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McCune JS, Navarro SL, Baker KS, Risler LJ, Phillips BR, Randolph TW, Shireman L, Schoch G, Deeg HJ, Zhang Y, Men A, Maton L, Huitema ADR. Prediction of Busulfan Clearance by Predose Plasma Metabolomic Profiling. Clin Pharmacol Ther 2023; 113:370-379. [PMID: 36369996 PMCID: PMC9888309 DOI: 10.1002/cpt.2794] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/07/2022] [Indexed: 11/13/2022]
Abstract
Intravenous busulfan doses are often personalized to a target plasma exposure (targeted busulfan) using an individual's busulfan clearance (BuCL). We evaluated whether BuCL could be predicted by a predose plasma panel of 841 endogenous metabolomic compounds (EMCs). In this prospective cohort of 132 hematopoietic cell transplantation (HCT) patients, all had samples collected immediately before busulfan administration (preBU) and 96 had samples collected 2 weeks before busulfan (2-week-preBU). BuCL was significantly associated with 37 EMCs after univariate linear regression analysis and controlling for false discovery (< 0.05) in the 132 preBU samples. In parallel, with preBU samples, we included all 841 EMCs in a least absolute shrinkage and selection operator-penalized regression which selected 13 EMCs as predominantly associated with BuCL. Then, we constructed a prediction model by estimating coefficients for these 13 EMCs, along with sex, using ordinary least-squares. When the resulting linear prediction model was applied to the 2-week-preBU samples, it explained 40% of the variation in BuCL (adjusted R2 = 0.40). Pathway enrichment analysis revealed 18 pathways associated with BuCL. Lysine degradation followed by steroid biosynthesis, which aligned with the univariate analysis, were the top two pathways. BuCL can be predicted before busulfan administration with a linear regression model of 13 EMCs. This pharmacometabolomics method should be prioritized over use of a busulfan test dose or pharmacogenomics to guide busulfan dosing. These results highlight the potential of pharmacometabolomics as a precision medicine tool to improve or replace pharmacokinetics to personalize busulfan doses.
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Affiliation(s)
- Jeannine S. McCune
- City of Hope, Department of Hematologic Malignancies Translational Sciences, Duarte, California (CA), 91010, United States of America (USA)
| | - Sandi L. Navarro
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (WA), 98109, USA
| | - K. Scott Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (WA), 98109, USA,Department of Pediatrics, University of Washington, Seattle, WA, 98195, USA
| | - Linda J. Risler
- Department of Pharmaceutics, University of Washington, Seattle, WA, 98195, USA
| | - Brian R. Phillips
- Department of Pharmaceutics, University of Washington, Seattle, WA, 98195, USA
| | - Timothy W. Randolph
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (WA), 98109, USA
| | - Laura Shireman
- Department of Pharmaceutics, University of Washington, Seattle, WA, 98195, USA
| | - Gary Schoch
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (WA), 98109, USA
| | - H. Joachim Deeg
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (WA), 98109, USA,Department of Medicine, University of Washington, Seattle, WA, 98195, USA
| | - Yuzheng Zhang
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (WA), 98109, USA
| | - Alex Men
- Department of Pharmaceutics, University of Washington, Seattle, WA, 98195, USA
| | - Loes Maton
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
| | - Alwin D. R. Huitema
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands,Department of Pharmacology, Princes Maxima & Pharmacology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands,Department of Clinical Pharmacy, University Medical Center Utrecht, The Netherlands
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2
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Lawson R, Paterson L, Fraser CJ, Hennig S. Evaluation of two software using Bayesian methods for monitoring exposure and dosing once-daily intravenous busulfan in paediatric patients receiving haematopoietic stem cell transplantation. Cancer Chemother Pharmacol 2021; 88:379-391. [PMID: 34021809 DOI: 10.1007/s00280-021-04288-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/22/2021] [Indexed: 11/24/2022]
Abstract
AIM To assess the ability of model-based personalised dosing tools to estimate busulfan exposure (i) in comparison to clinically used intensive sampling exposure estimation procedure, (ii) using limited sampling strategies and (iii) to predict changes in busulfan clearance during busulfan treatment. METHODS Data on intravenous busulfan dosing for patients with 4 consecutive days were entered into Bayesian forecasting software, InsightRX and NextDose. Prediction of busulfan cumulative exposure was compared to current clinical practice estimation, aiming for pre-defined individualised target of cumulative exposure. Estimation performance was tested given several limited sampling strategies. RESULTS Thirty-two paediatric patients (0.2-16.5 years) provided a total of 103 daily exposure measurements estimated using 7 samples taken per day (full sampling), with 19 patients having sampling following all doses administered. Both software tools utilising Bayesian methods provided acceptable relative bias and precision of cumulative exposure estimations under the tested sampling scenarios. Relative bias ranged from median RE of 0.1-14.6% using InsightRX and from 3.4-7.8% using NextDose. Precision ranged from median RMSE of 0.19-0.32 mg·h·L-1 for InsightRX and 0.08-0.1 mg·h·L-1 for NextDose. A median reduction in busulfan clearance from day 1 to day 4 was observed in the clinical data (-10.9%), when using InsightRX (-18.6%) and with NextDose (-14.7%). CONCLUSION Bayesian methods were shown to have relatively low bias and precisely estimate busulfan exposure using intensive sampling and several limited sampling strategies, which provides evidence for prospective studies to evaluate these tools in clinical practice. A trend to overestimation of exposure using Bayesian methods was observed compared to clinical practice. Reduction of busulfan clearance from day 1 to 4 of once daily dosing was confirmed and should be considered when adjusting doses.
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Affiliation(s)
- Rachael Lawson
- School of Pharmacy, University of Queensland, Brisbane, QLD, Australia. .,Pharmacy Department, Queensland Children's Hospital, Brisbane, QLD, Australia. .,Pharmacy Australia Centre of Excellence (PACE), University of Queensland, 20 Cornwall Street, Woolloongabba, QLD, 4102, Australia.
| | - Lachlan Paterson
- School of Pharmacy, University of Queensland, Brisbane, QLD, Australia.,School of Medicine, Griffith University, Southport, QLD, Australia
| | - Christopher J Fraser
- Blood and Marrow Transplant Service, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Stefanie Hennig
- School of Pharmacy, University of Queensland, Brisbane, QLD, Australia.,Certara, Inc, Princeton, NJ, USA.,Department of Clinical Pharmacy, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany.,School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, 4000, Australia
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3
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Yuan J, Sun N, Feng X, He H, Mei D, Zhu G, Zhao L. Optimization of Busulfan Dosing Regimen in Pediatric Patients Using a Population Pharmacokinetic Model Incorporating GST Mutations. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2021; 14:253-268. [PMID: 33623415 PMCID: PMC7894888 DOI: 10.2147/pgpm.s289834] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/11/2021] [Indexed: 12/28/2022]
Abstract
Purpose The aim of this study was to develop a novel busulfan dosing regimen, based on a population pharmacokinetic (PPK) model in Chinese children, and to achieve better area under the concentration-time curve (AUC) targeting. Patients and Methods We collected busulfan concentration-time samples from 69 children who received intravenous busulfan prior to allogeneic hematopoietic stem cell transplantation (allo-HSCT). A population pharmacokinetic model for busulfan was developed by nonlinear mixed effect modelling and was validated by an external dataset (n=14). A novel busulfan dosing regimen was developed through simulated patients, and has been verified on real patients. Limited sampling strategy (LSS) was established by Bayesian forecasting. Mean absolute prediction error (MAPE) and relative root mean Squared error (rRMSE) were calculated to evaluate predictive accuracy. Results A one-compartment model with first-order elimination best described the data. GSTA1 genotypes, body surface area (BSA) and aspartate aminotransferase (AST) were found to be significant covariates of Bu clearance, and BSA had significant impact of the volume of distribution. Moreover, two equations were obtained for recommended dose regimens: dose (mg)=34.14×BSA (m2)+3.75 (for GSTA1 *A/*A), Dose (mg)=30.99×BSA (m2)+3.21 (for GSTA1 *A/*B). We also presented a piecewise dosage based on BSA categories for each GSTA1 mutation. A two-point LSS, two hours and four hours after dosing, behaved well with acceptable prediction precision (rRMSE=1.026%, MAPE=6.55%). Conclusion We recommend a GSTA1-BSA and BSA-based dosing (Q6 h) based on a PPK model for personalizing busulfan therapy in pediatric population. Additionally, an optimal LSS (C2h and C4h) provides convenience for therapeutic drug monitoring (TDM) in the future.
