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Thompson EJ, Foote HP, Hill KD, Hornik CP. A point-of-care pharmacokinetic/pharmacodynamic trial in critically ill children: Study design and feasibility. Contemp Clin Trials Commun 2023; 35:101182. [PMID: 37485397 PMCID: PMC10362170 DOI: 10.1016/j.conctc.2023.101182] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/01/2023] [Accepted: 07/02/2023] [Indexed: 07/25/2023] Open
Abstract
Background High-quality, efficient, pharmacokinetic (PK), pharmacodynamic (PD), and safety studies in children are needed. Point-of-care trials in adults have facilitated clinical trial participation for patients and providers, minimized the disruption of clinical workflow, and capitalized on routine data collection. The feasibility and value of point-of-care trials to study PK/PD in children are unknown, but appear promising. The Opportunistic PK/PD Trial in Critically Ill Children with Heart Disease (OPTIC) is a programmatic point-of-care approach to PK/PD trials in critically ill children that seeks to overcome barriers of traditional pediatric PK/PD studies to generate safety, efficacy, PK, and PD data across multiple medications, ages, and disease processes. Methods This prospective, open-label, non-randomized point-of-care trial will characterize the PK/PD and safety of multiple drugs given per routine care to critically ill children with heart disease using opportunistic and scavenged biospecimen samples and data collected from the electronic health record. OPTIC has one informed consent form with drug-specific appendices, streamlining study structure and institutional review board approval. OPTIC capitalizes on routine data collection through multiple data sources that automatically capture demographics, medications, laboratory values, vital signs, flowsheets, and other clinical data. This innovative automatic data collection minimizes the burden of data collection and facilitates trial conduct. Data will be validated across sources to ensure accuracy of dataset variables. Discussion OPTIC's point-of-care trial design and automated data acquisition via the electronic health record may provide a mechanism for conducting minimal risk, minimal burden, high efficiency trials and support drug development in historically understudied patient populations. Trial registration clinicaltrials.gov number: NCT05055830. Registered on September 24, 2021.
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Affiliation(s)
| | - Henry P. Foote
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Kevin D. Hill
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Christoph P. Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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Developmental Pharmacokinetics of Antibiotics Used in Neonatal ICU: Focus on Preterm Infants. Biomedicines 2023; 11:biomedicines11030940. [PMID: 36979919 PMCID: PMC10046592 DOI: 10.3390/biomedicines11030940] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/22/2023] Open
Abstract
Neonatal Infections are among the most common reasons for admission to the intensive care unit. Neonatal sepsis (NS) significantly contributes to mortality rates. Empiric antibiotic therapy of NS recommended by current international guidelines includes benzylpenicillin, ampicillin/amoxicillin, and aminoglycosides (gentamicin). The rise of antibacterial resistance precipitates the growth of the use of antibiotics of the Watch (second, third, and fourth generations of cephalosporines, carbapenems, macrolides, glycopeptides, rifamycins, fluoroquinolones) and Reserve groups (fifth generation of cephalosporines, oxazolidinones, lipoglycopeptides, fosfomycin), which are associated with a less clinical experience and higher risks of toxic reactions. A proper dosing regimen is essential for effective and safe antibiotic therapy, but its choice in neonates is complicated with high variability in the maturation of organ systems affecting drug absorption, distribution, metabolism, and excretion. Changes in antibiotic pharmacokinetic parameters result in altered efficacy and safety. Population pharmacokinetics can help to prognosis outcomes of antibiotic therapy, but it should be considered that the neonatal population is heterogeneous, and this heterogeneity is mainly determined by gestational and postnatal age. Preterm neonates are common in clinical practice, and due to the different physiology compared to the full terms, constitute a specific neonatal subpopulation. The objective of this review is to summarize the evidence about the developmental changes (specific for preterm and full-term infants, separately) of pharmacokinetic parameters of antibiotics used in neonatal intensive care units.
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Emoto C, Johnson TN. Cytochrome P450 enzymes in the pediatric population: Connecting knowledge on P450 expression with pediatric pharmacokinetics. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2022; 95:365-391. [PMID: 35953161 DOI: 10.1016/bs.apha.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Cytochrome P450 enzymes play an important role in the pharmacokinetics, efficacy, and toxicity of drugs. Age-dependent changes in P450 enzyme expression have been studied based on several detection systems, as well as by deconvolution of in vivo pharmacokinetic data observed in pediatric populations. The age-dependent changes in P450 enzyme expression can be important determinants of drug disposition in childhood, in addition to the changes in body size and the other physiological parameters, and effects of pharmacogenetics and disease on organ functions. As a tool incorporating drug-specific and body-specific factors, physiologically-based pharmacokinetic (PBPK) models have become increasingly used to characterize and explore mechanistic insights into drug disposition. Thus, PBPK models can be a bridge between findings from basic science and utilization in predictive science. Pediatric PBPK models incorporate additional system specific information on developmental physiology and ontogeny and have been used to predict pharmacokinetic parameters from preterm neonates onwards. These models have been advocated by regulatory authorities in order to support pediatric clinical trials. The purpose of this chapter is to highlight accumulated knowledge and findings from basic research focusing on P450 enzymes, as well as the current status and future challenges of expanding the utilization of pediatric PBPK modeling.
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Affiliation(s)
- Chie Emoto
- Laboratory of Drug Metabolism and Pharmacokinetics, Showa Pharmaceutical University, Tokyo, Japan; Translational Research Division, Chugai Pharmaceutical Co., Ltd., Tokyo, Japan.
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Karatza E, Ganguly S, Hornik CD, Muller WJ, Al-Uzri A, James L, Balevic SJ, Gonzalez D. External Evaluation of Risperidone Population Pharmacokinetic Models Using Opportunistic Pediatric Data. Front Pharmacol 2022; 13:817276. [PMID: 35370711 PMCID: PMC8969425 DOI: 10.3389/fphar.2022.817276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/31/2022] [Indexed: 11/23/2022] Open
Abstract
Risperidone is approved to treat schizophrenia in adolescents and autistic disorder and bipolar mania in children and adolescents. It is also used off-label in younger children for various psychiatric disorders. Several population pharmacokinetic models of risperidone and 9-OH-risperidone have been published. The objectives of this study were to assess whether opportunistically collected pediatric data can be used to evaluate risperidone population pharmacokinetic models externally and to identify a robust model for precision dosing in children. A total of 103 concentrations of risperidone and 112 concentrations of 9-OH-risperidone, collected from 62 pediatric patients (0.16–16.8 years of age), were used in the present study. The predictive performance of five published population pharmacokinetic models (four joint parent-metabolite models and one parent only) was assessed for accuracy and precision of the predictions using statistical criteria, goodness of fit plots, prediction-corrected visual predictive checks (pcVPCs), and normalized prediction distribution errors (NPDEs). The tested models produced similarly precise predictions (Root Mean Square Error [RMSE]) ranging from 0.021 to 0.027 nmol/ml for risperidone and 0.053–0.065 nmol/ml for 9-OH-risperidone). However, one of the models (a one-compartment mixture model with clearance estimated for three subpopulations) developed with a rich dataset presented fewer biases (Mean Percent Error [MPE, %] of 1.0% vs. 101.4, 146.9, 260.4, and 292.4%) for risperidone. In contrast, a model developed with fewer data and a more similar population to the one used for the external evaluation presented fewer biases for 9-OH-risperidone (MPE: 17% vs. 69.9, 47.8, and 82.9%). None of the models evaluated seemed to be generalizable to the population used in this analysis. All the models had a modest predictive performance, potentially suggesting that sources of inter-individual variability were not entirely captured and that opportunistic data from a highly heterogeneous population are likely not the most appropriate data to evaluate risperidone models externally.
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Affiliation(s)
- Eleni Karatza
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Samit Ganguly
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Regeneron Pharmaceuticals, Inc., Tarrytown, NY, United States
| | - Chi D Hornik
- Duke Clinical Research Institute, Durham, NC, United States
| | - William J Muller
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Amira Al-Uzri
- Oregon Health and Science University, Portland, OR, United States
| | - Laura James
- Arkansas Children's Hospital Research Institute and the University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | | | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Gerhart JG, Carreño FO, Edginton AN, Sinha J, Perrin EM, Kumar KR, Rikhi A, Hornik CP, Harris V, Ganguly S, Cohen-Wolkowiez M, Gonzalez D. Development and Evaluation of a Virtual Population of Children with Obesity for Physiologically Based Pharmacokinetic Modeling. Clin Pharmacokinet 2022; 61:307-320. [PMID: 34617262 PMCID: PMC8813791 DOI: 10.1007/s40262-021-01072-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2021] [Indexed: 12/02/2022]
Abstract
BACKGROUND AND OBJECTIVE While one in five children in the USA are now obese, and more than three-quarters receive at least one drug during childhood, there is limited dosing guidance for this vulnerable patient population. Physiologically based pharmacokinetic modeling can bridge the gap in the understanding of how pharmacokinetics, including drug distribution and clearance, changes with obesity by incorporating known obesity-related physiological changes in children. The objective of this study was to develop a virtual population of children with obesity to enable physiologically based pharmacokinetic modeling, then use the novel virtual population in conjunction with previously developed models of clindamycin and trimethoprim/sulfamethoxazole to better understand dosing of these drugs in children with obesity. METHODS To enable physiologically based pharmacokinetic modeling, a virtual population of children with obesity was developed using national survey, electronic health record, and clinical trial data, as well as data extracted from the literature. The virtual population accounts for key obesity-related changes in physiology relevant to pharmacokinetics, including increased body size, body composition, organ size and blood flow, plasma protein concentrations, and glomerular filtration rate. The virtual population was then used to predict the pharmacokinetics of clindamycin and trimethoprim/sulfamethoxazole in children with obesity using previously developed physiologically based pharmacokinetic models. RESULTS Model simulations predicted observed concentrations well, with an overall average fold error of 1.09, 1.24, and 1.53 for clindamycin, trimethoprim, and sulfamethoxazole, respectively. Relative to children without obesity, children with obesity experienced decreased clindamycin and trimethoprim/sulfamethoxazole weight-normalized clearance and volume of distribution, and higher absolute doses under recommended pediatric weight-based dosing regimens. CONCLUSIONS Model simulations support current recommended weight-based dosing in children with obesity for clindamycin and trimethoprim/sulfamethoxazole, as they met target exposure despite these changes in clearance and volume of distribution.
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Affiliation(s)
- Jacqueline G Gerhart
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA
| | - Fernando O Carreño
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA
| | | | - Jaydeep Sinha
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA
| | - Eliana M Perrin
- Department of Pediatrics, School of Medicine and School of Nursing, Johns Hopkins University, Baltimore, MD, USA
| | - Karan R Kumar
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Aruna Rikhi
- Duke Clinical Research Institute, Durham, NC, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Vincent Harris
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA
| | - Samit Ganguly
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA.
