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Broekhuizen M, de Vries R, Smits MAW, Dik WA, Schoenmakers S, Koch BCP, Merkus D, Reiss IKM, Danser AHJ, Simons SHP, Hitzerd E. Pentoxifylline as a therapeutic option for pre-eclampsia: a study on its placental effects. Br J Pharmacol 2022; 179:5074-5088. [PMID: 35861684 PMCID: PMC9804511 DOI: 10.1111/bph.15931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 07/05/2022] [Accepted: 07/11/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND PURPOSE Recently pentoxifylline, a non-selective phosphodiesterase inhibitor and adenosine receptor antagonist, has attracted much interest for the treatment of the increased vascular resistance and endothelial dysfunction in pre-eclampsia. We therefore investigated the placental transfer, vascular effects and anti-inflammatory actions of pentoxifylline in healthy and pre-eclamptic human placentas. EXPERIMENTAL APPROACH The placental transfer and metabolism of pentoxifylline were studied using ex vivo placenta perfusion experiments. In wire myography experiments with chorionic plate arteries, pentoxifyllines vasodilator properties were investigated, focusing on the cGMP and cAMP pathways and adenosine receptors. Its effects on inflammatory factors were also studied in placental explants. KEY RESULTS Pentoxifylline transferred from the maternal to foetal circulation, reaching identical concentrations. The placenta metabolized pentoxifylline into its active metabolite lisofylline (M1), which was released into both circulations. In healthy placentas, pentoxifylline potentiated cAMP- and cGMP-induced vasodilation, as well as causing vasodilation by adenosine A1 antagonism and via NO synthase and PKG. Pentoxifylline also reduced inflammatory factors secretion. In pre-eclamptic placentas, we observed that its vasodilator capacity was preserved, however not via NO-PKG but likely through adenosine signalling. Pentoxifylline neither potentiated vasodilation through cAMP and cGMP, nor suppressed the release of inflammatory factors from these placentas. CONCLUSION AND IMPLICATIONS Pentoxifylline is transferred across and metabolized by the placenta. Its beneficial effects on the NO pathway and inflammation are not retained in pre-eclampsia, limiting its application in this disease, although it could be useful for other placenta-related disorders. Future studies might focus on selective A1 receptor antagonists as a new treatment for pre-eclampsia.
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Affiliation(s)
- Michelle Broekhuizen
- Division of Neonatology, Department of PaediatricsErasmus MC University Medical CenterRotterdamThe Netherlands,Division of Pharmacology and Vascular Medicine, Department of Internal MedicineErasmus MC University Medical CenterRotterdamThe Netherlands,Division of Experimental Cardiology, Department of CardiologyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Rene de Vries
- Division of Pharmacology and Vascular Medicine, Department of Internal MedicineErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Marja A. W. Smits
- Laboratory Medical Immunology, Department of ImmunologyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Willem A. Dik
- Laboratory Medical Immunology, Department of ImmunologyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Sam Schoenmakers
- Department of Obstetrics and GynaecologyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Birgit C. P. Koch
- Department of PharmacyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of CardiologyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Irwin K. M. Reiss
- Division of Neonatology, Department of PaediatricsErasmus MC University Medical CenterRotterdamThe Netherlands
| | - A. H. Jan Danser
- Division of Pharmacology and Vascular Medicine, Department of Internal MedicineErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Sinno H. P. Simons
- Division of Neonatology, Department of PaediatricsErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Emilie Hitzerd
- Division of Neonatology, Department of PaediatricsErasmus MC University Medical CenterRotterdamThe Netherlands,Division of Pharmacology and Vascular Medicine, Department of Internal MedicineErasmus MC University Medical CenterRotterdamThe Netherlands
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Kurul S, Fiebig K, Flint RB, Reiss IKM, Küster H, Simons SHP, Voller S, Taal HR. Knowledge gaps in late-onset neonatal sepsis in preterm neonates: a roadmap for future research. Pediatr Res 2022; 91:368-79. [PMID: 34497356 DOI: 10.1038/s41390-021-01721-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/13/2021] [Accepted: 08/17/2021] [Indexed: 12/16/2022]
Abstract
Late-onset neonatal sepsis (LONS) remains an important threat to the health of preterm neonates in the neonatal intensive care unit. Strategies to optimize care for preterm neonates with LONS are likely to improve survival and long-term neurocognitive outcomes. However, many important questions on how to improve the prevention, early detection, and therapy for LONS in preterm neonates remain unanswered. This review identifies important knowledge gaps in the management of LONS and describe possible methods and technologies that can be used to resolve these knowledge gaps. The availability of computational medicine and hypothesis-free-omics approaches give way to building bedside feedback tools to guide clinicians in personalized management of LONS. Despite advances in technology, implementation in clinical practice is largely lacking although such tools would help clinicians to optimize many aspects of the management of LONS. We outline which steps are needed to get possible research findings implemented on the neonatal intensive care unit and provide a roadmap for future research initiatives. IMPACT: This review identifies knowledge gaps in prevention, early detection, antibiotic, and additional therapy of late-onset neonatal sepsis in preterm neonates and provides a roadmap for future research efforts. Research opportunities are addressed, which could provide the means to fill knowledge gaps and the steps that need to be made before possible clinical use. Methods to personalize medicine and technologies feasible for bedside clinical use are described.
