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Schechter T, Lewis VA, Schultz KR, Mitchell D, Chen S, Seto W, Teuffel O, Gibson P, Doyle JJ, Gassas A, Sung L, Lee Dupuis L. Relationship between cyclosporine area-under-the curve and acute graft versus host disease in pediatric patients undergoing hematopoietic stem cell transplant: A prospective, multicenter study. Pediatr Hematol Oncol 2018; 35:288-296. [PMID: 30592246 DOI: 10.1080/08880018.2018.1520948] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Traditionally in hematopoietic stem cell transplant (HSCT), cyclosporine doses are individualized using cyclosporine trough concentrations (C0) while area under the concentration vs time curve (AUC) is used in solid organ transplant. AUC potentially has an important relationship with the development of acute graft-versus-host-disease (aGVHD). We conducted a prospective study to describe the relationship between severe (grade III-IV) aGVHD and cyclosporine AUC in pediatric HSCT recipients. Pediatric patients who underwent allogeneic myeloablative HSCT and scheduled to receive cyclosporine for aGVHD prophylaxis participated in this multicenter study. Cyclosporine doses were adjusted based on C0 according to each center's standard of care. Cyclosporine AUC was determined weekly until neutrophil engraftment or Day +42, whichever was later. Associations between severe aGVHD and cyclosporine AUC and other patient and treatment-related factors were evaluated. Of the 110 children enrolled, 97 were evaluable. Thirty-seven (38%) children developed aGVHD; 13 (13.4%) had severe aGVHD. On univariate analysis, there was no association between severe aGVHD and cyclosporine AUC at any time point before engraftment. Future research should focus on refinement of C0 targets for cyclosporine therapeutic drug monitoring in HSCT.
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Affiliation(s)
- Tal Schechter
- a Department of Pediatrics, Division of Haematology/Oncology, The Hospital of Sick Children and Faculty of Medicine , University of Toronto , Toronto , Canada
| | - Victor A Lewis
- b Section of Pediatric Oncology and Blood and Marrow Transplant, Alberta Children's Hospital; Departments of Oncology and Pediatrics, Cumming School of Medicine , University of Calgary , Calgary , Canada
| | - Kirk R Schultz
- c Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital and Research Institute , UBC , Vancouver , Canada
| | - David Mitchell
- d Pediatric Hematology/Oncology, McGill University Health Center; Faculty of Medicine, McGill University , Montréal , Canada
| | - Shiyi Chen
- e Clinical Research Services, The Hospital for Sick Children , Toronto , Canada
| | - Winnie Seto
- f Department of Pharmacy , The Hospital for Sick Children , Toronto , Canada.,g Leslie Dan Faculty of Pharmacy , University of Toronto , Toronto , Canada.,h Child Health Evaluative Services , Research Institute, The Hospital for Sick Children , Toronto , Canada
| | - Oliver Teuffel
- i University of Tuebingen , Tuebingen , Germany ; Division of Oncology , Medical Services of the Statutory Health Insurance, Baden-Wuerttemberg , Germany
| | - Paul Gibson
- j Pediatric Hematology/Oncology, Children's Hospital, London Health Sciences Centre, London , Canada
| | - John J Doyle
- k Department of Pediatric Hematology/Oncology, CancerCare Manitoba and Department of Pediatrics and Child Health , University of Manitoba , Winnipeg , Canada
| | - Adam Gassas
- l School of Clinical Sciences , University of Bristol and Bristol Royal Hospital for Children , Bristol , United Kingdom
| | - Lillian Sung
- a Department of Pediatrics, Division of Haematology/Oncology, The Hospital of Sick Children and Faculty of Medicine , University of Toronto , Toronto , Canada.,h Child Health Evaluative Services , Research Institute, The Hospital for Sick Children , Toronto , Canada
| | - L Lee Dupuis
- f Department of Pharmacy , The Hospital for Sick Children , Toronto , Canada.,g Leslie Dan Faculty of Pharmacy , University of Toronto , Toronto , Canada.,h Child Health Evaluative Services , Research Institute, The Hospital for Sick Children , Toronto , Canada
