1
|
Fan Q, Hui X, Li X, Li Q, Yang D, Wang Y. Reaching the cyclosporine a level target slowly in four weeks correlates with better prognosis for Chinese patients after allogeneic haematopoietic cell transplantation. Hematology 2023; 28:2275893. [PMID: 37975575 DOI: 10.1080/16078454.2023.2275893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 10/12/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVES This study investigated the impact of early cyclosporin A (CsA) initiation (day -5) on the risk of acute graft versus host disease (aGvHD) after allogeneic haematopoietic cell transplantation (allo-HSCT). METHODS Sixty-seven leukaemia patients who underwent allo-HSCT were investigated. The correlation between the CsA level in the first four weeks and the following indices was examined: GvHD, cumulative incidence (CI) of GvHD, CI of relapse at month 18, and non-relapse mortality (NRM) at month 18. RESULTS A significant association between aGvHD and CsA level in the fourth week after allo-HSCT was observed, with the incidence of aGvHD in the fourth week in the lower level group being higher than that in the higher level group (p = 0.044). The CI of aGvHD was 30.1% and 9.8% at day +90 and 42.3% and 17.1% at day +180 in the lower level and higher level groups, respectively. CONCLUSION For Chinese patients, early introduction and reaching the target CsA concentration within four weeks after allo-HSCT have a positive effect on preventing GvHD, especially in the fourth week after HSCT. Compared to the Western population, the target CsA concentration is lower and the time required to reach the target (within 4 weeks) is longer in the Chinese population (274.75 ng/mL).
Collapse
Affiliation(s)
- Qingqing Fan
- Department of Pharmacy, Jiangsu Province Hospital (The First Affiliated Hospital with Nanjing Medical University), Nanjing, People's Republic of China
| | - Xiang Hui
- Department of Pharmacy, Jiangsu Province Hospital (The First Affiliated Hospital with Nanjing Medical University), Nanjing, People's Republic of China
| | - Xiang Li
- Department of Pharmacy, Jiangsu Province Hospital (The First Affiliated Hospital with Nanjing Medical University), Nanjing, People's Republic of China
| | - Qian Li
- Department of Pharmacy, Jiangsu Province Hospital (The First Affiliated Hospital with Nanjing Medical University), Nanjing, People's Republic of China
| | - Dihong Yang
- Department of Pharmacy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, People's Republic of China
| | - Yongqing Wang
- Department of Pharmacy, Jiangsu Province Hospital (The First Affiliated Hospital with Nanjing Medical University), Nanjing, People's Republic of China
| |
Collapse
|
2
|
Beyron C, Ceraulo A, Bertrand Y, Bleyzac N, Philippe M. Impact of a Bayesian Individualization of Cyclosporine Dosage Regimen for Children Undergoing Allogeneic Hematopoietic Cell Transplantation: A Cost-Effectiveness Analysis. Ther Drug Monit 2021; 43:481-489. [PMID: 33814541 DOI: 10.1097/ftd.0000000000000886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/19/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cyclosporine A (CsA) is the main drug used to prevent graft-versus-host disease in patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT). CsA therapeutic drug monitoring (TDM) has been performed for ages, with studies revealing clinical benefits, but failing to examine its economic impact. In this article, the main objective was to evaluate the economic impact of the CsA TDM strategy, based on a Bayesian approach, by assessing costs related to its clinical impact. Furthermore, TDM effectiveness was analyzed for pharmacokinetics and clinical outcomes. METHODS A cost-effective, nonrandomized, retrospective, single-center study compared 2 CsA monitoring and dose adaptation strategies in pediatric patients undergoing HSCT. From 2014 to 2016, CsA TDM was performed using a population pharmacokinetics model-coupled Bayesian approach by a pharmacist ["pharmacist-assisted individualization" (PAI)]. From 2017 to 2018, CsA TDM was performed by the clinician without a Bayesian approach (non-PAI group). HSCT costs were evaluated from the French National Insurance perspective. Economic and clinical outcomes were assessed by measuring incremental cost-effectiveness ratios. RESULTS The study included 144 patients: 90 and 54 patients in PAI and non-PAI groups, respectively. Both groups were comparable for sociodemographic and clinical characteristics. The mean total cost per patient was significantly lower (P < 0.01) in the PAI group (€85,947) than in the non-PAI group (€100,435). Multivariate analysis revealed that TDM based on the Bayesian approach was a protective factor (odds ratio = 0.86) for severe acute graft-versus-host disease. We noted that pharmacist-based TDM was the dominant strategy. Bayesian method-based TDM allowed an increase in the percentage of target attainment at any period post-HSCT. CONCLUSIONS CsA TDM with a Bayesian approach is a cost-effective procedure, and highlighted clinical benefits encourage the development of new TDM strategies for HSCT.
Collapse
Affiliation(s)
- C Beyron
- Oncology Pharmacy Department, Centre Léon Bérard
| | - A Ceraulo
- Institute of Pediatric Hematology and Oncology, Hospices Civils de Lyon
- Claude Bernard University-Lyon 1
| | - Y Bertrand
- Institute of Pediatric Hematology and Oncology, Hospices Civils de Lyon
- Claude Bernard University-Lyon 1
| | - N Bleyzac
- Pharmacy Department, Hôpital Pierre Garraud, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon; and
- EMR 3738, Team 2-PK/PD Modeling in Oncology, Lyon-Sud Faculty of Medicine, Oullins, France
| | - M Philippe
- Oncology Pharmacy Department, Centre Léon Bérard
- Institute of Pediatric Hematology and Oncology, Hospices Civils de Lyon
| |
Collapse
|
3
|
Phan M, Chavan R, Beuttler R, Benipayo N, Magedman G, Buchbinder D, Tomaszewski D, Yang S. Evaluating risk factors for acute graft versus host disease in pediatric hematopoietic stem cell transplant patients receiving tacrolimus. Clin Transl Sci 2021; 14:1303-1313. [PMID: 33503293 PMCID: PMC8301588 DOI: 10.1111/cts.12982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/18/2020] [Accepted: 12/03/2020] [Indexed: 11/30/2022] Open
Abstract
To identify the clinical and pharmacological risk factors associated with tacrolimus pharmacodynamics for acute graft‐versus‐host disease (aGVHD) in pediatric patients receiving allogeneic hematopoietic stem cell transplantation (HSCT) from a matched related donor. A retrospective cohort single center chart review study was conducted with pediatric patients who received tacrolimus prophylaxis after allogeneic HSCT between January 1, 2017, and December 31, 2019. Potential risk factors were tested separately between aGVHD and non‐aGVHD cohorts and were further analyzed in a logistic regression model with backward elimination and a partial least squares discriminant analysis. Thirty‐three patient cases were included in our study and 52% (17/33) developed aGVHD while on tacrolimus prophylaxis. When tested independently, donor age and sibling versus parent donor/recipient relation were shown to be statistically significant between aGVHD and non‐aGVHD patients (p < 0.005). Pharmacological factors associated with tacrolimus treatment failed to demonstrate a significant impact on patient’s risk of aGVHD. Using a best fit logistic regression model that tested all the variables together, donor age was the only significant variable predicting patient’s risk of aGVHD (p < 0.01). Donor relationship and donor age were unable to be evaluated separately and are therefore confounding variables. Among pediatric patients receiving allogeneic HSCT, aGVHD risk is significantly decreased by either sibling donor and/or younger donors. Although no conclusions were drawn on the effect of tacrolimus therapy (p = 0.08), results warrant additional research with a larger sample size to evaluate the accuracy of monitoring tacrolimus serum trough levels.