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Kurul S, Taal HR, Flint RB, Mazela J, Reiss IKM, Allegaert K, Simons SHP. Protocol: Pentoxifylline optimal dose finding trial in preterm neonates with suspected late onset sepsis (PTX-trial). BMC Pediatr 2021; 21:517. [PMID: 34794420 PMCID: PMC8603542 DOI: 10.1186/s12887-021-02975-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Late onset sepsis is a leading cause of death and morbidity in preterm infants. Despite optimal antibiotic treatment, sepsis related mortality and morbidity is still high. Pentoxifylline (PTX) is a methylxanthine with promising immunomodulatory properties, which can be used as an additional therapy next to antibiotics in preterm infants. PTX is increasingly used off-label in neonatal intensive care units, however up till now no dose finding study has been done for PTX in this specific population. The aim of this study (PTX-trial) is to determine the optimal dose of PTX in preterm infants (gestational age < 30 weeks) with (suspected) late onset sepsis. Dose finding in this particular population is unique, since for most drugs used in neonates the optimal dosage has not been investigated in phase II dose-seeking studies. METHODS The PTX-trial is a prospective open label sequential dose-optimization study with an adapted continual reassessment method. An up-and-down dose-response design will be used, with dose step-up and step-down titration after every 3 patients. The PTX starting dosage will be 30 mg/kg/day in 6 hours as described in most previous neonatal studies. Efficacy is defined by means of biochemical and clinical parameters. Toxicity in these vulnerable patients is unwarranted. The optimal dose is defined as the ED75 (i.e., clinically and chemically effective dose for 75% of patients) in preterm neonates with late onset sepsis. We plan to include 30 neonates to determine the optimal dose using this study design. Subsequently, the optimal dose will be validated in 10 additional preterm neonates. In parallel, pharmacokinetics of PTX and its metabolites will be described as well as longitudinal evaluation of metabolomics and proteomics. DISCUSSION The study has been approved by the Regional Medical Ethics Board of Erasmus Medical Center University Rotterdam (MEC 2019-0477) and registered at Clinicaltrials.gov (NCT04152980). Results of the main trial and each of the secondary endpoints will be submitted for publications in peer-reviewed journals. TRIAL REGISTRATION Clinicaltrials.gov, NCT04152980 , Registered November 6th, 2019.
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Affiliation(s)
- Serife Kurul
- Department of Pediatrics, Division Neonatology, Research Neonatology (Sk-4246), Erasmus Medical Center, PO Box 2060, Rotterdam, 300 CB, The Netherlands
| | - H Rob Taal
- Department of Pediatrics, Division Neonatology, Research Neonatology (Sk-4246), Erasmus Medical Center, PO Box 2060, Rotterdam, 300 CB, The Netherlands
| | - Robert B Flint
- Department of Pediatrics, Division Neonatology, Research Neonatology (Sk-4246), Erasmus Medical Center, PO Box 2060, Rotterdam, 300 CB, The Netherlands
- Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan Mazela
- Department of Neonatology, Poznan University of Medical Sciences, Poznań, Poland
| | - Irwin K M Reiss
- Department of Pediatrics, Division Neonatology, Research Neonatology (Sk-4246), Erasmus Medical Center, PO Box 2060, Rotterdam, 300 CB, The Netherlands
| | - Karel Allegaert
- Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Development and Regeneration and Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Sinno H P Simons
- Department of Pediatrics, Division Neonatology, Research Neonatology (Sk-4246), Erasmus Medical Center, PO Box 2060, Rotterdam, 300 CB, The Netherlands.
