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Kado J, Salman S, Hla TK, Enkel S, Henderson R, Hand RM, Hort A, Page-Sharp M, Batty K, Moore BR, Bennett J, Anderson A, Carapetis J, Manning L. Subcutaneous infusion of high-dose benzathine penicillin G is safe, tolerable, and suitable for less-frequent dosing for rheumatic heart disease secondary prophylaxis: a phase 1 open-label population pharmacokinetic study. Antimicrob Agents Chemother 2023; 67:e0096223. [PMID: 37971244 PMCID: PMC10720493 DOI: 10.1128/aac.00962-23] [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: 07/24/2023] [Accepted: 10/04/2023] [Indexed: 11/19/2023] Open
Abstract
Since 1955, the recommended strategy for rheumatic heart disease (RHD) secondary prophylaxis has been benzathine penicillin G [BPG; 1.2 MU (900 mg)] injections administered intramuscularly every 4 weeks. Due to dosing frequency, pain, and programmatic challenges, adherence is suboptimal. It has previously been demonstrated that BPG delivered subcutaneously at a standard dose is safe and tolerable and has favorable pharmacokinetics, setting the scene for improved regimens with less frequent administration. The safety, tolerability, and pharmacokinetics of subcutaneous infusions of high-dose BPG were assessed in 24 healthy adult volunteers assigned to receive either 3.6, 7.2, or 10.8 MU (three, six, and nine times the standard dose, respectively) as a single subcutaneous infusion. The delivery of the BPG to the subcutaneous tissue was confirmed with ultrasonography. Safety assessments, pain scores, and penicillin concentrations were measured for 16 weeks post-dose. Subcutaneous infusion of penicillin (SCIP) was generally well tolerated with all participants experiencing transient, mild infusion-site reactions. Prolonged elevated penicillin concentrations were described using a combined zero-order (44 days) and first-order (t1/2 = 12 days) absorption pharmacokinetic model. In simulations, time above the conventionally accepted target concentration of 20 ng/mL (0.02 µg/mL) was 57 days for 10.8 MU delivered by subcutaneous infusion every 13 weeks compared with 9 days of every 4-weekly dosing interval for the standard 1.2 MU intramuscular dose (i.e., 63% and 32% of the dosing interval, respectively). High-dose SCIP (BPG) is safe, has acceptable tolerability, and may be suitable for up to 3 monthly dosing intervals for secondary prophylaxis of RHD.
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Affiliation(s)
- Joseph Kado
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Sam Salman
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Clinical Pharmacology and Toxicology Unit, PathWest, Western Australia, Australia
| | - Thel K. Hla
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Stephanie Enkel
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Robert Henderson
- Medical Imaging Department, Perth Children’s Hospital, Nedlands, Western Australia, Australia
| | - Robert M. Hand
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Adam Hort
- Western Australian Country Health Service, Perth, Western Australia, Australia
| | - Madhu Page-Sharp
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - Kevin Batty
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - Brioni R. Moore
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Anneka Anderson
- Te Kupenga Hauora Maori, University of Auckland, Auckland, New Zealand
| | - Jonathan Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, Western Australia, Australia
| | - Laurens Manning
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia
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García-López I, Chocarro-González L, Martín-Romero I, Vázquez-Sánchez JM, Avilés-Martínez M, Martino-Alba R. Pediatric Palliative Care at Home: A Prospective Study on Subcutaneous Drug Administration. J Pain Symptom Manage 2023; 66:e319-e326. [PMID: 37244525 DOI: 10.1016/j.jpainsymman.2023.05.011] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/17/2023] [Accepted: 05/19/2023] [Indexed: 05/29/2023]
Abstract
CONTEXT The subcutaneous route is a useful alternative for drug administration in palliative care. Although there is scientific evidence on its use in adult patients, the literature in pediatric palliative care is almost nonexistent. OBJECTIVES To describe the experience of a pediatric palliative care unit (PPCU) with in-home subcutaneous drug administration symptom control. METHODS Prospective observational study of patients receiving home-based subcutaneous treatment administered as part of a PPCU treatment regimen over 16 months. Analysis includes demographic and clinical variables and treatment received. RESULTS Fifty-four different subcutaneous lines were inserted in the 15 patients included, mainly in the thigh (85.2%). The median time of needle in situ was 5.5 days (range: 1-36 days). A single drug was administered in 55.7% of treatments. The most frequently used drugs were morphine chloride (82%) and midazolam (55.7%). Continuous subcutaneous infusion was the predominant administration route (96.7%), with infusion rates oscillating between 0.1 mL/h and 1.5 mL/h. A statistically significant relationship was found between the maximum infusion rate and induration onset. Of the 54 lines placed, 29 (53.7%) had an associated complication requiring line removal. The primary cause for removal was insertion-site induration (46.3%). Subcutaneous lines were mainly used to manage pain, dyspnea, and epileptic seizures. CONCLUSION In the pediatric palliative care patients studied, the subcutaneous route is most frequently used for administering morphine and midazolam in continuous infusion. The main complication was induration, especially with longer dwell times or higher infusion rates. However, further studies are required to optimize management and prevent complications.