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Affiliation(s)
- Jinjie Yuan
- Clinical Research Center, Beijing Children's Hospital, Capital Medical University, Beijing, People's Republic of China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, People's Republic of China
| | - Ning Sun
- Clinical Research Center, Beijing Children's Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xinying Feng
- Phase I Clinical Trials Centre, Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang, People's Republic of China
| | - Huan He
- Clinical Research Center, Beijing Children's Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Dong Mei
- Clinical Research Center, Beijing Children's Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Guanghua Zhu
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Libo Zhao
- Clinical Research Center, Beijing Children's Hospital, Capital Medical University, Beijing, People's Republic of China
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4
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Review of the Pharmacokinetics and Pharmacodynamics of Intravenous Busulfan in Paediatric Patients. Clin Pharmacokinet 2020; 60:17-51. [PMID: 33128207 DOI: 10.1007/s40262-020-00947-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2020] [Indexed: 12/13/2022]
Abstract
We aimed to review the pharmacokinetics (PK) of intravenous busulfan in paediatric patients, identify covariate factors influencing exposure, investigate evidence of changes in PK behaviour over time, and correlate exposure with efficacy and toxicity outcomes. A literature review was undertaken of original research published between 2007 and 2019, investigating the PK and pharmacodynamics (PD) of intravenous busulfan in patients ≤ 18 years of age. The review identified 41 publications characterising the PK, and 45 publications describing the PD, of busulfan. Median typical clearance (CL) was 0.22 L/h/kg and median typical volume of distribution was 0.69 L/kg. Patient weight, age, glutathione-S-transferase A1 (GSTA1) genotype and busulfan dosing day/time were the most commonly identified factors affecting CL. Of nine studies investigating changes in CL, seven reported reduced CL over the 4-day course of treatment. Exposure monitoring methods and therapeutic targets were heterogeneous across studies. Relationships between busulfan exposure and patient outcomes were observed in five studies. One study observed a cumulative area under the concentration-time curve over all days of treatment of between 78 and 101 mg/L·h, and two studies observed an average concentration at first dose of < 600 ng/mL improved overall survival, transplant-related mortality, or relapse. One study observed increased sinusoidal obstructive syndrome with maximum busulfan concentration > 1.88 ng/mL. Patient weight, age and GSTA1 genotype are important covariates to consider when individualising busulfan therapy. Reduced busulfan CL over time may need to be accounted for, particularly in patients not receiving phenytoin co-therapy. Standardised monitoring of busulfan exposure over the entire course of treatment and further investigation of the role of busulfan metabolites and pharmacogenomics is warranted.
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Sassen SDT, Zwaan CM, van der Sluis IM, Mathôt RAA. Pharmacokinetics and population pharmacokinetics in pediatric oncology. Pediatr Blood Cancer 2020; 67:e28132. [PMID: 31876123 DOI: 10.1002/pbc.28132] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 11/19/2019] [Accepted: 11/24/2019] [Indexed: 12/28/2022]
Abstract
Pharmacokinetic research has become increasingly important in pediatric oncology as it can have direct clinical implications and is a crucial component in individualized medicine. Population pharmacokinetics has become a popular method especially in children, due to the potential for sparse sampling, flexible sampling times, computing of heterogeneous data, and identification of variability sources. However, population pharmacokinetic reports can be complex and difficult to interpret. The aim of this article is to provide a basic explanation of population pharmacokinetics, using clinical examples from the field of pediatric oncology, to facilitate the translation of pharmacokinetic research into the daily clinic.
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Affiliation(s)
- Sebastiaan D T Sassen
- Department of Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - C Michel Zwaan
- Department of Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Ron A A Mathôt
- Department of Hospital Pharmacy, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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6
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Marsit H, Philippe M, Neely M, Rushing T, Bertrand Y, Ducher M, Leclerc V, Guitton J, Bleyzac N, Goutelle S. Intra-individual Pharmacokinetic Variability of Intravenous Busulfan in Hematopoietic Stem Cell-Transplanted Children. Clin Pharmacokinet 2020; 59:1049-1061. [PMID: 32157629 DOI: 10.1007/s40262-020-00877-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Busulfan therapeutic drug monitoring (TDM) is necessary to better achieve the target exposure in children before hematopoietic stem cell transplantation (HSCT). However, TDM-based dosing may be challenging if intra-individual pharmacokinetic variability (also denoted inter-occasion variability [IOV]) occurs during therapy. OBJECTIVES The objectives of this study were to describe and quantify busulfan IOV in children, and to investigate its potential determinants. METHODS We performed a new analysis of published data from children who received intravenous busulfan over 4 days before HSCT. We calculated individual pharmacokinetic parameters on each day of therapy using a published population pharmacokinetic model of busulfan and analyzed their changes. Population estimation of IOV was also performed with non-linear mixed effects (NLME) modeling. Potential predictors of significant decrease in busulfan clearance (CL) were assessed by using machine learning approaches. RESULTS IOV could be assessed in 136 children. Between day (D) 1 and D2, most patients (80%) experienced a decrease in busulfan CL, with a median change of - 7.9%. However, both large decreases (minimum, - 48.5%) and increases in CL (maximum, + 44%) were observed. Over D1-D3 of therapy, mean CL significantly decreased (- 15%), with a decrease of ≥ 20% in 22% of patients. Some patients also showed unstable CL from day to day. NLME modeling of IOV provided a coefficient of variation of 10.6% and 13.1% for volume of distribution (Vd) and CL, respectively. Some determinants of significant decreases in busulfan CL were identified, but predictive performance of the models was limited. CONCLUSIONS Significant busulfan intra-individual variability may occur in children who receive a HSCT and is hardly predictable. The main risk is busulfan overexposure. Performing TDM repeatedly over therapy appears to be the best way to accurately estimate busulfan exposure and perform precision dosing.
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Affiliation(s)
- Hanen Marsit
- Univ Lyon, Université Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France.,Université de Monastir, Faculté de Pharmacie, Monastir, Tunisia
| | | | - Michael Neely
- Laboratory of Applied Pharmacokinetics and Bioinformatics, Division of Pediatric Infectious Diseases, Children's Hospital Los Angeles and the University of Southern California, Los Angeles, CA, USA
| | - Teresa Rushing
- Pharmacy Department, Children's Hospital Los Angeles and the University of Southern California, Los Angeles, CA, USA
| | - Yves Bertrand
- Institut d'Hématologie et d'Oncologie Pédiatrique, Lyon, France
| | - Michel Ducher
- Service de Pharmacie, Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital Pierre Garraud, 136 rue du Commandant Charcot, 69005, Lyon, France.,Univ Lyon, Université Lyon 1, EMR 3738 PK/PD Modeling in Oncology and Hematology, Lyon, France
| | - Vincent Leclerc
- Service de Pharmacie, Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital Pierre Garraud, 136 rue du Commandant Charcot, 69005, Lyon, France.,Univ Lyon, Université Lyon 1, EMR 3738 PK/PD Modeling in Oncology and Hematology, Lyon, France
| | - Jérôme Guitton
- Univ Lyon, Université Lyon 1, EMR 3738 PK/PD Modeling in Oncology and Hematology, Lyon, France.,Laboratoire de Pharmacologie et Toxicologie, Hospices Civils de Lyon, Groupement Hospitalier Sud, Lyon, France
| | - Nathalie Bleyzac
- Service de Pharmacie, Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital Pierre Garraud, 136 rue du Commandant Charcot, 69005, Lyon, France.,Univ Lyon, Université Lyon 1, EMR 3738 PK/PD Modeling in Oncology and Hematology, Lyon, France
| | - Sylvain Goutelle
- Univ Lyon, Université Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France. .,Service de Pharmacie, Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital Pierre Garraud, 136 rue du Commandant Charcot, 69005, Lyon, France. .,Univ Lyon, Université Lyon 1, ISPB, Faculté de Pharmacie de Lyon, Lyon, France.
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7
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Solans BP, Chiesa R, Doncheva B, Prunty H, Veys P, Trocóniz IF, Standing JF. Modelling of neutrophil dynamics in children receiving busulfan or treosulfan for haematopoietic stem cell transplant conditioning. Br J Clin Pharmacol 2020; 86:1537-1549. [PMID: 32077123 DOI: 10.1111/bcp.14260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 01/16/2020] [Accepted: 02/01/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS Busulfan and treosulfan are cytotoxic agents used in the conditioning regime prior to paediatric haematopoietic stem cell transplantation (HSCT). These agents cause suppression of myeloid cells leaving patients severely immunocompromised in the early post-HSCT period. The main objectives were: (i) to establish a mechanistic pharmacokinetic-pharmacodynamic (PKPD) model for the treatment and engraftment effects on neutrophil counts comparing busulfan and treosulfan-based conditioning, and (ii) to explore current dosing schedules with respect to time to HSCT. METHODS Data on 126 patients, 72 receiving busulfan (7 months-18 years, 5.1-47.0 kg) and 54 treosulfan (4 months-17 years, 3.8-35.8 kg), were collected. In total, 8935 neutrophil count observations were recorded during the study period in addition to drug concentrations to develop a mechanistic PKPD model. Absolute neutrophil count profiles were modelled semimechanistically, accounting for transplant effects and differing set points pre- and post-transplant. RESULTS PK were best described by 2-compartment models for both drugs. The Friberg semimechanistic neutropenia model was applied with a linear model for busulfan and a maximum efficacy model for treosulfan describing drug effects at various stages of neutrophil maturation. System parameters were consistent across both drugs. The HSCT was represented by an amount of progenitor cells enhancing the neutrophils' proliferation and maturation compartments. Alemtuzumab was found to enhance the proliferative rate under which the absolute neutrophil count begin to grow after HSCT. CONCLUSION A semimechanistic PKPD model linking exposure to either busulfan or treosulfan to the neutrophil reconstitution dynamics was successfully built. Alemtuzumab coadministration enhanced the neutrophil proliferative rate after HSCT. Treosulfan administration was suggested to be delayed with respect to time to HSCT, leaving less time between the end of the administration and stem cell infusion.