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Bayraktar S, Tanyeri-Bayraktar B. Pentoxifylline in the treatment of neonatal vasospasm and thromboembolism: An observational case series study. J Clin Pharm Ther 2021; 47:455-461. [PMID: 34726284 DOI: 10.1111/jcpt.13565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 11/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Newborns, particularly preterm babies, are prone to vascular vasospasm and thromboembolism. Differences in the haemostatic system, small vessel diameter and presence of any serious diseases are predisposing causes of thromboembolic disease in newborns. The lack of randomized controlled studies on the management of vasospasm and thromboembolism exacerbates the problem. We present a case series of the successful and safe use of PTX for the treatment of vasospasm and thrombosis in neonates. METHODS The study was conducted in the Bezmialem Vakif University Hospital Neonatal Intensive Care Unit (NICU). A retrospective chart review was performed on consecutive patients treated for vascular spasm and thrombosis. Nine patients diagnosed with vasospasm or thrombosis were enrolled in the study. RESULTS Five patients had arterial injuries. Six patients were premature, and five patients were diagnosed with thrombosis by using Doppler ultrasonography (US). The drug was diluted with 5% dextrose and administered intravenously at a dose of 5 mg/kg/h over six hours, ranging from 1 to 5 days. No drug-related side effects were observed. All babies recovered, and no amputation was performed. WHAT IS NEW AND CONCLUSION PTX may be an alternative treatment for vascular vasospasm and thromboembolism with fewer side effects than anticoagulant and thrombolytic agents in neonates. Starting PTX in the early stages of vascular insult may prevent the development of vasospasm and thromboembolism and thus limb ischaemia.
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Affiliation(s)
- Süleyman Bayraktar
- Department of Pediatric Intensive Care, Haseki Research and Training Hospital, Istanbul, Turkey
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Senarathna SMDKG, Strunk T, Petrovski M, Batty KT. Stability of Pentoxifylline Injection: Application to Neonatal/Pediatric Care Setting. J Pharm Sci 2021; 110:3862-3865. [PMID: 34481836 DOI: 10.1016/j.xphs.2021.08.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/30/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
Pentoxifylline (PTX) is administered as 6- or 12-hour intravenous infusions in the treatment of sepsis or necrotizing enterocolitis in neonates; however, there is a paucity of formal stability data for PTX in the end-use solution. We investigated PTX stability in the simulated clinical conditions of neonatal intensive care, where PTX injection is diluted to 5 mg/mL and administered via syringe pump. A stability-indicating high performance liquid chromatography (HPLC) assay was established for PTX. The clinical simulation stability study comprised PTX 5 mg/mL in 20 mL syringes and was conducted at three temperatures, all protected from light: refrigerator (4°C); room temperature (22°C) and incubator/humidicrib (35°C). PTX stability also was evaluated at room temperature and exposed to light. Samples were drawn at pre-determined times over a 10 day period and stored frozen (-80°C) until assayed by HPLC. A single exponential equation was fitted to the concentration-time data to determine PTX stability. Forced degradation studies confirmed that PTX was stable at elevated temperature (up to 45°C), exposed to light and under acidic stress for up to 10 days, but subject to degradation under alkali and oxidative stress. PTX injection 5 mg/mL in 0.9% w/v sodium chloride or 5% w/v glucose was found to be stable when protected from light at 22°C and 35°C, and exposed to light at 22°C for at least 7 days. These data provide clinically relevant evidence that PTX injection is stable in the end-use, ICU/incubator clinical conditions for at least 24 hours.
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Affiliation(s)
| | - Tobias Strunk
- Medical School, University of Western Australia, Crawley, WA, Australia; Neonatal Directorate, King Edward Memorial Hospital, Child and Adolescent Health Service, WA, Australia; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia.
| | - Michael Petrovski
- Pharmacy Department, King Edward Memorial Hospital, Women and Newborn Health Service, WA, Australia.
| | - Kevin T Batty
- Curtin Medical School, Curtin University, Bentley, WA, Australia; Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia.
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Dianey GCS, Kaur H, Dosanjh HS, Narayanan J, Singh J, Yadav A, Kumar D, Luu SDN, Sharma A, Singh PP, Alberto HAC. Sunlight powered degradation of pentoxifylline Cs 0.5Li 0.5FeO 2 as a green reusable photocatalyst: Mechanism, kinetics and toxicity studies. J Hazard Mater 2021; 416:125762. [PMID: 33819643 DOI: 10.1016/j.jhazmat.2021.125762] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/08/2021] [Accepted: 03/23/2021] [Indexed: 06/12/2023]
Abstract
The degradation of Pentoxifylline (PXF) was achieved successfully by green energy in a built-in solar photocatalytic system using hybrid LiCs ferrites (Li0.5Cs0.5FeO2) as magnetically recoverable photocatalysts. Kinetics showed a first-order reaction rate with maximum PXF removal of 94.91% at mildly acidic pH; additionally, the ferromagnetic properties of catalyst allowed recovery and reuse multiple times, reducing costs and time in degradation processes. The degradation products were identified by HPLC-MS and allowed us to propose a thermodynamically feasible mechanism that was validated through DFT calculations. Additionally, toxicity studies have been performed in bacteria and yeast where high loadings of Cs showed to be harmful to Staphylococcus aureus (MIC≥ 4.0 mg/mL); Salmonella typhi (MIC≥ 8.0 mg/mL) and Candida albicans (MIC≥ 10.0 mg/mL). The presented setup shows effectiveness and robustness in a degradation process using alternative energy sources for the elimination of non-biodegradable pollutants.