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Baserga M, DuPont TL, Ostrander B, Minton S, Sheffield M, Balch AH, Bahr TM, Watt KM. Dexmedetomidine Use in Infants Undergoing Cooling Due to Neonatal Encephalopathy (DICE Trial): A Randomized Controlled Trial: Background, Aims and Study Protocol. FRONTIERS IN PAIN RESEARCH 2021; 2:770511. [PMID: 35295519 PMCID: PMC8915736 DOI: 10.3389/fpain.2021.770511] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/01/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Neonatal hypoxia-ischemia encephalopathy (HIE) is the leading cause of neonatal death and poor neurodevelopmental outcomes worldwide. Therapeutic hypothermia (TH), while beneficial, still leaves many HIE treated infants with lifelong disabilities. Furthermore, infants undergoing TH often require treatment for pain and agitation which may lead to further brain injury. For instance, morphine use in animal models has been shown to induce neuronal apoptosis. Dexmedetomidine is a potent α2-adrenergic receptor agonist that may be a better alternative to morphine for newborns with HIE treated with TH. Dexmedetomidine provides sedation, analgesia, and prevents shivering but does not suppress ventilation. Importantly, there is increasing evidence that dexmedetomidine has neuroprotective properties. Even though there are limited data on pharmacokinetics (PK), safety and efficacy of dexmedetomidine in infants with HIE, it has been increasingly administered in many centers. Objectives: To review the current approach to treatment of pain, sedation and shivering in infants with HIE undergoing TH, and to describe a new phase II safety and pharmacokinetics randomized controlled trial that proposes the use of dexmedetomidine vs. morphine in this population. Methods: This article presents an overview of the current management of pain and sedation in critically ill infants diagnosed with HIE and undergoing TH for 72 h. The article describes the design and methodology of a randomized, controlled, unmasked multicenter trial of dexmedetomidine vs. morphine administration enrolling 50 (25 per arm) neonates ≥36 weeks of gestation with moderate or severe HIE undergoing TH and that require pain/sedation treatment. Results and Conclusions: Dexmedetomidine may be a better alternative to morphine for the treatment of pain and sedation in newborns with HIE treated with TH. There is increasing evidence that dexmedetomidine has neuroprotective properties in several preclinical studies of injury models including ischemia-reperfusion, inflammation, and traumatic brain injury as well as adult clinical trials of brain trauma. The Dexmedetomidine Use in Infants undergoing Cooling due to Neonatal Encephalopathy (DICE) trial will evaluate whether administration of dexmedetomidine vs. morphine is safe, establish dexmedetomidine optimal dosing by collecting opportunistic PK data, and obtain preliminary neurodevelopmental data to inform a large Phase III efficacy trial with long term neurodevelopment impairment as the primary outcome.
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Affiliation(s)
- Mariana Baserga
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
- *Correspondence: Mariana Baserga
| | - Tara L. DuPont
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Betsy Ostrander
- Division of Neurology, Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | | | | | - Alfred H. Balch
- Division of Pediatric Clinical Pharmacology, University of Utah, Salt Lake City, UT, United States
| | | | - Kevin M. Watt
- Division of Pediatric Clinical Pharmacology and Division of Critical Care, University of Utah, Salt Lake City, UT, United States
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White A, Grady C, Little M, Sullivan K, Clark K, Ngwu M, Lyerly AD. IRB Decision-Making about Minimal Risk Research with Pregnant Participants. Ethics Hum Res 2021; 43:2-17. [PMID: 34496158 PMCID: PMC9199078 DOI: 10.1002/eahr.500100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pregnant individuals are often excluded from research without clear justification, even when the research poses minimal risk of harm to the fetus. Little is known about institutional review board (IRB) decision-making practices when reviewing such research. We conducted a survey of current and former IRB personnel in the United States to elicit their interpretations of "minimal risk"-a formal regulatory category-and to identify factors that may influence IRB decisions to approve or disapprove research involving pregnant participants. Study results revealed some consensus among IRB members about the risk level of individual research procedures and hypothetical study vignettes. However, we uncovered important variations not only in the assessment of risk but also in the willingness of IRB members to approve minimal risk research that includes pregnant women. Based on our findings, guidance is needed to assist IRB members in characterizing risk, applying federal regulations, and appropriately ensuring the inclusion or justified exclusion of pregnant people in research.
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Affiliation(s)
- Amina White
- Clinical associate professor in the Department of Obstetrics & Gynecology at the University of North Carolina at Chapel Hill
| | - Christine Grady
- Head of the Clinical Center Department of Bioethics at the National Institutes of Health
| | | | - Kristen Sullivan
- Research scientist at the Center for Bioethics in the Department of Social Medicine at the School of Medicine at the University of North Carolina at Chapel Hill
| | - Katie Clark
- Research associate at Yale University and research consultant at CHER Solutions
| | | | - Anne Drapkin Lyerly
- Professor in the Department of Social Medicine at the Center for Bioethics at the University of North Carolina at Chapel Hill
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Smith MJ, Boutzoukas A, Autmizguine J, Hudak ML, Zinkhan E, Bloom BT, Heresi G, Lavery AP, Courtney SE, Sokol GM, Cotten CM, Bliss JM, Mendley S, Bendel C, Dammann CE, Weitkamp JH, Saxonhouse MA, Mundakel GT, Debski J, Sharma G, Erinjeri J, Gao J, Benjamin DK, Hornik CP, Smith PB, Cohen-Wolkowiez M. Antibiotic Safety and Effectiveness in Premature Infants With Complicated Intraabdominal Infections. Pediatr Infect Dis J 2021; 40:550-555. [PMID: 33902072 PMCID: PMC9844130 DOI: 10.1097/inf.0000000000003034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND In premature infants, complicated intraabdominal infections (cIAIs) are a leading cause of morbidity and mortality. Although universally prescribed, the safety and effectiveness of commonly used antibiotic regimens have not been established in this population. METHODS Infants ≤33 weeks gestational age and <121 days postnatal age with cIAI were randomized to ≤10 days of ampicillin, gentamicin, and metronidazole (group 1); ampicillin, gentamicin, and clindamycin (group 2); or piperacillin-tazobactam and gentamicin (group 3) at doses stratified by postmenstrual age. Due to slow enrollment, a protocol amendment allowed eligible infants already receiving study regimens to enroll without randomization. The primary outcome was mortality within 30 days of study drug completion. Secondary outcomes included adverse events, outcomes of special interest, and therapeutic success (absence of death, negative cultures, and clinical cure score >4) 30 days after study drug completion. RESULTS One hundred eighty infants [128 randomized (R), 52 nonrandomized (NR)] were enrolled: 63 in group 1 (45 R, 18 NR), 47 in group 2 (41 R, 6 NR), and 70 in group 3 (42 R, 28 NR). Thirty-day mortality was 8%, 7%, and 9% in groups 1, 2, and 3, respectively. There were no differences in safety outcomes between antibiotic regimens. After adjusting for treatment group and gestational age, mortality rates through end of follow-up were 4.22 [95% confidence interval (CI): 1.39-12.13], 4.53 (95% CI: 1.21-15.50), and 4.07 (95% CI: 1.22-12.70) for groups 1, 2, and 3, respectively. CONCLUSIONS Each of the antibiotic regimens are safe in premature infants with cIAI. CLINICAL TRIAL REGISTRATION NCT0199499.
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Affiliation(s)
- Michael J. Smith
- Division of Pediatric Infectious Diseases, Duke University, Durham, NC
| | | | - Julie Autmizguine
- Division of Pediatric Infectious Diseases, Universitaire Sainte-Justine, Montreal, Canada
| | - Mark L. Hudak
- Division of Neonatology, University of Florida College of Medicine, Jacksonville, FL
| | - Erin Zinkhan
- Division of Neonatology, University of Utah, Salt Lake City, UT
| | - Barry T. Bloom
- Division of Neonatology, Wesley Medical Center, Wichita, KS
| | - Gloria Heresi
- Division of Pediatric Infectious Diseases, University of Texas, Houston, TX
| | | | - Sherry E. Courtney
- Division of Neonatology, University of Arkansas for Medical Sciences, Little Rock, AR
| | | | - C. Michael Cotten
- Division of Neonatal-Perinatal Medicine, Duke University, Durham, NC
| | | | - Susan Mendley
- Division of Nephrology, University of Maryland, Baltimore, MD
| | - Catherine Bendel
- Division of Neonatology, University of Minnesota, Minneapolis, MN
| | | | | | | | | | | | | | | | - Jamie Gao
- Duke Clinical Research Institute, Durham, NC
| | - Daniel K. Benjamin
- Division of Pediatric Infectious Diseases, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | | | - P. Brian Smith
- Division of Neonatal-Perinatal Medicine, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Michael Cohen-Wolkowiez
- Division of Pediatric Infectious Diseases, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
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Li Z, Li H, Wang C, Jiao Z, Xu F, Sun H. Establishment of a population pharmacokinetics model of vancomycin in 94 infants with septicemia and its application in individualized therapy. BMC Pharmacol Toxicol 2021; 22:26. [PMID: 33947475 PMCID: PMC8097779 DOI: 10.1186/s40360-021-00489-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 04/15/2021] [Indexed: 11/16/2022] Open
Abstract
Background We aim to develop a population pharmacokinetics (PopPK) model of vancomycin for the treatment of septicemia in infants younger than one year. Factors influence of the PK was investigated to optimize vancomycin dosing regimen. Methods The nonlinear mixed effects modelling software (NONMEM) was used to develop the PopPK model of vancomycin. The stability and predictive ability of the final model were assessed by using normalized prediction distribution errors (NPDE) and bootstrap methods. The final model was subjected to Monte Carlo simulation in order to determine the optimal dose. Results A total of 205 trough and peak concentrations in 94 infants (0–1 year of age) with septicemia were analyzed. The interindividual variability of the PK parameter was described by the exponential model. Residual error was better described by the proportional model than the mixed proportional and addition models. Serum creatinine concentration and body weight are the major factors that affect the PK parameters of vancomycin. The clearance was shown to be higher when ceftriaxone was co-treated. More than two model evaluation methods showed better stability than the base model, with superior predictive performance, which can develop individualized dosing regimens for clinical reference. Through prediction of final model, the trough concentration was more likely < 5 mg/L when a routine dose of 10 mg/kg is administered every 6 h to 3–9-month-old infants. Therefore, the dose should be increased in the treatment of infant septicemia. Conclusions The stable and effective PopPK model of vancomycin in Chinese infants with septicemia was established. This model has satisfactory predictive ability for clinically individualized dosing regimens in this vulnerable population.
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Affiliation(s)
- Zhiling Li
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, No. 355 Luding Road, Putuo District, Shanghai, 200062, China
| | - Hongjing Li
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, No. 355 Luding Road, Putuo District, Shanghai, 200062, China
| | - Chenyu Wang
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.
| | - Feng Xu
- Fengxian Hospital, Southern Medical University, Shanghai, China.
| | - Huajun Sun
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, No. 355 Luding Road, Putuo District, Shanghai, 200062, China.
