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Report from the 2018 consensus conference on immunomodulating agents in thoracic transplantation: Access, formulations, generics, therapeutic drug monitoring, and special populations. J Heart Lung Transplant 2020; 39:1050-1069. [DOI: 10.1016/j.healun.2020.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 06/29/2020] [Indexed: 01/06/2023] Open
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Gantar K, Škerget K, Mochkin I, Bajc A. Meeting Regulatory Requirements for Drugs with a Narrow Therapeutic Index: Bioequivalence Studies of Generic Once-Daily Tacrolimus. Drug Healthc Patient Saf 2020; 12:151-160. [PMID: 32982466 PMCID: PMC7489937 DOI: 10.2147/dhps.s256455] [Citation(s) in RCA: 4] [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: 04/09/2020] [Accepted: 08/15/2020] [Indexed: 12/21/2022] Open
Abstract
Despite growing clinical confidence in generics and their potential to reduce long-term healthcare costs, the transplant community have had real concerns about the use of generic immunosuppressants. One such immunosuppressant is tacrolimus, a cornerstone of lifelong treatment for patients who have undergone a solid organ transplant. Tacrolimus has a narrow therapeutic index (NTI), giving rise to questions about the potential for clinically relevant altered drug exposure. Its use in transplant patients also gives rise to questions about the most discriminative subject population for bioequivalence studies. The recognised need for stringent criteria to support approval of generic drugs with an NTI led the European Medicines Association and Health Canada to provide detailed information on requirements for bioequivalence studies and introduce tighter bioequivalence limits for these drugs, including tacrolimus. The aim of this article is to illustrate how regulatory guidance is implemented during the clinical development of generic immunosuppressants, using a generic, once-daily prolonged-release formulation of tacrolimus as an example.
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Affiliation(s)
- Kaja Gantar
- Sandoz Development Center Slovenia, Lek Pharmaceuticals d.d, Ljubljana1526, Slovenia
| | - Katja Škerget
- Sandoz Development Center Slovenia, Lek Pharmaceuticals d.d, Ljubljana1526, Slovenia
| | - Ilya Mochkin
- Sandoz International GmbH, Holzkirchen83607, Germany
| | - Aleksander Bajc
- Sandoz Development Center Slovenia, Lek Pharmaceuticals d.d, Ljubljana1526, Slovenia
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Fung SKS, Chau KF, Chow KM. Clinical practice guidelines for the provision of renal service in Hong Kong: Potential Kidney Transplant Recipient Wait-listing and Evaluation, Deceased Kidney Donor Evaluation, and Kidney Transplant Postoperative Care. Nephrology (Carlton) 2019; 24 Suppl 1:60-76. [PMID: 30900332 DOI: 10.1111/nep.13502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | - Ka Foon Chau
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Kai Ming Chow
- Department of Medicine & Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong
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Rottembourg J, Rostoker G. [The use of generics in transplantation: Towards rational and safe solutions!]. Presse Med 2018; 47:199-210. [PMID: 29555162 DOI: 10.1016/j.lpm.2017.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 11/27/2017] [Accepted: 12/13/2017] [Indexed: 10/17/2022] Open
Abstract
Generic immunosuppressive drugs are available in Europe Canada and the United States. Between countries, there are large differences in penetration of generic drugs in general, and for immunosuppressive drugs in particular. The registration for generic immunosuppressive drugs are slightly different, but the criteria for registration of narrow therapeutic index drugs and bioequivalence studies, performed only in healthy volunteers, will remain in the medical landscape. About 50 studies compare the clinical efficacy and bioequivalence of the generic immunosuppressive drugs in patients with solid organ transplants. To allow for safe substitution, a number of criteria need to be fulfilled. Consensus statements were made by most transplant organizations. Authorities and payers should refrain from forcing pharmacists to dispense generic drugs in patients on maintenance immunosuppressive treatment. Generic substitution could be safe if realized by the treating physician, for a well-informed patient. Substitution must be followed by control visits to check if the patient is taking the medication correctly and if the drug exposure, through a close monitoring, remains stable. Substitution from one generic to another generic should be avoided, in all cases.
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Affiliation(s)
- Jacques Rottembourg
- Groupe hospitalier Pitié-Salpêtrière, service de néphrologie, 83, boulevard de l'Hôpital, 75013 Paris, France.
| | - Guy Rostoker
- Hôpital privé Claude-Galien, Ramsay-Générale de Santé, service de néphrologie et de dialyse, 91480 Quincy-sous-Sénart, France
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Ericson JE, Zimmerman KO, Gonzalez D, Melloni C, Guptill JT, Hill KD, Wu H, Cohen-Wolkowiez M. A Systematic Literature Review Approach to Estimate the Therapeutic Index of Selected Immunosuppressant Drugs After Renal Transplantation. Ther Drug Monit 2017; 39:13-20. [PMID: 28081041 PMCID: PMC5235278 DOI: 10.1097/ftd.0000000000000364] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Drugs that exhibit close margins between therapeutic and toxic blood concentrations are considered to have a narrow therapeutic index (NTI). The Food and Drug Administration has proposed that NTI drugs should have more stringent bioequivalence standards for approval of generic formulations. However, many immunosuppressant drugs do not have a well-defined therapeutic index (TI). METHODS We sought to determine whether safety, efficacy, and pharmacokinetic data obtained from the medical literature through a comprehensive literature search could be used to estimate the TI of cyclosporine, tacrolimus, and sirolimus. In this analysis, we considered TI ≤2 as a criterion to define a drug as having an NTI. RESULTS Published literature indicates that cyclosporine has a TI of 2-3, which falls just short of our criteria to be classified as having an NTI. We found sirolimus and tacrolimus to have a therapeutic range of 5-12 ng/mL and of 5-20 ng/mL, respectively, but were unable to calculate the TI. CONCLUSIONS Although the current literature does not provide a clear indication that these drugs have an NTI, the routine use of therapeutic drug monitoring in clinical practice suggests that more stringent testing of their pharmacokinetic and pharmacodynamic properties should be performed before the approval of generic formulations.