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Affiliation(s)
| | - Harpeet Kaur
- Department of Chemistry, School of Chemical Engineering and Physical Sciences, Lovely Professional University, Phagwara 144411, India
| | - H S Dosanjh
- Department of Chemistry, School of Chemical Engineering and Physical Sciences, Lovely Professional University, Phagwara 144411, India
| | - Jayanthi Narayanan
- Division of Nanotechnology, Universidad Politécnica del Valle de México, 54901 Tultitlán, Mexico
| | - Jashanpreet Singh
- Department of Chemistry, School of Chemical Engineering and Physical Sciences, Lovely Professional University, Phagwara 144411, India.
| | - Alpa Yadav
- Department of Applied Chemistry, School of Vocational Studies & Applied Sciences, Gautam Budha University, Greater Noida, Uttar Pradesh 201308, India
| | - Deepak Kumar
- Department of Chemistry, School of Chemical Engineering and Physical Sciences, Lovely Professional University, Phagwara 144411, India
| | - Son D N Luu
- Institute of Research and Development, Duy Tan University, Da Nang 550000, Viet Nam
| | - Ajit Sharma
- Department of Chemistry, School of Chemical Engineering and Physical Sciences, Lovely Professional University, Phagwara 144411, India
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Gastine S, Hsia Y, Clements M, Barker CI, Bielicki J, Hartmann C, Sharland M, Standing JF. Variation in Target Attainment of Beta-Lactam Antibiotic Dosing Between International Pediatric Formularies. Clin Pharmacol Ther 2021; 109:958-970. [PMID: 33521971 PMCID: PMC8358626 DOI: 10.1002/cpt.2180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/15/2021] [Indexed: 12/26/2022]
Abstract
As antimicrobial susceptibility of common bacterial pathogens decreases, ensuring optimal dosing may preserve the use of older antibiotics in order to limit the spread of resistance to newer agents. Beta-lactams represent the most widely prescribed antibiotic class, yet most were licensed prior to legislation changes mandating their study in children. As a result, significant heterogeneity persists in the pediatric doses used globally, along with quality of evidence used to inform dosing. This review summarizes dosing recommendations from the major pediatric reference sources and tries to answer the questions: Does beta-lactam dose heterogeneity matter? Does it impact pharmacodynamic target attainment? For three important severe clinical infections-pneumonia, sepsis, and meningitis-pharmacokinetic models were identified for common for beta-lactam antibiotics. Real-world demographics were derived from three multicenter point prevalence surveys. Simulation results were compared with minimum inhibitory concentration distributions to inform appropriateness of recommended doses in targeted and empiric treatment. While cephalosporin dosing regimens are largely adequate for target attainment, they also pose the most risk of neurotoxicity. Our review highlights aminopenicillin, piperacillin, and meropenem doses as potentially requiring review/optimization in order to preserve the use of these agents in future.
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Affiliation(s)
- Silke Gastine
- Infection, Immunity and Inflammation Research and Teaching DepartmentUCL Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - Yingfen Hsia
- School of PharmacyQueen’s University BelfastBelfastUK
| | | | - Charlotte I.S. Barker
- Department of Medical & Molecular GeneticsKing’s College LondonLondonUK
- Paediatric Infectious Diseases Research GroupInstitute for Infection and ImmunitySt George’s University of LondonLondonUK
| | - Julia Bielicki
- Paediatric Infectious Diseases Research GroupInstitute for Infection and ImmunitySt George’s University of LondonLondonUK
- Paediatric Pharmacology GroupUniversity of Basel Children’s HospitalBaselSwitzerland
| | | | - Mike Sharland
- Paediatric Infectious Diseases Research GroupInstitute for Infection and ImmunitySt George’s University of LondonLondonUK
| | - Joseph F. Standing
- Infection, Immunity and Inflammation Research and Teaching DepartmentUCL Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- Department of PharmacyGreat Ormond Street Hospital for ChildrenLondonUK
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Liu YX, Wen H, Niu WJ, Li JJ, Li ZL, Jiao Z. External Evaluation of Vancomycin Population Pharmacokinetic Models at Two Clinical Centers. Front Pharmacol 2021; 12:623907. [PMID: 33897418 PMCID: PMC8058705 DOI: 10.3389/fphar.2021.623907] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/15/2021] [Indexed: 01/19/2023] Open
Abstract
Background: Numerous vancomycin population pharmacokinetic models in neonates have been published; however, their predictive performances remain unknown. This study aims to evaluate their external predictability and explore the factors that might affect model performance. Methods: Published population pharmacokinetic models in neonates were identified from the literature and evaluated using datasets from two clinical centers, including 171 neonates with a total of 319 measurements of vancomycin levels. Predictive performance was assessed by prediction- and simulation-based diagnostics and Bayesian forecasting. Furthermore, the effect of model structure and a number of identified covariates was also investigated. Results: Eighteen published pharmacokinetic models of vancomycin were identified after a systematic literature search. Using prediction-based diagnostics, no model had a median prediction error of ≤ ± 15%, a median absolute prediction error of ≤30%, and a percentage of prediction error that fell within ±30% of >50%. A simulation-based visual predictive check of most models showed there were large deviations between observations and simulations. After Bayesian forecasting with one or two prior observations, the predicted performance improved significantly. Weight, age, and serum creatinine were identified as the most important covariates. Moreover, employing a maturation model based on weight and age as well as nonlinear model to incorporate serum creatinine level significantly improved predictive performance. Conclusion: The predictability of the pharmacokinetic models for vancomycin is closely related to the approach used for modeling covariates. Bayesian forecasting can significantly improve the predictive performance of models.