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Rose K, Grant-Kels JM, Ettienne EB, Tanjinatus O, Striano P, Neubauer D. COVID-19 and Treatment and Immunization of Children-The Time to Redefine Pediatric Age Groups is Here. Rambam Maimonides Med J 2021; 12:RMMJ.10433. [PMID: 33780329 PMCID: PMC8092959 DOI: 10.5041/rmmj.10433] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Children are infected with coronavirus disease 2019 (COVID-19) as often as adults, but with fewer symptoms. During the first wave of the COVID-19 pandemic, multisystem inflammatory syndrome (MIS) in children (MIS-C), with symptoms similar to Kawasaki syndrome, was described in young minors testing positive for COVID-19. The United States (US) Centers for Disease Control and Prevention (CDC) defined MIS-C as occurring in <21-year-olds, triggering hundreds of PubMed-listed papers. However, postpubertal adolescents are no longer children biologically; the term MIS-C is misleading. Furthermore, MIS also occurs in adults, termed MIS-A by the CDC. Acute and delayed inflammations can be triggered by COVID-19. The 18th birthday is an administrative not a biological age limit, whereas the body matures slowly during puberty. This blur in defining children leads to confusion regarding MIS-C/MIS-A. United States and European Union (EU) drug approval is handled separately for children, defined as <18-year-olds, ascribing non-existent physical characteristics up to the 18th birthday. This blur between the administrative and the physiological meanings for the term child is causing flawed demands for pediatric studies in all drugs and vaccines, including those against COVID-19. Effective treatment of all conditions, including COVID-19, should be based on actual physiological need. Now, the flawed definition for children in the development of drugs and vaccines and their approval is negatively impacting prevention and treatment of COVID-19 in minors. This review reveals the necessity for redefining pediatric age groups to rapidly establish recommendations for optimal prevention and treatment in minors.
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Affiliation(s)
- Klaus Rose
- klausrose Consulting, Riehen, Switzerland
- To whom correspondence should be addressed. E-mail:
| | | | | | | | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, ‘G. Gaslini’ Institute, Genova, Italy
| | - David Neubauer
- Department of Child, Adolescent & Developmental Neurology, University Children’s Hospital, Ljubljana, Slovenia
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Girdwood ST, Kaplan J, Vinks AA. Methodologic Progress Note: Opportunistic Sampling for Pharmacology Studies in Hospitalized Children. J Hosp Med 2021; 16:35-37. [PMID: 32118552 PMCID: PMC7768918 DOI: 10.12788/jhm.3380] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 12/26/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Sonya Tang Girdwood
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Address correspondence to: Sonya Tang Girdwood, MD, PhD; E-mail: ; Telephone: 513-803-2690; Twitter: @STangGirdwood
| | - Jennifer Kaplan
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
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12
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Abdulla A, Edwina EE, Flint RB, Allegaert K, Wildschut ED, Koch BCP, de Hoog M. Model-Informed Precision Dosing of Antibiotics in Pediatric Patients: A Narrative Review. Front Pediatr 2021; 9:624639. [PMID: 33708753 PMCID: PMC7940353 DOI: 10.3389/fped.2021.624639] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 02/03/2021] [Indexed: 12/17/2022] Open
Abstract
Optimal pharmacotherapy in pediatric patients with suspected infections requires understanding and integration of relevant data on the antibiotic, bacterial pathogen, and patient characteristics. Because of age-related physiological maturation and non-maturational covariates (e.g., disease state, inflammation, organ failure, co-morbidity, co-medication and extracorporeal systems), antibiotic pharmacokinetics is highly variable in pediatric patients and difficult to predict without using population pharmacokinetics models. The intra- and inter-individual variability can result in under- or overexposure in a significant proportion of patients. Therapeutic drug monitoring typically covers assessment of pharmacokinetics and pharmacodynamics, and concurrent dose adaptation after initial standard dosing and drug concentration analysis. Model-informed precision dosing (MIPD) captures drug, disease, and patient characteristics in modeling approaches and can be used to perform Bayesian forecasting and dose optimization. Incorporating MIPD in the electronic patient record system brings pharmacometrics to the bedside of the patient, with the aim of a consisted and optimal drug exposure. In this narrative review, we evaluated studies assessing optimization of antibiotic pharmacotherapy using MIPD in pediatric populations. Four eligible studies involving amikacin and vancomycin were identified from 418 records. Key articles, independent of year of publication, were also selected to highlight important attributes of MIPD. Although very little research has been conducted until this moment, the available data on vancomycin indicate that MIPD is superior compared to conventional dosing strategies with respect to target attainment. The utility of MIPD in pediatrics needs to be further confirmed in frequently used antibiotic classes, particularly aminoglycosides and beta-lactams.
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Affiliation(s)
- Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Elma E Edwina
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Robert B Flint
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands.,Division of Neonatology, Department of Pediatrics, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Enno D Wildschut
- Department of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Matthijs de Hoog
- Department of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
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13
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The Utility of Pharmacometric Models in Clinical Pharmacology Research in Infants. ACTA ACUST UNITED AC 2020; 6:260-266. [PMID: 33767946 DOI: 10.1007/s40495-020-00234-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Purpose of commentary Acquiring knowledge on drug disposition and action in infant is challenging because of the problem of sparse and unbalanced data obtained for each individual infant due to the limited blood volume as well as the issue of extensive inter-subject and intra-subject variability in drug exposure and response due to the fast growth and dynamic maturation changes in infants. This commentary highlights the importance of using population-based pharmacometric models to improve knowledge on drug disposition and action in infants. Recent findings Pharmacometric modeling remains to be critical in clinical pharmacology research in infants. Many pediatric covariate models developed for scaling of drug clearance use a combination of allometric weight scaling to account for size change and a sigmoid function of antenatal development and postnatal maturation to characterize the age-related maturation. To expedite the development of safe and effective dosing regimens in infants, a number of strategies have been proposed recently, including the use of pediatric covariate model obtained from one drug for extrapolation to other drugs undergoing similar elimination pathways, as well as the combination of opportunistic clinical studies and population-based pharmacometrics models. Summary Population-based pharmacometric modeling plays a pivotal role in clinical pharmacology research in infants. Most of the covariate models reported so far focus on antibiotics undergoing renal elimination. Novel modeling strategies have been proposed recently to facilitate clinical pharmacology research and expedite the dose optimization process in infants.
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14
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Ameer B, Weintraub MA. Dosing Common Medications in Hospitalized Pediatric Patients with Obesity: A Review. Obesity (Silver Spring) 2020; 28:1013-1022. [PMID: 32441477 DOI: 10.1002/oby.22739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 12/17/2019] [Indexed: 12/31/2022]
Abstract
Medication management in children and adolescents with obesity is challenging because both developmental and pathophysiological changes may impact drug disposition and response. Evidence to date indicates an effect of obesity on drug disposition for certain drugs used in this population. This work identified published studies evaluating drug dosing, pharmacokinetics (PK), and effect in pediatric patients with obesity, focusing on 70 common medications used in a pediatric network of 42 US medical centers. A PubMed search revealed 33 studies providing PK and/or effectiveness data for 23% (16 of 70) of medications, 44% of which have just one study and can be considered exploratory. This work appraising 4 decades of literature shows several promising approaches: greater use of PK models applied to prospective clinical studies, dosing recommendations derived from both PK and safety, and multiyear effectiveness data on drugs for chronic conditions (e.g., asthma). Most studies make dose recommendations but are weakened by retrospective study design, small study populations, and no controls or historic controls. Dosing decisions continue to rely on extrapolating knowledge, including targeting systemic drug exposure typically achieved in adults. Optimal weight-based dosing strategies vary by drug and warrant prospective, controlled studies incorporating PK and modeling and simulation to complement clinical assessment.
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Affiliation(s)
- Barbara Ameer
- Department of Medicine, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - Michael A Weintraub
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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15
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Maharaj AR, Wu H, Hornik CP, Arrieta A, James L, Bhatt-Mehta V, Bradley J, Muller WJ, Al-Uzri A, Downes KJ, Cohen-Wolkowiez M. Use of normalized prediction distribution errors for assessing population physiologically-based pharmacokinetic model adequacy. J Pharmacokinet Pharmacodyn 2020; 47:199-218. [PMID: 32323049 PMCID: PMC7293575 DOI: 10.1007/s10928-020-09684-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 03/27/2020] [Indexed: 12/19/2022]
Abstract
Currently employed methods for qualifying population physiologically-based pharmacokinetic (Pop-PBPK) model predictions of continuous outcomes (e.g., concentration-time data) fail to account for within-subject correlations and the presence of residual error. In this study, we propose a new method for evaluating Pop-PBPK model predictions that account for such features. The approach focuses on deriving Pop-PBPK-specific normalized prediction distribution errors (NPDE), a metric that is commonly used for population pharmacokinetic model validation. We describe specific methodological steps for computing NPDE for Pop-PBPK models and define three measures for evaluating model performance: mean of NPDE, goodness-of-fit plots, and the magnitude of residual error. Utility of the proposed evaluation approach was demonstrated using two simulation-based study designs (positive and negative control studies) as well as pharmacokinetic data from a real-world clinical trial. For the positive-control simulation study, where observations and model simulations were generated under the same Pop-PBPK model, the NPDE-based approach denoted a congruency between model predictions and observed data (mean of NPDE = - 0.01). In contrast, for the negative-control simulation study, where model simulations and observed data were generated under different Pop-PBPK models, the NPDE-based method asserted that model simulations and observed data were incongruent (mean of NPDE = - 0.29). When employed to evaluate a previously developed clindamycin PBPK model against prospectively collected plasma concentration data from 29 children, the NPDE-based method qualified the model predictions as successful (mean of NPDE = 0). However, when pediatric subpopulations (e.g., infants) were evaluated, the approach revealed potential biases that should be explored.
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Affiliation(s)
- Anil R Maharaj
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Huali Wu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Antonio Arrieta
- Children's Hospital of Orange County Research Institute, Orange, CA, USA
| | - Laura James
- Arkansas Children's Hospital Research Center, Little Rock, AR, USA
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Varsha Bhatt-Mehta
- University of Michigan College of Pharmacy and Michigan Medicine, Ann Arbor, MI, USA
| | - John Bradley
- Rady Children's Hospital and Health Center, San Diego, CA, USA
| | - William J Muller
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Amira Al-Uzri
- Oregon Health and Science University, Portland, OR, USA
| | - Kevin J Downes
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
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16
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Ye PP, Zheng Y, Du B, Liu XT, Tang BH, Kan M, Zhou Y, Hao GX, Huang X, Su LQ, Wang WQ, Yu F, Zhao W. First dose in neonates: pharmacokinetic bridging study from juvenile mice to neonates for drugs metabolized by CYP3A. Xenobiotica 2020; 50:1275-1284. [PMID: 32400275 DOI: 10.1080/00498254.2020.1768454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
First dose prediction is challenging in neonates. Our objective in this proof-of-concept study was to perform a pharmacokinetic (PK) bridging study from juvenile mice to neonates for drugs metabolized by CYP3A. We selected midazolam and clindamycin as model drugs. We developed juvenile mice population PK models using NONMEM. The PK parameters of these two drugs in juvenile mice were used to bridge PK parameters in neonates using different correction methods. The bridging results were evaluated by the fold-error of 0.5- to 1.5-fold. Simple allometry with and without a correction factor for maximum lifespan potential could be used for a bridging of clearance (CL) and volume of distribution (Vd), respectively, from juvenile mice to neonates. Simulation results demonstrated that for midazolam, 100% of clinical studies for which both the predictive CL and Vd were within 0.5- to 1.5-fold of the observed. For clindamycin, 75% and 100% of clinical studies for which the predictive CL and Vd were within 0.5- to 1.5-fold of the observed. A PK bridging of drugs metabolized by CYP3A is feasible from juvenile mice to neonates. It could be a complement to the ADE and PBPK models to support the first dose in neonates.
