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Hartman SJF, Upadhyay PJ, Mathôt RAA, van der Flier M, Schreuder MF, Brüggemann RJ, Knibbe CA, de Wildt SN. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:1725-1732. [PMID: 35383374 PMCID: PMC9155601 DOI: 10.1093/jac/dkac095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/03/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Stan J. F. Hartman
- Department of Pharmacology and Toxicology, Radboud Institute of Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Parth J. Upadhyay
- Systems Biomedicine and Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands
| | - Ron A. A. Mathôt
- Department of Clinical Pharmacology and Hospital Pharmacy - Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Michiel van der Flier
- Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
- Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital, and Section Pediatric Infectious Diseases, Radboudumc, Nijmegen, The Netherlands
| | - Michiel F. Schreuder
- Department of Pediatrics, Division of Pediatric Nephrology, Amalia Children’s Hospital, Radboud Institute of Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands
| | | | - Catherijne A. Knibbe
- Systems Biomedicine and Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Saskia N. de Wildt
- Department of Pharmacology and Toxicology, Radboud Institute of Health Sciences, Radboudumc, Nijmegen, The Netherlands
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Intensive Care Medicine, Radboud Institute of Health Sciences, Radboudumc, Nijmegen, The Netherlands
- Corresponding author. E-mail:
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Hartman SJF, Upadhyay PJ, Hagedoorn NN, Mathôt RAA, Moll HA, van der Flier M, Schreuder MF, Brüggemann RJ, Knibbe CA, de Wildt SN. Current Ceftriaxone Dose Recommendations are Adequate for Most Critically Ill Children: Results of a Population Pharmacokinetic Modeling and Simulation Study. Clin Pharmacokinet 2021; 60:1361-1372. [PMID: 34036552 PMCID: PMC8505376 DOI: 10.1007/s40262-021-01035-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2021] [Indexed: 12/01/2022]
Abstract
Background and Objective Ceftriaxone is a cornerstone antibiotic for critically ill children with severe infections. Despite its widespread use, information on the pharmacokinetics of ceftriaxone is lacking in this population. We aimed to determine ceftriaxone pharmacokinetics in critically ill children and to propose ceftriaxone dosing guidelines resulting in adequate target attainment using population pharmacokinetic modeling and simulation. Methods Critically ill children (aged 0–18 years) treated with intravenous ceftriaxone (100 mg/kg once daily, infused in 30 minutes) and a central or arterial line in place were eligible. Opportunistic blood sampling for total and unbound ceftriaxone concentrations was used. Population pharmacokinetic analysis was performed using non-linear mixed-effects modeling on NONMEM™ Version 7.4.3. Simulations were performed to select optimal doses using probability of target attainment for two pharmacokinetic targets of the minimum inhibitory concentration (MIC) reflecting the susceptibility of pathogens (f T > MIC 100% and fT > 4 × MIC 100%). Results Two hundred and five samples for total and 43 time-matched samples for unbound plasma ceftriaxone concentrations were collected from 45 patients, median age 2.5 (range 0.1–16.7) years. A two-compartment model with bodyweight as the co-variate for volume of distribution and clearance, and creatinine-based estimated glomerular filtration rate as an additional covariate for clearance, best described ceftriaxone pharmacokinetics. For a typical patient (2.5 years, 14 kg) with an estimated glomerular filtration rate of 80 mL/min/1.73 m2, the current 100-mg/kg once-daily dose results in a probability of target attainment of 96.8% and 60.8% for a MIC of 0.5 mg/L and 4 × MIC (2 mg/L), respectively, when using fT > MIC 100% as a target. For a 50-mg/kg twice-daily regimen, the probability of target attainment was 99.9% and 93.4%, respectively. Conclusions The current dosing regimen of ceftriaxone provides adequate exposure for susceptible pathogens in most critically ill children. In patients with an estimated glomerular filtration rate of > 80 mL/min/1.73 m2 or in areas with a high prevalence of less-susceptible pathogens (MIC ≥ 0.5 mg/L), a twice-daily dosing regimen of 50 mg/kg can be considered to improve target attainment. Clinical Trial Registration POPSICLE study (ClinicalTrials.gov, NCT03248349, registered 14 August, 2017), PERFORM study (ClinicalTrials.gov, NCT03502993, registered 19 April, 2018). Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01035-9.