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Affiliation(s)
- Jessica E. Ericson
- Departments of Pediatrics, Pennsylvania State University, Hershey, PA
- Duke Clinical Research Institute, Durham, NC
| | - Kanecia O. Zimmerman
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | | | - Kevin D. Hill
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Huali Wu
- Duke Clinical Research Institute, Durham, NC
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
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Bamoulid J, Staeck O, Halleck F, Khadzhynov D, Paliege A, Brakemeier S, Dürr M, Budde K. Immunosuppression and Results in Renal Transplantation. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.eursup.2016.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Guada M, Beloqui A, Kumar MNVR, Préat V, Dios-Viéitez MDC, Blanco-Prieto MJ. Reformulating cyclosporine A (CsA): More than just a life cycle management strategy. J Control Release 2016; 225:269-82. [PMID: 26829101 DOI: 10.1016/j.jconrel.2016.01.056] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 01/27/2016] [Accepted: 01/28/2016] [Indexed: 01/01/2023]
Abstract
Cyclosporine A (CsA) is a well-known immunosuppressive agent that gained considerable importance in transplant medicine in the late 1970s due to its selective and reversible inhibition of T-lymphocytes. While CsA has been widely used to prevent graft rejection in patients undergoing organ transplant it was also used to treat several systemic and local autoimmune disorders. Currently, the neuro- and cardio-protective effects of CsA (CiCloMulsion®; NeuroSTAT®) are being tested in phase II and III trials respectively and NeuroSTAT® received orphan drug status from US FDA and Europe in 2010. The reformulation strategies focused on developing Cremophor® EL free formulations and address variable bioavailability and toxicity issues of CsA. This review is an attempt to highlight the progress made so far and the room available for further improvements to realize the maximum benefits of CsA.
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Affiliation(s)
- Melissa Guada
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Navarra, C/Irunlarrea 1, E-31008 Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra, IdiSNA, C/Irunlarrea 3, E-31008 Pamplona, Spain
| | - Ana Beloqui
- Université catholique de Louvain, Louvain Drug Research Institute, Advanced Drug Delivery and Biomaterials, Brussels, Belgium
| | - M N V Ravi Kumar
- Department of Pharmaceutical Sciences, Texas A&M Health Science Center, College Station, TX 77845, USA
| | - Véronique Préat
- Université catholique de Louvain, Louvain Drug Research Institute, Advanced Drug Delivery and Biomaterials, Brussels, Belgium
| | - Maria Del Carmen Dios-Viéitez
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Navarra, C/Irunlarrea 1, E-31008 Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra, IdiSNA, C/Irunlarrea 3, E-31008 Pamplona, Spain
| | - Maria J Blanco-Prieto
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Navarra, C/Irunlarrea 1, E-31008 Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra, IdiSNA, C/Irunlarrea 3, E-31008 Pamplona, Spain.
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Tsipotis E, Gupta NR, Raman G, Zintzaras E, Jaber BL. Bioavailability, Efficacy and Safety of Generic Immunosuppressive Drugs for Kidney Transplantation: A Systematic Review and Meta-Analysis. Am J Nephrol 2016; 44:206-18. [PMID: 27576318 PMCID: PMC6584577 DOI: 10.1159/000449020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 07/05/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Concerns exist over the extrapolation of bioavailability studies of generic immunosuppressive drugs in healthy volunteers, regarding their efficacy and safety in kidney transplant recipients. We conducted a meta-analysis of trials examining the bioavailability of generic (test) immunosuppressive drugs relative to their brand (reference) counterparts in healthy volunteers, based on the US Food and Drug Administration requirements for approval of generics, and their efficacy and safety in kidney transplant recipients. METHODS Eligible studies were identified in PubMed, Cochrane Central Register of Controlled Trials, Scopus, ClinicalTrials.gov, and conference abstracts. RESULTS Twenty crossover trials of healthy volunteers (n = 641) and 6 parallel-arm randomized controlled trials of kidney transplant recipients (n = 594) were identified. The 90% CI of the pooled test-to-reference drug ratio for maximum or peak plasma concentration (Cmax) and area under the plasma concentration time-curve from time 0 to time of last determinable concentration (AUC(0-t)) fell within the required range (0.80-1.25) for cyclosporine (Cmax 0.91; 90% CI 0.86-0.95; and AUC(0-t) 0.97; 90% CI 0.94-1.00), tacrolimus (Cmax 1.17; 90% CI 1.09-1.24; and AUC(0-t) 1.00; 90% CI 0.97-1.03) and mycophenolate mofetil (Cmax 0.98; 90% CI 0.96-1.01; and AUC(0-t) 1.00; 90% CI 0.99-1.01). In subgroup analyses, some generic cyclosporine formulations did not meet criteria for bioequivalence. No significant differences were observed in the time to maximum plasma concentration and terminal plasma half-life between generic and brand drugs. In parallel-arm trials, generic cyclosporine was non-inferior to brand counterpart in terms of acute allograft rejection, infections, and death. CONCLUSIONS Not all generic immunosuppressive drugs have similar relative bioavailability to their brand name counterparts. Evidence on their efficacy and safety is inconclusive. Tighter regulatory requirement for approval of generic drugs with narrow therapeutic index is needed.