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Affiliation(s)
- Pan-Pan Ye
- Department of Clinical Pharmacy, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.,Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yi Zheng
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bin Du
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xi-Ting Liu
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bo-Hao Tang
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Min Kan
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yue Zhou
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xin Huang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Le-Qun Su
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Wen-Qi Wang
- Clinical Research Center, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Feng Yu
- Department of Clinical Pharmacy, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Wei Zhao
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University, Jinan, China.,Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.,Clinical Research Center, The First Affiliated Hospital of Shandong First Medical University, Jinan, China.,Department of Pediatrics, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
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17
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Abstract
BACKGROUND Despite the absence of adequate safety or efficacy data, clindamycin is widely prescribed in the neonatal intensive care unit. We evaluated the association between clindamycin exposure and adverse events, as well as antibiotic effectiveness in infants. METHODS This was a retrospective cohort study of infants receiving clindamycin before postnatal day 121 who were discharged from a Pediatrix Medical Group neonatal intensive care unit (1997-2015). Using a previously developed pharmacokinetic model, we performed simulations to predict clindamycin exposure based on available dosing data. We used multivariable logistic regression to evaluate the association between clindamycin exposure and safety outcomes during and after clindamycin therapy. We reported the proportion of infants with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and clearance of MRSA bacteremia. RESULTS A total of 4089 infants received clindamycin at a median (25th-75th percentile) dose of 15 mg/kg/d (12-16). Clearance increased with older gestational age. Infants with the highest total clindamycin exposure had marginally increased odds of necrotizing enterocolitis within 7 days (adjusted odds ratio = 1.95 [1.04-3.63]), but exposure was not associated with death, sepsis, seizures, intestinal perforation or intestinal strictures. Of 25 infants who had MRSA bacteremia, 19 (76%) cleared the infection by the end of the clindamycin course. CONCLUSIONS Higher clindamycin exposure was not associated with increased odds of death or nonlaboratory adverse events. The use of pharmacokinetic models combined with available electronic health record data offers a valuable, cost-effective approach to analyzing the safety and effectiveness of drugs in infants when large-scale trials are not feasible.
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18
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State-of-the-Art Review on Physiologically Based Pharmacokinetic Modeling in Pediatric Drug Development. Clin Pharmacokinet 2020; 58:1-13. [PMID: 29777528 DOI: 10.1007/s40262-018-0677-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Physiologically based pharmacokinetic modeling and simulation is an important tool for predicting the pharmacokinetics, pharmacodynamics, and safety of drugs in pediatrics. Physiologically based pharmacokinetic modeling is applied in pediatric drug development for first-time-in-pediatric dose selection, simulation-based trial design, correlation with target organ toxicities, risk assessment by investigating possible drug-drug interactions, real-time assessment of pharmacokinetic-safety relationships, and assessment of non-systemic biodistribution targets. This review summarizes the details of a physiologically based pharmacokinetic modeling approach in pediatric drug research, emphasizing reports on pediatric physiologically based pharmacokinetic models of individual drugs. We also compare and contrast the strategies employed by various researchers in pediatric physiologically based pharmacokinetic modeling and provide a comprehensive overview of physiologically based pharmacokinetic modeling strategies and approaches in pediatrics. We discuss the impact of physiologically based pharmacokinetic models on regulatory reviews and product labels in the field of pediatric pharmacotherapy. Additionally, we examine in detail the current limitations and future directions of physiologically based pharmacokinetic modeling in pediatrics with regard to the ability to predict plasma concentrations and pharmacokinetic parameters. Despite the skepticism and concern in the pediatric community about the reliability of physiologically based pharmacokinetic models, there is substantial evidence that pediatric physiologically based pharmacokinetic models have been used successfully to predict differences in pharmacokinetics between adults and children for several drugs. It is obvious that the use of physiologically based pharmacokinetic modeling to support various stages of pediatric drug development is highly attractive and will rapidly increase, provided the robustness and reliability of these techniques are well established.
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19
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Matsuo Y, Matsumoto S, Wajima T, Matsubara K. Pharmacokinetic modeling and simulation for dose rationale of doripenem in neonates and infants. Drug Metab Pharmacokinet 2020; 35:145-150. [PMID: 31969257 DOI: 10.1016/j.dmpk.2019.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 09/25/2019] [Accepted: 10/15/2019] [Indexed: 11/18/2022]
Abstract
The aims of this study were to construct a population pharmacokinetic model of doripenem in neonates and infants and to assess the dosing regimen for patients <3 months of age using Monte-Carlo pharmacokinetic/pharmacodynamic (PKPD) simulations. In the population pharmacokinetic analysis using 187 plasma concentrations from 47 neonates and infants, a two-compartment model well described plasma doripenem concentrations with the most significant covariates of chronological age and gestational age identified for the pharmacokinetics of doripenem. Monte-Carlo simulations suggested that the selected dosages for neonates and infants based on chronological age and gestational age (5 or 10 mg/kg) would provide ≥90% target attainment of 40%fT>MIC against MIC of 2 μg/mL in all age groups. These results would be useful for understanding the PKPD characteristics of doripenem, which could provide essential information on optimal therapeutic treatment for neonates and infants.
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Affiliation(s)
- Yumiko Matsuo
- Clinical Pharmacology & Pharmacokinetics, Project Management Department, Shionogi & Co., Ltd, Japan.
| | - Sayaka Matsumoto
- Clinical Pharmacology & Pharmacokinetics, Project Management Department, Shionogi & Co., Ltd, Japan
| | - Toshihiro Wajima
- Clinical Pharmacology & Pharmacokinetics, Project Management Department, Shionogi & Co., Ltd, Japan
| | - Kazuo Matsubara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Japan
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20
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Applying Pharmacodynamics and Antimicrobial Stewardship to Pediatric Preseptal and Orbital Cellulitis. Paediatr Drugs 2019; 21:427-438. [PMID: 31608423 DOI: 10.1007/s40272-019-00357-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Orbital and preseptal cellulitis are most commonly caused by organisms that originate in the upper respiratory tract or from the skin. There is significant variation in antibiotics used, but ampicillin-sulbactam, ceftriaxone, metronidazole, clindamycin, amoxicillin, amoxicillin-clavulanate, cefuroxime, and vancomycin are often used in the treatment of these infections. The choice of antibiotic, however, is only one consideration. It is also important that antibiotics are dosed to optimize their pharmacodynamic target attainment. Like other serious infections, therapy can be transitioned from initial intravenous therapy to an oral regimen when there are clear signs of clinical and laboratory improvement. The total duration of therapy for these infections have also been decreasing in recent years with durations of approximately 2 weeks becoming more common, even for orbital or subperiosteal infections. Antimicrobial stewardship programs can work closely with providers who manage these infections to create pathways, choose optimal antibiotics and dosage, transition from intravenous to oral therapy, and provide shortest effective durations.
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21
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Rose K, Grant-Kels JM. The Meanings of "Pediatric Drug Development". Ther Innov Regul Sci 2019; 53:767-774. [PMID: 30526039 DOI: 10.1177/2168479018812060] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 10/18/2018] [Indexed: 07/09/2024]
Abstract
Pediatric drug development (PDD) became an industry goal when the Food and Drug Administration (FDA) granted patent extensions. This was later expanded to obligations for pediatric studies and to the European Medicines Agency's (EMA's) strict pediatric investigation plans (PIPs). Industry now sponsors many often international studies in young patients that are difficult or impossible to recruit. PDD's intellectual foundations characterize children as "therapeutic orphans," allegedly discriminated in drug treatment and development. While toxicities occured in newborns, demanding separate efficacy and safety (E&S) studies in all age groups is wasteful and reflects hidden conflicts of interest. The American Academy of Pediatrics (AAP) successfully procured pediatric research funds; the FDA dislikes pediatric off-label use and envisions labels as instructions for physicians. Pediatricians have continuously improved child health care by careful use of available drugs. Instead of physiologically defining children vis-à-vis drug treatment, the FDA defines children as ≤16 years old, offering convincing pretense for the need for mostly senseless "pediatric" studies in young adults, adolescents, and children. Although these studies may help advance pediatric academic careers, they do not improve pediatric health care. The EMA defines children as <18 years old and demands even more senseless and potentially harmful "pediatric" studies. Young patients need pharmacokinetic/pharmacodynamic and dose finding, but not separate E&S, studies. Institutional review boards and ethics committees should suspend or reject questionable FDA/EMA-demanded "pediatric" studies. Industry and science need repositioning towards "PDD"; US/EU pediatric laws need revision. We hope this will not take decades.
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Affiliation(s)
- Klaus Rose
- klausrose Consulting, Riehen, BS, Switzerland
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22
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Korth-Bradley JM. The Path to Perfect Pediatric Posology - Drug Development in Pediatrics. J Clin Pharmacol 2019; 58 Suppl 10:S48-S57. [PMID: 30248197 DOI: 10.1002/jcph.1081] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 12/21/2017] [Indexed: 11/06/2022]
Abstract
Reluctance to enroll pediatric subjects in clinical trials has left gaps in information about dosing, safety, and efficacy of medications. Pharmacotherapeutic information for pediatric patients may be available for only a small range of ages and may be deficient, as children respond differently as they grow and mature from prematurity to adolescence. Current regulations, however, require early planning for the participation of children in drug development, as pediatric plans must be submitted at the end of phase 1 (European Union) or the end of phase 2 (United States). These plans are extensive, outlining planned studies, subjects to be enrolled, dose and dosage form justification, planned observations, and statistical analysis as well as planned modeling, simulation, and extrapolation analyses. The extent to which efficacy information in adults can be extrapolated to children depends on how similar the disease is in adults and each of the 5 pediatric age groups. Extrapolation may not be possible for conditions that do not occur in adults, requiring a complete development plan in adults, or extrapolation may be complete because of similar pathology and response to treatment. Pharmacokinetic and safety information cannot be extrapolated and must be collected in children of all ages, unless a waiver is granted. Physiologically based pharmacokinetic modeling, optimal design, population pharmacokinetics, and scavenged samples are all examples of new methodologies being used to study pediatric therapeutics. Clinicaltrials.gov and EU Clinical Trials registry are good sources of results of pediatric trials, although sponsors are also working toward prompt publication of study results in peer-reviewed journals.