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Affiliation(s)
- Belén P Solans
- Pharmacometrics and Systems Pharmacology, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain.,IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Robert Chiesa
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, London, UK
| | - Bilyana Doncheva
- Department of Pharmacy, Great Ormond Street Hospital for Children, London, UK
| | - Helen Prunty
- Department of Chemical Pathology, Great Ormond Street Hospital for Children, London, UK
| | - Paul Veys
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, London, UK
| | - Iñaki F Trocóniz
- Pharmacometrics and Systems Pharmacology, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain.,IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Joseph F Standing
- Department of Pharmacy, Great Ormond Street Hospital for Children, London, UK.,Infection, Immunity, Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, UK.,Paediatric Infectious Diseases Group, St George's, University of London, UK
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8
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Limited Sampling Strategies Supporting Individualized Dose Adjustment of Intravenous Busulfan in Children and Young Adults. Ther Drug Monit 2019; 42:427-434. [PMID: 31479045 DOI: 10.1097/ftd.0000000000000700] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) for busulfan supports dose adjustment during conditioning for stem cell transplantation. The authors aimed to develop and validate limited sampling strategies (LSS) of 4-5 samples for a precise estimation of the area under concentration (AUC)-time curve of busulfan, in plasma as an alternative to an intensive sampling strategy (ISS) requiring 9-10 samples. METHODS ISS TDM data from 297 patients (≤18 years of age) were used. AUCLSS was calculated using the trapezoidal rule and multiple linear regression (MLR). Unlike more complex modeling methods, MLR does not require sophisticated software or advanced training of personnel. MLR coefficients were estimated in the development subset containing randomly selected 50% of the records and were then used to calculate the AUCLSS of the remaining records (the validation subset). The agreement between dose adjustment recommendations (DAR) based on ISS and LSS, in the validation subset, was evaluated by a Bland-Altman analysis. A DAR deviating from an ISS-based reference by <15% was deemed acceptable. RESULTS Twelve LSSs were acceptable. Sampling at 0, 120, 180, and 240 minutes after the start of the second infusion (LSS15) yielded the best performance, with DAR deviating from the reference by <10% for 95% of cases; the AUCLSS was determined as follows: AUCLSS = 74.7954 × C(0) + 81.8948 × C(120) + 38.1771 × C(180) + 138.1404 × C(240) + 54.1837. This LSS and LSS13 performed similarly well in an independent external validation. CONCLUSIONS MLR-based estimates of AUCLSS provide DARs that deviate minimally from the reference. LSSs allow the reduction of patient discomfort, a ∼50% reduction of TDM-related workload for nursing staff and blood loss and a ∼25% reduction in laboratory workload. These benefits may encourage wider use of busulfan TDM, supporting safe and efficacious personalized dosing.
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McCune JS, Wang T, Bo-Subait K, Aljurf M, Beitinjaneh A, Bubalo J, Cahn JY, Cerny J, Chhabra S, Cumpston A, Dupuis LL, Lazarus HM, Marks DI, Maziarz RT, Norkin M, Prestidge T, Mineishi S, Krem MM, Pasquini M, Martin PJ. Association of Antiepileptic Medications with Outcomes after Allogeneic Hematopoietic Cell Transplantation with Busulfan/Cyclophosphamide Conditioning. Biol Blood Marrow Transplant 2019; 25:1424-1431. [PMID: 30871976 PMCID: PMC6615968 DOI: 10.1016/j.bbmt.2019.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 03/03/2019] [Indexed: 01/07/2023]
Abstract
High-dose busulfan (BU) followed by high-dose cyclophosphamide (CY) before allogeneic hematopoietic cell transplantation (HCT) has long been used as treatment for hematologic malignancies. Administration of phenytoin or newer alternative antiepileptic medications (AEMs) prevents seizures caused by BU. Phenytoin induces enzymes that increase exposure to active CY metabolites in vivo, whereas alternative AEMs do not have this effect. Lower exposure to active CY metabolites with the use of alternative AEMs could decrease the risk of toxicity but might increase the risk of recurrent malignancy after HCT. Previous studies have not determined whether outcomes with alternative AEMs differ from those with phenytoin in patients treated with BU/CY before allogeneic HCT. We studied a cohort of 2155 patients, including 1460 treated with phenytoin and 695 treated with alternative AEMs, who received BU/CY before allogeneic HCT between 2004 and 2014. We found no differences suggesting decreased overall survival or relapse-free survival or increased risks of relapse, nonrelapse mortality, acute or chronic graft-versus-host disease, or regimen-related toxicity associated with the use of alternative AEMs compared with phenytoin. The risk of dialysis was lower in the alternative AEM group than in the phenytoin group. Alternative AEMs are safe for prevention of seizures after BU administration and can avoid the undesirable toxicities and drug interactions caused by phenytoin.
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Affiliation(s)
- Jeannine S McCune
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington, Seattle, WA, USA; Department of Population Sciences, City of Hope, Duarte, CA, USA.
| | - Tao Wang
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Khalid Bo-Subait
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mahmoud Aljurf
- Adult HSCT Program, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Amer Beitinjaneh
- Department of Medicine, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Joseph Bubalo
- Department of Medicine, Oregon Health and Science University Hospital, Portland, OR, USA
| | - Jean-Yves Cahn
- Department of Medicine, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Jan Cerny
- Department of Medicine, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Saurabh Chhabra
- Department of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Aaron Cumpston
- Division of Oncology, West Virginia University Hospitals, Morgantown, WV, USA
| | - L Lee Dupuis
- The Hospital for Sick Children and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Hillard M Lazarus
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - David I Marks
- Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Richard T Maziarz
- Department of Medicine, Oregon Health and Science University Hospital, Portland, OR, USA
| | - Maxim Norkin
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Tim Prestidge
- Blood and Cancer Centre, Starship Child Health, Central Auckland, New Zealand
| | - Shin Mineishi
- Department of Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Maxwell M Krem
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Marcelo Pasquini
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington, Seattle, WA, USA
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10
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Therapeutic Drug Monitoring of Busulfan for the Management of Pediatric Patients: Cross-Validation of Methods and Long-Term Performance. Ther Drug Monit 2018; 40:84-92. [PMID: 29189665 DOI: 10.1097/ftd.0000000000000468] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Busulfan (Bu) is an alkylating agent used as part of the conditioning regimen in pediatric patients before hematopoietic stem cell transplantation. Despite intravenous (IV) administration and dosing recommendations based on age and weight, reports have revealed interindividual variability in Bu pharmacokinetics and the outcomes of hematopoietic stem cell transplantation. In this context, adjusting doses to Bu's narrow therapeutic window is advised. We aimed to assess the utility of therapeutic drug monitoring (TDM) of Bu in children, the reliability of Bu quantification methods, and its stability in plasma when stored for up to 5 years. METHODS Eighteen patients from our TDM center (252 samples) were included. All of them received a 2-hour Bu IV infusion 4 times daily for a total of 16 doses. The first dose of Bu was age/weight-based, and the subsequent doses were adjusted from third or fifth dose onward based on the estimated first dose pharmacokinetic parameters to target steady-state concentrations (Css) of 600-900 ng/mL. The performance of our unit's high-performance liquid chromatography with tandem mass spectrometry method was assessed using a quality control (QC, 35 series) chart. International, multicenter, cross-validation test (n = 21) was conducted to validate different analytical methods. To assess Bu stability, regression analyses and Bland-Altman plots were performed on measurements at repeated time points on samples stored at -80°C for up to 5 years. RESULTS We observed a 4.2-fold interindividual variability in Bu Css after the first dose, with only 28% of children having a Css within the target range. During the 4 days of conditioning, 83% of children had their doses modified according to TDM recommendations. This achieved a Css within the target range in 75% of the children. Routine QC measurements were generally within the ±15% range around theoretical values, showing the optimal robustness of our center's analytical method. Two of the 21 Bu TDM centers returned inadequate results during cross-validation testing; both used a UV detection method. Storage at -80°C led to a fall in Bu content of 14.9% ± 13.4% at 2-4 years and of 20% ± 5% by 5 years (roverall = 0.92). CONCLUSIONS We conclude that TDM is an effective method of achieving targeted Bu levels in children. QC programs are crucial to monitoring and maintaining the quality of an analytical method.