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Affiliation(s)
- Evangelos Tsipotis
- Department of Medicine, Tufts University School of
Medicine, Boston, Mass., USA,Department of Medicine, Division of Nephrology, St.
Elizabeth’s Medical Center, Tufts University School of Medicine, Boston,
Mass., USA
| | - Navin R. Gupta
- Department of Medicine, Tufts University School of
Medicine, Boston, Mass., USA
| | - Gowri Raman
- Center for Clinical Evidence Synthesis, The Institute for
Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University
School of Medicine, Boston, Mass., USA
| | - Elias Zintzaras
- Center for Clinical Evidence Synthesis, The Institute for
Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University
School of Medicine, Boston, Mass., USA,Department of Biomathematics, Evidence-Based Medicine Unit,
University of Thessaly School of Medicine, Larissa, Greece
| | - Bertrand L. Jaber
- Department of Medicine, Tufts University School of
Medicine, Boston, Mass., USA,Department of Medicine, Division of Nephrology, St.
Elizabeth’s Medical Center, Tufts University School of Medicine, Boston,
Mass., USA
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Bamoulid J, Staeck O, Halleck F, Dürr M, Paliege A, Lachmann N, Brakemeier S, Liefeldt L, Budde K. Advances in pharmacotherapy to treat kidney transplant rejection. Expert Opin Pharmacother 2015; 16:1627-48. [PMID: 26159444 DOI: 10.1517/14656566.2015.1056734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Current immunosuppressive combination therapy provides excellent prevention of T-cell-mediated rejection following renal transplantation; however, antibody-mediated rejection remains of high concern and accounts for a large number of long-term allograft losses. The recent development of protocol biopsies resulted in the definition of subclinical rejection (SCR), showing histologic evidence for rejection but unremarkable clinical course. AREAS COVERED This review describes the current knowledge and evidence of pharmacotherapy to treat kidney allograft rejections and covers SCR treatment options. Each substance is analyzed with regard to its classical indication and further discussed for the treatment of other forms of rejection. EXPERT OPINION Despite a lack of randomized trials, early acute T-cell-mediated rejection can be treated effectively in most cases without graft loss. The necessity to treat SCR is currently unclear. Due to a lack of effective therapies, new treatment approaches for antibody-mediated rejection are an urgent medical need to improve long-term outcomes. Future research should aim to better define pathophysiology and histology, stratify risk, and develop rational treatment strategies from randomized controlled trials, in order to establish the value of novel therapies in the arsenal of rejection pharmacotherapy. However, the effective prevention of rejection with minimal side effects still remains the goal in immunosuppression.
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Affiliation(s)
- Jamal Bamoulid
- Charité Universitätsmedizin Berlin, Department of Nephrology , Berlin , Germany +49 30 450 514002 ; +49 30 450 514902 ;
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Hauch A, John M, Smith A, Dortonne I, Patel U, Kandil E, Killackey M, Paramesh A, Lee B, Zhang R, Buell JF. Generics: Are all immunosuppression agents created equally? Surgery 2015. [PMID: 26206317 DOI: 10.1016/j.surg.2015.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Molnar AO, Fergusson D, Tsampalieros AK, Bennett A, Fergusson N, Ramsay T, Knoll GA. Generic immunosuppression in solid organ transplantation: systematic review and meta-analysis. BMJ 2015; 350:h3163. [PMID: 26101226 PMCID: PMC4476317 DOI: 10.1136/bmj.h3163] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare the clinical efficacy and bioequivalence of generic immunosuppressive drugs in patients with solid organ transplants. DESIGN Systematic review and meta-analysis of all studies comparing generic with innovator immunosuppressive drugs. DATA SOURCES Medline and Embase from 1980 to September 2014. REVIEW METHODS A literature search was performed for all studies comparing a generic to an innovator immunosuppressive drug in solid organ transplantation. Two reviewers independently extracted data and assessed quality of studies. Meta-analyses of prespecified outcomes were performed when deemed appropriate. Outcomes included patient survival, allograft survival, acute rejection, adverse events and bioequivalence. RESULTS 1679 citations were screened, of which 50 studies met eligibility criteria (17 randomized trials, 15 non-randomized interventional studies, and 18 observational studies). Generics were compared with Neoral (cyclosporine) (32 studies), Prograf (tacrolimus) (12 studies), and Cellcept (mycophenolate mofetil) (six studies). Pooled analysis of randomized controlled trials in patients with kidney transplants that reported bioequivalence criteria showed that Neoral (two studies) and Prograf (three studies) were not bioequivalent with generic preparations according to criteria of the European Medicines Agency. The single Cellcept trial also did not meet bioequivalence. Acute rejection was rare but did not differ between groups. For Neoral, the pooled Peto odds ratio was 1.23 (95% confidence interval 0.64 to 2.36) for kidney randomized controlled trials and 0.66 (0.40 to 1.08) for observational studies. For kidney observational studies, the pooled Peto odds ratios were 0.98 (0.37 to 2.60) for Prograf and 0.49 (0.09 to 2.56) for Cellcept. Meta-analyses for non-renal solid organ transplants were not performed because of a lack of data.There were insufficient data reported on patient or graft survival. Pooling of results was limited by inconsistent study methods and reporting of outcomes. Many studies did not report standard criteria used to determine bioequivalence. While rates of acute rejection seemed similar and were relatively rare, few studies were designed to properly compare clinical outcomes. Most studies had short follow-up times and included stable patients without a history of rejection. CONCLUSIONS High quality data showing bioequivalence and clinical efficacy of generic immunosuppressive drugs in patients with transplants are lacking. Given the serious consequences of rejection and allograft failure, well designed studies on bioequivalence and safety of generic immunosuppression in transplant recipients are needed.