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Affiliation(s)
- Stan J F Hartman
- Department of Pharmacology and Toxicology, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Parth J Upadhyay
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands
| | - Nienke N Hagedoorn
- Division of General Pediatrics, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy-Clinical Pharmacology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henriëtte A Moll
- Division of General Pediatrics, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michiel van der Flier
- Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,Section Pediatric Infectious Diseases, Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Radboudumc, Nijmegen, The Netherlands
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboud Institute of Molecular Life Sciences, Amalia Children's Hospital, Radboudumc, Nijmegen, The Netherlands
| | - Roger J Brüggemann
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Catherijne A Knibbe
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands.,Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands. .,Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands. .,Department of Intensive Care Medicine, Radboud Institute of Health Sciences, Radboudumc, Nijmegen, The Netherlands.
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Wasmann RE, Ter Heine R, van Dongen EP, Burger DM, Lempers VJ, Knibbe CA, Brüggemann RJ. Pharmacokinetics of Anidulafungin in Obese and Normal-Weight Adults. Antimicrob Agents Chemother 2018; 62:e00063-18. [PMID: 29712664 PMCID: PMC6021625 DOI: 10.1128/aac.00063-18] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/20/2018] [Indexed: 12/20/2022] Open
Abstract
In 2025, approximately one out of five adults will be obese. Physiological changes associated with obesity have been shown to influence the pharmacokinetics of drugs. Anidulafungin is frequently used in critically ill patients, and to achieve optimal efficacy, it is essential that its dose is appropriate for each patient's characteristics. We combined data from obese subjects with data from normal-weight subjects and determined an optimal dosing regimen for obese patients by population pharmacokinetic modeling. Twenty adults, 12 of which were normal-weight healthy subjects (median weight, 67.7 kg; range, 61.5 to 93.6 kg) and 8 of which were morbidly obese subjects (median weight, 149.7 kg; range, 124.1 to 166.5 kg) were included in the analysis. Subjects received a single dose of 100 mg anidulafungin intravenously over 90 min, upon which blood samples were obtained. Monte Carlo simulations were performed to optimize dosing in obesity. A three-compartment model and equal volumes of distribution described the data best. Total body weight was identified as a descriptor for both clearance and the volume of distribution, but the effect of weight on these parameters was limited. Simulations showed that with the licensed 100-mg dose, more than 97% of subjects with a weight above 140 kg will have an area under the concentration-time curve from 0 to 24 h of less than 99 mg · h/liter (the reference value for normal-weight individuals). We found that in obese and normal-weight subjects, weight influenced both of the anidulafungin pharmacokinetic parameters clearance and volume of distribution, implying a lower exposure to anidulafungin in (morbidly) obese individuals. Consequently, a 25% increase in the loading and maintenance doses could be considered in patients weighing more than 140 kg.
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Affiliation(s)
- Roeland E Wasmann
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Center of Expertise in Mycology, Radboudumc/CWZ, Nijmegen, The Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eric P van Dongen
- Department of Anesthesiology, Intensive Care and Pain Management, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Vincent J Lempers
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catherijne A Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Roger J Brüggemann
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Center of Expertise in Mycology, Radboudumc/CWZ, Nijmegen, The Netherlands
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Allegaert K, Simons SHP, Tibboel D, Krekels EH, Knibbe CA, van den Anker JN. Non-maturational covariates for dynamic systems pharmacology models in neonates, infants, and children: Filling the gaps beyond developmental pharmacology. Eur J Pharm Sci 2017; 109S:S27-S31. [PMID: 28506866 DOI: 10.1016/j.ejps.2017.05.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 05/11/2017] [Indexed: 02/07/2023]
Abstract
Pharmacokinetics and -dynamics show important changes throughout childhood. Studies on the different maturational processes that influence developmental pharmacology have been used to create population PK/PD models that can yield individualized pediatric drug dosages. These models were subsequently translated to semi-physiologically or physiology-based PK (PBPK) models that support predictions in pediatric patient cohorts and other special populations. Although these translational efforts are crucial, these models should be further improved towards individual patient predictions by including knowledge on non-maturational covariates. These efforts are needed to ultimately get to systems pharmacology models for children. These models take developmental changes relating to the pediatric dynamical system into account but also other aspects that may be of importance such as abnormal body composition, pharmacogenetics, critical illness and inflammatory status.