Collapse
Affiliation(s)
- Michael Phan
- Department of Pharmacy Practice, Chapman University School of Pharmacy, Irvine, California, USA
| | - Rishikesh Chavan
- The Hyundai Cancer Institute, CHOC Children's Hospital, Orange, California, USA
| | - Richard Beuttler
- Department of Biomedical and Pharmaceutical Sciences, Chapman University School of Pharmacy, Irvine, California, USA
| | - Nicole Benipayo
- Chapman University School of Pharmacy, Irvine, California, USA
| | - Grace Magedman
- Department of Pharmacy, CHOC Children's Hospital, Orange, California, USA
| | - David Buchbinder
- The Hyundai Cancer Institute, CHOC Children's Hospital, Orange, California, USA
| | - Daniel Tomaszewski
- Department of Biomedical and Pharmaceutical Sciences, Chapman University School of Pharmacy, Irvine, California, USA
| | - Sun Yang
- Department of Pharmacy Practice, Chapman University School of Pharmacy, Irvine, California, USA
| |
Collapse
|
4
|
Wölfl M, Qayed M, Benitez Carabante MI, Sykora T, Bonig H, Lawitschka A, Diaz-de-Heredia C. Current Prophylaxis and Treatment Approaches for Acute Graft-Versus-Host Disease in Haematopoietic Stem Cell Transplantation for Children With Acute Lymphoblastic Leukaemia. Front Pediatr 2021; 9:784377. [PMID: 35071133 PMCID: PMC8771910 DOI: 10.3389/fped.2021.784377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
Acute graft-versus-host disease (aGvHD) continues to be a leading cause of morbidity and mortality following allogeneic haematopoietic stem cell transplantation (HSCT). However, higher event-free survival (EFS) was observed in patients with acute lymphoblastic leukaemia (ALL) and grade II aGvHD vs. patients with no or grade I GvHD in the randomised, controlled, open-label, international, multicentre Phase III For Omitting Radiation Under Majority age (FORUM) trial. This finding suggests that moderate-severity aGvHD is associated with a graft-versus-leukaemia effect which protects against leukaemia recurrence. In order to optimise the benefits of HSCT for leukaemia patients, reduction of non-relapse mortality-which is predominantly caused by severe GvHD-is of utmost importance. Herein, we review contemporary prophylaxis and treatment options for aGvHD in children with ALL and the key challenges of aGvHD management, focusing on maintaining the graft-versus-leukaemia effect without increasing the severity of GvHD.
Collapse
Affiliation(s)
- Matthias Wölfl
- Pediatric Hematology, Oncology and Stem Cell Transplantation, Children's Hospital, Würzburg University Hospital, Würzburg, Germany
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Maria Isabel Benitez Carabante
- Department of Pediatric Hematology and Oncology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Tomas Sykora
- Haematopoietic Stem Cell Transplantation Unit, Department of Pediatric Haematology and Oncology, Comenius University Children's Hospital, Bratislava, Slovakia
| | - Halvard Bonig
- Institute for Transfusion Medicine and Immunohematology, Goethe-University Frankfurt/Main, Frankfurt, Germany.,German Red Cross Blood Service BaWüHe, Frankfurt, Germany
| | - Anita Lawitschka
- Department of Pediatrics, St. Anna Kinderspital and Children's Cancer Research Institute, Medical University of Vienna, Vienna, Austria
| | - Cristina Diaz-de-Heredia
- Department of Pediatric Hematology and Oncology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| |
Collapse
|
5
|
Goal-Oriented Monitoring of Cyclosporine Is Effective for Graft-versus-Host Disease Prevention after Hematopoietic Stem Cell Transplantation in Sickle Cell Disease and Thalassemia Major. Biol Blood Marrow Transplant 2020; 26:2285-2291. [DOI: 10.1016/j.bbmt.2020.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 01/21/2020] [Accepted: 01/23/2020] [Indexed: 11/21/2022]
|
6
|
García-Romero MT, Sáez-de-Ocariz M, Hernández-Zepeda C, Reyes M, García de la Puente S, Ridaura-Sanz C, López-Hernández G, Olaya-Vargas A. Early clinical, histological, and immunohistochemical findings in suspected acute graft-versus-host disease and their association with patient outcomes. Pediatr Dermatol 2020; 37:613-621. [PMID: 32242989 DOI: 10.1111/pde.14152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES Acute graft-versus-host disease (aGVHD) is a serious condition after allogeneic hematopoietic stem cell transplantation (HSCT), frequently involving skin, gut, and liver. It can be difficult to diagnose early, yet this is vital for adequate management. We sought to identify initial clinical and histopathological features in children with suspected GVHD and the association with clinical course and outcomes. METHODS Retrospective study of patients with skin biopsies for suspected aGVHD from 2006 to 2016. We collected demographic and clinical information, histologic, and immunohistochemical (IHC) findings, and outcomes during follow-up. Bivariate and multivariate analyses were done to identify risk factors associated with remission, development of severe/life-threatening aGVHD, and mortality. RESULTS We included 42 patients, 15 females. Skin manifestations occurred 51 days (median) after HSCT. On biopsy, 76.2% had mild (stage 1-2) skin aGVHD; during the course of the disease, severity and systemic involvement increased to global grade III/IV in 66.6%. All patients received treatment; 15 are in remission from aGVHD and 23 have died. Histologic features were diagnostic in 83.3%. On bivariate and multivariate analysis, we identified initial clinical and histologic findings that were associated with the measured outcomes: odds of remission from aGVHD were increased when focal vacuolar changes were found on skin biopsy (OR 6.028; 95%CI:1.253-28.992) but decreased by initial hepatic aGVHD (OR 0.112; 95%CI: 0.017-0.748); severe/life-threatening aGVHD was associated with initial gastrointestinal aGVHD (OR 6.054; 95%CI:1.257-29.159); and odds of mortality were decreased with male donor (OR 0.056; 95%CI:0.004-0.804), nulliparous female donor (OR 0.076; 95%CI:0.009-0.669), and focal vacuolar changes on skin biopsy (OR 0.113; 95%CI:0.017-0.770). CONCLUSIONS We found novel indicators predictive of remission, severity, and mortality in children with aGVHD. Further studies of this condition in children are needed.
Collapse
Affiliation(s)
| | | | | | - Montserrat Reyes
- Department of Pathology, National Institute for Pediatrics, Mexico City, Mexico
| | | | | | - Gerardo López-Hernández
- Department of Hematopoietic Stem Cell Transplantation, National Institute for Pediatrics, Mexico City, Mexico
| | - Alberto Olaya-Vargas
- Department of Hematopoietic Stem Cell Transplantation, National Institute for Pediatrics, Mexico City, Mexico
| |
Collapse
|
7
|
Chung EK, Yee J, Kim JY, Gwak HS. Low cyclosporine concentrations in children and time to acute graft versus host disease. BMC Pediatr 2020; 20:206. [PMID: 32393210 PMCID: PMC7212619 DOI: 10.1186/s12887-020-02125-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 05/05/2020] [Indexed: 11/19/2022] Open
Abstract
Background Achievement of target blood concentrations of cyclosporine (CsA) early after transplantation is known to be highly effective for reducing the incidence of acute graft versus host disease (aGVHD). However, no research has been conducted for predicting aGVHD occurrence with low CsA concentrations at different time periods. The objective of this study was to investigate the risk of aGVHD according to low CsA concentrations at lag days in children with allogenic hematopoietic stem cell transplantation (HSCT). Methods The records of 61 consecutive children who underwent allogeneic HSCT and received CsA as prophylaxis against aGVHD between May 2012 and March 2015 were retrospectively evaluated. The main outcome was any association between low CsA concentrations at lag days and aGVHD occurrence, which was examined for the first month after transplantation. Mean CsA concentrations at three lag periods were calculated: lag days 0–6, 7–13, and 14–20 before aGVHD occurrence. Results Patients whose mean CsA concentrations at lag days 0–6 did not reach the initial target concentration had 11.0-fold (95% confidence interval [CI]: 2.3–51.9) greater incidence of aGVHD. In addition, the AORs of low CsA concentrations at lag days 7–13 and 14–20 for developing aGVHD were 108.2 (95% CI: 7.7–1515.5) and 12.1 (95% CI: 1.1–138.1), respectively. Conclusions After low CsA concentrations are detected, careful attention needs to be paid to prevent aGVHD.