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Martin P, Bleyzac N, Souillet G, Galambrun C, Bertrand Y, Maire PH, Jelliffe RW, Aulagner G. Relationship between CsA trough blood concentration and severity of acute graft-versus-host disease after paediatric stem cell transplantation from matched-sibling or unrelated donors. Bone Marrow Transplant 2003; 32:777-84. [PMID: 14520421 DOI: 10.1038/sj.bmt.1704213] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In order to determine optimal CsA trough blood concentrations (TBC) in the early post transplantation period, we analysed relationships between TBC and acute graft-versus-host disease (aGVHD) in paediatric SCT. A total of 94 children consecutively underwent allogeneic stem cell transplantation (SCT) from: matched-sibling (MSD) (n=36), mismatched-related (MMRD) (n=3) and unrelated donors (UD) (n=55). GVHD prophylaxis usually included CsA alone or with methotrexate. Antithymocyte globulin was added in UD-SCT. TBC during the first weeks of post transplantation were estimated retrospectively by a Bayesian pharmacokinetic method and statistically associated with aGVHD. In MSD-SCT, the mean TBC during the first 2 weeks post transplantation were 42+/-10 and 90+/-7 ng/ml, respectively, in patients with grade II-IV and 0-I aGVHD (P=0.001). In SCT from UD and MMRD, TBC were 73+/-4 vs 95+/-8 ng/ml (P=0.284). For TBC >85 ng/ml, no patient developed grade II-IV aGVHD, 10 developed mild aGVHD and 30 had no aGVHD. For TBC <65 ng/ml, 7/11 patients receiving an MSD-SCT and 4/18 receiving an UD- or MMRD-SCT developed grade II-IV aGVHD. The mean TBC corresponding to each grade were: no GVHD: 101+/-10 ng/ml, mild: 77+/-11 ng/ml, moderate: 61+/-13 ng/ml, severe: 56+/-15 ng/ml (P <0.001). These results reveal a strong relationship between TBC during the early post transplantation period and the severity of aGVHD in paediatric SCT.
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Affiliation(s)
- P Martin
- Department of Pharmacy, Debrousse Hospital, Lyon, France
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Schultz KR, Nevill TJ, Balshaw RF, Toze CL, Corr T, Currie CJ, Strong DK, Keown PA. Effect of gastrointestinal inflammation and age on the pharmacokinetics of oral microemulsion cyclosporin A in the first month after bone marrow transplantation. Bone Marrow Transplant 2000; 26:545-51. [PMID: 11019845 DOI: 10.1038/sj.bmt.1702545] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cyclosporin A (CsA) absorption is highly variable in BMT patients. Neoral, a new microemulsion formulation of CsA, permits increased absorption with less variable pharmacokinetic parameters in non-BMT patients. We evaluated the pharmacokinetics of CsA after BMT in patients received microemulsion CsA. Two oral doses of 3mg/kg were given 48 h apart between 14 and 28 days after allogeneic BMT in 20 adults, and one dose in seven children, while subjects were receiving a continuous i.v. infusion of CsA. Whole blood samples were taken throughout the dosing interval to calculate the incremental CsA exposure using maximum concentration (Cmax), time to Cmax (tmax), concentration at 12 h after the dose (C12), the area under the concentration-time curve (AUC), and to establish inter- and intra-patient pharmacokinetic variability. Drug exposure was substantially lower in children than adults, with an AUC of 861+/-805 vs 2629+/-1487 micromg x h/l (P = 0.001), respectively, and absorption was delayed and diminished in both groups by comparison with solid organ recipients. Intra-patient variability in adults for AUC was high at 0.59+/-0.34, while inter-patient variability, measured as the coefficient of variation (c.v.), was 0.55 for the first and 0.54 for the second dose. In adults, gastrointestinal (GI) inflammation due to either mucositis or GVHD resulted in a higher AUC of 3077+/-1551 microg x h/l compared to 1795+/-973 microg x h/l (P = 0.02), and a similar trend was observed in children. AUC seemed little affected by the CsA formulation (liquid or capsule), or co-administration with liquids or food. Trough (12 h) CsA levels correlated poorly with incremental AUC. Sparse sample modeling of the AUC using two-point predictors taken at 2.5 and 5 h after dosing accurately approximated AUC in adults (r2 = 0.94), while 1.5 and 5 h was superior in children (r2 = 0.98). These data suggest that 12 h postdose trough measurements of CsA may not be the most appropriate way to evaluate CsA blood concentrations in order to establish therapeutic efficacy in BMT patients. Based on this study, the dose of microemulsion CsA should be adjusted based on recipient age, and the presence of GI inflammation secondary to mucositis or GVHD. These data would suggest that sparse sampling at time points earlier than the trough more accurately reflects the AUC and may correlate more closely with therapeutic efficacy early post-BMT.
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Affiliation(s)
- K R Schultz
- Department of Pediatrics, University of British Columbia and British Columbia's Children's Hospital, Vancouver, Canada
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