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Affiliation(s)
- Karel Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Development and Regeneration KU Leuven, Leuven, Belgium
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Elke H Krekels
- Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden, the Netherlands
| | - Catherijne A Knibbe
- Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden, the Netherlands; Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - John N van den Anker
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands; Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA; Division of Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
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Välitalo PA, Krekels EH, van Dijk M, Simons S, Tibboel D, Knibbe CA. Morphine Pharmacodynamics in Mechanically Ventilated Preterm Neonates Undergoing Endotracheal Suctioning. CPT Pharmacometrics Syst Pharmacol 2017; 6:239-248. [PMID: 28109060 PMCID: PMC5397563 DOI: 10.1002/psp4.12156] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 11/03/2016] [Indexed: 11/08/2022]
Abstract
To date, morphine pharmacokinetics (PKs) are well quantified in neonates, but results about its efficacy are ambiguous. This work presents an analysis of a previously published study on pain measurements in mechanically ventilated preterm neonates who received either morphine or placebo to improve comfort during invasive ventilation. The research question was whether morphine reduces the pain associated with endotracheal or nasal suctioning before, during, and after suctioning. Because these neonates cannot verbalize their pain levels, pain was assessed on the basis of several validated pain measurement instruments (i.e., COMFORT‐B, preterm infant pain profile [PIPP], Neonatal Infant Pain Scale (NIPS), and visual analogue scale (VAS)). The item response theory (IRT) was used to analyze the data in order for us to handle the data from multiple‐item pain scores. The analysis showed an intra‐individual relationship between morphine concentrations and pain reduction, as measured by COMFORT‐B and VAS. However, the small magnitude of the morphine effect was not considered clinically relevant for this intervention in preterm neonates.
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Affiliation(s)
- P A Välitalo
- Division of Pharmacology, Leiden University, Leiden, The Netherlands
| | - E H Krekels
- Division of Pharmacology, Leiden University, Leiden, The Netherlands
| | - M van Dijk
- Intensive Care and Department of Pediatric Surgery Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Shp Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - D Tibboel
- Intensive Care and Department of Pediatric Surgery Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - C A Knibbe
- Division of Pharmacology, Leiden University, Leiden, The Netherlands.,Intensive Care and Department of Pediatric Surgery Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
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Brill MJ, van Rongen A, van Dongen EP, van Ramshorst B, Hazebroek EJ, Darwich AS, Rostami-Hodjegan A, Knibbe CA. The Pharmacokinetics of the CYP3A Substrate Midazolam in Morbidly Obese Patients Before and One Year After Bariatric Surgery. Pharm Res 2015. [PMID: 26202517 PMCID: PMC4628089 DOI: 10.1007/s11095-015-1752-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Purpose Bariatric surgery is nowadays commonly applied as treatment for morbid obesity (BMI > 40 kg/m2). As information about the effects of this procedure on a drug’s pharmacokinetics is limited, we aimed to evaluate the pharmacokinetics of CYP3A probe substrate midazolam after oral and intravenous administration in a cohort of morbidly obese patients that was studied before and 1 year post bariatric surgery. Methods Twenty morbidly obese patients (aged 26–58 years) undergoing bariatric surgery participated in the study of which 18 patients returned 1 year after surgery. At both occasions, patients received 7.5 mg oral and 5 mg intravenous midazolam separated by 160 ± 48 min. Per patient and occasion, a mean of 22 blood samples were collected. Midazolam concentrations were analyzed using population pharmacokinetic modeling. Results One year after bariatric surgery, systemic clearance of midazolam was higher [0.65 (7%) versus 0.39 (11%) L/min, mean ± RSE (P < 0.01), respectively] and mean oral transit time (MTT) was faster [23 (20%) versus 51 (15%) minutes (P < 0.01)], while oral bioavailability was unchanged (0.54 (9%)). Central and peripheral volumes of distribution were overall lower (P < 0.05). Conclusions In this cohort study in morbidly obese patients, systemic clearance was 1.7 times higher 1 year after bariatric surgery, which may potentially result from an increase in hepatic CYP3A activity per unit of liver weight. Although MTT was found to be faster, oral bioavailability remained unchanged, which considering the increased systemic clearance implies an increase in the fraction escaping intestinal first pass metabolism. Electronic supplementary material The online version of this article (doi:10.1007/s11095-015-1752-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Margreke J Brill
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Department of Clinical Pharmacy, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Anne van Rongen
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Department of Clinical Pharmacy, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Eric P van Dongen
- Department of Anaesthesiology and Intensive Care, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Bert van Ramshorst
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Eric J Hazebroek
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Adam S Darwich
- Manchester Pharmacy School, University of Manchester, Manchester, Great Britain, UK
| | | | - Catherijne A Knibbe
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.