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Brooks KM, Jarosinski P, Hughes T, Kang E, Shah NN, Gall JBL, Hickstein DD, De Ravin SS, George JM, Kumar P. Test Dose Pharmacokinetics in Pediatric Patients Receiving Once-Daily IV Busulfan Conditioning for Hematopoietic Stem Cell Transplant: A Reliable Approach? J Clin Pharmacol 2017; 58:332-339. [PMID: 29238995 DOI: 10.1002/jcph.1049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 10/30/2017] [Indexed: 12/19/2022]
Abstract
Intravenous (IV) busulfan test dose pharmacokinetics (PK) has been shown to accurately predict once-daily dose requirements and improve outcomes in adult transplant patients, but there are limited data to support this approach in children. Test doses of busulfan ∼0.8 mg/kg were infused over 2 to 3 hours, followed by serial sampling to 4-6 hours postinfusion in pediatric hematopoietic stem cell transplant recipients (n = 5). Once-daily busulfan doses were calculated based on a myelosuppressive area under the concentration-time curve (AUC) target of ∼3700 to 4000 μmol·min/L and assumed dose-proportionality to the test dose. PK analysis was then repeated at full daily doses within 6-8 days of test dose administration. Plasma PK samples collected under test and full-dose conditions were analyzed using validated commercial assays and noncompartmental methods. In 4 out of 5 patients, PK estimates after once-daily IV busulfan administration differed in comparison to test dose estimates (AUC range -38.2% to +49.7%, clearance range -34.3% to +61.8%). Patients 1, 2, and 3 required increases in remaining daily busulfan doses to achieve AUC targets, and no adjustment was required in patient 4. Patient 5's AUC was 49.7% higher than expected, and he subsequently developed fatal sinusoidal obstruction syndrome. In our experience with pediatric patients, test dose PK failed to reliably predict daily dosing requirements with large discrepancies from predicted AUC targets. This article highlights the necessity for therapeutic drug monitoring of IV busulfan and inadvisability of relying solely on test-dose busulfan PK in pediatric patients. Furthermore, clinicians should consider strategies to expedite dose adjustments in real time.
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Affiliation(s)
- Kristina M Brooks
- Clinical Pharmacokinetics Research Unit, Clinical Center Pharmacy Department, National Institutes of Health, Bethesda, MD, USA
| | - Paul Jarosinski
- Clinical Center Pharmacy Department, National Institutes of Health, Bethesda, MD, USA
| | - Thomas Hughes
- Clinical Center Pharmacy Department, National Institutes of Health, Bethesda, MD, USA
| | - Elizabeth Kang
- Genetic Immunotherapy Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Nirali N Shah
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - John B Le Gall
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Dennis D Hickstein
- Experimental Transplantation & Immunology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Suk See De Ravin
- Genetic Immunotherapy Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jomy M George
- Clinical Pharmacokinetics Research Unit, Clinical Center Pharmacy Department, National Institutes of Health, Bethesda, MD, USA
| | - Parag Kumar
- Clinical Pharmacokinetics Research Unit, Clinical Center Pharmacy Department, National Institutes of Health, Bethesda, MD, USA
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12
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Wu X, Xie H, Lin W, Yang T, Li N, Lin S, Yuan X, Ren J, Li X, Huang X. Population pharmacokinetics analysis of intravenous busulfan in Chinese patients undergoing hematopoietic stem cell transplantation. Clin Exp Pharmacol Physiol 2017; 44:529-538. [PMID: 28135768 DOI: 10.1111/1440-1681.12735] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 01/06/2017] [Accepted: 01/16/2017] [Indexed: 11/29/2022]
Abstract
There are several reports describing population pharmacokinetic (popPK) models of busulfan (BU). However, limited information is available in Chinese hematopoietic stem cell transplantation (HSCT) patients. The present study aimed to establish a popPK model of intravenous BU in Chinese HSCT patients for individualized drug therapy. The popPK model of BU was developed from a total of 284 concentration-time points from 53 patients. The effects of demographic and biochemical covariates were investigated by nonlinear mixed effect model (NONMEM) software. Plots, visual predictive check (VPC), bootstrap and normalized prediction distribution error (NPDE) were performed to determine the stability and the reliability of the final model. A one-compartment model with first-order elimination process was confirmed as the final structural model for BU. For a typical patient whose body surface area (BSA) is 1.7 m2 , the population typical values of CL and Vd were 11.86 L/h, and 48.2 L, respectively. The result suggested BSA showed significant influence on CL and Vd (P<.001). Plots revealed the final model was performing a goodness fit. The steady rate verified by bootstrap was 100%, relative deviation was less than 4.00%, estimated value of final model was in the 95% confidence interval (CI). The VPC results showed the observed values were almost all positioned within the 5th and 95th CIs. The mean and variance of the NPDE were 0.0363 (Wilcoxon signed-rank test, 0.298) and 0.877 (Fisher variance test, 0.134; SW test of normality, 0.108), respectively. The global adjusted P value was 0.305, which indicated that the prediction of the BU popPK model was adequate. A physician-friendly Microsoft Excel-base tool was implemented using the final popPK model for designing individualized dosing regimens.
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Affiliation(s)
- Xuemei Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fujian, China
| | - Helin Xie
- Department of Pharmacy, Fujian Medical University Union Hospital, Fujian, China
| | - Weiwei Lin
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Ting Yang
- Department of Haematology, Fujian Medical University Union Hospital, Fujian, China
| | - Nainong Li
- Department of Haematology, Fujian Medical University Union Hospital, Fujian, China
| | - Shanshan Lin
- Department of Pharmacy, Fujian Medical University Union Hospital, Fujian, China
| | - Xiaohong Yuan
- Department of Haematology, Fujian Medical University Union Hospital, Fujian, China
| | - Jinhua Ren
- Department of Haematology, Fujian Medical University Union Hospital, Fujian, China
| | - Xiaofan Li
- Department of Haematology, Fujian Medical University Union Hospital, Fujian, China
| | - Xian Huang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fujian, China
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13
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Lin YS, Kerr SJ, Randolph T, Shireman LM, Senn T, McCune JS. Prediction of Intravenous Busulfan Clearance by Endogenous Plasma Biomarkers Using Global Pharmacometabolomics. Metabolomics 2016; 12:161. [PMID: 28827982 PMCID: PMC5562150 DOI: 10.1007/s11306-016-1106-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION High-dose busulfan (busulfan) is an integral part of the majority of hematopoietic cell transplantation conditioning regimens. Intravenous (IV) busulfan doses are personalized using pharmacokinetics (PK)-based dosing where the patient's IV busulfan clearance is calculated after the first dose and is used to personalize subsequent doses to a target plasma exposure. PK-guided dosing has improved patient outcomes and is clinically accepted but highly resource intensive. OBJECTIVE We sought to discover endogenous plasma biomarkers predictive of IV busulfan clearance using a global pharmacometabolomics-based approach. METHODS Using LC-QTOF, we analyzed 59 (discovery) and 88 (validation) plasma samples obtained before IV busulfan administration. RESULTS In the discovery dataset, we evaluated the association of the relative abundance of 1885 ions with IV busulfan clearance and found 21 ions that were associated with IV busulfan clearance tertiles (r2 ≥ 0.3). Identified compounds were deoxycholic acid and/or chenodeoxycholic acid, and linoleic acid. We used these 21 ions to develop a parsimonious seven-ion linear predictive model that accurately predicted IV busulfan clearance in 93% (discovery) and 78% (validation) of samples. CONCLUSION IV busulfan clearance was significantly correlated with the relative abundance of 21 ions, seven of which were included in a predictive model that accurately predicted IV busulfan clearance in the majority of the validation samples. These results reinforce the potential of pharmacometabolomics as a critical tool in personalized medicine, with the potential to improve the personalized dosing of drugs with a narrow therapeutic index such as busulfan.
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Affiliation(s)
- Yvonne S. Lin
- Department of Pharmaceutics, University of Washington, Seattle, WA
| | - Savannah J. Kerr
- Department of Pharmaceutics, University of Washington, Seattle, WA
| | | | | | - Tauri Senn
- Department of Pharmaceutics, University of Washington, Seattle, WA
| | - Jeannine S. McCune
- Department of Pharmaceutics, University of Washington, Seattle, WA
- Department of Pharmacy, University of Washington, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
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14
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Palmer J, McCune JS, Perales MA, Marks D, Bubalo J, Mohty M, Wingard JR, Paci A, Hassan M, Bredeson C, Pidala J, Shah N, Shaughnessy P, Majhail N, Schriber J, Savani BN, Carpenter PA. Personalizing Busulfan-Based Conditioning: Considerations from the American Society for Blood and Marrow Transplantation Practice Guidelines Committee. Biol Blood Marrow Transplant 2016; 22:1915-1925. [PMID: 27481448 DOI: 10.1016/j.bbmt.2016.07.013] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 07/21/2016] [Indexed: 12/12/2022]
Abstract
The Practice Guidelines Committee of the American Society of Blood or Marrow Transplantation (ASBMT) sought to develop an evidence-based review about personalizing busulfan-based conditioning. The Committee sought to grade the relevant published studies (June 1, 2008 through March 31, 2016) according to criteria set forth by the Steering Committee for Evidence Based Reviews from ASBMT. Unfortunately, the published literature was too heterogeneous and lacked adequately powered and sufficiently controlled studies for this to be feasible. Despite this observation, the continued interest in this topic led the Practice Guidelines Committee to develop a list of most frequently asked questions (FAQs) regarding personalized busulfan dosing. This "Considerations" document is a list of these FAQs and their responses, addressing topics of practical relevance to hematopoietic cell transplantation clinicians.