Collapse
Affiliation(s)
- Eun Kyung Chung
- Graduate School of Converging Clinical & Public Health, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, Korea.,Department of Pharmacy, Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul, 05535, Korea
| | - Jeong Yee
- College of Pharmacy & Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, Korea
| | - Jae Youn Kim
- Department of Pharmacy, Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul, 05535, Korea
| | - Hye Sun Gwak
- Graduate School of Converging Clinical & Public Health, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, Korea. .,College of Pharmacy & Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, Korea.
| |
Collapse
|
8
|
Lawitschka A, Lucchini G, Strahm B, Dalle JH, Balduzzi A, Gibson B, Diaz De Heredia C, Wachowiak J, Dalissier A, Vettenranta K, Yaniv I, Bordon V, Bauer D, Bader P, Meisel R, Peters C, Corbacioglu S. Pediatric acute graft-versus-host disease prophylaxis and treatment: surveyed real-life approach reveals dissimilarities compared to published recommendations. Transpl Int 2020; 33:762-772. [PMID: 32133691 PMCID: PMC7384018 DOI: 10.1111/tri.13601] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/06/2020] [Accepted: 02/28/2020] [Indexed: 12/22/2022]
Abstract
Pediatric allogeneic hematopoietic cell transplantation (HCT) practices differ from those of adults, particularly the heterogeneity of transplantable nonmalignant diseases and the lower incidence of graft‐versus‐host disease (GVHD). Several guidelines regarding the management of acute (a) GVHD in adult HCT have been published. We aimed to capture the real‐life approaches for pediatric aGVHD prophylaxis/treatment, and data from 75/193 (response rate 39%) EBMT centers (26 countries) were included, representing half (48%) of the pediatric EBMT‐HCT activity. Results with ≥75% approval from respondents (74/75) for GVHD prophylaxis after myeloablative HCT for malignancies partially contradict published guidelines: Single‐agent cyclosporine A (CsA) was used for matched sibling donor HCT in 47%; blood CsA levels were reported lower; the relapse risk in malignant diseases influenced GVHD prophylaxis with early withdrawal of CsA; distinct longer duration of CsA was employed in nonmalignant diseases. Most centers used additional anti‐thymocyte globulin for matched unrelated and mismatched donor HCT, but not for matched siblings. Regarding prophylaxis in nonmyeloablative conditioning (mainly for nonmalignant diseases), responses showed broad heterogeneity. High conformity was found for first‐line treatment; however, results regarding steroid‐refractory aGVHD indicate an earlier diagnosis in children. Our findings highlight the need for standardized pediatric approaches toward aGVHD prophylaxis/treatment differentiated for malignant and nonmalignant underlying diseases.
Collapse
Affiliation(s)
- Anita Lawitschka
- SCT-Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Giovanna Lucchini
- Stem Cell Transplantation Department, Great Ormond Street Hospital, London, UK
| | - Brigitte Strahm
- Division of Pediatric Hematology, and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Centre, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jean-Hugues Dalle
- Hemato-Immunology Department, Robert Debré Hospital, Paris, France.,Immuno-Hematology Unit, Robert Debré Hospital, Paris 7 - Paris Diderot University, Paris, France
| | - Adriana Balduzzi
- Clinica Pediátrica, Università degli Studi di Milano Bicocca, Monza, Italy
| | - Brenda Gibson
- Brenda E.S. Gibson, Royal Hospital for Sick Children, Glasgow, UK
| | | | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, University of Medical Sciences, Poznan, Poland
| | - Arnaud Dalissier
- EBMT Pediatric Diseases Working Party Office, Hematology and Cell Therapy Department, Saint-Antoine Teaching Hospital, Paris, France
| | - Kim Vettenranta
- Hospital for Children & Adolescents, University of Helsinki, Helsinki, Finland
| | - Isaac Yaniv
- Department of Pediatric Haematology Oncology and BMT Unit, Sackler Faculty of Medicine, Schneider Children's Medical Center of Israel, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Victoria Bordon
- Pediatric Hematology, Oncology and Stem Cell Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Dorothea Bauer
- SCT-Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Peter Bader
- Division for Stem Cell Transplantation, University Children's Hospital, Frankfurt/Main, Germany
| | - Roland Meisel
- Division of Pediatric Stem Cell Therapy, Clinic for Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Christina Peters
- SCT-Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Hospital Regensburg, Regensburg, Germany
| | | |
Collapse
|
9
|
Stocker N, Duléry R, Battipaglia G, Brissot E, Médiavilla C, Sestili S, Paviglianiti A, Ledraa T, Mohty R, Bazarbachi A, Belhocine R, Vekhoff A, Ruggeri A, Mohty M, Malard F. Impact of cyclosporine A concentration on acute graft‐vs‐host disease incidence after haploidentical hematopoietic cell transplantation. Eur J Haematol 2019; 103:10-17. [DOI: 10.1111/ejh.13233] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 04/01/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Nicolas Stocker
- INSERM, Centre de Recherche Saint‐Antoine (CRSA) Sorbonne Université Paris France
| | - Remy Duléry
- Service d'Hématologie Clinique AP‐HP, Hôpital Saint‐Antoine Paris France
| | | | - Eolia Brissot
- INSERM, Centre de Recherche Saint‐Antoine (CRSA) Sorbonne Université Paris France
- Service d'Hématologie Clinique AP‐HP, Hôpital Saint‐Antoine Paris France
| | - Clémence Médiavilla
- INSERM, Centre de Recherche Saint‐Antoine (CRSA) Sorbonne Université Paris France
- Service d'Hématologie Clinique AP‐HP, Hôpital Saint‐Antoine Paris France
| | - Simona Sestili
- Service d'Hématologie Clinique AP‐HP, Hôpital Saint‐Antoine Paris France
| | | | - Tounes Ledraa
- INSERM, Centre de Recherche Saint‐Antoine (CRSA) Sorbonne Université Paris France
- Service d'Hématologie Clinique AP‐HP, Hôpital Saint‐Antoine Paris France
| | - Razan Mohty
- Service d'Hématologie Clinique AP‐HP, Hôpital Saint‐Antoine Paris France
| | | | - Ramdane Belhocine
- Service d'Hématologie Clinique AP‐HP, Hôpital Saint‐Antoine Paris France
| | - Anne Vekhoff
- Service d'Hématologie Clinique AP‐HP, Hôpital Saint‐Antoine Paris France
| | - Annalisa Ruggeri
- Service d'Hématologie Clinique AP‐HP, Hôpital Saint‐Antoine Paris France
| | - Mohamad Mohty
- INSERM, Centre de Recherche Saint‐Antoine (CRSA) Sorbonne Université Paris France
- Service d'Hématologie Clinique AP‐HP, Hôpital Saint‐Antoine Paris France
| | - Florent Malard
- INSERM, Centre de Recherche Saint‐Antoine (CRSA) Sorbonne Université Paris France
- Service d'Hématologie Clinique AP‐HP, Hôpital Saint‐Antoine Paris France
| |
Collapse
|
10
|
Elgarten CW, Arnold DE, Bunin NJ, Seif AE. Outcomes of matched sibling donor bone marrow transplantation in children using single-agent calcineurin inhibitors as prophylaxis for graft versus host disease. Pediatr Blood Cancer 2018; 65:10.1002/pbc.26726. [PMID: 28748621 PMCID: PMC5699955 DOI: 10.1002/pbc.26726] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/20/2017] [Accepted: 06/22/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Optimal graft versus host disease (GVHD) prophylaxis prevents severe manifestations without excess immunosuppression. Standard prophylaxis includes a calcineurin inhibitor (CNI) with low-dose methotrexate. However, single-agent CNI may be sufficient prophylaxis for a defined group of patients. Single-agent CNI has been used for GVHD prophylaxis for human leukocyte antigen (HLA)-matched sibling donor (MSD) bone marrow transplants (BMTs) in young patients at the Children's Hospital of Philadelphia for over 20 years. Here, we describe outcomes using this prophylactic strategy in a recent cohort. PROCEDURE We performed a single-institution chart review and retrospective analysis of consecutive children undergoing MSD BMT who received single-agent CNI for GVHD prophylaxis between January 2002 and December 2014. RESULTS Fifty-two children with a median age of 6.1 years (interquartile range [IQR] 2.5-8.3) and donor age of 6 years (IQR 3-10), with malignant and nonmalignant diseases (n = 35 and 17, respectively) were evaluated. Forty-three (82.6%) received oral prophylaxis with single-agent tacrolimus after initial intravenous therapy. Rates of GVHD were consistent with reported rates on dual prophylaxis: the overall incidence of grades 2-4 acute GVHD was 25.5%, grades 3-4 GVHD 9.8%, and chronic GVHD 10.4%. The cumulative incidence of relapse among children with malignancy was 20% at a median of 237 days (IQR 194-318) post-transplant. Two-year overall survival was 82.7% (95% confidence interval [CI]: 69.4-90.6%) and event-free survival was 78.9% (95% CI: 65.1-87.7%). No patient experienced graft failure. CONCLUSIONS Single-agent CNI is a safe, effective approach to GVHD prophylaxis in young patients undergoing HLA-identical sibling BMT. Additionally, single-agent oral tacrolimus is a reasonable alternative to cyclosporine in this population.