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Affiliation(s)
- Joan M Korth-Bradley
- Clinical Pharmacology, Global Product Development, Pfizer Inc., Collegeville, PA, USA
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23
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Rose K, Neubauer D, Grant-Kels JM. Rational Use of Medicine in Children-The Conflict of Interests Story. A Review. Rambam Maimonides Med J 2019; 10:RMMJ.10371. [PMID: 31335307 PMCID: PMC6649781 DOI: 10.5041/rmmj.10371] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND United States (US) and European Union (EU) legislation attempts to counterbalance the presumed discrimination in pediatric drug treatment and development. METHODS We analyzed the history of drug development, US/EU pediatric laws, and pediatric studies required by US/EU regulatory authorities and reviewed relevant literature. RESULTS The US and EU definitions of a child are defined administratively (rather than physiologically) as being aged <17 years and <18 years, respectively. However, children mature physiologically well before their seventeenth or eighteenth birthdays. The semantic blur for these differing definitions may indicate certain conflicts of interest. CONCLUSIONS Pediatric healthcare today is better than ever. Regulatory-related requirements for "pediatric" studies focus on labeling. Most of these studies lack medical usefulness and may even harm "pediatric" patients through administration of placebo and/or substandard treatment, despite the resultant publications, networking, patent extensions, and strengthened regulatory standing. Clinicians, parents, and ethics committees should be aware of these issues. New rules are needed to determine new pharmaceutical dose estimates in prepubescent patients, and when/how to clinically confirm them. Internet-based structures to divulge this information should be established between drug developers, clinicians, and regulatory authorities. A prerequisite for the rational use of pharmaceuticals in children would be to correct the flawed concept that children are discriminated against in drug treatment and development, and to abandon separate "pediatric" drug approval processes.
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Affiliation(s)
- Klaus Rose
- klausrose Consulting, Pediatric Drug Development & More, Riehen, Switzerland
| | - David Neubauer
- Department of Child, Adolescent and Developmental Neurology, University Children’s Hospital, Ljubljana, Slovenia
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24
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Wu Q, Peters SA. A Retrospective Evaluation of Allometry, Population Pharmacokinetics, and Physiologically-Based Pharmacokinetics for Pediatric Dosing Using Clearance as a Surrogate. CPT Pharmacometrics Syst Pharmacol 2019; 8:220-229. [PMID: 30762304 PMCID: PMC6482279 DOI: 10.1002/psp4.12385] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/10/2019] [Indexed: 12/13/2022] Open
Abstract
Physiologically-based pharmacokinetic models are increasingly applied for pediatric dose selection along with traditional methods such as allometry and population pharmacokinetic models. We report a retrospective evaluation of the three methods. Pediatric population pharmacokinetic models sourced from literature for a subset of eight compounds were used to predict clearances for children < 2 years when they were within the modeled age range (interpolation, N = 11) or including those outside the modeled age range (interpolation and extrapolation, N = 18). Pediatric/adult clearance ratios were evaluated with a strict performance criterion of 0.8-1.25 and with twofold criteria. For children > 2 years, 58-75% of the clinical studies (N = 10) met the strict criteria, and > 80% of the clinical studies were predicted within twofold by all three methods. For children < 2 years, physiologically-based pharmacokinetic, allometry with age-dependent exponents, and pediatric population pharmacokinetic models predict 54%, 82%, and 64% within twofold of the observed, respectively.
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Affiliation(s)
- Qier Wu
- Quantitative PharmacologyMerck KGaADarmstadtGermany
- University of Paris DescartesParisFrance
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25
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Hahn D, Emoto C, Euteneuer JC, Mizuno T, Vinks AA, Fukuda T. Influence of OCT1 Ontogeny and Genetic Variation on Morphine Disposition in Critically Ill Neonates: Lessons From PBPK Modeling and Clinical Study. Clin Pharmacol Ther 2018; 105:761-768. [PMID: 30300922 DOI: 10.1002/cpt.1249] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/01/2018] [Indexed: 01/12/2023]
Abstract
Morphine is commonly used for analgesia in the neonatal intensive care unit (NICU) despite having highly variable pharmacokinetics (PKs) between individual patients. The pharmacogenetic (PG) effect of variants at the loci of organic cation transporter 1 (OCT1) and UDP-glucuronosyltransferase 2B7 (UGT2B7) on age-dependent morphine clearance were evaluated in a cohort of critically ill neonatal patients using an opportunistic sampling design. Our primary results demonstrate the significant influence of OCT1 genotype (P < 0.05) and gestational age (P ≤ 0.005) on morphine PKs. A physiologically based pharmacokinetic (PBPK) model for morphine that accounted for OCT1 ontogeny and PG effect in post-term neonates adequately described the clinically observed variability in morphine PKs. This study serves as a proof of concept for genotype-dependent drug transporter ontogeny in neonates.
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Affiliation(s)
- David Hahn
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Chie Emoto
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Joshua C Euteneuer
- Division of Neonatology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Neonatology, Children's Hospital & Medical Center, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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26
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Balevic SJ, Cohen-Wolkowiez M. Innovative Study Designs Optimizing Clinical Pharmacology Research in Infants and Children. J Clin Pharmacol 2018; 58 Suppl 10:S58-S72. [PMID: 30248192 PMCID: PMC6310922 DOI: 10.1002/jcph.1053] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 11/07/2017] [Indexed: 12/16/2022]
Abstract
Almost half of recent pediatric trials failed to achieve labeling indications, in large part because of inadequate study design. Therefore, innovative study methods are crucial to optimizing trial design while also reducing the potential harms inherent with drug investigation. Several methods exist to optimize the amount of pharmacokinetic data collected from the smallest possible volume and with the fewest number of procedures, including the use of opportunistic and sparse sampling, alternative and noninvasive matrices, and microvolume assays. In addition, large research networks using master protocols promote collaboration, reduce regulatory burden, and increase trial efficiency for both early- and late-phase trials. Large pragmatic trials that leverage electronic health records can capitalize on central management strategies to reduce costs, enroll patients with rare diseases on a large scale, and augment study generalizability. Further, trial efficiency and safety can be optimized through Bayesian adaptive techniques that permit planned protocol changes based on analyses of prior and accumulated data. In addition to these trial design features, advances in modeling and simulation have paved the way for systems-based and physiologically based models that individualize pediatric dosing recommendations and support drug approval. Last, given the low prevalence of many pediatric diseases, collecting deidentified genetic and clinical data on a large scale is a potentially transformative way to augment clinical pharmacology research in children.
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Affiliation(s)
- Stephen J. Balevic
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
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27
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DeRonde KJ, Girotto JE, Nicolau DP. Management of Pediatric Acute Hematogenous Osteomyelitis, Part II: A Focus on Methicillin-Resistant Staphylococcus aureus, Current and Emerging Therapies. Pharmacotherapy 2018; 38:1021-1037. [PMID: 29989190 DOI: 10.1002/phar.2164] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) has become the most prevalent cause of acute hematogenous osteomyelitis (AHO) in pediatric patients. This increase in MRSA is due to the rise in community-acquired MRSA. Therefore, it is important that clinicians are aware of the various and upcoming therapies that cover this bacterium. A literature search of the Medline database was performed from creation through January 2018. Articles chosen for the review emphasize well-established MRSA treatment options for pediatric AHO, newer therapies on the horizon, and important pharmacokinetics and pharmacodynamic concepts for treatment. Traditional therapies, including vancomycin and clindamycin, remain effective for the treatment of pediatric AHO. When these agents cannot be used, evidence in AHO has been growing for daptomycin, linezolid, and ceftaroline. Further initial pediatric data with the long-acting lipoglycopeptides show promise and in the future may provide a role in AHO treatment in children.
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Affiliation(s)
- Kailynn J DeRonde
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, Connecticut.,Department of Pharmacy, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Jennifer E Girotto
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, Connecticut.,Department of Pharmacy, Connecticut Children's Medical Center, Hartford, Connecticut.,Division of Infectious Diseases and Immunology, Connecticut Children's Medical Center, Hartford, Connecticut
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut.,Division of Infectious Diseases, Hartford Hospital, Hartford, Connecticut
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28
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Sherwin J, Thompson E, Hill KD, Watt K, Lodge AJ, Gonzalez D, Hornik CP. Clinical pharmacology considerations for children supported with ventricular assist devices. Cardiol Young 2018; 28:1082-1090. [PMID: 29991374 PMCID: PMC6299825 DOI: 10.1017/s1047951118001075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The ventricular assist device is being increasingly used as a "bridge-to-transplant" option in children with heart failure who have failed medical management. Care for this medically complex population must be optimised, including through concomitant pharmacotherapy. Pharmacokinetic/pharmacodynamic alterations affecting pharmacotherapy are increasingly discovered in children supported with extracorporeal membrane oxygenation, another form of mechanical circulatory support. Similarities between extracorporeal membrane oxygenation and ventricular assist devices support the hypothesis that similar alterations may exist in ventricular assist device-supported patients. We conducted a literature review to assess the current data available on pharmacokinetics/pharmacodynamics in children with ventricular assist devices. We found two adult and no paediatric pharmacokinetic/pharmacodynamic studies in ventricular assist device-supported patients. While mechanisms may be partially extrapolated from children supported with extracorporeal membrane oxygenation, dedicated investigation of the paediatric ventricular assist device population is crucial given the inherent differences between the two forms of mechanical circulatory support, and pathophysiology that is unique to these patients. Commonly used drugs such as anticoagulants and antibiotics have narrow therapeutic windows with devastating consequences if under-dosed or over-dosed. Clinical studies are urgently needed to improve outcomes and maximise the potential of ventricular assist devices in this vulnerable population.
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Affiliation(s)
- Jennifer Sherwin
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | | | - Kevin D. Hill
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Kevin Watt
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Andrew J. Lodge
- Department of Surgery, Duke University Hospital, Durham, NC, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Christoph P. Hornik
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
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29
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Dallefeld SH, Atz AM, Yogev R, Sullivan JE, Al-Uzri A, Mendley SR, Laughon M, Hornik CP, Melloni C, Harper B, Lewandowski A, Mitchell J, Wu H, Green TP, Cohen-Wolkowiez M. A pharmacokinetic model for amiodarone in infants developed from an opportunistic sampling trial and published literature data. J Pharmacokinet Pharmacodyn 2018; 45:419-430. [PMID: 29435949 PMCID: PMC5955725 DOI: 10.1007/s10928-018-9576-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 01/31/2018] [Indexed: 01/18/2023]
Abstract
Amiodarone is a first-line antiarrhythmic for life-threatening ventricular fibrillation or ventricular tachycardia in children, yet little is known about its pharmacokinetics (PK) in this population. We developed a population PK (PopPK) model using samples collected via an opportunistic study design of children receiving amiodarone per standard of care supplemented by amiodarone PK data from the literature. Both study data and literature data were predominantly from infants < 2 years old, so our analysis was restricted to this group. The final combined dataset consisted of 266 plasma drug concentrations in 45 subjects with a median (interquartile range) postnatal age of 40.1 (11.0-120.4) days and weight of 3.9 (3.1-5.1) kg. Since the median sampling time after the first dose was short (study: 95 h; literature: 72 h) relative to the terminal half-life estimated in adult PopPK studies, values of the deep compartment volume and flow were fixed to literature values. A 3-compartment model best described the data and was validated by visual predictive checks and non-parametric bootstrap analysis. The final model included body weight as a covariate on all volumes and on both inter-compartmental and elimination clearances. The empiric Bayesian estimates for clearance (CL), volume of distribution at steady state, and terminal half-life were 0.25 (90% CL 0.14-0.36) L/kg/h, 93 (68-174) L/kg, and 266 (197-477) h, respectively. These studies will provide useful information for future PopPK studies of amiodarone in infants and children that could improve dosage regimens.