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Affiliation(s)
- Jeanne Palmer
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona.
| | - Jeannine S McCune
- Department of Pharmacology University of Washington, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Miguel-Angel Perales
- Division of Hematology/Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David Marks
- Pediatric Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Joseph Bubalo
- Department of Pharmacy Practice, Oregon Health Sciences University, Portland, Oregon
| | - Mohamad Mohty
- Department of Hematology, Hospital Saint-Antoine, University UPMC, Paris, France
| | - John R Wingard
- Division of Hematology/Oncology, University of Florida, Gainesville, Florida
| | - Angelo Paci
- Pharmacology and Drug Analysis Department, Institut de Cancerologie Gustav Roussy, Villejuif, France
| | - Moustapha Hassan
- Department of Clinical Research Centre, Karolinska Institutet, Stockholm, Sweden
| | - Christopher Bredeson
- Hematology, Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Joseph Pidala
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Nina Shah
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Paul Shaughnessy
- Adult Blood and Marrow Transplant, Texas Transplant Physician's Group, San Antonio, Texas
| | - Navneet Majhail
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Jeff Schriber
- Cancer Transplant Institute, Honor Health, Scottsdale, Arizona
| | - Bipin N Savani
- Division of Hematology/Oncology, Vanderbuilt-Ingram Cancer Center, Nashville, Tennessee
| | - Paul A Carpenter
- Department of Pediatrics, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington
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15
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Neely M, Philippe M, Rushing T, Fu X, van Guilder M, Bayard D, Schumitzky A, Bleyzac N, Goutelle S. Accurately Achieving Target Busulfan Exposure in Children and Adolescents With Very Limited Sampling and the BestDose Software. Ther Drug Monit 2016; 38:332-42. [PMID: 26829600 PMCID: PMC4864122 DOI: 10.1097/ftd.0000000000000276] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Busulfan dose adjustment is routinely guided by plasma concentration monitoring using 4-9 blood samples per dose adjustment, but a pharmacometric Bayesian approach could reduce this sample burden. METHODS The authors developed a nonparametric population model with Pmetrics. They used it to simulate optimal initial busulfan dosages, and in a blinded manner, they compared dosage adjustments using the model in the BestDose software to dosage adjustments calculated by noncompartmental estimation of area under the time-concentration curve at a national reference laboratory in a cohort of patients not included in model building. RESULTS Mean (range) age of the 53 model-building subjects was 7.8 years (0.2-19.0 years) and weight was 26.5 kg (5.6-78.0 kg), similar to nearly 120 validation subjects. There were 16.7 samples (6-26 samples) per subject to build the model. The BestDose cohort was also diverse: 10.2 years (0.25-18 years) and 46.4 kg (5.2-110.9 kg). Mean bias and imprecision of the 1-compartment model-predicted busulfan concentrations were 0.42% and 9.2%, and were similar in the validation cohorts. Initial dosages to achieve average concentrations of 600-900 ng/mL were 1.1 mg/kg (≤12 kg, 67% in the target range) and 1.0 mg/kg (>12 kg, 76% in the target range). Using all 9 concentrations after dose 1 in the Bayesian estimation of dose requirements, the mean (95% confidence interval) bias of BestDose calculations for the third dose was 0.2% (-2.4% to 2.9%, P = 0.85), compared with the standard noncompartmental method based on 9 concentrations. With 1 optimally timed concentration 15 minutes after the infusion (calculated with the authors' novel MMopt algorithm) bias was -9.2% (-16.7% to -1.5%, P = 0.02). With 2 concentrations at 15 minutes and 4 hours bias was only 1.9% (-0.3% to 4.2%, P = 0.08). CONCLUSIONS BestDose accurately calculates busulfan intravenous dosage requirements to achieve target plasma exposures in children up to 18 years of age and 110 kg using only 2 blood samples per adjustment compared with 6-9 samples for standard noncompartmental dose calculations.
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Affiliation(s)
- Michael Neely
- Laboratory of Applied Pharmacokinetics and Bioinformatics, Division of Pediatric Infectious Diseases, University of Southern California Children’s Hospital Los Angeles, Los Angeles, USA
| | - Michael Philippe
- Institute of Pediatric Hematology and Oncology, Lyon, France
- Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France
| | - Teresa Rushing
- Pharmacy Department, University of Southern California Children’s Hospital Los Angeles, Los Angeles, USA
| | - Xiaowei Fu
- Pathology and Laboratory Medicine, University of Southern California Children’s Hospital Los Angeles, Los Angeles, USA
| | - Michael van Guilder
- Laboratory of Applied Pharmacokinetics and Bioinformatics, Division of Pediatric Infectious Diseases, University of Southern California Children’s Hospital Los Angeles, Los Angeles, USA
| | - David Bayard
- Laboratory of Applied Pharmacokinetics and Bioinformatics, Division of Pediatric Infectious Diseases, University of Southern California Children’s Hospital Los Angeles, Los Angeles, USA
| | - Alan Schumitzky
- Laboratory of Applied Pharmacokinetics and Bioinformatics, Division of Pediatric Infectious Diseases, University of Southern California Children’s Hospital Los Angeles, Los Angeles, USA
| | - Nathalie Bleyzac
- Institute of Pediatric Hematology and Oncology, Lyon, France
- Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France
| | - Sylvain Goutelle
- Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France
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16
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Barrett JS. Paediatric models in motion: requirements for model-based decision support at the bedside. Br J Clin Pharmacol 2015; 79:85-96. [PMID: 24251868 DOI: 10.1111/bcp.12287] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 10/31/2013] [Indexed: 11/30/2022] Open
Abstract
Optimal paediatric pharmacotherapy is reliant on a detailed understanding of the individual patient including their developmental status and disease state as well as the pharmaceutical agents he/she is receiving for treatment or management of side effects. Our appreciation for size and maturation effects on the pharmacokinetic/pharmacodynamic (PK/PD) phenomenon has improved to the point that we can develop predictive models that permit us to individualize therapy, especially in the situation where we are monitoring drug effects or therapeutic concentrations. The growth of efforts to guide paediatric pharmacotherapy via model-based decision support necessitates a coordinated and systematic approach to ensuring reliable and robust output to caregivers that represents the current standard of care and adheres to governance imposed by the host institution or coalition responsible. Model-based systems which guide caregivers on dosing paediatric patients in a more comprehensive manner are in development at several institutions. Care must be taken that these systems provide robust guidance with the current best practice. These systems must evolve as new information becomes available and ultimately are best constructed from diverse data representing global input on demographics, ethnic / racial diversity, diet and other lifestyle factors. Multidisciplinary involvement at the project team level is key to the ultimate clinical valuation. Likewise, early engagement of clinical champions is also critical for the success of model-based tools. Adherence to regulatory requirements as well as best practices with respect to software development and testing are essential if these tools are to be used as part of the routine standard of care.
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Affiliation(s)
- Jeffrey S Barrett
- Department of Pediatrics, Division of Clinical Pharmacology and Therapeutics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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17
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de Castro FA, Piana C, Simões BP, Lanchote VL, Della Pasqua O. Busulfan dosing algorithm and sampling strategy in stem cell transplantation patients. Br J Clin Pharmacol 2015; 80:618-29. [PMID: 25819742 DOI: 10.1111/bcp.12648] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 02/25/2015] [Accepted: 03/24/2015] [Indexed: 01/22/2023] Open
Abstract
AIM The aim of this investigation was to develop a model-based dosing algorithm for busulfan and identify an optimal sampling scheme for use in routine clinical practice. METHODS Clinical data from an ongoing study (n = 29) in stem cell transplantation patients were used for the purposes our analysis. A one compartment model was selected as basis for sampling optimization and subsequent evaluation of a suitable dosing algorithm. Internal and external model validation procedures were performed prior to the optimization steps using ED-optimality criteria. Using systemic exposure as parameter of interest, dosing algorithms were considered for individual patients with the scope of minimizing the deviation from target range as determined by AUC(0,6 h). RESULTS Busulfan exposure after oral administration was best predicted after the inclusion of adjusted ideal body weight and alanine transferase as covariates on clearance. Population parameter estimates were 3.98 h(-1), 48.8 l and 12.3 l h(-1) for the absorption rate constant, volume of distribution and oral clearance, respectively. Inter-occasion variability was used to describe the differences between test dose and treatment. Based on simulation scenarios, a dosing algorithm was identified, which ensures target exposure values are attained after a test dose. Moreover, our findings show that a sparse sampling scheme with five samples per patient is sufficient to characterize the pharmacokinetics of busulfan in individual patients. CONCLUSION The use of the proposed dosing algorithm in conjunction with a sparse sampling scheme may contribute to considerable improvement in the safety and efficacy profile of patients undergoing treatment for stem cell transplantation.