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Affiliation(s)
- Amber O Molnar
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6 Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Canada, K1H 8L6
| | - Dean Fergusson
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6 Division of Nephrology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Canada, K1H 8L1
| | - Anne K Tsampalieros
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6 Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Canada, K1H 8L6
| | - Alexandria Bennett
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6 Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Canada, K1H 8L6
| | - Nicholas Fergusson
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6 Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Canada, K1H 8L6
| | - Timothy Ramsay
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6
| | - Greg A Knoll
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6
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El Hajj S, Kim M, Phillips K, Gabardi S. Generic immunosuppression in transplantation: current evidence and controversial issues. Expert Rev Clin Immunol 2015; 11:659-72. [DOI: 10.1586/1744666x.2015.1026895] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Kaló Z, Holtorf AP, Alfonso-Cristancho R, Shen J, Ágh T, Inotai A, Brixner D. Need for multicriteria evaluation of generic drug policies. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:346-51. [PMID: 25773570 DOI: 10.1016/j.jval.2014.12.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 10/26/2014] [Accepted: 12/10/2014] [Indexed: 05/16/2023]
Abstract
Policymakers tend to focus on improving patented drug policies because they are under pressure from patients, physicians, and manufacturers to increase access to novel therapies. The success of pharmaceutical innovation over the last few decades has led to the availability of many off-patent drugs to treat disease areas with the greatest public health need. Therefore, the success of public health programs in improving the health status of the total population is highly dependent on the efficiency of generic drug policies. The objective of this article was to explore factors influencing the true efficiency of generic prescription drug policies in supporting public health initiatives in the developed world. Health care decision makers often assess the efficiency of generic drug policies by the level of price erosion and market share of generics. Drug quality, bioequivalence, in some cases drug formulations, supply reliability, medical adherence and persistence, health outcomes, and nondrug costs, however, are also attributes of success for generic drug policies. Further methodological research is needed to measure and improve the efficiency of generic drug policies. This also requires extension of the evidence base of the impact of generic drugs, partly based on real-world evidence. Multicriteria decision analysis may assist policymakers and researchers to evaluate the true value of generic drugs.
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Affiliation(s)
- Zoltán Kaló
- Faculty of Social Sciences, Department of Health Policy and Health Economics, Eötvös Loránd University (ELTE), Budapest, Hungary; Syreon Research Institute, Budapest, Hungary.
| | - Anke-Peggy Holtorf
- Health Outcomes Strategies, Basel, Switzerland; Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | | | - Jie Shen
- Abbott Products Operations AG, Allschwil, Switzerland
| | - Tamás Ágh
- Syreon Research Institute, Budapest, Hungary
| | | | - Diana Brixner
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
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Allard J, Fortin MC. Is it ethical to prescribe generic immunosuppressive drugs to renal transplant patients? Can J Kidney Health Dis 2014; 1:23. [PMID: 25780612 PMCID: PMC4349684 DOI: 10.1186/s40697-014-0023-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 08/11/2014] [Indexed: 01/07/2023] Open
Abstract
PURPOSE OF THE REVIEW This review was conducted to determine the ethical acceptability of prescribing generic immunosuppressive drugs to renal transplant patients. SOURCES OF INFORMATION The literature search was conducted using Pubmed and Google Scholar. FINDINGS The use of generic immunosuppressive drugs (ISDs) in transplantation is a controversial topic. There is a consensus among transplant societies that clinical data is lacking and that caution should be exercised. The reluctance to use generic ISDs in organ transplantation is partly related to the fact that most are "critical dose drugs", and that either low dosing or overdosing could have serious adverse consequences for both patients and society (i.e., the loss of scarce organs). In this paper, we examine the various ethical issues involved such as distributive justice, physician duties, risks versus benefits, conflict of interest, informed consent, and logistical and economic issues. LIMITATIONS Our analysis was limited by the paucity of clinical data on generic ISDs and the absence of health economics studies to quantify the benefits of prescribing generic ISDs. IMPLICATIONS Our study led us to conclude that it would be ethical to prescribe generic ISDs provided certain conditions were met. These include regulatory safeguards to minimize the risks of substitution; education of patients; and further clinical and health economics studies to better inform clinicians, patients and society of the risks and costs related to drug substitution.