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Affiliation(s)
- Samantha H Dallefeld
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt St, Durham, NC, 27705, USA
| | - Andrew M Atz
- Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Ram Yogev
- Ann and Robert H. Lurie Children's Hospital of Chicago/Northwestern University, Chicago, IL, USA
| | - Janice E Sullivan
- University of Louisville-KCPCRU and Norton Children's Hospital, Louisville, KY, USA
| | - Amira Al-Uzri
- Oregon Health and Science University, Portland, OR, USA
| | | | - Matthew Laughon
- University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt St, Durham, NC, 27705, USA
| | - Chiara Melloni
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt St, Durham, NC, 27705, USA
| | - Barrie Harper
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt St, Durham, NC, 27705, USA
| | | | | | - Huali Wu
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt St, Durham, NC, 27705, USA
| | - Thomas P Green
- Ann and Robert H. Lurie Children's Hospital of Chicago/Northwestern University, Chicago, IL, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt St, Durham, NC, 27705, USA.
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30
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Maharaj AR, Gonzalez D, Cohen-Wolkowiez M, Hornik CP, Edginton AN. Improving Pediatric Protein Binding Estimates: An Evaluation of α1-Acid Glycoprotein Maturation in Healthy and Infected Subjects. Clin Pharmacokinet 2018; 57:577-589. [PMID: 28779462 PMCID: PMC5797516 DOI: 10.1007/s40262-017-0576-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Differences in plasma protein levels observed between children and adults can alter the extent of xenobiotic binding in plasma, resulting in divergent patterns of exposure. OBJECTIVE This study aims to quantify the ontogeny of α1-acid glycoprotein in both healthy and infected subjects. METHODS Data pertaining to α1-acid glycoprotein from healthy subjects were compiled over 26 different publications. For subjects diagnosed or suspected of infection, α1-acid glycoprotein levels were obtained from 214 individuals acquired over three clinical investigations. The analysis evaluated the use of linear, power, exponential, log-linear, and sigmoid E max models to describe the ontogeny of α1-acid glycoprotein. Utility of the derived ontogeny equation for estimation of pediatric fraction unbound was evaluated using average-fold error and absolute average-fold error as measures of bias and precision, respectively. A comparison to fraction unbound estimates derived using a previously proposed linear equation was also instituted. RESULTS The sigmoid E max model provided the comparatively best depiction of α1-acid glycoprotein ontogeny in both healthy and infected subjects. Despite median α1-acid glycoprotein levels in infected subjects being more than two-fold greater than those observed in healthy subjects, a similar ontogeny pattern was observed when levels were normalized toward adult levels. For estimation of pediatric fraction unbound, the α1-acid glycoprotein ontogeny equation derived from this work (average fold error 0.99; absolute average fold error 1.24) provided a superior predictive performance in comparison to the previous equation (average fold error 0.74; absolute average fold error 1.45). CONCLUSION The current investigation depicts a proficient modality for estimation of protein binding in pediatrics and will, therefore, aid in reducing uncertainty associated with pediatric pharmacokinetic predictions.
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Affiliation(s)
- Anil R Maharaj
- School of Pharmacy, University of Waterloo, 10A Victoria St. S, Kitchener, ON, Canada
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Christoph P Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Andrea N Edginton
- School of Pharmacy, University of Waterloo, 10A Victoria St. S, Kitchener, ON, Canada.
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31
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Snowden J, Darden P, Palumbo P, Saul P, Lee J. The institutional development award states pediatric clinical trials network: building research capacity among the rural and medically underserved. Curr Opin Pediatr 2018; 30:297-302. [PMID: 29517535 PMCID: PMC5927618 DOI: 10.1097/mop.0000000000000597] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW The institutional development award (IDeA) program was created to increase the competitiveness of investigators in states with historically low success rates for National Institutes of Health (NIH) research funding applications. IDeA states have high numbers of rural and medically underserved residents with disproportionately high rates of infant mortality, obesity, and poverty. This program supports the development and expansion of research infrastructure and research activities in these states. The IDeA States Pediatric Clinical Trials Network (ISPCTN) is part of the environmental influences on child health outcomes program. Its purpose is to build research capacity within IDeA states and provide opportunities for children in IDeA states to participate in clinical trials. This review describes the current and future activities of the network. RECENT FINDINGS In its initial year, the ISPCTN created an online series on clinical trials, initiated participation in a study conducted by the pediatric trials network, and proposed two novel clinical trials for obese children. Capacity building and clinical trial implementation will continue in future years. SUMMARY The ISPCTN is uniquely poised to establish and support new pediatric clinical research programs in underserved populations, producing both short and long-term gains in the understanding of child health.
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Affiliation(s)
| | - Paul Darden
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | | | - Phil Saul
- West Virginia University, Morgantown, West Virginia
| | - Jeannette Lee
- Data Coordinating and Operations Center, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Abstract
Since 2007, new drugs need a paediatric investigation plan (PIP) for EU registration. The PIPs' justifications can be traced back to concerns expressed by Shirkey that label warnings against paediatric use made children "therapeutic orphans", and the American Academy of Pediatrics' claim that all children differ considerably from adults. US legislation first encouraged, then also required, separate, adult-style safety and efficacy studies in all paediatric subpopulations. This triggered paediatric regulatory studies by the pharmaceutical industry. There were also negative outcomes, as a result of using the legal definition of childhood as a medical/physiological term. The "therapeutic orphans" concept became dogma that supported/expanded adult-style regulatory testing into all age groups even when poorly justified in adolescents or where other methods are available to generate needed data. PIPs are especially problematic because they lack the limitations imposed on the Food and Drug Administration's (FDA's) regulatory actions and more practical approaches used in the USA. Many PIP studies are medically senseless or even questionable and/or unfeasible with poor risk/benefit ratios. For example, physiologically mature adolescents have been exposed to treatments and doses known to be suboptimal in adults. Unfeasible PIP studies in rare diseases may harm patients by preventing their participation in more beneficence-driven studies. PIP-required studies can prevent effective treatment of allergic rhinitis during years of placebo treatment, exposing minors to the risk of disease progression to asthma. The PIP system should be revised; more should be done by key players, including institutional review boards/ethics committees, to ensure that all paediatric clinical studies are medically justified, rather than legislation driven, and can produce scientifically valid results.
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Affiliation(s)
- Klaus Rose
- klausrose Consulting, Pediatric Drug Development and More, Aeussere Baselstrasse 308, 4125, Riehen, Switzerland.
| | - Philip D Walson
- Walson Consulting, LLC, Seattle, Washington, USA.,Department of Clinical Pharmacology, University Medical Center, Göttingen, Germany
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33
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Hornik CP, Wu H, Edginton AN, Watt K, Cohen-Wolkowiez M, Gonzalez D. Development of a Pediatric Physiologically-Based Pharmacokinetic Model of Clindamycin Using Opportunistic Pharmacokinetic Data. Clin Pharmacokinet 2017; 56:1343-1353. [PMID: 28290120 PMCID: PMC5597447 DOI: 10.1007/s40262-017-0525-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Physiologically-based pharmacokinetic (PBPK) modeling is a powerful tool used to characterize maturational changes in drug disposition to inform dosing across childhood; however, its use is limited in pediatric drug development. Access to pediatric pharmacokinetic data is a barrier to widespread application of this model, which impedes its development and optimization. To support the development of a pediatric PBPK model, we sought to leverage opportunistically-collected plasma concentrations of the commonly used antibiotic clindamycin. The pediatric PBPK model was optimized following development of an adult PBPK model that adequately described literature data. We evaluated the predictability of the pediatric population PBPK model across four age groups and found that 63-93% of the observed data were captured within the 90% prediction interval of the model. We then used the pediatric PBPK model to optimize intravenous clindamycin dosing for a future prospective validation trial. The optimal dosing proposed by this model was 9 mg/kg/dose in children ≤5 months of age, 12 mg/kg/dose in children >5 months-6 years of age, and 10 mg/kg/dose in children 6-18 years of age, all administered every 8 h. The simulated exposures achieved with the dosing regimen proposed were comparable with adult plasma and tissue exposures for the treatment of community-acquired methicillin-resistant Staphylococcus aureus infections. Our model demonstrated the feasibility of using opportunistic pediatric data to develop pediatric PBPK models, extending the reach of this powerful modeling tool and potentially transforming the pediatric drug development field.
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Affiliation(s)
- Christoph P Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
| | - Huali Wu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | - Kevin Watt
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Daniel Gonzalez
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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34
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Carpenter D, Gonzalez D, Retsch-Bogart G, Sleath B, Wilfond B. Methodological and Ethical Issues in Pediatric Medication Safety Research. Pediatrics 2017; 140:e20170195. [PMID: 28778857 PMCID: PMC5574727 DOI: 10.1542/peds.2017-0195] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 12/26/2022] Open
Abstract
In May 2016, the Eshelman School of Pharmacy at The University of North Carolina at Chapel Hill convened the PharmSci conference to address the topic of "methodological and ethical issues in pediatric medication safety research." A multidisciplinary group of experts representing a diverse array of perspectives, including those of the US Food and Drug Administration, children's hospitals, and academia, identified important considerations for pediatric medication safety research and opportunities to advance the field. This executive summary describes current challenges that clinicians and researchers encounter related to pediatric medication safety research and identifies innovative and ethically sound methodologies to address these challenges to improve children's health. This article addresses 5 areas: (1) pediatric drug development and drug trials; (2) conducting comparative effectiveness research in pediatric populations; (3) child and parent engagement on study teams; (4) improving communication with children and parents; and (5) assessing child-reported outcomes and adverse drug events.