- Department of Clinical Pharmacy, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.
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Braam HJ, Schellens JH, Boot H, van Sandick JW, Knibbe CA, Boerma D, van Ramshorst B. Selection of chemotherapy for hyperthermic intraperitoneal use in gastric cancer. Crit Rev Oncol Hematol 2015; 95:282-96. [PMID: 25921419 DOI: 10.1016/j.critrevonc.2015.04.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 01/22/2015] [Accepted: 04/07/2015] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Several studies have shown the potential benefit of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) in gastric cancer patients. At present the most effective chemotherapeutic regime in HIPEC for gastric cancer is unknown. The aim of this review was to provide a comprehensive overview of chemotherapeutic agents used for HIPEC in gastric cancer. METHODS A literature search was conducted using the PubMed database to identify studies on chemotherapy used for HIPEC in gastric cancer patients. RESULTS AND CONCLUSION The chemotherapeutic regime of choice in HIPEC for gastric cancer has yet to be determined. The wide variety in studies and study parameters, such as chemotherapeutic agents, dosage, patient characteristics, temperature of perfusate, duration of perfusion, carrier solutions, intraperitoneal pressure and open or closed perfusion techniques, warrant more experimental and clinical studies to determine the optimal treatment schedule. A combination of drugs probably results in a more effective treatment.
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Affiliation(s)
- H J Braam
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | - J H Schellens
- Division of Clinical Pharmacology, Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Science Faculty, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - H Boot
- Division of Gastroenterology and Hepatology, Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - J W van Sandick
- Department of Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - C A Knibbe
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands; Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - D Boerma
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - B van Ramshorst
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
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Chidambaran V, Sadhasivam S, Diepstraten J, Esslinger H, Cox S, Schnell BM, Samuels P, Inge T, Vinks AA, Knibbe CA. Evaluation of propofol anesthesia in morbidly obese children and adolescents. BMC Anesthesiol 2013; 13:8. [PMID: 23602008 PMCID: PMC3644256 DOI: 10.1186/1471-2253-13-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 04/16/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Poor characterization of propofol pharmacokinetics and pharmacodynamics in the morbidly obese (MO) pediatric population poses dosing challenges. This study was conducted to evaluate propofol total intravenous anesthesia (TIVA) in this population. METHODS After IRB approval, a prospective study was conducted in 20 MO children and adolescents undergoing laparoscopic surgery under clinically titrated propofol TIVA. Propofol doses/infusion rates, hemodynamic variables, times to induction and emergence, and postoperative occurrence of respiratory adverse events (RAE) were recorded, along with intraoperative blinded Bispectral Index/BIS and postoperative Ramsay sedation scores (RSS). Study subjects completed awareness questionnaires on postoperative days 1 and 3. Propofol concentrations were obtained at predetermined intra- and post-operative time points. RESULTS Study subjects ranged 9 - 18 years (age) and 97 - 99.9% (BMI for age percentiles). Average percentage variability of hemodynamic parameters from baseline was ≈ 20%. Patients had consistently below target BIS values (BIS < 40 for >90% of maintenance phase), delayed emergence (25.8 ± 22 minutes), increased somnolence (RSS ≥ 4) in the first 30 minutes of recovery from anesthesia and 30% incidence of postoperative RAE, the odds for which increased by 14% per unit increase in BMI (p ≤ 0.05). Mean propofol concentration was 6.2 mg/L during maintenance and 1.8 mg/L during emergence from anesthesia. CONCLUSIONS Our findings indicate clinical overestimation of propofol requirements and highlight the challenges of clinically titrated propofol TIVA in MO adolescents. In this setting, it may be advantageous to titrate propofol to targeted BIS levels until more accurate weight-appropriate dosing regimens are developed, to minimize relative overdosing and its consequences.