Collapse
Affiliation(s)
- Caitlin W. Elgarten
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Danielle E. Arnold
- Division of Immunology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nancy J. Bunin
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alix E. Seif
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
11
|
Friedrich P, Guerra-García P, Stetson A, Duncan C, Lehmann L. Young Female Donors Do Not Increase the Risk of Graft-versus-Host Disease or Impact Overall Outcomes in Pediatric HLA-Matched Sibling Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2017; 24:96-102. [PMID: 28958895 DOI: 10.1016/j.bbmt.2017.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 09/20/2017] [Indexed: 01/29/2023]
Abstract
Optimal donor selection is critical in hematopoietic stem cell transplantation (HSCT). Donor-recipient sex mismatch, donor age, and female donor-donor parity are known to impact graft-versus-host disease (GVHD) and outcomes in adults. Minor histocompatibility antigens encoded by the human Y chromosome can result in specific antibody formation in some female donors, may increase in frequency with increasing donor age, and may be contributory to the increased incidence of GVHD. To better understand the role of donor age/sex and sex matching in HSCT outcomes, we conducted a retrospective study of pediatric patients receiving their first myeloablative sibling donor HSCT (n = 244) from 1998 to 2012. Observed rates of GVHD were low: 17% of patients surviving past engraftment (n = 243) developed grades II to IV acute GVHD (aGVHD) and 14% surviving ≥ 100 days (n = 229) developed chronic GVHD (cGVHD). On multivariate analysis the risk of aGVHD, cGVHD, and death increased with patient age as expected. Female donor sex and sex mismatch (female donor-male recipient) had no impact on the development of aGVHD. cGVHD was increased with female donors only if the donor was ≥12 years old. No cGVHD was observed among 109 patients aged < 10 years who received a 6/6 HLA-matched marrow HSCT, regardless of donor age or sex. Survival was mostly driven by diagnosis. Results suggest that in pediatric HSCT, young HLA-matched siblings are equivalently good donors regardless of sex or donor-recipient sex mismatch.
Collapse
Affiliation(s)
- Paola Friedrich
- Department of Oncology and Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Pilar Guerra-García
- Department of Pediatric Hematology and Oncology, University Hospital 12 de Octubre, Madrid, Spain
| | - Alyssa Stetson
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Christine Duncan
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Leslie Lehmann
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.
| |
Collapse
|
12
|
Improved outcome of children transplanted for high-risk leukemia by using a new strategy of cyclosporine-based GVHD prophylaxis. Bone Marrow Transplant 2016; 51:698-704. [DOI: 10.1038/bmt.2015.350] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 12/01/2015] [Accepted: 12/16/2015] [Indexed: 11/09/2022]
|
13
|
Tafazoli A. Cyclosporine use in hematopoietic stem cell transplantation: pharmacokinetic approach. Immunotherapy 2015; 7:811-36. [DOI: 10.2217/imt.15.47] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Cyclosporine is one of the most vital agents in the process of successful allogeneic hematopoietic stem cell transplantation. Despite a long history and worldwide extent of cyclosporine use for prevention of graft versus host disease, currently there are lots of uncertainties about its optimal method of application to reach the best clinical outcome. A major portion of this problem stems from complicated cyclosporine pharmacokinetics. Study of cyclosporine pharmacokinetic behavior can significantly help recognition of its effectiveness and consequently, optimization of dosing, administration, monitoring and management of adverse effects. In this review, highly accredited but sparse scientific data are gathered in order to provide a better insight for preparation of practice guidelines and directing future studies for allogeneic hematopoietic cell recipients.
Collapse
Affiliation(s)
- Ali Tafazoli
- Clinical Pharmacy Department, School of Pharmacy, Shahid Beheshti University of Medical Sciences (SBMU), Vali-e-Asr Avenue, Niayesh Junction, PO Box: 14155/6153 Tehran, Iran
- Taleghani Bone Marrow Transplantation Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences (SBMU), Vali-e-Asr Avenue, Niayesh Junction, PO Box 14155/6153 Tehran, Iran
| |
Collapse
|
14
|
Bernard E, Goutelle S, Bertrand Y, Bleyzac N. Pharmacokinetic drug-drug interaction of calcium channel blockers with cyclosporine in hematopoietic stem cell transplant children. Ann Pharmacother 2014; 48:1580-4. [PMID: 25280976 DOI: 10.1177/1060028014550644] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Cyclosporine (CsA) is frequently responsible for hypertension in bone marrow transplant children. Calcium channel blockers (CCBs) are considered to be the best treatment for CsA-induced hypertension, but they may alter the exposure and the effect of CsA by inhibiting the CYP3A4 pathway of CsA metabolism or P-gp. However, the inhibitory effect on CYP3A4 may vary among CCBs. METHODS This study aimed to quantify the pharmacokinetic drug-drug interaction between CsA and nicardipine, amlodipine, and lacidipine. In all, 51 children who received CsA and CCB concomitantly were included. RESULTS Dose-normalized CsA trough blood concentrations significantly increased in patients treated with nicardipine and amlodipine, whereas they remained stable in patients treated with lacidipine. CONCLUSIONS Because lacidipine appears to have no effect on CsA exposure, it may be the best option among CCBs for treating high blood pressure caused by CsA in children.
