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Kirubakaran R, Uster DW, Hennig S, Carland JE, Day RO, Wicha SG, Stocker SL. Adaptation of a population pharmacokinetic model to inform tacrolimus therapy in heart transplant recipients. Br J Clin Pharmacol 2023; 89:1162-1175. [PMID: 36239542 PMCID: PMC10952588 DOI: 10.1111/bcp.15566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 09/24/2022] [Accepted: 10/03/2022] [Indexed: 11/28/2022] Open
Abstract
AIM Existing tacrolimus population pharmacokinetic models are unsuitable for guiding tacrolimus dosing in heart transplant recipients. This study aimed to develop and evaluate a population pharmacokinetic model for tacrolimus in heart transplant recipients that considers the tacrolimus-azole antifungal interaction. METHODS Data from heart transplant recipients (n = 87) administered the oral immediate-release formulation of tacrolimus (Prograf®) were collected. Routine drug monitoring data, principally trough concentrations, were used for model building (n = 1099). A published tacrolimus model was used to inform the estimation of Ka , V2 /F, Q/F and V3 /F. The effect of concomitant azole antifungal use on tacrolimus CL/F was quantified. Fat-free mass was implemented as a covariate on CL/F, V2 /F, V3 /F and Q/F on an allometry scale. Subsequently, stepwise covariate modelling was performed. Significant covariates influencing tacrolimus CL/F were included in the final model. Robustness of the final model was confirmed using prediction-corrected visual predictive check (pcVPC). The final model was externally evaluated for prediction of tacrolimus concentrations of the fourth dosing occasion (n = 87) from one to three prior dosing occasions. RESULTS Concomitant azole antifungal therapy reduced tacrolimus CL/F by 80%. Haematocrit (∆OFV = -44, P < .001) was included in the final model. The pcVPC of the final model displayed good model adequacy. One recent drug concentration is sufficient for the model to guide tacrolimus dosing. CONCLUSION A population pharmacokinetic model that adequately describes tacrolimus pharmacokinetics in heart transplant recipients, considering the tacrolimus-azole antifungal interaction was developed. Prospective evaluation is required to assess its clinical utility to improve patient outcomes.
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Affiliation(s)
- Ranita Kirubakaran
- School of Clinical Medicine, Faculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt. Vincent's HospitalSydneyNew South WalesAustralia
- Department of PharmacyHospital Seberang JayaPenangMalaysia
| | - David W. Uster
- Department of Clinical Pharmacy, Institute of PharmacyUniversity of HamburgHamburgGermany
| | - Stefanie Hennig
- Certara Inc.PrincetonNew JerseyUSA
- School of Clinical Sciences, Faculty of HealthQueensland University of TechnologyBrisbaneQueenslandAustralia
| | - Jane E. Carland
- School of Clinical Medicine, Faculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt. Vincent's HospitalSydneyNew South WalesAustralia
| | - Richard O. Day
- School of Clinical Medicine, Faculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt. Vincent's HospitalSydneyNew South WalesAustralia
| | - Sebastian G. Wicha
- Department of Clinical Pharmacy, Institute of PharmacyUniversity of HamburgHamburgGermany
| | - Sophie L. Stocker
- School of Clinical Medicine, Faculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt. Vincent's HospitalSydneyNew South WalesAustralia
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
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Kirubakaran R, Hennig S, Maslen B, Day RO, Carland JE, Stocker SL. Evaluation of published population pharmacokinetic models to inform tacrolimus dosing in adult heart transplant recipients. Br J Clin Pharmacol 2021; 88:1751-1772. [PMID: 34558092 DOI: 10.1111/bcp.15091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/26/2021] [Accepted: 09/13/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND AIM Identification of the most appropriate population pharmacokinetic model-based Bayesian estimation is required prior to its implementation in routine clinical practice to inform tacrolimus dosing decisions. This study aimed to determine the predictive performances of relevant population pharmacokinetic models of tacrolimus developed from various solid organ transplant recipient populations in adult heart transplant recipients, stratified based on concomitant azole antifungal use. Concomitant azole antifungal therapy alters tacrolimus pharmacokinetics substantially, necessitating dose adjustments. METHODS Population pharmacokinetic models of tacrolimus were selected (n = 17) for evaluation from a recent systematic review. The models were transcribed and implemented in NONMEM version 7.4.3. Data from 85 heart transplant recipients (2387 tacrolimus concentrations) administered the oral immediate-release formulation of tacrolimus (Prograf) were obtained up to 391 days post-transplant. The performance of each model was evaluated using: (i) prediction-based assessment (bias and imprecision) of the individual predicted tacrolimus concentration of the fourth dosing occasion (MAXEVAL = 0, FOCE-I) from 1-3 prior dosing occasions; and (ii) simulation-based assessment (prediction-corrected visual predictive check). Both assessments were stratified based on concomitant azole antifungal use. RESULTS Regardless of the number of prior dosing occasions (1-3) and concomitant azole antifungal use, all models demonstrated unacceptable individual predicted tacrolimus concentration of the fourth dosing occasion (n = 152). The prediction-corrected visual predictive check graphics indicated that these models inadequately predicted observed tacrolimus concentrations. CONCLUSION All models evaluated were unable to adequately describe tacrolimus pharmacokinetics in adult heart transplant recipients included in this study. Further work is required to describe tacrolimus pharmacokinetics for our heart transplant recipient cohort.
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Affiliation(s)
- Ranita Kirubakaran
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.,Ministry of Health, Putrajaya, Malaysia
| | - Stefanie Hennig
- Certara Inc., Princeton, NJ, USA.,School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Ben Maslen
- Mark Wainwright Analytical Centre, University of New South Wales, Sydney, NSW, Australia
| | - Richard O Day
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.,Garvan Institute of Medical Research, Sydney, NSW, Australia
| | - Jane E Carland
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.,School of Medical Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Sophie L Stocker
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.,Garvan Institute of Medical Research, Sydney, NSW, Australia.,School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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