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Affiliation(s)
- Yi-Xi Liu
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
- Department of Pharmacy, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haini Wen
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wan-Jie Niu
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Jing-Jing Li
- Department of Pharmacy, Suzhou Hospital Affiliated to Nanjing Medical University, Suzhou, China
| | - Zhi-Ling Li
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Chavarría AP, Vázquez RRV, Cherit JGD, Bello HH, Suastegui HC, Moreno-Castañeda L, Alanís Estrada G, Hernández F, González-Marcos O, Saucedo-Orozco H, Manzano-Pech L, Márquez-Velasco R, Guarner-Lans V, Pérez-Torres I, Soto ME. Antioxidants and pentoxifylline as coadjuvant measures to standard therapy to improve prognosis of patients with pneumonia by COVID-19. Comput Struct Biotechnol J 2021; 19:1379-1390. [PMID: 33680348 PMCID: PMC7910139 DOI: 10.1016/j.csbj.2021.02.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/01/2021] [Accepted: 02/16/2021] [Indexed: 01/08/2023] Open
Abstract
The type 2 coronavirus causes severe acute respiratory syndrome (SARS-CoV-2) and produces pneumonia with pulmonary alveolar collapse. In some cases it also causes sepsis and septic shock. There is no specific treatment for coronavirus disease 2019 (COVID-19). Vitamin C (Vit C), Vitamin E (Vit E), N-acetylcysteine (NAC) and Melatonin (MT) increase the intracellular content of GSH, kidnap free radicals and protect DNA, proteins in the cytosol and lipids in cell membranes. Pentoxifylline (Px) has anti-inflammatory activities. Here we evaluate the effect of Vit C, Vit E, NAC, and MT plus Px in COVID-19 patients with moderate and severe pneumonia. 110 patients of either sex were included. They were divided into five groups with 22 patients each. Group 1 received Vit C + Px, group 2 Vit E + Px, group 3 NAC + Px, group 4 MT + Px, and group 5 only Px. Oxidative stress (OS) markers such as lipid peroxidation (LPO) levels, total antioxidant capacity (TAC) and nitrites (NO2 -) were evaluated in plasma. The antioxidant therapy improved the survival scores including the Sequential Organ Failure Assessment (SOFA), the Acute Physiology and chronic Health Evaluation II (Apache II), the Simplified Acute Physiology Score II (SAPS II), the Critical Illness Risk Score, Launched during COVID-19 crisis (COVIDGRAM) and the Glasgow Coma Scale (GCS). We found that LPO (p≤0.04) and inflammation markers such as interleukin-6 (IL-6, p≤ 0.01), C reactive protein (CRP, p ≤ 0.01) and procalcitonin (PCT, p ≤ 0.05) were elevated. TAC (p ≤ 0.03) and NO2 - (p ≤ 0.04) found themselves diminished in diminished in COVID-19 patients upon admission to the hospital. The different antioxidants reversed this alteration at the end of the treatment. The treatment with antioxidant supplements such as Vit C, E, NAC, and MT plus Px could decelerate the aggressive and lethal development of COVID-19. Antioxidant therapy can be effective in this pandemia since it improves the survival scores including SOFA, Apache II, SAPS II, COVIDGRAM, GCS by lowering the LPO, IL-6, CRP, PCT and increasing systemic TAC and NO2 -.