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Affiliation(s)
- Francine A de Castro
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Chiara Piana
- Leiden Academic Centre for Drug Research, Division of Pharmacology, Leiden University, Leiden, The Netherlands
| | - Belinda P Simões
- Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Vera L Lanchote
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - O Della Pasqua
- Leiden Academic Centre for Drug Research, Division of Pharmacology, Leiden University, Leiden, The Netherlands.,Clinical Pharmacology & Therapeutics, University College London, London, UK
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18
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Ward J, Kletzel M, Duerst R, Fuleihan R, Chaudhury S, Schneiderman J, Tse WT. Single Daily Busulfan Dosing for Infants with Nonmalignant Diseases Undergoing Reduced-Intensity Conditioning for Allogeneic Hematopoietic Progenitor Cell Transplantation. Biol Blood Marrow Transplant 2015; 21:1612-21. [PMID: 26025482 DOI: 10.1016/j.bbmt.2015.05.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 05/19/2015] [Indexed: 11/15/2022]
Abstract
Busulfan (Bu) is widely used in conditioning regimens for infants undergoing allogeneic hematopoietic progenitor cell transplantation (HPCT), but the best approach to administer Bu in this population is still unknown. Here, we report a single-center experience of the use of a test dose to guide dose adjustment of intravenous (i.v.) Bu therapy in infants. Between 2004 and 2013, 33 infants younger than 1 year with nonmalignant conditions received allogeneic peripheral blood or cord blood HPCT after a reduced-intensity conditioning (RIC) regimen consisting of fludarabine, antithymocyte globulin, and 2 single daily doses of i.v. Bu. Pharmacokinetic results of a test dose of i.v. Bu (.8 mg/kg) were used to determine the dose of 2 single daily i.v. Bu regimen doses, adjusted to target an area under the curve (AUC) of 4000 μMol*minute per day in a first cohort (n = 12) and 5000 μMol*minute in a second cohort (n = 21). The mean Bu clearance in our infant patients was found to be 3.67 ± 1.03 mL/minute/kg, and the test dose clearance was highly predictive of the regimen dose clearance. The mean AUC achieved after the first single daily regimen dose was 3951 ± 1239 in the AUC 4000 cohort and 4884 ± 766 for the AUC 5000 cohort. No patient in either cohort developed hepatic sinusoidal obstructive syndrome or seizures attributable to Bu. Primary graft failure occurred in 4 patients and secondary graft failure occurred in 3, predominantly in the AUC 4000 cohort (6 of 7). Among the engrafted patients (n = 28), 16 achieved full donor chimerism and 9 patients attained stable mixed chimerism. Overall survival of patients at 6 years after transplantation was 59.5% for the AUC 4000 cohort and 85.4% for the AUC 5000 cohort, with primary graft failure in the first cohort being a major contributor to morbidity. Logistic regression analysis showed that the risk of graft failure increased significantly if cord blood hematopoietic progenitor cells were used or if total Bu exposure was below 4000 μMol*minute per day for 2 days. The difference in clinical outcomes between the 2 cohorts supports the conclusion that targeting a higher Bu AUC of 5000 μMol*minute per day for 2 days improves donor engraftment in infants with nonmalignant conditions undergoing RIC HPCT without increasing toxicity. Measuring i.v. Bu pharmokinetics using a test dose allows timely adjustment of single daily regimen doses and optimization of total Bu exposure, resulting in an effective and safe regimen for these infants.
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Affiliation(s)
- Jessica Ward
- Stem Cell Transplant Program, Division of Hematology-Oncology-Transplant, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Morris Kletzel
- Stem Cell Transplant Program, Division of Hematology-Oncology-Transplant, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Reggie Duerst
- Stem Cell Transplant Program, Division of Hematology-Oncology-Transplant, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ramsay Fuleihan
- Division of Allergy and Immunology, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sonali Chaudhury
- Stem Cell Transplant Program, Division of Hematology-Oncology-Transplant, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jennifer Schneiderman
- Stem Cell Transplant Program, Division of Hematology-Oncology-Transplant, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - William T Tse
- Stem Cell Transplant Program, Division of Hematology-Oncology-Transplant, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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19
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Gaziev J, Isgrò A, Mozzi AF, Petain A, Nguyen L, Ialongo C, Dinallo V, Sodani P, Marziali M, Andreani M, Testi M, Paciaroni K, Gallucci C, De Angelis G, Alfieri C, Ribersani M, Lucarelli G. New insights into the pharmacokinetics of intravenous busulfan in children with sickle cell anemia undergoing bone marrow transplantation. Pediatr Blood Cancer 2015; 62:680-6. [PMID: 25557687 DOI: 10.1002/pbc.25376] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 11/04/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Busulfan (Bu) is an integral part of conditioning regimens for patients with sickle cell anemia (SCA) undergoing transplantation. Patients with SCA might predispose to transplant-related neurological and pulmonary toxicities due to pre-existing disease-related cerebrovascular and lung injury. Bu therapy appears to be an important contributing factor in this context. PROCEDURE We studied the pharmacokinetics of intravenous Bu and clinical outcomes of 36 children with SCA undergoing bone marrow transplantation. Most patients had pre-existing organ system damage. Busulfan was administered every 6 hr for 4 days with pharmacokinetic-guided dose adjustment to target a conservative area under the concentration versus time curve (AUC) range of 900-1,350 µMol*min. RESULTS We found that the first-dose Bu clearance was significantly higher (P < 0.0005) than the subsequent daily clearance, which remained unchanged during the following days. After the first-dose, 69% of patients achieved the target range. We adapted a new dose-adjustment strategy targeting exposures to the lower end (900 µMol*min) of the AUC range after the first dose of Bu to avoid unnecessary dose increases on subsequent days due to differences in clearance. This strategy enabled most patients to maintain the AUC within therapeutic range following dose adjustments. CONCLUSIONS Differences in Bu clearance after the first-dose and subsequent daily doses in patients with SCA should be considered for pharmacokinetic-guided dose adjustment. Conservative AUC range and targeting exposures to the lower end of the range after the first dose was associated with negligible toxicity, and high engraftment and sickle cell-free survival rates.
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Affiliation(s)
- Javid Gaziev
- International Center for Transplantation in Thalassemia and Sickle Cell Anemia, Mediterranean Institute of Hematology, Policlinico Tor Vergata, Rome, Italy
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20
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Wright FA, Bebawy M, O'Brien TA. An analysis of the therapeutic benefits of genotyping in pediatric hematopoietic stem cell transplantation. Future Oncol 2015; 11:833-51. [PMID: 25757685 DOI: 10.2217/fon.14.307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Hematopoietic stem cell transplantation is a high-risk procedure that is offered, with curative intent, to patients with malignant and nonmalignant disease. The clinical benefits of personalization of therapy by genotyping have been demonstrated by the reduction in transplant related mortality from donor-recipient HLA matching. However, defining the relationship between genotype and transplant conditioning agents is yet to be translated into clinical practice. A number of the therapeutic agents used in stem cell transplant preparative regimens have pharmacokinetic parameters that predict benefit of incorporating pharmacogenomic data into dosing strategies. Busulfan, cyclophosphamide, thio-TEPA and etoposide have well-described drug metabolism pathways, however candidate gene studies have identified there is a gap in the identification of pharmacogenomic data that can be used to improve transplant outcomes. Incorporating pharmacogenomics into pharmacokinetic modeling may demonstrate the therapeutic benefits of genotyping in transplant preparative regimen agents.
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Affiliation(s)
- Felicity A Wright
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
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21
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Copelan EA, Avalos BR, Ahn KW, Zhu X, Gale RP, Grunwald MR, Hamadani M, Hamilton BK, Hale GA, Marks DI, Waller EK, Savani BN, Costa LJ, Ramanathan M, Cahn JY, Khoury HJ, Weisdorf DJ, Inamoto Y, Kamble RT, Schouten HC, Wirk B, Litzow MR, Aljurf MD, van Besien KW, Ustun C, Bolwell BJ, Bredeson CN, Fasan O, Ghosh N, Horowitz MM, Arora M, Szer J, Loren AW, Alyea EP, Cortes J, Maziarz RT, Kalaycio ME, Saber W. Comparison of outcomes of allogeneic transplantation for chronic myeloid leukemia with cyclophosphamide in combination with intravenous busulfan, oral busulfan, or total body irradiation. Biol Blood Marrow Transplant 2014; 21:552-8. [PMID: 25528388 DOI: 10.1016/j.bbmt.2014.12.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 12/10/2014] [Indexed: 12/21/2022]
Abstract
Cyclophosphamide (Cy) in combination with busulfan (Bu) or total body irradiation (TBI) is the most commonly used myeloablative conditioning regimen in patients with chronic myeloid leukemia (CML). We used data from the Center for International Bone Marrow Transplantation Research to compare outcomes in adults who underwent hematopoietic cell transplantation for CML in first chronic phase after myeloablative conditioning with Cy in combination with TBI, oral Bu, or intravenous (i.v.) Bu. Four hundred thirty-eight adults received human leukocyte antigen (HLA)-matched sibling grafts and 235 received well-matched grafts from unrelated donors (URD) from 2000 through 2006. Important differences existed between the groups in distribution of donor relation, exposure to tyrosine kinase inhibitors, and year of transplantation. In multivariate analysis, relapse occurred less frequently among patients receiving i.v. Bu compared with TBI (relative risk [RR], .36; P = .022) or oral Bu (RR, .39; P = .028), but nonrelapse mortality and survival were similar. A significant interaction was detected between donor relation and the main effect in leukemia-free survival (LFS). Among recipients of HLA-identical sibling grafts, but not URD grafts, LFS was better in patients receiving i.v. Bu (RR, .53; P = .025) or oral Bu (RR, .64; P = .017) compared with TBI. In CML in first chronic phase, Cy in combination with i.v. Bu was associated with less relapse than TBI or oral Bu. LFS was better after i.v. or oral Bu compared with TBI.