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Affiliation(s)
- Julie Allard
- Centre de recherche du Centre hospitalier de l′Université de Montréal (CRCHUM), 900 Saint-Denis Street, Montreal, Quebec H2X 0A9 Canada
| | - Marie-Chantal Fortin
- Centre de recherche du Centre hospitalier de l′Université de Montréal (CRCHUM), 900 Saint-Denis Street, Montreal, Quebec H2X 0A9 Canada ,Nephrology and Transplantation Division, Centre hospitalier de l’Université de Montréal (CHUM), 1560 Sherbrooke Street East, Montreal, Quebec H2L 4 M1 Canada ,Department of Social and Preventive Medicine, Bioethics Program, School of Public Health, Université de Montréal, Montreal, Canada
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Snell GI, Paraskeva MA, Levvey BJ, Westall GP. Immunosuppression for lung transplant recipients. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s13665-014-0081-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Abstract
The enduring success of lung transplantation is built on the use of immunosuppressive drugs to stop the immune system from rejecting the newly transplanted lung allograft. Most patients receive a triple-drug maintenance immunosuppressive regimen consisting of a calcineurin inhibitor, an antiproliferative and corticosteroids. Induction therapy with either an antilymphocyte monoclonal or an interleukin-2 receptor antagonist are prescribed by many centres aiming to achieve rapid inhibition of recently activated and potentially alloreactive T lymphocytes. Despite this generic approach acute rejection episodes remain common, mandating further fine-tuning and augmentation of the immunosuppressive regimen. While there has been a trend away from cyclosporine and azathioprine towards a preference for tacrolimus and mycophenolate mofetil, this has not translated into significant protection from the development of chronic lung allograft dysfunction, the main barrier to the long-term success of lung transplantation. This article reviews the problem of lung allograft rejection and the evidence for immunosuppressive regimens used both in the short- and long-term in patients undergoing lung transplantation.
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Heavner MS, Tichy EM, Yazdi M, Formica RN, Kulkarni S, Emre S. Clinical outcomes associated with conversion from brand-name to generic tacrolimus in hospitalized kidney transplant recipients. Am J Health Syst Pharm 2014; 70:1507-12. [PMID: 23943182 DOI: 10.2146/ajhp120783] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The safety of converting kidney transplant recipients on brand-name tacrolimus to generic tacrolimus during hospitalization was evaluated. METHODS A single-center observational study compared tacrolimus dosages and trough tacrolimus levels in kidney transplant recipients who had a kidney transplant more than 90 days before hospital admission. Patients in the "brand" group were maintained on brand-name tacrolimus throughout the entire study period. Patients in the generic group were maintained on brand-name tacrolimus before hospital admission, converted to the generic formulation during hospitalization, and returned to the brand-name product at discharge. Tacrolimus dosages were converted on a milligram-per-milligram basis and adjusted, if needed. Outcomes evaluated included the percentage of patients requiring a dosage change, absolute change in average tacrolimus trough level, and frequency of biopsy-proven acute rejection within six months of discharge. RESULTS A total of 100 patients were evaluated for inclusion in the brand group, with 42 meeting study criteria; 98 patients were evaluated in the generic group, with 36 qualifying for the study. There were no significant differences between the brand and generic groups with respect to dosage adjustments required or trough tacrolimus levels at any point in the transition of care. Mean trough concentrations were similar between groups during all periods of care. The only occurrence of new-onset acute rejection within six months after admission occurred in the brand group. CONCLUSION Substitution of a generic formulation of tacrolimus for the innovator product during hospitalization of kidney transplant recipients was safely implemented. Tacrolimus dosage adjustments were common throughout the transitions of care, regardless of the formulation used.
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Affiliation(s)
- Mojdeh S Heavner
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT 06510, USA
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Johnston A. Equivalence and interchangeability of narrow therapeutic index drugs in organ transplantation. Eur J Hosp Pharm 2013; 20:302-307. [PMID: 24089632 PMCID: PMC3786630 DOI: 10.1136/ejhpharm-2012-000258] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 07/30/2013] [Accepted: 08/01/2013] [Indexed: 01/05/2023] Open
Abstract
The calcineurin inhibitors (CNIs), ciclosporin and tacrolimus, are the mainstay of immunosuppression in solid organ transplantation. Generic formulations of these drugs are now available. With increasing pressure on healthcare budgets and the consequent need to match health expectations to available resources, substitution with a generic product appears an attractive option to reduce costs. Approval of generic products differs from innovator drugs, and narrow therapeutic index drugs (NTIs; including CNIs) bring their own particular considerations. With NTIs, small variations in drug exposure could result in reduced immunosuppression or drug toxicity with potentially adverse effects on patient outcomes. NTIs are subject to stricter regulatory approval versus many other generic drugs. However, different generic formulations may still not necessarily be therapeutically equivalent in individuals, raising the possibility of significant differences in exposure between products. Although regional recommendations vary, many guidelines emphasise the need for NTI drug substitution to be initiated by the transplant physician, thus ensuring careful therapeutic monitoring and reduced negative patient impact. The need for therapeutic monitoring during generic substitution has important implications for the overall costs of generic treatment as these costs have to be factored in to the potential savings made from using generic formulations. The reduced acquisition costs of generic products may not necessarily translate into lower overall healthcare costs. This article examines the issue of equivalence and interchangeability of NTI drugs used in organ transplantation, the implications of the approval process for generic drugs on treatment efficacy and safety, and the effective management of substitutions between products.