Collapse
Affiliation(s)
- Elodie Bernard
- Institut d'Hématologie et d'Oncologie Pédiatrique, Lyon, France
| | - Sylvain Goutelle
- Laboratoire de Biométrie et Biologie Evolutive, Université Lyon 1, Villeurbanne, France
| | - Yves Bertrand
- Institut d'Hématologie et d'Oncologie Pédiatrique, Lyon, France
| | - Nathalie Bleyzac
- Institut d'Hématologie et d'Oncologie Pédiatrique, Lyon, France Laboratoire de Biométrie et Biologie Evolutive, Université Lyon 1, Villeurbanne, France
| |
Collapse
|
15
|
Efficacité et tolérance de la lacidipine dans le traitement de l’hypertension artérielle en onco-hématologie pédiatrique. Arch Pediatr 2014; 21:1101-5. [DOI: 10.1016/j.arcped.2014.06.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 04/16/2014] [Accepted: 06/27/2014] [Indexed: 11/20/2022]
|
16
|
Vossen JM, Guiot HFL, Lankester AC, Vossen ACTM, Bredius RGM, Wolterbeek R, Bakker HDJ, Heidt PJ. Complete suppression of the gut microbiome prevents acute graft-versus-host disease following allogeneic bone marrow transplantation. PLoS One 2014; 9:e105706. [PMID: 25180821 PMCID: PMC4152127 DOI: 10.1371/journal.pone.0105706] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 07/22/2014] [Indexed: 11/18/2022] Open
Abstract
The hypothesis that elimination of facultative and strict anaerobic microorganisms from the gastro-intestinal tract by antimicrobial drugs in the period of time around allogeneic bone marrow transplantation (BMT) prevents acute graft-versus-host disease (GVHD), was examined in a cohort of 112 children grafted between 1989 and 2002 for hematological malignancies. All patients received T-cell replete marrow from human leukocyte antigens (HLA) matched sibling donors under identical transplantation conditions. To eliminate microorganisms from the gastro-intestinal tract, total gastro-intestinal decontamination (GID) was applied by high doses of non-absorbable antimicrobial drugs while the graft recipient was maintained in strict protective isolation. About half of the children (51%) proved to be successfully decontaminated, and about half (49%) unsuccessfully. One recipient got acute GVHD in the first group and 8 in the second group (p = 0.013). The degree of success of total GID was decisive for the occurrence of acute GVHD, irrespective of the presence of other risk factors such as higher age of recipient and/or donor, female donor for male recipient and carriership or reactivation of herpesviruses. Our results demonstrate that successful total GID of the graft recipient prevents moderate to severe acute GVHD. We suppose that substantial translocation of gastro-intestinal microorganisms or parts of these, functioning as microbial-associated molecular patterns (MAMP's), triggering macrophages/dendritic cells via pattern recognizing receptors (PRR's) is prohibited. As a consequence the initiation and progression of an inflammatory process leading to acute GVHD is inhibited.
Collapse
Affiliation(s)
- Jaak M. Vossen
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
| | - Harry F. L. Guiot
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan C. Lankester
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Ann C. T. M. Vossen
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Ron Wolterbeek
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Hanny D. J. Bakker
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter J. Heidt
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
- Biomedical Primate Research Centre, Rijswijk, The Netherlands
| |
Collapse
|
17
|
Early coagulation disorder after allogeneic stem cell transplantation is a strong prognostic factor for transplantation-related mortality, and intervention with recombinant human thrombomodulin improves the outcome: a single-center experience. Int J Hematol 2013; 98:533-42. [DOI: 10.1007/s12185-013-1443-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 09/11/2013] [Accepted: 09/11/2013] [Indexed: 01/04/2023]
|
18
|
Dupuis LL, Seto W, Teuffel O, Gibson P, Schultz KR, Doyle JD, Gassas A, Egeler RM, Sung L, Schechter T. Prediction of area under the cyclosporine concentration versus time curve in children undergoing hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2012; 19:418-23. [PMID: 23128321 DOI: 10.1016/j.bbmt.2012.10.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 10/28/2012] [Indexed: 10/27/2022]
Abstract
This prospective study aimed to validate a previously developed first-dose limited sampling strategy (LSS) to predict the area under the cyclosporine concentration-versus-time curve (AUC) and to develop and then validate an LSS to predict cyclosporine AUC at steady state. This two-center Canadian study included children (ages .4 to 17.2 years) undergoing myeloablative allogeneic hematopoietic stem cell transplantation receiving cyclosporine for acute graft-versus-host disease prophylaxis. There were three cohorts, each incorporating 24 AUC determinations: first-dose LSS validation, steady-state LSS development, and steady-state LSS validation. Patients contributing data to either of the development cohorts were excluded from the corresponding validation group. Cyclosporine was given every 12 hours as a 2-hour infusion. Cyclosporine AUC was determined after administration of the first cyclosporine dose (8 samples) and then once weekly (9 samples) until engraftment. Steady-state LSSs were developed using stepwise multiple linear regression. An LSS was considered to provide an acceptable estimate of AUC if the lower limit of the 95% confidence limit (CL) of the intraclass coefficient was .8 or higher and both bias and precision were 15% or less. Fifty-three children age .4 to 18 years participated. Cyclosporine concentrations drawn up to 4 hours from the start of the infusion correlated most strongly with AUC. The previously developed first-dose LSSs and three steady-state LSSs met criteria for acceptability. The intraclass coefficients of the three-point first-dose LSS validation cohort, three-point steady-state LSS development cohort, and three-point steady-state LSS validation cohort were .974 (95% CL: .941 to .988), .984 (95% CL: .965 to .993), and .993 (95% CL: .984 to .997), respectively. The three-point first-dose (2, 6, and 8 hours) and steady-state (2, 2.5, and 8 hours) LSSs are valid measures of cyclosporine AUC after intravenous administration over 2 hours. Their use in a prospective evaluation of the relationship between cyclosporine AUC and hematopoietic stem cell transplantation clinical outcomes in children is suggested.
Collapse
Affiliation(s)
- L Lee Dupuis
- Department of Pharmacy, SickKids, 555 University Ave., Toronto, Ontario, Canada.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Kedmi M, Dray L, Grisariu S, Resnick IB, Stepensky P, Aker M, Or R, Shapira MY. The effect of cyclosporine initiation time on the outcome of matched allogeneic stem-cell transplantation following fludarabine-based conditioning. Transpl Int 2012; 25:1241-7. [PMID: 22974004 DOI: 10.1111/j.1432-2277.2012.01559.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cyclosporine (CSA) is the most commonly used medication for GVHD prophylaxis. The initiation time varies from day -4 to day 0. Initially, we gave CSA starting on day -1. However, since 2003 we have changed CSA initiation timing policy in most of our protocols to day -4, to achieve stable and controlled pretransplant CSA levels. Here, we assessed if initiation time impact the outcome of allogeneic stem-cell transplantation (allo-SCT). Data of 261 patients who underwent allo-SCT for hematological malignancies from a fully matched donor, treated with CSA as a single agent for GVHD prophylaxis were prospectively collected. Patients were divided according to CSA initiation time and analyzed for outcome. The acute GVHD severity, cGVHD extent, GVHD-associated mortality were significantly lower in the CSA -4 group. There was no difference in the rate and timing of acute or chronic GVHD. Overall survival did not differ between the groups. We conclude that the initiation of CSA at day -4 reduced the severity of aGVHD, extent of cGVHD, and GVHD-associated mortality without impact on overall survival.