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Affiliation(s)
- Edward A Copelan
- Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina.
| | - Belinda R Avalos
- Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Kwang Woo Ahn
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Xiaochun Zhu
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert Peter Gale
- Division of Experimental Medicine, Department of Medicine, Hematology Research Centre, Imperial College of London, London, United Kingdom
| | - Michael R Grunwald
- Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Mehdi Hamadani
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Betty K Hamilton
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Gregory A Hale
- Department of Hematology/Oncology, All Children's Hospital, St Petersburg, Florida
| | - David I Marks
- University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Edmund K Waller
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Luciano J Costa
- Division of Hematology/Oncology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Muthalagu Ramanathan
- Division of Hematology Oncology, UMass Memorial Medical Center, Worcester, Massachusetts
| | - Jean-Yves Cahn
- Department of Hematology, University Hospital, Grenoble, France
| | - H Jean Khoury
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Yoshihiro Inamoto
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Rammurti T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Harry C Schouten
- Divison of Hematology, Academische Ziekenhuis Maastricht, Maastricht, Netherlands
| | - Baldeep Wirk
- Department of Internal Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Mark R Litzow
- Department of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Mahmoud D Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Koen W van Besien
- Department of Medical Oncology, Weill Cornell Medical College, New York, New York
| | - Celalettin Ustun
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Brian J Bolwell
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Christopher N Bredeson
- The Ottawa Hospital Blood & Marrow Transplant Program and the Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Omotayo Fasan
- Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Nilanjan Ghosh
- Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Mary M Horowitz
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Jeffrey Szer
- Department of Clinical Haematology and Bone Marrow Transplantation, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Alison W Loren
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edwin P Alyea
- Center of Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jorge Cortes
- Division of Cancer Medicine, Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Richard T Maziarz
- Center for Hematologic Malignancies, Oregon Health and Science University, Portland, Oregon
| | - Matt E Kalaycio
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Wael Saber
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
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22
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Diestelhorst C, Boos J, McCune JS, Russell J, Kangarloo SB, Hempel G. Predictive performance of a physiologically based pharmacokinetic model of busulfan in children. Pediatr Hematol Oncol 2014; 31:731-42. [PMID: 25007236 DOI: 10.3109/08880018.2014.927945] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
A physiologically based pharmacokinetic (PBPK) model of the DNA-alkylating agent busulfan was slightly modified and scaled from adults to children in order to predict the systemic busulfan drug exposure in children. Capitalizing on the recent major software release of PK-Sim®, we refined our PBPK model by implementing glutathione S transferase (GST) in 11 organs using the software integrated enzyme expression database. In addition, two irreversible binding processes (i.e., DNA and plasma protein binding) were applied by using Koff and KD values. The model was scaled from adults to children. Simulations were computed and compared to concentration-time data after intravenous (i.v.) busulfan administration to 36 children. Based on the results, an age-dependent enzyme activity and maturation ratio was tailored and evaluated with an external dataset consisting of 23 children. Initial adult to children scaling indicated lower clearance values for children in comparison to adults. Subsequent age-dependent maturation ratio resulted in three different age groups: Activity of busulfan-glutathione conjugate formation was 80%, 61%, and 89% in comparison to adults for children with an age of up to 2 years, > 2-6 years, and > 6-18 years, respectively. Patients of the evaluation dataset were simulated with a mean percentage error (MPE) for all patients of 3.9% with 3/23 children demonstrating a MPE of > ±30%. The PBPK model parameterization sufficiently described the observed concentration-time data of the validation dataset while showing an adequate predictive performance. This PBPK model could be helpful to determine the first dose of busulfan in children.
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Affiliation(s)
- Christian Diestelhorst
- 1Department of Pharmaceutical and Medical Chemistry - Clinical Pharmacy, University of Münster, Münster, Germany
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23
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Optimizing drug therapy in pediatric SCT: focus on pharmacokinetics. Bone Marrow Transplant 2014; 50:165-72. [PMID: 25347008 DOI: 10.1038/bmt.2014.235] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 08/08/2014] [Accepted: 08/27/2014] [Indexed: 12/19/2022]
Abstract
Given age-related differences in drug metabolism and indications for hematopoietic SCT (HSCT), personalized drug dosing of the conditioning regimen and post-transplant immunosuppression may reduce graft rejection, relapse rates and toxicity in pediatric HSCT recipients. This manuscript summarizes the pharmacokinetic/dynamic data of HSCT conditioning and post-grafting immunosuppression, presented at the First Annual Pediatric Bone Marrow Transplant Consortium (PBMTC) meeting in April 2013. Personalized dosing of BU to a target plasma exposure reduces graft rejection in children and improves relapse/toxicity rates in adults. Current weight-based dosing achieves the target BU exposure in only a minority (24.3%) of children. The initial BU dose should be based on the European Medicines Agency nomogram or population pharmacokinetic models to improve the numbers of children achieving the target exposure. There are limited pharmacokinetic data for treosulfan, CY, fludarabine and alemtuzumab as HSCT conditioning in children. For post-grafting immunosuppression, mycophenolic acid (MPA) clearance may be increased in younger children (<12 years). The preferred MPA pharmacokinetic monitoring parameters and target range are still evolving in HSCT recipients. Multi-institutional trials incorporating properly powered pharmacokinetic/dynamic studies are needed to assess the effect of variability in the plasma exposure of drugs/metabolites on clinical outcomes in pediatric HSCT recipients.
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24
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Tyagi AK, Huezo-Diaz P, Ansari M. Personalizing busulfan therapy for children undergoing hematopoietic stem cell transplantation. Per Med 2014; 11:463-466. [PMID: 29758775 DOI: 10.2217/pme.14.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Anuj K Tyagi
- Department of Pediatrics, Onco-Hematology Unit, Geneva University Hospital, Geneva, Switzerland and CANSEARCH Research Laboratory, Geneva Medical University, Geneva, Switzerland
| | - Patricia Huezo-Diaz
- Department of Pediatrics, Onco-Hematology Unit, Geneva University Hospital, Geneva, Switzerland and CANSEARCH Research Laboratory, Geneva Medical University, Geneva, Switzerland
| | - Marc Ansari
- Department of Pediatrics, Onco-Hematology Unit, Geneva University Hospital, Geneva, Switzerland and CANSEARCH Research Laboratory, Geneva Medical University, Geneva, Switzerland
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25
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ten Brink MH, van Bavel T, Swen JJ, van der Straaten T, Bredius RGM, Lankester AC, Zwaveling J, Guchelaar HJ. Effect of genetic variants GSTA1 and CYP39A1 and age on busulfan clearance in pediatric patients undergoing hematopoietic stem cell transplantation. Pharmacogenomics 2014; 14:1683-90. [PMID: 24192117 DOI: 10.2217/pgs.13.159] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Busulfan is used in preparative regimens prior to stem cell transplantation in pediatric patients. There is significant interpatient variability in busulfan pharmacokinetics (PK) and exposure is related to outcome. To date, only polymorphisms in genes encoding for glutathione-S-transferases were studied, but could only explain a small portion of the variability in PK. AIM To investigate the effect of seven genetic markers on busulfan clearance and the effect of ontogenesis on these genetic variants in a pediatric population. MATERIALS & METHODS In an earlier study of our group seven genetic markers in GSTA1, CYP2C19, CYP39A1, ABCB4, SLC22A4 and SLC7A8 were associated with busulfan clearance in adult patients. Eighty four pediatric patients were genotyped for these markers and genotype was associated with busulfan clearance. RESULTS & CONCLUSION GSTA1 and CYP39A1 were found to be associated with busulfan clearance. When combined, the two haplotypes explained 17% of the variability in busulfan clearance. Furthermore, the effect of GSTA1 haplotype on clearance was dependent on age.
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Affiliation(s)
- Marloes H ten Brink
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
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26
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Talano JM, Pulsipher MA, Symons HJ, Militano O, Shereck EB, Giller RH, Hancock L, Morris E, Cairo MS. New frontiers in pediatric Allo-SCT. Bone Marrow Transplant 2014; 49:1139-45. [PMID: 24820213 DOI: 10.1038/bmt.2014.89] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 03/13/2014] [Accepted: 03/15/2014] [Indexed: 01/02/2023]
Abstract
The inaugural meeting of 'New Frontiers in Pediatric Allogeneic Stem Cell Transplantation' organized by the Pediatric Blood and Transplant Consortium (PBMTC) was held at the American Society of Pediatric Hematology and Oncology Annual Meeting. This meeting provided an international platform for physicians and investigators active in the research and utilization of pediatric Allo-SCT in children and adolescents with malignant and non-malignant disease (NMD), to share information and develop future collaborative strategies. The primary objectives of the conference included: (1) to present advances in Allo-SCT in pediatric ALL and novel pre and post-transplant immunotherapy; (2) to highlight new strategies in alternative allogeneic stem cell donor sources for children and adolescents with non-malignant hematological disorders; (3) to discuss timing of immune reconstitution after Allo-SCT and methods of facilitating more rapid recovery of immunity; (4) to identify strategies of utilizing Allo-SCT in pediatric myeloproliferative disorders; (5) to develop diagnostic and therapeutic approaches to hematological complications post pediatric Allo-SCT; (6) to enhance the understanding of new novel cellular therapeutic approaches to pediatric malignant and non-malignant hematological disorders; and (7) to discuss optimizing drug therapy in pediatric recipients of Allo-SCT. This paper will provide a brief overview of the conference.