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Krisl JC, Fortier CR, Taber DJ. Disruptions in the supply of medications used in transplantation: implications and management strategies for the transplant clinician. Am J Transplant 2013; 13:20-30. [PMID: 23126622 DOI: 10.1111/j.1600-6143.2012.04308.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 09/07/2012] [Accepted: 09/11/2012] [Indexed: 01/25/2023]
Abstract
Drug shortages are a threat to patient care and public health, and the number of drugs on shortage is growing at an exponential rate. The major therapy areas affected by these shortages are oncology, anti-infective, cardiovascular and central nervous system. However, drugs utilized in the transplant patient population have not been exempt, and can have significant influence on posttransplant outcomes. The purpose of this review is to discuss the current and historical solid organ transplant-related disruptions in the supply of medications and implications on patient care and safety. Transplant centers should be armed with an implementation plan when imperative transplant-related drugs such as tacrolimus, mycophenolate, or antithymocyte globulin go on shortage. This plan should provide steps to manage the shortage, and provide effective therapeutic alternatives.
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Affiliation(s)
- J C Krisl
- Department of Surgery, Division of Transplantation, University of Cincinnati, OH, USA.
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21
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Remport A, Dankó D, Gerlei Z, Czebe K, Kiss I. [Special considerations in generic substitution of immunosuppressive drugs in transplantation]. Orv Hetil 2012; 153:1341-9. [PMID: 22913916 DOI: 10.1556/oh.2012.29429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Long-term success in solid organ transplantation strongly depends on the optimal use of maintenance immunosuppressive treatment. Cyclosporin and tacrolimus are the most frequently administered immunosuppressants and they are designed to narrow therapeutic index drugs. The substitution of the branded formulation by their generic counterparts may lead to economic benefit only if equivalent clinical outcomes can be achieved. There is no published evidence to date on the guarantee of their long-term therapeutic equivalence and cases of therapeutic failures have been reported due to inadvertent drug conversion. The disadvantageous clinical consequences of a non medical, mechanistic forced switch from the original to generic formulation of tacrolimus and the estimated loss of the payer's presumed savings are presented in a kidney transplant recipient population. Special problems related to pediatric patients, drug interactions with concurrent medications and the burden of additional therapeutic drug monitoring and follow up visits are also discussed. The authors are convinced that the implementation of the European Society of Organ Transplantation guidelines on generic substitution may provide a safe way for patients and healthcare payers.
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Affiliation(s)
- Adám Remport
- Szent Imre Kórház Nefrológia-Hypertonia Profil Budapest Tétényi.
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22
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Hulbert AL, Pilch NA, Taber DJ, Chavin KD, Baliga PK. Generic immunosuppression: deciphering the message our patients are receiving. Ann Pharmacother 2012; 46:671-7. [PMID: 22570436 DOI: 10.1345/aph.1r028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The introduction of generic immunosuppressants elicited controversy within the transplant community and it is unknown whether patient attitudes mirror the ambiguity of provider perceptions. With the current health care economic crisis, it is necessary to consider generic immunosuppression as an option. A greater understanding of patient perceptions would enhance vital communication between providers and patients to facilitate education and appropriate monitoring. OBJECTIVE To evaluate transplant recipients' perceptions of generic versus brand immunosuppressants based on experience with these agents and the willingness of patients to convert treatment from brand to generic formulations based on socioeconomic variables and baseline demographics. METHODS Key informant interviews were conducted to inform the development of the survey instrument. The survey was distributed to solid organ transplant recipients at a large, academic medical center from October to December 2010. RESULTS Nine patients participated in key informant interviews. Financial considerations and provider recommendations were the most commonly identified factors to influence perceptions of generic immunosuppressants. A total of 255 patients completed the survey; treatment in 81 (32%) participants had been converted to a generic immunosuppressant. Those currently receiving a generic immunosuppressant expressed higher beliefs of generic and brand equivalency (75% vs 54%, p = 0.006) and an increased willingness to convert treatment to a generic given equivalent cost (51% vs 32%, p = 0.024). African American participants were found to have a decreased belief of generic and brand equivalency compared to other ethnicities (60% vs 75%, p = 0.013). Participants with an annual income of less than $30,000 had higher beliefs of generic and brand equivalency (60% vs 40%, p = 0.0001). Education level and age did not impact beliefs of generic efficacy or willingness to convert therapy. CONCLUSIONS Patient ethnicity, income, and experience with generic immunosuppressants appear to contribute to perceptions of generic immunosuppressants. The prevalence of generic immunosuppressant use supports the importance of communication of this issue between providers and patients.
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Affiliation(s)
- Amanda L Hulbert
- Department of Pharmacy Services, The Ohio State University Medical Center, Columbus, OH, USA
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23
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Cyclosporine: A Commentary on Brand versus Generic Formulation Exchange. J Transplant 2011; 2011:480642. [PMID: 22174986 PMCID: PMC3235899 DOI: 10.1155/2011/480642] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 09/26/2011] [Indexed: 11/25/2022] Open
Abstract
The evidence for conversion from brand name to generic equivalent cyclosporine is conflicting. Cyclosporine is a narrow therapeutic-range drug for which small variations in exposure may have severe clinical consequences for transplant patients. There is currently a lack of comparative outcome data relating to the pharmacokinetics of the reference formulation, Neoral, and generic formulations in transplant recipients. A major common concern is the potential inability to attain similar trough levels, an issue that can be easily corrected by ongoing therapeutic drug monitoring to ensure that the new steady state falls within an intended target range. Prospective clinical studies investigating the efficacy and safety of generic formulations in both de novo and long-term transplant patients are also awaited. Until further evidence is available on the conversion of transplant patients to or between generic formulations of cyclosporine, any transfer to a different cyclosporine formulation should be undertaken with close supervision. The best available information to date, however, does not support the frequently held but unsubstantiated belief that generic preparations of immunosuppressive drugs are not as effective as brand names or that conversion from brand to generic is associated with significant danger. This paper attempts to initiate a discussion of these issues.