Collapse
Affiliation(s)
- Meirav Kedmi
- Departments of Bone Marrow Transplantation & Cancer Immunotherapy and Pediatrics, Hadassah, Hebrew University Medical Center, Jerusalem, Israel
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Update on the mechanism of action and on clinical efficacy of extracorporeal photopheresis in the treatment of acute and chronic graft versus host disease in children. Transfus Apher Sci 2011; 46:203-9. [PMID: 22079263 DOI: 10.1016/j.transci.2011.10.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 10/13/2011] [Indexed: 11/21/2022]
Abstract
Extracorporeal photopheresis (ECP) has been used for treatment of steroid-refractory graft versus host disease (GVHD) with encouraging results. Although its exact mechanism of action is not fully understood, photoapheresed cells seem to induce a selective immune response directed against alloreactive T cell populations without causing generalized immunosuppression. Current pediatric experience with ECP for GVHD is available in the form of a few retrospective small studies concerning children with steroid refractory GVHD. Reviewing these data we conclude that ECP is a safe procedure, well tolerated even in low-weight pediatric patients, which warrants further evaluation in well-designed, prospective, controlled studies.
Collapse
|
21
|
HU STEPHANIEW, COTLIAR JONATHAN. Acute graft-versus-host disease following hematopoietic stem-cell transplantation. Dermatol Ther 2011; 24:411-23. [DOI: 10.1111/j.1529-8019.2011.01436.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
22
|
Goussetis E, Paisiou A, Kitra V, Peristeri I, Vessalas G, Stefanaki K, Panayotou I, Giamaiou K, Kontou E, Kitzoni M, Dimopoulou MN, Karkelis S, Kafritsa Y, Rapsomaniki E, Papassotiriou I, Tsirigotis P, Roma E, Graphakos S. Acute Gastrointestinal Graft-versus-Host Disease in Pediatric Patients: Serum Albumin on Day 5 from Initiation of Therapy Correlates with Nonrelapse Mortality and Overall Survival. Biol Blood Marrow Transplant 2011; 17:1058-66. [DOI: 10.1016/j.bbmt.2010.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Accepted: 11/03/2010] [Indexed: 11/26/2022]
|
23
|
Gérard C, Bleyzac N, Girard P, Freyer G, Bertrand Y, Tod M. Links Between Cyclosporin Exposure in Tissues and Graft-Versus-Host Disease in Pediatric Bone Marrow Transplantation: Analysis by a PBPK Model. Pharm Res 2010; 28:531-9. [DOI: 10.1007/s11095-010-0299-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 09/28/2010] [Indexed: 11/24/2022]
|
24
|
Influence of Dosing Schedule on Organ Exposure to Cyclosporin in Pediatric Hematopoietic Stem Cell Transplantation: Analysis with a PBPK Model. Pharm Res 2010; 27:2602-13. [DOI: 10.1007/s11095-010-0252-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 08/16/2010] [Indexed: 10/19/2022]
|
25
|
Choi SW, Levine JE, Ferrara JLM. Pathogenesis and management of graft-versus-host disease. Immunol Allergy Clin North Am 2010; 30:75-101. [PMID: 20113888 DOI: 10.1016/j.iac.2009.10.001] [Citation(s) in RCA: 131] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is an important therapeutic option for various malignant and nonmalignant conditions. As allogeneic HCT continues to increase, greater attention is given to improvements in supportive care, infectious prophylaxis, immunosuppressive medications, and DNA-based tissue typing. However, graft versus host disease (GVHD) remains the most frequent and serious complication following allogeneic HCT and limits the broader application of this important therapy. Recent advances in the understanding of the pathogenesis of GVHD have led to new approaches to its management, including using it to preserve the graft versus leukemia effect following allogeneic transplant. This article reviews the important elements in the complex immunologic interactions involving cytokine networks, chemokine gradients, and the direct mediators of cellular cytotoxicity that cause clinical GVHD, and discusses the risk factors and strategies for management of GVHD.
Collapse
Affiliation(s)
- Sung W Choi
- Department of Pediatrics, Blood and Marrow Transplant Program, University of Michigan Medical School, 1500 E. Medical Center Drive, 6303 Comprehensive Cancer Center, Ann Arbor, MI 48109-5942, USA.
| | | | | |
Collapse
|
26
|
Multi-center evaluation of a commercial Kit for tacrolimus determination by LC/MS/MS. Clin Biochem 2010; 43:910-20. [DOI: 10.1016/j.clinbiochem.2010.03.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 03/02/2010] [Accepted: 03/27/2010] [Indexed: 11/24/2022]
|
27
|
CsA exposure is associated with acute GVHD and relapse in children after SCT. Bone Marrow Transplant 2009; 45:1056-61. [DOI: 10.1038/bmt.2009.299] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
28
|
Malard F, Szydlo RM, Brissot E, Chevallier P, Guillaume T, Delaunay J, Ayari S, Dubruille V, Le Gouill S, Mahe B, Gastinne T, Blin N, Saulquin B, Harousseau JL, Moreau P, Mohty M. Impact of cyclosporine-A concentration on the incidence of severe acute graft-versus-host disease after allogeneic stem cell transplantation. Biol Blood Marrow Transplant 2009; 16:28-34. [PMID: 20053329 DOI: 10.1016/j.bbmt.2009.08.010] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Accepted: 08/20/2009] [Indexed: 12/30/2022]
Abstract
This single-center retrospective study analyzed 85 consecutive patients who underwent allogeneic stem cell transplantation (allo-SCT) with the aim to assess whether there is a correlation between exposure to cyclosporine-A (CsA; as measured by CsA concentrations during the first month after allo-SCT) and the risk for developing severe grade III-IV acute graft-versus-host disease (aGVHD). The median concentrations of CsA in the blood at 1, 2, 3, and 4 weeks after allo-SCT were 348 (range: 172-733), 284 (range: 137-535), 274 (range: 107-649), and 247 (range: 37-695) ng/mL, respectively. Overall, grade II-IV aGVHD occurred in 36 patients (42%) at a median of 29 (range: 6-100) days after allo-SCT. The incidence of grade III-IV aGVHD (n = 20) was 23% (95% confidence interval [CI], 14%-32%). In univariate analysis, patients receiving allo-SCT from an HLA-matched unrelated donor had a higher risk of grade III-IV aGVHD, and patients having the lowest CsA concentration in the first and second weeks after allo-SCT had a significantly higher risk of grade III-IV aGVHD. In a multivariate logistic regression analysis, a higher CsA concentration measured during the first week following graft infusion was the strongest parameter significantly associated with a reduced risk of severe grade II-IV aGVHD (P = .012; relative risk [RR] = 0.24; 95% CI, 0.08-0.73). Of note, when adjusted by donor type, CsA concentration in week 1 remained significantly associated with risk of severe grade II-IV aGVHD (P = .014). We conclude that precise monitoring of CsA concentrations and adjustment of CsA dose early after allo-SCT may be effective to prevent onset of severe aGVHD.
Collapse
Affiliation(s)
- Florent Malard
- Centre Hospitalier et Universitaire (CHU) de Nantes, Service d'Hématologie Clinique, Nantes, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Schrauder A, Saleh S, Sykora KW, Hoy H, Welte K, Boos J, Hempel G, Grigull L. Pharmacokinetic monitoring of intravenous cyclosporine A in pediatric stem-cell transplant recipients. The trough level is not enough. Pediatr Transplant 2009; 13:444-50. [PMID: 18482216 DOI: 10.1111/j.1399-3046.2008.00968.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In order to monitor CsA serum levels after SCT, trough levels (C0) are widely used. The aim of this study was to estimate the population and individual PK parameters for patients receiving intravenous CsA after SCT. In 27 pediatric patients after SCT receiving CsA (3 mg/kg/day) every 12 h, a total of 289 CsA concentrations was obtained. To describe the PK parameters of CsA, a two-compartment model with first order elimination was used. Covariate analysis identified body weight, age, and the co-administration with itraconazole and tobramycine as factors influencing the Cl. The statistical comparison of AUC, trough level, and C2 indicates a correlation between AUC and C2, but no correlation between the AUC and C0, r = 0.24 (p = 0.146) vs. r = 0.526 (p = 0.000692), respectively. Our results underscore the fact that CsA trough levels do not reflect the drug exposure in patients receiving intravenous CsA after SCT. By contrast, CsA blood levels measured 2-6 h after CsA infusion showed a better correlation with the AUC. Our data provide new information to optimize the balancing act between GvHD-prophylaxis, graft vs. leukemia effect, and CsA side-effects after SCT.