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Affiliation(s)
- J M Talano
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - M A Pulsipher
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - H J Symons
- Department of Oncology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - O Militano
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - E B Shereck
- Oregon Health and Science University, Portland, OR, USA
| | - R H Giller
- Children's Hospital Colorado, Aurora, CO, USA
| | - L Hancock
- Pediatric Blood and Marrow Transplant Consortium, Monrovia, CA, USA
| | - E Morris
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - M S Cairo
- 1] Department of Pediatrics, New York Medical College, Valhalla, NY, USA [2] Department of Medicine, New York Medical College, Valhalla, NY, USA [3] Department of Pathology, New York Medical College, Valhalla, NY, USA [4] Department of Microbiology and Immunology, New York Medical College, Valhalla, NY, USA [5] Department of Cell Biology and Anatomy, New York Medical College, Valhalla, NY, USA
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27
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Population pharmacokinetics of intravenous busulfan in children: revised body weight-dependent NONMEM® model to optimize dosing. Eur J Clin Pharmacol 2014; 70:839-47. [DOI: 10.1007/s00228-014-1692-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 04/24/2014] [Indexed: 10/25/2022]
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28
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McCune JS, Bemer MJ, Barrett JS, Scott Baker K, Gamis AS, Holford NHG. Busulfan in infant to adult hematopoietic cell transplant recipients: a population pharmacokinetic model for initial and Bayesian dose personalization. Clin Cancer Res 2013; 20:754-63. [PMID: 24218510 DOI: 10.1158/1078-0432.ccr-13-1960] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Personalizing intravenous busulfan doses to a target plasma concentration at steady state (Css) is an essential component of hematopoietic cell transplantation (HCT). We sought to develop a population pharmacokinetic model to predict i.v. busulfan doses over a wide age spectrum (0.1-66 years) that accounts for differences in age and body size. EXPERIMENTAL DESIGN A population pharmacokinetic model based on normal fat mass and maturation based on postmenstrual age was built from 12,380 busulfan concentration time points obtained after i.v. busulfan administration in 1,610 HCT recipients. Subsequently, simulation results of the initial dose necessary to achieve a target Css with this model were compared with pediatric-only models. RESULTS A two-compartment model with first-order elimination best fit the data. The population busulfan clearance was 12.4 L/h for an adult male with 62 kg normal fat mass (equivalent to 70 kg total body weight). Busulfan clearance, scaled to body size-specifically normal fat mass, is predicted to be 95% of the adult clearance at 2.5 years postnatal age. With a target Css of 770 ng/mL, a higher proportion of initial doses achieved the therapeutic window with this age- and size--dependent model (72%) compared with dosing recommended by the U.S. Food and Drug Administration (57%) or the European Medicines Agency (70%). CONCLUSION This is the first population pharmacokinetic model developed to predict initial i.v. busulfan doses and personalize to a target Css over a wide age spectrum, ranging from infants to adults.
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Affiliation(s)
- Jeannine S McCune
- Authors' Affiliations: University of Washington Schools of Pharmacy and Medicine; Fred Hutchinson Cancer Research Center; Seattle Children's Hospital, Seattle, Washington; Division of Clinical Pharmacology & Therapeutics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Children's Mercy Hospitals and Clinics, Kansas City, Missouri; and Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
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29
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Savic RM, Cowan MJ, Dvorak CC, Pai SY, Pereira L, Bartelink IH, Boelens JJ, Bredius RGM, Wynn RF, Cuvelier GDE, Shaw PJ, Slatter MA, Long-Boyle J. Effect of weight and maturation on busulfan clearance in infants and small children undergoing hematopoietic cell transplantation. Biol Blood Marrow Transplant 2013; 19:1608-14. [PMID: 24029650 DOI: 10.1016/j.bbmt.2013.08.014] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 08/26/2013] [Indexed: 02/01/2023]
Abstract
Little information is currently available regarding the pharmacokinetics (PK) of busulfan in infants and small children to help guide decisions for safe and efficacious drug therapy. The objective of this study was to develop an algorithm for individualized dosing of i.v. busulfan in infants and children weighing ≤12 kg, that would achieve targeted exposure with the first dose of busulfan. Population PK modeling was conducted using intensive time-concentration data collected through the routine therapeutic drug monitoring of busulfan in 149 patients from 8 centers. Busulfan PK was well described by a 1-compartment base model with linear elimination. The important clinical covariates affecting busulfan PK were actual body weight and age. Based on our model, the predicted clearance of busulfan increases approximately 1.7-fold between 6 weeks to 2 years of life. For infants age <5 months, the model-predicted doses (mg/kg) required to achieve a therapeutic concentration at steady state of 600-900 ng/mL (area under the curve range, 900-1350 μM·min) were much lower compared with standard busulfan doses of 1.1 mg/kg. These results could help guide clinicians and inform better dosing decisions for busulfan in young infants and small children undergoing hematopoietic cell transplantation.
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Affiliation(s)
- Radojka M Savic
- Department of Bioengineering and Therapeutics, University of California San Francisco, San Francisco, California
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30
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Diestelhorst C, Boos J, McCune JS, Russell J, Kangarloo SB, Hempel G. Physiologically based pharmacokinetic modelling of Busulfan: a new approach to describe and predict the pharmacokinetics in adults. Cancer Chemother Pharmacol 2013; 72:991-1000. [PMID: 24061863 DOI: 10.1007/s00280-013-2275-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 08/20/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE A physiologically based pharmacokinetic (PBPK) model was established and evaluated describing the pharmacokinetics (PK) of the DNA-alkylating agent Busulfan in adults in order to predict the systemic Busulfan drug exposure in both plasma and toxicity-related organs. METHODS A generic PBPK model was tailored to describe Busulfan PK by implementing compound-specific physicochemical and metabolism data. With regard to possible influences of glutathione S transferase (GST) variations on Busulfan PK, two different PBPK model parameterizations were investigated: a first parameterization with individual GST activity (expressed as different estimated V(max) values) for each patient, and a resulting second model parameterization with a mean GST activity for all patients. Simulations were computed and compared to concentration-time data after intravenous Busulfan administration to 108 adults serving as development dataset. Subsequently, appropriateness of the PBPK model was evaluated with an external dataset not used for model development, consisting of 95 adults. RESULTS Both PBPK model parameterizations of Busulfan successfully described the observed plasma concentrations. For the validation dataset, calculated PK parameters were as follows: clearance 0.16 ± 0.03 L/h/kg and volume of distribution 0.65 ± 0.06 L/kg (mean ± standard deviation). Mean absolute percentage error was less than 30 % for each PK parameter. Mass balances for distribution and excretion were in good agreement with the literature data. CONCLUSIONS Both PBPK model parameterizations sufficiently described the observed concentration-time data while showing an adequate predictive performance. The model should be further evaluated for its ability to explain the between-subject variability in intravenous Busulfan PK parameters.
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Affiliation(s)
- Christian Diestelhorst
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Münster, Corrensstr. 48, 48149, Münster, Germany
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31
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de Castro FA, Lanchote VL, Voltarelli JC, Colturato VAR, Simões BP. Influence of fludarabine on the pharmacokinetics of oral busulfan during pretransplant conditioning for hematopoietic stem cell transplantation. J Clin Pharmacol 2013; 53:1205-11. [PMID: 23955479 DOI: 10.1002/jcph.130] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 06/10/2013] [Indexed: 11/07/2022]
Abstract
This study evaluated the influence of fludarabine on the pharmacokinetics of busulfan administered orally to patients receiving a conditioning regimen for hematopoietic allogeneic stem cell transplantation (HSCT). Twenty-six patients treated with oral busulfan (1 mg/kg/6 h for 4 days) were divided into two groups according to the concomitant administration of fludarabine (n = 11; 30 mg/m(2) for 5 days) or subsequent administration of cyclophosphamide (n = 15; 60 mg/kg for 2 days). Serial blood samples were collected on Day 4 of busulfan administration. Plasma busulfan concentrations were determined by HPLC-UV and the pharmacokinetic parameters were calculated using the WinNonlin program. Patients concomitantly treated with fludarabine showed reduced apparent clearance of busulfan (110.5 mL/h/kg vs. 157.4 mL/h/kg) and higher AUC0-6 (area under the plasma concentrations vs. time curve) than patients subsequently treated with cyclophosphamide (7.9 µg h/mL vs. 5.7 µg h/mL). No association was observed between busulfan AUC0-6 and clinical evolution of the patients. Although plasma busulfan concentrations were higher in patients receiving concomitant fludarabine, myelosuppression-related toxicity was less frequent than in patients treated with busulfan and cyclophosphamide. The results suggest that patients treated with fludarabine should receive 30% lower busulfan doses during conditioning protocols for HSCT.
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Affiliation(s)
- Francine Attié de Castro
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
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