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Affiliation(s)
- Isabel García-López
- Pharmacy Department (I.G-L., I.M-R.), Hospital Infantil Universitario Niño Jesús, Madrid, Spain.
| | - Lourdes Chocarro-González
- Pediatric Palliative Care Unit (L.C.G., J.M.V-S., M.A.M., R.M-A.), Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Irene Martín-Romero
- Pediatric Palliative Care Unit (L.C.G., J.M.V-S., M.A.M., R.M-A.), Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Juan Manuel Vázquez-Sánchez
- Pediatric Palliative Care Unit (L.C.G., J.M.V-S., M.A.M., R.M-A.), Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - María Avilés-Martínez
- Pediatric Palliative Care Unit (L.C.G., J.M.V-S., M.A.M., R.M-A.), Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Ricardo Martino-Alba
- Pediatric Palliative Care Unit (L.C.G., J.M.V-S., M.A.M., R.M-A.), Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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Au YK, Baker L, Hindmarsh J. The Impact of an Electronic Prescribing Template with Decision Support upon the Prescribing of Subcutaneous Infusions at the End of Life in a Community Setting: A Future Vision for Community Palliative Care. Pharmacy (Basel) 2022; 10. [PMID: 36136845 DOI: 10.3390/pharmacy10050112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/31/2022] [Accepted: 09/06/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives: To assess the impact of an electronic prescribing template with decision support upon the frequency of prescription errors, guideline adherence (relating to dose ranges), and prescription legality when prescribing continuous subcutaneous infusions (CSCI) in a palliative demographic. Design, setting, and participants: Before-and-after study across a large UK city utilizing local prescribing data taken from patients receiving end-of-life care. Intervention: An electronic prescribing template with decision support. Main outcome measures: The following were assessed: (1) the rate of prescription errors; (2) the proportion of prescriptions specifying a dose range and if the specified range complied with local recommendations; and (3) the proportion of prescriptions specifying legal mixing directions. Results: The intervention was associated with a significant reduction in errors of omission, with all prescriptions clearly stating drug indication, route of administration, drug dose, and infusion duration. The numbers of continuous subcutaneous infusion prescriptions that specified dose ranges were similar at baseline and post-intervention, at 71% (n = 122) and 72% (n = 179), respectively. At baseline, 69% (n = 84) of CSCI prescriptions specifying a dose range were deemed safe, and post-intervention, 97% (n = 173) were determined to be safe. At baseline, mixing directions were not specified correctly on any continuous subcutaneous infusion prescriptions, while post-intervention, such directions were correct on 75% (n = 157; p < 0.05) of the prescriptions. Conclusions: The intervention eliminated errors of omission, ensured the safety of prescribed dose ranges, and improved compliance with legislation surrounding the mixing of multicomponent infusions. Overall, the intervention has the potential to improve patient safety at the end of life and to increase the efficiency of community services.
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Klamroth R, Feistritzer C, Friedrich U, Lentz SR, Reichwald K, Zak M, Chowdary P. Pharmacokinetics, immunogenicity, safety, and preliminary efficacy of subcutaneous turoctocog alfa pegol in previously treated patients with severe hemophilia A (alleviate 1). J Thromb Haemost 2020; 18:341-351. [PMID: 31618804 PMCID: PMC7027501 DOI: 10.1111/jth.14660] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 10/08/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND The current standard of care for patients with hemophilia A is regular prophylaxis with factor VIII (FVIII) administered intravenously. Interest in subcutaneous (s.c.) administration, to potentially increase convenience, reduce the treatment burden and improve compliance, is increasing. OBJECTIVES Evaluate the pharmacokinetics (PK), immunogenicity, safety, and preliminary efficacy of s.c. administration of turoctocog alfa pegol (s.c. N8-GP) in adult or adolescent previously treated patients (PTPs) with severe hemophilia A (alleviate 1; NCT02994407). PATIENTS/METHODS In part A, 24 PTPs received a single dose of s.c. N8-GP (12.5, 25, 50, or 100 IU/kg) with 6 patients per cohort. PK modelling of data from part A supported a suitable dose for part B. Part B comprised a multiple dose trial in 26 PTPs; patients <60 kg received 2000 IU and patients ≥60 kg received 4000 IU s.c. N8-GP daily for 3 months. RESULTS Single-dose s.c. N8-GP supported dose linearity. Daily prophylaxis with s.c. N8-GP appeared well tolerated and efficacious, achieving a mean trough FVIII activity close to 10% at steady state. Five patients developed anti-N8-GP binding antibodies after 42 to 91 exposure days, one of whom developed an inhibitor to FVIII. Anti-N8-GP antibody appearance was associated with a decline in FVIII plasma activity in four of the five patients. Five patients reported a total of nine treatment-requiring bleeding episodes during prophylaxis. CONCLUSIONS Subcutaneous administration of N8-GP is associated with a high incidence of antibodies in PTPs with severe hemophilia A. Further clinical development of s.c. N8-GP has been suspended.
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Affiliation(s)
- Robert Klamroth
- Department of Internal MedicineHemophilia Treatment CentreVivantes Klinikum im FriedrichshainBerlinGermany
| | - Clemens Feistritzer
- Internal Medicine V—Hematology and OncologyMedical University of InnsbruckInnsbruckAustria
| | | | - Steven R. Lentz
- The University of Iowa Carver College of MedicineIowa CityIAUSA
| | | | | | - Pratima Chowdary
- KD Haemophilia and Thrombosis CentreRoyal Free London NHS Foundation TrustLondonUK
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