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Affiliation(s)
- Adrián Palacios Chavarría
- Critical Care Unit of the Temporal COVID-19 Unit, Citibanamex Center Av. del Conscripto 311, Lomas de Sotelo, Hipódromo de las Américas, Miguel Hidalgo, 11200 Ciudad de México, CDMX, Mexico
- Critical Care in American British Cowdray (ABC) Medical Center, I.A.P. ABC I.A.P. ABC Sur 136 No. 116 Col. Las Américas, México City 01120 , Mexico
| | - Rafael Ricardo Valdez Vázquez
- Critical Care Unit of the Temporal COVID-19 Unit, Citibanamex Center Av. del Conscripto 311, Lomas de Sotelo, Hipódromo de las Américas, Miguel Hidalgo, 11200 Ciudad de México, CDMX, Mexico
| | - José Guillermo Domínguez Cherit
- Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán” Vasco de Quiroga 15, Sección XVI, Tlalpan, México City 14000, Mexico
- Tecnológico de Monterrey EMCS, Mexico
| | - Héctor Herrera Bello
- Critical Care Unit of the Temporal COVID-19 Unit, Citibanamex Center Av. del Conscripto 311, Lomas de Sotelo, Hipódromo de las Américas, Miguel Hidalgo, 11200 Ciudad de México, CDMX, Mexico
| | - Humberto Castillejos Suastegui
- Critical Care Unit of the Temporal COVID-19 Unit, Citibanamex Center Av. del Conscripto 311, Lomas de Sotelo, Hipódromo de las Américas, Miguel Hidalgo, 11200 Ciudad de México, CDMX, Mexico
| | - Lidia Moreno-Castañeda
- Critical Care Unit of the Temporal COVID-19 Unit, Citibanamex Center Av. del Conscripto 311, Lomas de Sotelo, Hipódromo de las Américas, Miguel Hidalgo, 11200 Ciudad de México, CDMX, Mexico
| | - Gabriela Alanís Estrada
- Critical Care Unit of the Temporal COVID-19 Unit, Citibanamex Center Av. del Conscripto 311, Lomas de Sotelo, Hipódromo de las Américas, Miguel Hidalgo, 11200 Ciudad de México, CDMX, Mexico
| | - Fabián Hernández
- Critical Care Unit of the Temporal COVID-19 Unit, Citibanamex Center Av. del Conscripto 311, Lomas de Sotelo, Hipódromo de las Américas, Miguel Hidalgo, 11200 Ciudad de México, CDMX, Mexico
| | - Omar González-Marcos
- Critical Care Unit of the Temporal COVID-19 Unit, Citibanamex Center Av. del Conscripto 311, Lomas de Sotelo, Hipódromo de las Américas, Miguel Hidalgo, 11200 Ciudad de México, CDMX, Mexico
| | - Huitzilihuitl Saucedo-Orozco
- Cardioneumology Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico
- Cardioneumology Department, Centro Médico Nacional La Raza Instituto Mexicano del Seguro Social Seris y Zaachila, Col. La Raza Azcapotzalco, 02990 Ciudad de México, CDMX, Mexico
| | - Linaloe Manzano-Pech
- Department of Cardiovascular Biomedicine, Instituto Nacional de Cardiología Ignacio Chávez. Badiano 1, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Ricardo Márquez-Velasco
- Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez. Badiano 1, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Verónica Guarner-Lans
- Department of Physiology, Instituto Nacional de Cardiología Ignacio Chávez. Badiano 1, Sección XVI, Tlalpan, México City 14080 Mexico
| | - Israel Pérez-Torres
- Department of Cardiovascular Biomedicine, Instituto Nacional de Cardiología Ignacio Chávez. Badiano 1, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Maria Elena Soto
- Department of Immunology , Instituto Nacional de Cardiología Ignacio Chávez. Juan Badiano 1 , Sección XVI , Tlalpan , México City 14080 , Mexico
- American British Cowdray (ABC) Medical Center , I.A.P. ABC I.A.P. ABC Sur 136 No. 116 Col. Las Américas , México City 01120 , Mexico
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10
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Speer EM, Diago-Navarro E, Ozog LS, Raheel M, Levy O, Fries BC. A Neonatal Murine Escherichia coli Sepsis Model Demonstrates That Adjunctive Pentoxifylline Enhances the Ratio of Anti- vs. Pro-inflammatory Cytokines in Blood and Organ Tissues. Front Immunol 2020; 11:577878. [PMID: 33072121 PMCID: PMC7538609 DOI: 10.3389/fimmu.2020.577878] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/18/2020] [Indexed: 12/11/2022] Open
Abstract