Collapse
Affiliation(s)
- A Schrauder
- Department of Pediatric Hematology and Oncology, Children's Hospital, Medical University, Kiel, Germany
| | | | | | | | | | | | | | | |
Collapse
|
30
|
Bleyzac N. The use of pharmacokinetic models in paediatric onco-haematology: effects on clinical outcome through the examples of busulfan and cyclosporine. Fundam Clin Pharmacol 2009; 22:605-8. [PMID: 19049662 DOI: 10.1111/j.1472-8206.2008.00652.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Overall survival after allogeneic haematopoietic stem cell transplantation (HSCT) is reduced by the high rate of transplantation-related mortality (TRM), especially because of liver veno-occlusive disease (VOD) or acute graft-vs.-host disease (GVHD) because of the toxicity or inefficacy of busulfan and cyclosporine (CsA), respectively. Results of clinical outcome of previous studies performed to optimize busulfan and CsA therapy by controlling their pharmacokinetic variability by means of maximum a posteriori (MAP) Bayesian individualization of both drugs are presented. The 90-day VOD-free survival was significantly higher in patients with individualized busulfan doses: 97% vs. 76%. Monitoring CsA trough blood concentrations allowed us to obtain a successful GVHD outcome (mild or moderate GVHD and graft vs. leukaemia effect (GVL) in malignant diseases and no GVHD (in non-malignant ones) in the majority of our patients. Severe GVHD occurred in <5% of patients. TRM in children can be significantly decreased by using population pharmacokinetic models and MAP Bayesian individualization of dose regimens for drugs such as CsA and busulfan.
Collapse
Affiliation(s)
- N Bleyzac
- Institut d'Hématologie et d'Oncologie Pédiatrique, 1 Place Joseph Renaut, 69 008 Lyon, France.
| |
Collapse
|
31
|
Patel NC, Chinen J, Rosenblatt HM, Hanson IC, Brown BS, Paul ME, Abramson SL, Ritz J, Shearer WT. Long-term outcomes of nonconditioned patients with severe combined immunodeficiency transplanted with HLA-identical or haploidentical bone marrow depleted of T cells with anti-CD6 mAb. J Allergy Clin Immunol 2009; 122:1185-93. [PMID: 19084111 DOI: 10.1016/j.jaci.2008.10.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Revised: 10/21/2008] [Accepted: 10/23/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Between 1981 and 1995, 20 children with severe combined immunodeficiency (SCID; median age at transplant, 6.5 [range, 0.5-145] mo, 12 with serious infection) were treated with haploidentical T cell-depleted (anti-CD6 antibody) bone marrow (median number of 5.7 [0.8-18.8] x 10(8) nucleated cells/kg) from mismatched related donors (MMRDs), and 5 children with SCID (median age at transplant, 1.8 [0.5-5.0] mo, 1 with serious infection) were given unmanipulated bone marrow from matched related donors (MRDs). No conditioning or graft-versus-host disease (GvHD) prophylaxis was used. OBJECTIVE To assess the outcomes of patients with SCID who received bone marrow from MMRDs or MRDs. METHODS We reviewed the medical records of these 25 consecutive patients with SCID (4 with Omenn syndrome). RESULTS Of the 20 patients who received bone marrow from MMRDs, 12 engrafted, 10 survived at a median age of 15.2 [10.0-19.1] years, 4 had chronic GvHD (lung, intestine, skin), 5 required intravenous immunoglobulin, and 8 attended school or college. Two of 5 patients who died had chronic GvHD, and 2 developed lymphoproliferative disease. Of the 5 patients who received bone marrow from MRDs, 5 engrafted, 5 survived at a median age of 23.3 [18.5-26] years, 1 had chronic GvHD (lung, skin), 2 required intravenous immunoglobulin, and 4 attended school or college. CONCLUSIONS Treatment of critically ill patients with SCID with anti-CD6 antibody T cell-depleted MMRD marrow resulted in an overall 50% long-term survival of patients (83% survival of those engrafted). The principal barriers to long-term survival were delay in diagnosis, life-threatening infection, failure to engraft, and chronic GvHD. Educational goals were achieved in most of the survivors.
Collapse
Affiliation(s)
- Niraj C Patel
- Department of Pediatrics, Section of Allergy and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77039, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
|
33
|
Matched unrelated bone marrow transplant for T+ combined immunodeficiency. Bone Marrow Transplant 2008; 41:947-52. [DOI: 10.1038/bmt.2008.11] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
34
|
Achievement of Target Cyclosporine Concentrations as a Predictor of Severe Acute Graft Versus Host Disease in Children Undergoing Hematopoietic Stem Cell Transplantation and Receiving Cyclosporine and Methotrexate Prophylaxis. Ther Drug Monit 2007; 29:750-7. [DOI: 10.1097/ftd.0b013e31815c12ca] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
35
|
|
36
|
Izumi N, Furukawa T, Sato N, Okazuka K, Tsukada N, Abe T, Yano T, Kurasaki T, Masuko M, Toba K, Takahashi M, Aizawa Y. Risk factors for acute graft-versus-host disease after allogeneic hematopoietic stem cell transplantation: retrospective analysis of 73 patients who received cyclosporin A. Bone Marrow Transplant 2007; 40:875-80. [PMID: 17724440 DOI: 10.1038/sj.bmt.1705834] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cyclosporin A (CsA) has been used most widely as an immunosuppressive agent for preventing graft-versus-host disease (GVHD). To explore the risk factors including CsA blood levels for grades II-IV acute GVHD, we retrospectively analyzed the data of patients who underwent allogeneic hematopoietic stem cell transplantation in our hospital between March 1989 and July 2001. Seventy-three patients (47 males and 26 females) received CsA and short-term methotrexate for GVHD prophylaxis. CsA 1.5 mg/kg was administered as a 3-h infusion twice daily from day 1 until the patient recovered from the toxic gastrointestinal complication. Methotrexate was given at a dose of 15 mg/m(2) on day 1 and 10 mg/m(2) on days 3, 6 and 11. Grades II-IV acute GVHD occurred in 18 patients (24.7%). Multivariate Cox regression analysis revealed that higher C(5) (the whole-blood CsA concentration at 5 h after the start of infusion) before the onset of acute GVHD reduced the onset of grades II-IV acute GVHD with a hazard ratio of 0.994 (95% confidence interval 0.989-0.999) for every increase of 1 ng/ml. Our data indicate that inadequate exposures of CsA can be a vital risk for developing acute GVHD. From our results, we consider that precise monitoring of CsA concentrations and adjustment of CsA dose using the concentration may be effective to prevent the onset of severe acute GVHD. To confirm this finding, further prospective study will be needed.