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Ensor CR, Trofe-Clark J, Gabardi S, McDevitt-Potter LM, Shullo MA. Generic Maintenance Immunosuppression in Solid Organ Transplant Recipients. Pharmacotherapy 2011; 31:1111-29. [DOI: 10.1592/phco.31.11.1111] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Al Ameri MN, Whittaker C, Tucker A, Yaqoob M, Johnston A. A survey to determine the views of renal transplant patients on generic substitution in the UK. Transpl Int 2011; 24:770-9. [DOI: 10.1111/j.1432-2277.2011.01268.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ryan C, Amor KT, Menter A. The use of cyclosporine in dermatology: part II. J Am Acad Dermatol 2010; 63:949-72; quiz 973-4. [PMID: 21093660 DOI: 10.1016/j.jaad.2010.02.062] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 02/01/2010] [Accepted: 02/08/2010] [Indexed: 01/11/2023]
Abstract
UNLABELLED Cyclosporine is highly effective in the treatment of a multitude of dermatoses. Concern over its side effect profile has limited its use in dermatology. Adverse effects are, for the most part, dose dependent and related to duration of therapy. Using the recommended monitoring protocols results in a significant decrease in the incidence of cyclosporine-related toxicities. This article provides a comprehensive review of the pharmacokinetics of cyclosporine, potential drug interactions, adverse effects, and recommendations for monitoring in patients treated with cyclosporine. The use of cyclosporine in pregnancy and in the pediatric population is also addressed. LEARNING OBJECTIVES After completing this learning activity, participants should be familiar with the monitoring guidelines of cyclosporine, its contraindications, its possible drug interactions, its adverse effect profile, and its use in pregnancy and the childhood and adolescent populations.
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Affiliation(s)
- Caitriona Ryan
- Department of Dermatology at Baylor University Medical Center, Dallas, Texas 75246, USA
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AlAmeri M, Epstein M, Johnston A. Generic and therapeutic substitutions: are they always ethical in their own terms? ACTA ACUST UNITED AC 2010; 32:691-5. [DOI: 10.1007/s11096-010-9429-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Petan JA, Undre N, First MR, Saito K, Ohara T, Iwabe O, Mimura H, Suzuki M, Kitamura S. Physiochemical properties of generic formulations of tacrolimus in Mexico. Transplant Proc 2008; 40:1439-42. [PMID: 18589125 DOI: 10.1016/j.transproceed.2008.03.091] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Revised: 02/12/2008] [Accepted: 03/11/2008] [Indexed: 11/18/2022]
Abstract
Tacrolimus is an important immunosuppressive agent used to prevent allograft rejection after transplantation. Tacrolimus has a narrow therapeutic index; therefore, it is essential that the physicochemical properties of generic formulations be identical to the brand-name formulation, Prograf. In this study, the physicochemical properties of generic tacrolimus formulations were compared with Prograf. The drug dissolution profiles of generic formulations of tacrolimus were different from that of Prograf. Tacrobell and T-Inmun exhibited faster dissolution than Prograf, and Tenacrine, Framebin, and Talgraf showed slower and incomplete drug dissolution, releasing 24% to 51% of tacrolimus within 2 hours. Generic formulations of tacrolimus demonstrated decreased solubility compared with Prograf. The solubility of Prograf was 35.7 microg/mL at 2 hours and 29.5 microg/mL at 24 hours. The solubility of Tenacrine, Framebin, and Talgraf at 2 hours was 5.5, 12.6, and 7.8 microg/mL, respectively, and the solubility decreased to 0.5, 2.3, and 2.1 microg/mL, respectively, at 24 hours. Whereas Prograf demonstrated content uniformity, the content of the generic tacrolimus formulations varied widely. The standard deviation of content for Tenacrine, Tacrobell, and T-Inmun were high at 29.3, 6.9, and 5.6, respectively. Furthermore, the mean percentage of labeled amount of T-Inmun was 84.2% with a relative standard deviation of 6.7% (minimum value; 72.7%; maximum value; 100.7%). These results indicate that generic formulations of tacrolimus tested in this study are not bioequivalent to Prograf, which suggests that their use may be of potential risk to transplant patients.
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Affiliation(s)
- J A Petan
- Medical Affairs Astellas Pharma Europe Limited, Munich, Germany
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32
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Chen AY, Wu S. Dispensing pattern of generic and brand-name drugs in children. ACTA ACUST UNITED AC 2008; 8:189-94. [PMID: 18501866 DOI: 10.1016/j.ambp.2007.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Revised: 12/19/2007] [Accepted: 12/25/2007] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe the dispensing patterns of generic and brand-name drugs in children and to identify patient sociodemographic characteristics associated with generic drug use. METHODS We analyzed data from the 2002 Medical Expenditures Panel Survey. This survey is conducted by the Agency for Healthcare Research and Quality and consists of a nationally representative sample of civilian noninstitutionalized population of the United States. The 2002 survey included 14 828 families and 37 418 individuals, 11 099 of whom were children 0 to 17 years of age. Our unit of analysis was individual prescription drugs dispensed to children 0 to 17 years of age. The main dependent variable for the logistic model was the use of generic drugs. Independent variables included age, gender, race, insurance type, family income, Metropolitan Statistical Area status, and health status. RESULTS Generic drugs were filled in 40.6% of the 24 465 prescriptions analyzed. Average expenditure for generic drugs was $20.92 (SD 24.53) per prescription versus $71.65 (SD $170.22) for brand-name drugs. Use of generic versus brand-name drugs varied by conditions and medication class. Uninsured patients were more likely than privately insured patients to have a generic drug dispensed than brand-name drugs (odds ratio [OR] 1.42; 95% confidence interval [CI], 1.10-1.84). Asian children were more likely than white children to receive generic drugs (OR, 1.66; 95% CI, 1.07-2.57). Girls were also more likely than boys to receive generic drugs over brand-name drugs (OR, 1.36; 95% CI, 1.08-1.73). CONCLUSIONS Generic drugs were dispensed more often to uninsured children, Asian children, and girls.