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Affiliation(s)
| | | | - George Retsch-Bogart
- Department of Pediatrics, School of Medicine
- Clinical and Translational Research Center of the North Carolina Translational and Clinical Sciences Institute, and
- Cystic Fibrosis Therapeutics Development Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | | | - Benjamin Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, University of Washington, Seattle, Washington
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35
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Gonzalez D, Rao GG, Bailey SC, Brouwer KLR, Cao Y, Crona DJ, Kashuba ADM, Lee CR, Morbitzer K, Patterson JH, Wiltshire T, Easter J, Savage SW, Powell JR. Precision Dosing: Public Health Need, Proposed Framework, and Anticipated Impact. Clin Transl Sci 2017; 10:443-454. [PMID: 28875519 PMCID: PMC5698804 DOI: 10.1111/cts.12490] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 06/28/2017] [Indexed: 12/19/2022] Open
Affiliation(s)
- Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Gauri G Rao
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Stacy C Bailey
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kim L R Brouwer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Yanguang Cao
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Daniel J Crona
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA.,University of North Carolina Medical Center, Chapel Hill, NC
| | - Angela D M Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kathryn Morbitzer
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - J Herbert Patterson
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Tim Wiltshire
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jon Easter
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Scott W Savage
- University of North Carolina Medical Center, Chapel Hill, NC.,Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - J Robert Powell
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
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36
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Krekels EHJ, van Hasselt JGC, van den Anker JN, Allegaert K, Tibboel D, Knibbe CAJ. Evidence-based drug treatment for special patient populations through model-based approaches. Eur J Pharm Sci 2017; 109S:S22-S26. [PMID: 28502674 DOI: 10.1016/j.ejps.2017.05.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 05/11/2017] [Indexed: 10/19/2022]
Abstract
The majority of marketed drugs remain understudied in some patient populations such as pregnant women, paediatrics, the obese, the critically-ill, and the elderly. As a consequence, currently used dosing regimens may not assure optimal efficacy or minimal toxicity in these patients. Given the vulnerability of some subpopulations and the challenges and costs of performing clinical studies in these populations, cutting-edge approaches are needed to effectively develop evidence-based and individualized drug dosing regimens. Five key issues are presented that are essential to support and expedite the development of drug dosing regimens in these populations using model-based approaches: 1) model development combined with proper validation procedures to extract as much valid information from available study data as possible, with limited burden to patients and costs; 2) integration of existing data and the use of prior pharmacological and physiological knowledge in study design and data analysis, to further develop knowledge and avoid unnecessary or unrealistic (large) studies in vulnerable populations; 3) clinical proof-of-principle in a prospective evaluation of a developed drug dosing regimen, to confirm that a newly proposed regimen indeed results in the desired outcomes in terms of drug concentrations, efficacy, and/or safety; 4) pharmacodynamics studies in addition to pharmacokinetics studies for drugs for which a difference in disease progression and/or in exposure-response relation is anticipated compared to the reference population; 5) additional efforts to implement developed dosing regimens in clinical practice once drug pharmacokinetics and pharmacodynamics have been characterized in special patient populations. The latter remains an important bottleneck, but this is essential to truly realize evidence-based and individualized drug dosing for special patient populations. As all tools required for this purpose are available, we have the moral and societal obligation to make safe and effective pharmacotherapy available for these patients too.
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Affiliation(s)
- Elke H J Krekels
- Leiden Academic Center for Drug Research, Systems Pharmacology Cluster, Division of Pharmacology, Leiden University, Leiden, The Netherlands.
| | - J G Coen van Hasselt
- Leiden Academic Center for Drug Research, Systems Pharmacology Cluster, Division of Pharmacology, Leiden University, Leiden, The Netherlands; Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John N van den Anker
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands; Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA; Division of Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Catherijne A J Knibbe
- Leiden Academic Center for Drug Research, Systems Pharmacology Cluster, Division of Pharmacology, Leiden University, Leiden, The Netherlands; Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
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Smith MJ, Gonzalez D, Goldman JL, Yogev R, Sullivan JE, Reed MD, Anand R, Martz K, Berezny K, Benjamin DK, Smith PB, Cohen-Wolkowiez M, Watt K. Pharmacokinetics of Clindamycin in Obese and Nonobese Children. Antimicrob Agents Chemother 2017; 61:e02014-16. [PMID: 28137820 PMCID: PMC5365720 DOI: 10.1128/aac.02014-16] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 01/12/2017] [Indexed: 12/12/2022] Open
Abstract
Although obesity is prevalent among children in the United States, pharmacokinetic (PK) data for obese children are limited. Clindamycin is a commonly used antibiotic that may require dose adjustment in obese children due to its lipophilic properties. We performed a clindamycin population PK analysis using data from three separate trials. A total of 420 samples from 220 children, 76 of whom had a body mass index greater than or equal to the 95th percentile for age, were included in the analysis. Compared to other metrics, total body weight (TBW) was the most robust measure of body size. The final model included TBW and a sigmoidal maturation relationship between postmenstrual age (PMA) and clearance (CL): CL (liters/hour) = 13.8 × (TBW/70)0.75 × [PMA2.83/(39.52.83+PMA2.83)]; volume of distribution (V) was associated with TBW, albumin (ALB), and alpha-1 acid glycoprotein (AAG): V (liters) = 63.6 × (TBW/70) × (ALB/3.3)-0.83 × (AAG/2.4)-0.25 After accounting for differences in TBW, obesity status did not explain additional interindividual variability in model parameters. Our findings support TBW-based dosing for obese and nonobese children.
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Affiliation(s)
- Michael J Smith
- Division of Pediatric Infectious Diseases, University of Louisville, Louisville, Kentucky, USA
- Kosair Charities Pediatric Clinical Research Unit, University of Louisville, Louisville, Kentucky, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Ram Yogev
- Northwestern University, Chicago, Illinois, USA
| | - Janice E Sullivan
- Kosair Charities Pediatric Clinical Research Unit, University of Louisville, Louisville, Kentucky, USA
| | | | | | | | - Katherine Berezny
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel K Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - P Brian Smith
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
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Rose K, Walson PD. Do the European Medicines Agency Decisions Hurt Pediatric Melanoma Patients? Clin Ther 2017; 39:253-265. [PMID: 28159363 DOI: 10.1016/j.clinthera.2017.01.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 01/08/2017] [Accepted: 01/09/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE US pediatric legislation was introduced in 1997 and was followed by European Union pediatric legislation that, since 2007, requires a European Medicines Agency (EMA)-approved pediatric investigation plan (PIP) for registration of new medicines unless they are PIP exempted. In 2008, the EMA decided that enough adolescent patients with melanoma existed and removed melanoma from the list of PIP-exempted diseases (class waiver list). We examined the logic and the results of this decision. METHODS We analyzed the EMA class waiver decision, the melanoma PIP decisions, the wording of the European Union pediatric legislation, and melanoma trials listed in www.clinicaltrials.gov and www.clinicaltrialsregister.eu that recruit adults and minors or only minors. FINDINGS There are 12 melanoma PIP decisions. Two apparently PIP-triggered melanoma trials were terminated in 2016 because of slow recruitment, and 4 are ongoing. Numerous non-PIP-driven trials are recruiting both adults and minors with melanoma worldwide, thus competing with PIP-triggered melanoma trials. IMPLICATIONS Revoking the melanoma class waiver was not based on science but on flawed logic. It resulted in PIP-demanded pediatric trials that do not make medical sense, fail to recruit adequately, and prevent participants from more promising off-label treatment or treatment in clinically, scientifically, and ethically superior non-PIP-triggered studies. Institutional review boards and ethics committees should consult both www.clinicaltrials.gov and www.clinicaltrialsregister.eu for competing trials in the same population and reject or withdraw approval for questionable trials. A major revision or replacement of the European Union pediatric legislation is needed to prevent children from being enrolled in unnecessary, unfeasible, or scientifically invalid trials.
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Affiliation(s)
- Klaus Rose
- klausrose Consulting: Pediatric Drug Development & More, Riehen, Switzerland.
| | - Philip D Walson
- Department of Clinical Pharmacology, University Medical School, Goettingen, Germany
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39
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Antimicrobial Agent Dosing in Infants. Clin Ther 2016; 38:1948-60. [DOI: 10.1016/j.clinthera.2016.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/29/2016] [Accepted: 06/30/2016] [Indexed: 11/19/2022]
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Thakkar N, Gonzalez D, Cohen-Wolkowiez M, Massaro M, Bernhardt J, Zane NR, Laughon MM. An opportunistic study evaluating pharmacokinetics of sildenafil for the treatment of pulmonary hypertension in infants. J Perinatol 2016; 36:744-7. [PMID: 27171763 PMCID: PMC5002251 DOI: 10.1038/jp.2016.79] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 03/23/2016] [Accepted: 04/01/2016] [Indexed: 12/02/2022]
Abstract
OBJECTIVE The objective of this study is to assess sildenafil and N-desmethyl sildenafil (DMS) exposure in infants receiving sildenafil for the treatment of pulmonary hypertension (PH). STUDY DESIGN Data were collected from six infants receiving sildenafil for the treatment of PH and plasma samples were collected at the time of routine laboratory blood draws. The echocardiography results were assessed for improvement in right ventricular (RV) hypertension following sildenafil treatment. RESULT The median (range) sildenafil and DMS concentrations were 27.4 ng ml(-1) (2.6 to 434.0) and 105.5 ng ml(-1) (3.6 to 314.0), respectively. The median metabolite-to-parent ratio was higher in infants receiving co-medications that can induce cytochrome P450 (CYP) enzymes (5.2 vs 0.7). The echocardiography results showed improvement in RV hypertension for the majority of infants (5/6). CONCLUSION The concentrations of sildenafil and DMS were within the previously observed ranges. Our results suggest that caution may be warranted when CYP-related co-medications are administered during sildenafil treatment for PH.
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Affiliation(s)
- Nilay Thakkar
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Matthew Massaro
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Janice Bernhardt
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nicole R. Zane
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Matthew M. Laughon
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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41
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Abstract
In the United States, the Best Pharmaceuticals for Children Act and the Pediatric Research Equity Act continue to promote clinical trials in pediatric populations across all age ranges. In 2014 and 2015, over 70 changes were made to drug labels with updates on information regarding pediatric populations. Additionally, multiple new therapies have received first-approvals for the treatment of pediatric indications ranging form rare genetic metabolic diseases to oncology. In the European Union, there have been more than 30 new authorizations for medicines used in children and 130 approved pediatric investigation plans. Despite the progress that has been made over the last two years, much work remains to further the development of safe and effective therapies for pediatric patients.
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Affiliation(s)
- Laura A Wang
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA; Department of Pediatrics, Children's Health Center, College of Medicine, Duke University, T901, Durham, NC 27705, USA.
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 301 Pharmacy Lane, CB #7569, Chapel Hill, NC 27599, USA
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42
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Gonzalez D, Delmore P, Bloom BT, Cotten CM, Poindexter BB, McGowan E, Shattuck K, Bradford KK, Smith PB, Cohen-Wolkowiez M, Morris M, Yin W, Benjamin DK, Laughon MM. Clindamycin Pharmacokinetics and Safety in Preterm and Term Infants. Antimicrob Agents Chemother 2016; 60:2888-94. [PMID: 26926644 PMCID: PMC4862454 DOI: 10.1128/aac.03086-15] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/20/2016] [Indexed: 01/01/2023] Open
Abstract
Clindamycin may be active against methicillin-resistant Staphylococcus aureus, a common pathogen causing sepsis in infants, but optimal dosing in this population is unknown. We performed a multicenter, prospective pharmacokinetic (PK) and safety study of clindamycin in infants. We analyzed the data using a population PK analysis approach and included samples from two additional pediatric trials. Intravenous data were collected from 62 infants (135 plasma PK samples) with postnatal ages of <121 days (median [range] gestational age of 28 weeks [23 to 42] and postnatal age of 17 days [1 to 115]). In addition to body weight, postmenstrual age (PMA) and plasma protein concentrations (albumin and alpha-1 acid glycoprotein) were found to be significantly associated with clearance and volume of distribution, respectively. Clearance reached 50% of the adult value at PMA of 39.5 weeks. Simulated PMA-based intravenous dosing regimens administered every 8 h (≤32 weeks PMA, 5 mg/kg; 32 to 40 weeks PMA, 7 mg/kg; >40 to 60 weeks PMA, 9 mg/kg) resulted in an unbound, steady-state concentration at half the dosing interval greater than a MIC for S. aureus of 0.12 μg/ml in >90% of infants. There were no adverse events related to clindamycin use. (This study has been registered at ClinicalTrials.gov under registration no. NCT01728363.).
