in the study sample, 159 (66.0%) had a body mass index (BMI) of 40.0-49.9 kg/m2, and 82 (34.0%) had a BMI of ≥50.0 kg/m2. The median (5th, 95th percentile) weight of patients was 136 (103, 204) kg, and baseline characteristics were similar between BMI groups. The mean ± S.D. V was lower in patients with a BMI of 40.0-49.9 kg/m2 than in those with a BMI of ≥50.0 kg/m2 (72.4 ± 19.6 L versus 79.3 ± 20.6 L, p = 0.009); however, body size poorly predicted V in regression analyses (R2 < 0.20). A fixed estimate of V (75 L) and use of a weight-based value (0.52 L/kg by total body weight [TBW]) yielded similar bias and error in this population. CONCLUSION Results of the largest analysis of vancomycin V in class III obesity to date indicated that use of a fixed V value (75 L) and use of a TBW-based estimate (0.52 L/kg) for estimation of vancomycin V in patients with a BMI of ≥40.0 kg/m2 have similar bias. Two postdistribution vancomycin concentrations are needed to accurately determine patient-specific pharmacokinetic parameters, estimate area under the curve, and improve the precision of vancomycin dosing in this patient population.
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Affiliation(s)
- Ryan D Dunn
- Department of Pharmacy, Morton Plant Hospital, BayCare Health System, Clearwater, FL
| | - Ryan L Crass
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI
| | - Joseph Hong
- Department of Pharmacy, Morton Plant Hospital, BayCare Health System, Clearwater, FL
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI
| | - Lynne C Krop
- Department of Pharmacy, Morton Plant Hospital, BayCare Health System, Clearwater, FL
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48
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Yu A, Koenigsknecht MJ, Hens B, Baker JR, Wen B, Jackson TL, Pai MP, Hasler W, Amidon GL, Sun D. Mechanistic Deconvolution of Oral Absorption Model with Dynamic Gastrointestinal Fluid to Predict Regional Rate and Extent of GI Drug Dissolution. AAPS J 2019; 22:3. [PMID: 31712917 DOI: 10.1208/s12248-019-0385-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 09/23/2019] [Indexed: 12/20/2022]
Abstract
Multiple approaches such as mathematical deconvolution and mechanistic oral absorption models have been used to predict in vivo drug dissolution in the gastrointestinal (GI) tract. However, these approaches are often validated by plasma pharmacokinetic profiles, but not by in vivo drug dissolution due to the limited data available regarding the local GI environment. It is also challenging to predict and validate in vivo dissolution in different regions of the GI tract (stomach, duodenum, jejunum, and ileum). In this study, the dynamic fluid compartment absorption and transport (DFCAT) model was used to predict the in vivo dissolution profiles of ibuprofen, which was administered as an 800-mg immediate-release tablet to healthy subjects, in different regions of the GI tract. The prediction was validated with concentration time-courses of ibuprofen (BCS class 2a) in different regions of the GI tract that we have obtained over the past few years. The computational model predicted that the dissolution of ibuprofen was minimal in the stomach (2%), slightly more in the duodenum (6.3%), and primarily dissolved in the jejunum (63%) and the ileum (25%). The detailed model prediction of drug dissolution in different regions of GI can provide a quantitative reference of in vivo dissolution that may provide valuable insight in developing in vitro tests for drug product optimization and quality.
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Affiliation(s)
- Alex Yu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Mark J Koenigsknecht
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Bart Hens
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, 48109, USA.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Jason R Baker
- Department of Internal Medicine, College of Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Bo Wen
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Trachette L Jackson
- Department of Mathematics, College of Literature, Science, and the Arts, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, 48109, USA
| | - William Hasler
- Department of Internal Medicine, College of Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Gordon L Amidon
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Duxin Sun
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, 48109, USA. .,North Campus Research Complex (NCRC), Room 3353, Building 520,1600 Huron Parkway, Ann Arbor, MI, 48109, USA.