Introduction: Neonatal sepsis triggers an inflammatory response that contributes to mortality and multiple organ injury. Pentoxifylline (PTX), a phosphodiesterase inhibitor which suppresses pro-inflammatory cytokines, is a candidate adjunctive therapy for newborn sepsis. We hypothesized that administration of PTX in addition to antibiotics decreases live bacteria-induced pro-inflammatory and/or enhances anti-inflammatory cytokine production in septic neonatal mice without augmenting bacterial growth. Methods: Newborn C57BL/6J mice (< 24 h old) were injected intravenously with 105 colony forming units (CFUs)/g weight of a bioluminescent derivative of the encapsulated clinical isolate Escherichia coli O18:K1. Adequacy of intravenous injections was validated using in vivo bioluminescence imaging and Evans blue. Pups were treated with gentamicin (GENT), PTX, (GENT + PTX) or saline at 0, 1.5, or 4 h after sepsis initiation, and euthanized after an additional 4 h. CFUs and cytokines were measured from blood and homogenized organ tissues. Results: GENT alone inhibited bacterial growth, IL-1β, and IL-6 production in blood and organs. Addition of PTX to GENT profoundly inhibited E. coli-induced TNF and enhanced IL-10 in blood of newborn mice at all timepoints, whereas it primarily upregulated IL-10 production in peripheral organs (lung, spleen, brain). PTX, whether alone or adjunctive to GENT, did not increase microbial colony counts in blood and organs. Conclusion: Addition of PTX to antibiotics in murine neonatal E. coli sepsis promoted an anti-inflammatory milieu through inhibition of plasma TNF and enhancement of IL-10 production in plasma and organs without increasing bacterial growth, supporting its utility as a potential adjunctive agent for newborn sepsis.
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Affiliation(s)
- Esther M Speer
- Department of Pediatrics, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | - Elizabet Diago-Navarro
- Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | - Lukasz S Ozog
- Department of Pediatrics, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | - Mahnoor Raheel
- Department of Pediatrics, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | - Ofer Levy
- Precision Vaccine Program, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States.,Broad Institute of MIT and Harvard, Cambridge, MA, United States
| | - Bettina C Fries
- Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States.,U.S. Department of Veterans Affairs, Northport VA Medical Center, Northport, NY, United States
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11
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Schüller SS, Kempf K, Unterasinger L, Strunk T, Berger A. Intravenous pentoxifylline is well tolerated in critically ill preterm infants with sepsis or necrotizing enterocolitis. Eur J Pediatr 2020; 179:1325-1330. [PMID: 32179980 DOI: 10.1007/s00431-020-03612-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/03/2020] [Accepted: 02/10/2020] [Indexed: 02/07/2023]
Abstract
Pentoxifylline (PTX) is a candidate adjuvant medication for the treatment of sepsis and necrotizing enterocolitis in preterm infants. There is only limited data on safety and compatibility with other commonly used intravenous medications. This retrospective single-center study of 198 preterm infants (September 2012-September 2018) was performed at a level IV neonatal intensive care unit. Electronic data of all preterm infants who received pentoxifylline for sepsis or necrotizing were extracted from routine databases. We analyzed a total of 1081 PTX treatment days from 217 treatment episodes in 198 preterm infants (mean gestational age 27 weeks; mean birth weight 1060 g). At a mean daily dose of 28 mg/kg, no clinically relevant side effects were observed. PTX therapy was not associated with clinically significant changes of blood biochemistry and hematology parameters. Concomitant infusion of PTX with other common NICU medications was well tolerated, and there was no evidence of incompatibility.Conclusion: Intravenous PTX is compatible with standard NICU drugs and well tolerated in critically ill preterm infants. What is Know: •Currently, there are no evidence-based adjuvant medications available that target the harmful inflammatory host response in neonatal sepsis or necrotizing enterocolitis. •Pentoxifylline (PTX) is a candidate adjuvant medication for the treatment of sepsis and necrotizing enterocolitis in preterm infants; however, safety data are rare and PTX is currently used off-label. What is New: •Here we report on our experience in the pragmatic routine use of PTX as adjuvant therapy in 198 preterm infants with sepsis or NEC. •Concomitant infusion of PTX with other common NICU medications was well tolerated, and there was no evidence of incompatibility. No clinically relevant side effects were observed.
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Affiliation(s)
- Simone S Schüller
- Department of Paediatrics, Division of Neonatology, Pediatric Intensive Care Medicine and Neuropaediatrics, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria. .,Centre for Neonatal Research and Education, University of Western Australia, Perth, WA, Australia. .,Neonatal Directorate, King Edward Memorial Hospital, 374 Bagot Rd, Subiaco, WA, 6008, Australia.