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Affiliation(s)
- Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Paula Delmore
- Department of Neonatology, Wesley Medical Center, Wichita, Kansas, USA
| | - Barry T Bloom
- Department of Neonatology, Wesley Medical Center, Wichita, Kansas, USA
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brenda B Poindexter
- Department of Pediatrics, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, USA
| | - Elisabeth McGowan
- Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts, USA
| | - Karen Shattuck
- Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas, USA
| | - Kathleen K Bradford
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Maurine Morris
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Daniel K Benjamin
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew M Laughon
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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43
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Van Driest SL, Marshall MD, Hachey B, Beck C, Crum K, Owen J, Smith AH, Kannankeril PJ, Woodworth A, Caprioli RM, Choi L. Pragmatic pharmacology: population pharmacokinetic analysis of fentanyl using remnant samples from children after cardiac surgery. Br J Clin Pharmacol 2016; 81:1165-74. [PMID: 26861166 DOI: 10.1111/bcp.12903] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 01/29/2016] [Accepted: 02/03/2016] [Indexed: 12/25/2022] Open
Abstract
AIMS One barrier contributing to the lack of pharmacokinetic (PK) data in paediatric populations is the need for serial sampling. Analysis of clinically obtained specimens and data may overcome this barrier. To add evidence for the feasibility of this approach, we sought to determine PK parameters for fentanyl in children after cardiac surgery using specimens and data generated in the course of clinical care, without collecting additional blood samples. METHODS We measured fentanyl concentrations in plasma from leftover clinically-obtained specimens in 130 paediatric cardiac surgery patients and successfully generated a PK dataset using drug dosing data extracted from electronic medical records. Using a population PK approach, we estimated PK parameters for this population, assessed model goodness-of-fit and internal model validation, and performed subset data analyses. Through simulation studies, we compared predicted fentanyl concentrations using model-driven weight-adjusted per kg vs. fixed per kg fentanyl dosing. RESULTS Fentanyl clearance for a 6.4 kg child, the median weight in our cohort, is 5.7 l h(-1) (2.2-9.2 l h(-1) ), similar to values found in prior formal PK studies. Model assessment and subset analyses indicated the model adequately fit the data. Of the covariates studied, only weight significantly impacted fentanyl kinetics, but substantial inter-individual variability remained. In simulation studies, model-driven weight-adjusted per kg fentanyl dosing led to more consistent therapeutic fentanyl concentrations than fixed per kg dosing. CONCLUSIONS We show here that population PK modelling using sparse remnant samples and electronic medical records data provides a powerful tool for assessment of drug kinetics and generation of individualized dosing regimens.
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Affiliation(s)
- Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew D Marshall
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brian Hachey
- Department of Biochemistry, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cole Beck
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kim Crum
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jill Owen
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew H Smith
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Prince J Kannankeril
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alison Woodworth
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard M Caprioli
- Department of Biochemistry, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
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Discovery of an ultra-short linear antibacterial tetrapeptide with anti-MRSA activity from a structure-activity relationship study. Eur J Med Chem 2015; 105:138-44. [PMID: 26489599 DOI: 10.1016/j.ejmech.2015.10.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/05/2015] [Accepted: 10/07/2015] [Indexed: 11/20/2022]
Abstract
The overuse and misuse of antibiotics has resulted in the emergence of drug-resistant pathogenic bacteria, including meticillin-resistant Staphylococcus aureus (MRSA), the primary pathogen responsible for human skin and soft-tissue infections. Antibacterial peptides are known to kill bacteria by rapidly disrupting their membranes and are deemed plausible alternatives to conventional antibiotics. One advantage of their membrane-targeting mode of action is that bacteria are unlikely to develop resistance as changing their cell membrane structure and morphology would likely involve extensive genetic mutations. However, major concerns in using peptides as antibacterial drugs include their instability towards plasma proteases, toxicity towards human cells due to their membrane-targeting mode of action and high manufacturing cost. These concerns can be mitigated by developing peptides as topical agents, by the judicial selection of amino acids and developing very short peptides respectively. In this preliminary report, we reveal a linear, non-hemolytic tetrapeptide with rapid bactericidal activity against MRSA developed from a structure-activity relationship study based on the antimicrobial hexapeptide WRWRWR-NH2. Our finding opens promising avenues for the development of ultra-short antibacterials to treat multidrug-resistant MRSA skin and soft tissue infections.
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45
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Vinks AA, Emoto C, Fukuda T. Modeling and simulation in pediatric drug therapy: Application of pharmacometrics to define the right dose for children. Clin Pharmacol Ther 2015; 98:298-308. [PMID: 26073179 DOI: 10.1002/cpt.169] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 06/10/2015] [Accepted: 06/11/2015] [Indexed: 12/20/2022]
Abstract
During the past decades significant progress has been made in our understanding of the importance of age-appropriate development of new drug therapies in children. Importantly, several regulatory initiatives in Europe and the US have provided a framework for a rationale. In the US, most notably the enactment of the Best Pharmaceuticals for Children Act (BPCA) and Product Research and Equity Act (PREA) has facilitated the studying of on-patent and off-patent drugs in children. The biggest challenge in pediatric studies is defining a safe and effective dose or dose range in a patient population that can span from premature neonates to adolescents. From a mechanism-based perspective, advances in the science of quantitative pharmacology and pharmacometrics have resulted in the development of model-based approaches to better describe and understand important age-related factors influencing drug disposition and response in pediatric patients. The application of modeling and simulation has been shown to result in better estimates of pediatric doses as evidenced by several studies, although the optimal approach is still being debated. The extrapolation of efficacy findings from adults to the pediatric population has streamlined the development process especially for studies in older children. However, a focus on developmental changes in neonates and infants as well as further developing a paradigm for conducting pharmacodynamic studies in neonates, infants, and children remain important unmet needs. In this overview we will review current approaches for age-appropriate dose selection and highlight ongoing efforts to define exposure-response and clinical outcome relationships across the pediatric age spectrum.
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Affiliation(s)
- A A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - C Emoto
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - T Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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46
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Abstract
To prevent the devastating consequences of infection, most infants admitted to the neonatal intensive care unit are exposed to antibiotics. However, dosing regimens are often extrapolated from data in adults and older children, increasing the risk for drug toxicity and lack of clinical efficacy because they fail to account for developmental changes in infant physiology. However, newer technologies are emerging with minimal-risk study designs, including ultra-low-volume assays, pharmacokinetic modeling and simulation, and opportunistic drug protocols. With minimal-risk study designs, pharmacokinetic data and dosing regimens for infants are now available for ampicillin, clindamycin, meropenem, metronidazole, and piperacillin/tazobactam.
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Affiliation(s)
| | - Kevin M. Watt
- Department of Pediatrics, Duke University, Durham, NC,Duke Clinical Research Institute, Durham, NC
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47
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Blanchard AC, Quach C, Autmizguine J. Staphylococcal infections in infants: updates and current challenges. Clin Perinatol 2015; 42:119-32, ix. [PMID: 25678000 DOI: 10.1016/j.clp.2014.10.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Staphylococci are common pathogens in the neonatal period. Increased survival of premature infants leads to prolonged hospital stay with associated risk factors for developing invasive staphylococcal disease. Challenges of diagnosing coagulase-negative staphylococcal infections result in conflicting definitions and inconsistent clinical practice. Resistance to methicillin influences the choice of empirical therapy.
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Affiliation(s)
- Ana C Blanchard
- Department of Pediatrics, CHU Sainte Justine, University of Montreal, 3175 Chemin Côte Sainte-Catherine, Montreal, Quebec H3T 1C5, Canada
| | - Caroline Quach
- Division of Infectious Diseases, Department of Medical Microbiology, The Montreal Children's Hospital, McGill University Health Centre, 2300 Tupper Street, Suite C1242, Montreal, Quebec H3H 1P3, Canada; Department of Pediatrics, The Montreal Children's Hospital, McGill University Health Centre, 2300 Tupper Street, Suite C1242, Montreal, Quebec H3H 1P3, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Pine Avenue West, Montreal, Quebec H3A 1A2, Canada
| | - Julie Autmizguine
- Department of Pediatrics, CHU Sainte Justine, University of Montreal, 3175 Chemin Côte Sainte-Catherine, Montreal, Quebec H3T 1C5, Canada; Department of Pharmacology, University of Montreal, 2900 Boulevard Edouard-Montpetit, Montreal, Quebec H3T 1J4, Canada; Research Center CHU Sainte-Justine, 3175 Chemin Côte Sainte Catherine, Montreal, Quebec H3T 1C5, Canada.
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48
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Gonzalez D, Melloni C, Poindexter BB, Yogev R, Atz AM, Sullivan JE, Mendley SR, Delmore P, Delinsky A, Zimmerman K, Lewandowski A, Harper B, Lewis KC, Benjamin DK, Cohen-Wolkowiez M. Simultaneous determination of trimethoprim and sulfamethoxazole in dried plasma and urine spots. Bioanalysis 2015; 7:1137-49. [PMID: 26039810 PMCID: PMC4455038 DOI: 10.4155/bio.15.38] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Trimethoprim-sulfamethoxazole (TMP-SMX) is an antimicrobial drug combination commonly prescribed in children and adults. The study objectives were to validate and apply an HPLC-MS/MS method to quantify TMP-SMX in dried plasma spots (DPS) and dried urine spots (DUS), and perform a comparability analysis with liquid matrices. RESULTS For TMP the validated range was 100-50,000 ng/ml for DPS and 500-250,000 ng/ml for DUS; for SMX, the validated range was 1000-500,000 ng/ml for both DPS and DUS. Good agreement was noted between DPS/DUS and liquid plasma and urine samples for TMP, while only modest agreement was observed for SMX in both matrices. CONCLUSION A precise, accurate and reproducible method was developed to quantify TMP-SMX in DPS and DUS samples.
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Affiliation(s)
- Daniel Gonzalez
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Chiara Melloni
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Brenda B Poindexter
- Department of Pediatrics, Riley Hospital for Children, Indiana University, Indianapolis, IN, USA
| | - Ram Yogev
- Ann & Robert H Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Andrew M Atz
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Janice E Sullivan
- Kosair Charities Pediatric Clinical Research Unit, Department of Pediatrics, University of Louisville, Kosair Children's Hospital, Louisville, KY, USA
| | - Susan R Mendley
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Paula Delmore
- Department of Neonatology, Wesley Medical Center, Wichita, KS, USA
| | - Amy Delinsky
- OpAns, LLC, 4134 S Alston Ave # 101, Durham, NC 27713, USA
| | - Kanecia Zimmerman
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | | | - Barrie Harper
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | | | - Daniel K Benjamin
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
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49
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McCune SK, Mulugeta YA. Regulatory science needs for neonates: a call for neonatal community collaboration and innovation. Front Pediatr 2014; 2:135. [PMID: 25520945 PMCID: PMC4248839 DOI: 10.3389/fped.2014.00135] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 11/17/2014] [Indexed: 11/13/2022] Open
Affiliation(s)
- Susan K McCune
- Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration , Silver Spring, MD , USA
| | - Yeruk Ager Mulugeta
- Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration , Silver Spring, MD , USA ; Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration , Silver Spring, MD , USA
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