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49
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Souza E, Felton J, Crass RL, Hanaya K, Pai MP. Development of a sensitive LC-MS/MS method for quantification of linezolid and its primary metabolites in human serum. J Pharm Biomed Anal 2019; 178:112968. [PMID: 31727360 DOI: 10.1016/j.jpba.2019.112968] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 08/22/2019] [Revised: 10/13/2019] [Accepted: 11/01/2019] [Indexed: 11/25/2022]
Abstract
Linezolid (LZD) is a widely used antimicrobial that is active against a broad range of disease-causing bacteria. Myelosuppression is major treatment-limiting toxicity of LZD that occurs more frequently in patients with renal insufficiency. Quantification of LZD and its two primary metabolites (PNU-142300 and PNU-142586), which undergo significant renal elimination, may support design of improved dosing strategies to mitigate the risk of myelosuppression. In this study, we established the first liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the simultaneous quantification of LZD and its main metabolites in human serum. Proteins in serum samples were precipitated with acetonitrile containing a deuterated internal standard. Chromatographic separation of analytes was performed with Waters X-bridge column (C18, 150 × 4.6 mm, 3.5 μm) at 25 °C and subjected to mass analysis using positive electro-spray ionization. The mobile phase A was water with 0.1% formic acid, and mobile phase B was acetonitrile with 0.1% formic acid at a flow rate of 0.6 mL/min, within a 15 min run time. Standard curves were linear and correlation coefficients (r2) were ≥0.99 for concentration ranges of 0.1-50 μg/mL for LZD and PNU-142300, and 0.1-25 μg/mL for PNU-142586. The inter- and intra-assay precisions were <15% for all analytes in quality control samples, and the accuracies ranged from 97 to 112%. Extraction recoveries ranged from 78 to 103% for all analytes, and there was no significant matrix effect. Samples from 10 patients (5 with renal impairment) were assayed. Mean (SD) LZD, PNU-142300 and PNU-142586 trough concentrations were 19.4(6.8), 11.6(6.8), 25.7(16.4) μg/mL, respectively, in patients with renal impairment. These values were 2.5-, 5.8-, and 6.8-fold higher for LZD, PNU-142300 and PNU-142586, respectively compared to patients without renal impairment. The method was effectively applied in the determination of LZD and its main metabolites in human serum.
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Affiliation(s)
- Ernane Souza
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, MI 48109, USA
| | - Jeremy Felton
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, MI 48109, USA
| | - Ryan L Crass
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, MI 48109, USA
| | - Kengo Hanaya
- Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo 105-8512, Japan
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, MI 48109, USA.
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50
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Pai MP, Wilcox MH, Curran M, Chitra S, Garrity-Ryan L, McGovern PC. 700. Safety and Efficacy of Omadacycline in Patients with Diabetes in Phase 3 Clinical Studies. Open Forum Infect Dis 2019. [PMCID: PMC6811084 DOI: 10.1093/ofid/ofz360.768] [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] [Indexed: 12/02/2022] Open
Abstract
Background The risk of serious infections and poor treatment outcomes is reported to be higher in patients with diabetes compared with the general population. Omadacycline (OMC) is an intravenous (IV) and oral aminomethylcycline antibiotic approved in the US to treat acute bacterial skin and skin structure infections (ABSSSI) and community-acquired bacterial pneumonia (CABP) in adults. Here we assessed safety and efficacy results from OMC Phase 3 studies (ABSSSI: Omadacycline in Acute Skin and skin structure Infections Study [OASIS]-1 and OASIS-2; CABP: Omadacycline for Pneumonia Treatment In the Community study [OPTIC]), by diabetes history. Methods In OASIS-1 (IV to optional oral medication) and OASIS-2 (oral only), patients were randomized to OMC or linezolid (LZD) for 7–14 days. In OPTIC, patients were randomized to IV OMC or moxifloxacin (MOX) for 7–14 days, with optional transition to oral medication. Data from OASIS-1 and OASIS-2 were pooled, and patient subgroups were defined by any medical history of diabetes (type 1, type 2, or unspecified), or no medical history of diabetes. Efficacy outcomes were early clinical response (ECR) and investigator’s assessment of clinical response at post-treatment evaluation (PTE), as defined for each indication. Safety was assessed by treatment-emergent adverse events (TEAEs) and laboratory measures, and data were pooled across the three studies. Results A total of 2,150 patients were included, of whom 238 (11.1%) had any history of diabetes (n = 105 for ABSSSI, n = 133 for CABP). In the pooled ABSSSI studies and the CABP study, clinical success at ECR and PTE was similar between patients with or without diabetes, and between OMC and the respective comparator (figure). TEAEs and serious TEAEs, respectively, were reported in similar numbers of OMC-, LZD-, and MOX-treated patients with diabetes (41.8–49.3%, 4.5–7.0%) and without (41.2–48.3%, 1.6–6.9%). Rates of nausea and vomiting, respectively, in patients with diabetes were similar across treatment arms: OMC (5.0%, 5.0%), LZD (7.5%, 6.0%), MOX (7.0%, 2.8%). Conclusion Omadacycline efficacy and safety were similar and consistent in patients with or without diabetes. ![]()
Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | - Mark H Wilcox
- Leeds Teaching Hospitals and University of Leeds, Leeds, UK
| | - Marla Curran
- Paratek Pharmaceuticals Inc., King of Prussia, Pennsylvania
| | - Surya Chitra
- Paratek Pharmaceuticals Inc., King of Prussia, Pennsylvania
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