| | - Kristina Kempf
- Department of Paediatrics, Division of Neonatology, Pediatric Intensive Care Medicine and Neuropaediatrics, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria
| | - Lukas Unterasinger
- Department of Paediatrics, Division of Neonatology, Pediatric Intensive Care Medicine and Neuropaediatrics, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria
| | - Tobias Strunk
- Centre for Neonatal Research and Education, University of Western Australia, Perth, WA, Australia.,Neonatal Directorate, King Edward Memorial Hospital, 374 Bagot Rd, Subiaco, WA, 6008, Australia
| | - Angelika Berger
- Department of Paediatrics, Division of Neonatology, Pediatric Intensive Care Medicine and Neuropaediatrics, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria
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13
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Salman S, Hibbert J, Page-Sharp M, Manning L, Simmer K, Doherty DA, Patole S, Batty KT, Strunk T. Effects of maturation and size on population pharmacokinetics of pentoxifylline and its metabolites in very preterm infants with suspected late-onset sepsis or necrotizing enterocolitis: a pilot study incorporating clinical outcomes. Br J Clin Pharmacol 2018; 85:147-159. [PMID: 30281170 DOI: 10.1111/bcp.13775] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 08/08/2018] [Accepted: 09/09/2018] [Indexed: 01/10/2023] Open
Abstract
AIMS Infection-induced inflammation is associated with adverse long-term outcomes in preterm infants. Pentoxifylline (PTX) is a candidate for adjunct immunomodulatory therapy in preterm infants with late-onset sepsis (LOS) and necrotizing enterocolitis (NEC), but pharmacokinetic data in this population are extremely limited. This study aims to characterize the pharmacokinetic properties of intravenous PTX and its metabolites in preterm infants. METHOD An open label pilot clinical study of intravenous PTX as an adjunct therapy in preterm infants (gestation <32 weeks) with suspected LOS or NEC was undertaken. PTX was infused for 12 h for two days (60 mg kg-1 per 12 h), and in infants with confirmed diagnosis of LOS or NEC, for 6 h for another 4 days (30 mg kg-1 per 6 h). Plasma concentrations of PTX and its principal metabolites from collected blood samples were measured using a validated LCMS assay. NONMEM was used to analyse the data using population pharmacokinetic modelling. RESULTS The preterm infants (n = 26) had a median (range) gestation of 24.8 weeks (23.3-30.4) and birthweight of 689 g (370-1285). PTX was well tolerated and without treatment-limiting adverse effects. Changes in size (weight) and maturation were successfully modelled for PTX and metabolites. After allometric scaling, clearance increased with postmenstrual age, increasing by approximately 30% per week for PTX and M1 (lisofylline) and simulations of current dosing demonstrated a six-fold difference in exposure between 24 and 35 weeks postmenstrual age. CONCLUSIONS The developed model can be used to explore dosing strategies based on size and maturation for preterm infants.
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MESH Headings
- Administration, Intravenous
- Body Weight/physiology
- Drug Therapy, Combination/methods
- Enterocolitis, Necrotizing/blood
- Enterocolitis, Necrotizing/drug therapy
- Female
- Humans
- Infant
- Infant, Extremely Premature/blood
- Infant, Extremely Premature/physiology
- Infant, Newborn
- Infant, Premature, Diseases/blood
- Infant, Premature, Diseases/drug therapy
- Infant, Very Low Birth Weight/blood
- Infant, Very Low Birth Weight/physiology
- Male
- Metabolic Clearance Rate/physiology
- Models, Biological
- Pentoxifylline/administration & dosage
- Pentoxifylline/pharmacokinetics
- Phosphodiesterase Inhibitors/administration & dosage
- Phosphodiesterase Inhibitors/pharmacokinetics
- Pilot Projects
- Sepsis/blood
- Sepsis/drug therapy
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Sam Salman
- Medical School, University of Western Australia, Crawley, WA, Australia
| | - Julie Hibbert
- Centre for Neonatal Research and Education, School of Medicine, University of Western Australia, Crawley, WA, Australia
| | - Madhu Page-Sharp
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, WA, Australia
| | - Laurens Manning
- Medical School, University of Western Australia, Crawley, WA, Australia
| | - Karen Simmer
- Centre for Neonatal Research and Education, School of Medicine, University of Western Australia, Crawley, WA, Australia
- Neonatal Directorate, King Edward Memorial Hospital, Subiaco, WA, Australia
| | - Dorota A Doherty
- Division of Obstetrics and Gynaecology, University of Western Australia, Crawley, WA, Australia
| | - Sanjay Patole
- Centre for Neonatal Research and Education, School of Medicine, University of Western Australia, Crawley, WA, Australia
- Neonatal Directorate, King Edward Memorial Hospital, Subiaco, WA, Australia
| | - Kevin T Batty
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, WA, Australia
| | - Tobias Strunk
- Centre for Neonatal Research and Education, School of Medicine, University of Western Australia, Crawley, WA, Australia
- Neonatal Directorate, King Edward Memorial Hospital, Subiaco, WA, Australia
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