Collapse
Affiliation(s)
- N Izumi
- Division of Hematology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Wang H, Grzywacz B, Sukovich D, McCullar V, Cao Q, Lee AB, Blazar BR, Cornfield DN, Miller JS, Verneris MR. The unexpected effect of cyclosporin A on CD56+CD16- and CD56+CD16+ natural killer cell subpopulations. Blood 2007; 110:1530-9. [PMID: 17495133 PMCID: PMC1975839 DOI: 10.1182/blood-2006-10-048173] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cyclosporin A (CSA) is commonly used to prevent graft-versus-host disease. The influence of CSA on T-cell function has been extensively investigated; however, the effect of CSA on natural killer (NK) cells is less understood. NK cells were cultured with IL-2 and IL-15 with and without CSA for 1 week. Compared with controls, CSA-treated cultures showed fewer CD56(+)CD16(+)KIR(+) NK cells and a reciprocal increase in CD56(+)CD16(-)KIR(-) cells. These changes were due mainly to a reduced proliferation of the CD56(dim) NK-cell subpopulation and a relative resistance of CD56(bright) NK cells to CSA. Following coculture with K562 targets, CSA-exposed NK cells differed from controls and lacked Ca(2+) oscillations, nuclear factor of activated T cells (NFAT) dephosphorylation, and NFAT nuclear translocation. NK cells cultured in CSA retained cytotoxicity against K562, Raji, and KIR ligand-expressing lymphoblastoid cells. NK cells cultured in CSA showed increases in NKp30 and reductions in NKp44 and NKG2D. Following IL-12 and IL-18 stimulation, CSA-treated NK cells showed more IFN-gamma-producing cells. Using in vitro NK-cell differentiation, progenitor cells gave rise to more CD56(+)KIR(-) NK cells in the presence of CSA than controls. Collectively, these studies show that CSA influences NK-cell function and phenotype, which may have important implications for graft-versus-leukemia effects.
Collapse
Affiliation(s)
- Hongbo Wang
- Department of Pediatrics, Cancer Center, University of Minnesota, Minneapolis, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Russell JA, Turner AR, Larratt L, Chaudhry A, Morris D, Brown C, Quinlan D, Stewart D. Adult Recipients of Matched Related Donor Blood Cell Transplants Given Myeloablative Regimens Including Pretransplant Antithymocyte Globulin Have Lower Mortality Related to Graft-versus-Host Disease: A Matched Pair Analysis. Biol Blood Marrow Transplant 2007; 13:299-306. [DOI: 10.1016/j.bbmt.2006.10.017] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2004] [Accepted: 10/12/2006] [Indexed: 12/01/2022]
|
39
|
Dupuis LL, Taylor T, Saunders EF. Disposition of two oral formulations of cyclosporine in pediatric patients receiving hematopoietic stem cell transplants. Pharmacotherapy 2006; 26:15-22. [PMID: 16509024 DOI: 10.1592/phco.2006.26.1.15] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES To compare the disposition of cyclosporine after the administration of two oral formulations to children undergoing hematopoietic stem cell transplantation, and to evaluate the relationship between whole blood cyclosporine concentrations during the dosing interval and the area under the whole blood concentration-time curve. DESIGN Prospective, descriptive, crossover study.Setting. Hematopoietic stem cell transplantation unit in a tertiary-quaternary university-affiliated pediatric hospital. PATIENTS Twenty-four pediatric patients aged 0.5-16.9 years undergoing allogeneic hematopoietic stem cell transplantation. INTERVENTION The modified oral formulation of cyclosporine was given on the first day (divided as two doses), and a single identical dose of the original oral formulation was given on the morning of the second day. MEASUREMENTS AND MAIN RESULTS Blood samples were obtained at 0, 0.5, 1.25, 2, 4, 6, 9, and 12 hours after the morning dose from the lumen of the central venous catheter not previously used for intravenous cyclosporine administration. Cyclosporine concentration-time data were analyzed by using noncompartmental methods. Mean +/- SD maximum concentrations were significantly higher after administration of the modified form than after administration of the original form (594.9 +/- 349.7 vs 483.0 +/- 363.0 microg/L, p=0.003), as was the area under the concentration-time curve from 0-12 hours (AUC0-12; 3432 +/- 1563 vs 3144 +/- 1780 microg/L x hr, p=0.022). For both formulations, cyclosporine concentrations at 4 hours after administration were most strongly correlated with the AUC0-12. Unlike that of the original formulation, the trough cyclosporine concentration of the modified form had the weakest relationship with AUC (Spearman rho coefficient 0.584, p=0.003). CONCLUSION Cyclosporine absorption is lower in children undergoing hematopoietic stem cell transplantation than in children receiving solid organ transplants. Dosage adjustment for the modified formulation based on trough concentration may not be appropriate because its relationship with the AUC was weak. The link between pharmacokinetic parameters and clinical outcomes, such as graft-versus-host disease, must be further studied.
Collapse
Affiliation(s)
- L Lee Dupuis
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | | | | |
Collapse
|
40
|
Huang XJ, Jiang Q, Chen H, Xu L, Liu D, Chen Y, Han W, Zhang Y, Liu K, Lu D. Low-dose methotrexate for the treatment of graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2005; 36:343-8. [PMID: 15968295 DOI: 10.1038/sj.bmt.1705034] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Methotrexate (MTX) is commonly used in the prophylaxis of graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). In order to evaluate the efficacy and safety of low-dose MTX treatment in patients with GVHD after allo-HSCT, 38 patients with acute GVHD (aGVHD), chronic GVHD (cGVHD) or GVHD post-donor lymphocyte infusion (post-DLI GVHD) after allo-HSCT received intravenous MTX at a dose of 5 or 10 mg every 5-- days until a complete or partial response was seen, or there was treatment failure or intolerable side effects. The overall response rate was 94.7% (18/19 patients) in patients with aGVHD, 76.2% (16/21 patients) in patients with cGVHD and 2/2 in patients with post-DLI GVHD. The response rate for GVHD involving various organs was 100% in skin, 75% in gut, 55.6% in liver, 75% in mouth and 100% in the eye, among all enrolled patients. Side effects were minor. Short-term, low-dose MTX is a tolerable and an effective regimen for patients with aGVHD, cGVHD or post-DLI GVHD after allo-HSCT.
Collapse
Affiliation(s)
- X-J Huang
- Institute of Hematology, Peking University, People'Hospital, Beijing, China.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Bertolle V, Martin P, Bleyzac N, Aulagner G. [Busulfan and cycosporin in bone graft children]. ANNALES PHARMACEUTIQUES FRANÇAISES 2004; 62:165-76. [PMID: 15243350 DOI: 10.1016/s0003-4509(04)94299-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Most drugs exhibit both inter- and intra-individual pharmacokinetic and pharmacodynamic variability. This variability explains the different responses observed in patients exposed to standard doses and must be taken into consideration when the therapeutic window is narrow. Population pharmacokinetics provides mean (or median) values of pharmacokinetic parameters as well as the distribution pattern and the statistical relationship with covariables in a group of individuals presenting common characteristics. Among the different methods developed for population pharmacokinetics, the data pool method, as well as the two-step and one-step methods (NONMEM and NPEM) are attractive. Population models can then be developed using bayesian logistics to obtain an estimation of the pharmacokinetic parameters of a given patient and predict the most adapted dose in light of the therapeutic target (residual serum concentration, mean concentration.). Busulfan is an alkylizing agent used instead of radiotherapy for pre-graft preparation before bone marrow grafts in children. This compound requires dose monitoring because of its narrow therapeutic window: under-dosing raises the risk of graft rejection; inversely over-dosing can cause potentially fatal complications such as occlusive venous disease. Interindividual variability is characteristic of busulfan kinetics. Several factors can explain part of this variability: age, underlying disease, changes in liver function, drug bioavailability, chronobiology. The short treatments used (most protocols have 16 doses given in four days) require rapid monitoring to propose effective adjustments. In this context, use of bayesian logistics to estimate the patient's pharmokinetic parameters is very useful for correct dosing. This type of monitoring could also be used for other compounds such as cyclosporine, with a narrow therapeutic window.
Collapse
|