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Affiliation(s)
- Alex Y Chen
- Division of General Pediatrics, Department of Pediatrics, Children's Hospital Los Angeles, Calif., USA.
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33
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Spasovski G, Masin-Spasovska J, Ivanovski N. Do we have the same clinical results with Neoral and Equoral treatment in kidney transplant recipients? A pilot study. Transpl Int 2007; 21:392-4. [PMID: 18069921 DOI: 10.1111/j.1432-2277.2007.00612.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Johnston A, He X, Holt DW. Bioequivalence of enteric-coated mycophenolate sodium and mycophenolate mofetil: a meta-analysis of three studies in stable renal transplant recipients. Transplantation 2007; 82:1413-8. [PMID: 17164710 DOI: 10.1097/01.tp.0000242137.68863.89] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mycophenolic acid (MPA) is an inhibitor of lymphocyte proliferation and is well established as an immunosuppressive agent in solid organ transplantation. The initial formulation of the drug was a prodrug formulation, mycophenolate mofetil (MMF, Cellcept), which is well absorbed and rapidly converted to mycophenolate in plasma. However, the use of MMF is associated with adverse gastrointestinal events, which can lead to withdrawal of therapy. In an effort to reduce the gastrointestinal effects of MMF, an enteric-coated formulation of the drug was developed, based on the sodium salt of MPA (EC-MPS, Myfortic). METHODS Although bioequivalence has been demonstrated in an individual study in maintenance kidney transplant patients, this manuscript documents bioequivalence in a much larger data set of 82 patients by a meta-analysis of data from clinical trials. RESULTS The results confirm the bioequivalence of EC-MPS and MMF for both mycophenolate and metabolite exposure, and for maximum plasma mycophenolate concentrations, across three studies. The 90% confidence interval of the ratio of EC-MPS to MMF for mycophenolate plasma AUC in the 82 patients was 101.1 to 114.5% and for Cmax was 83.0% to 112.7%. CONCLUSION These findings provide reassurance to transplant professionals and patients that, when choosing between EC-MPS and MMF, they are choosing between formulations that give equivalent mycophenolate exposure.
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Affiliation(s)
- Atholl Johnston
- Clinical Pharmacology, Barts and The London, London, United Kingdom.
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36
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Schiff J, Cole E, Cantarovich M. Therapeutic monitoring of calcineurin inhibitors for the nephrologist. Clin J Am Soc Nephrol 2007; 2:374-84. [PMID: 17699437 DOI: 10.2215/cjn.03791106] [Citation(s) in RCA: 183] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The calcineurin inhibitors (CNI) cyclosporine and tacrolimus remain the backbone of immunosuppression for most kidney transplant recipients. Despite many years of experience, protocols that optimize efficacy with minimal toxicity remain a subject of debate. Nevertheless, studies of the pharmacokinetic properties of the CNI, particularly cyclosporine, have led to improved dosing strategies. The purpose of this article is to review the current understanding of CNI pharmacokinetics and its relevance to proper dosing and monitoring of these medications. This article also reviews the trials that have helped to define the optimal dosages and discusses the effect of adjunctive immunosuppressive agents on CNI pharmacokinetics and dosing.
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Affiliation(s)
- Jeffrey Schiff
- Division of Nephrology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
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Griffiths CEM, Katsambas A, Dijkmans BAC, Finlay AY, Ho VC, Johnston A, Luger TA, Mrowietz U, Thestrup-Pedersen K. Update on the use of ciclosporin in immune-mediated dermatoses. Br J Dermatol 2006; 155 Suppl 2:1-16. [PMID: 16774579 DOI: 10.1111/j.1365-2133.2006.07343.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Immune-mediated dermatoses, such as psoriasis and atopic dermatitis, affect a significant proportion of the population. Although most cases are not life threatening, these diseases can have a profound effect on the sufferer's quality of life and that of their family. Systemic therapy, such as ciclosporin, is often indicated for severe or recalcitrant disease. The efficacy of ciclosporin in the treatment of psoriasis and atopic dermatitis has been established and clinical data also demonstrate its efficacy in treating less common but equally challenging conditions such as pyoderma gangrenosum, lichen planus, autoimmune bullous disease, recalcitrant chronic idiopathic urticaria and chronic dermatitis of the hands and feet. The risk of potential adverse events associated with ciclosporin is greatly reduced if current treatment and monitoring guidelines are followed.
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Affiliation(s)
- C E M Griffiths
- Dermatology Centre, University of Manchester, Hope Hospital, Manchester, UK.
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