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Affiliation(s)
- Vidya Chidambaran
- Department of Anesthesia and Paediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 2001, Cincinnati, OH, 45229, USA
- University of Cincinnati, Cincinnati, OH, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia and Paediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 2001, Cincinnati, OH, 45229, USA
- University of Cincinnati, Cincinnati, OH, USA
| | - Jeroen Diepstraten
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, Netherlands
| | - Hope Esslinger
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Shareen Cox
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Beverly M Schnell
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Paul Samuels
- Department of Anesthesia and Paediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 2001, Cincinnati, OH, 45229, USA
- University of Cincinnati, Cincinnati, OH, USA
| | - Thomas Inge
- Division of Paediatric Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology and Department of Paediatrics, Cincinnati Childrens Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati, Cincinnati, OH, USA
| | - Catherijne A Knibbe
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, Netherlands
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, Netherlands
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Valkenburg AJ, van Dijk M, de Leeuw TG, Meeussen CJ, Knibbe CA, Tibboel D. Anaesthesia and postoperative analgesia in surgical neonates with or without Down's syndrome: is it really different? Br J Anaesth 2011; 108:295-301. [PMID: 22201181 DOI: 10.1093/bja/aer421] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Reports conflict on optimal postoperative analgesic treatment in children with intellectual disability. We retrospectively compared postoperative analgesics consumption between neonates with and without Down's syndrome in relation to anaesthesia requirements and pain scores. METHODS We analysed hypnotic and analgesic drug administration, pain scores [COMFORT-Behaviour (COMFORT-B) scale], and duration of mechanical ventilation during the first 48 h after surgical repair of congenital duodenal obstruction in neonates, between 1999 and 2011. Data of 15 children with Down's syndrome were compared with data of 30 children without Down's syndrome. RESULTS General anaesthesia requirements did not differ. The median (inter-quartile range) maintenance dose of morphine during the first 24 h after operation was 9.5 (7.8-10.1) µg kg(-1) h(-1) in the Down's syndrome group vs 7.7 (5.0-10.0) µg kg(-1) h(-1) in the control group (P=0.46). Morphine doses at postoperative day 2 and COMFORT-B scores at day 1 did not significantly differ between the two groups. COMFORT-B scores at day two were lower in children with Down's syndrome (P=0.04). The duration of postoperative mechanical ventilation did not statistically differ between the two groups (P=0.89). CONCLUSIONS In this study, neonates with and without Down's syndrome received adequate postoperative analgesia, as judged from comparable analgesic consumption and pain scores. We recommend prospective studies in children of different age groups with Down's syndrome and in other groups of intellectually disabled children to provide further investigation of the hypothesis that intellectual disability predisposes to different analgesic requirements.
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Affiliation(s)
- A J Valkenburg
- Department of Paediatric Surgery, Erasmus University Medical Centre, Sophia Children'sHospital, 3015 GJ Rotterdam, The Netherlands.
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Van Gulik L, Brouwer H, Ahlers SJ, Van Boven W, Knibbe CA, Van Dongen E, Bruins P. Is delirium associated with pain and administered morphine in patients in the ICU after cardiac surgery? Crit Care 2011. [PMCID: PMC3067015 DOI: 10.1186/cc9761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Grootenboers MJ, Hendriks JM, van Boven WJ, Knibbe CA, Van Schil PE, Schramel FM. PHARMACOKINETIC ANALYSIS OF ISOLATED LUNG PERFUSION WITH MELPHALAN IN PATIENTS WITH RESECTABLE PULMONARY METASTASES. Chest 2005. [DOI: 10.1378/chest.128.4_meetingabstracts.313s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Knibbe CA, Aarts LP, Kuks PF, Voortman HJ, Lie-A-Huen L, Bras LJ, Danhof M. Pharmacokinetics and pharmacodynamics of propofol 6% SAZN versus propofol 1% SAZN and Diprivan-10 for short-term sedation following coronary artery bypass surgery. Eur J Clin Pharmacol 2000; 56:89-95. [PMID: 10853884 DOI: 10.1007/s002280050726] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE A new formulation of propofol 6% in Lipofundin MCT/LCT 10% (propofol 6% SAZN) has been developed in order to reduce the fat, emulsifier and volume load that is given during prolonged infusions of propofol. The pharmacokinetics, pharmacodynamics and safety characteristics of propofol 6% SAZN were investigated during a short-term infusion and compared with the commercially available product propofol 1% in Intralipid 10% (Diprivan-10) and propofol 1% in Lipofundin MCT/LCT 10% (propofol 1% SAZN). METHODS In a randomised double-blind study, 24 male patients received a 5-h infusion of propofol at the rate of 1 mg/kg/h for sedation in the immediate postoperative period following coronary artery bypass surgery. RESULTS The average pharmacokinetic parameter estimates of clearance (Cl), volume of distribution at steady state (Vd,ss), elimination half-life (t1/2,beta) and distribution half-life (t1/2,alpha) observed in the three groups were 28 +/- 1.1 ml/kg/min, 1.8 +/- 0.12 l/kg, 94 +/- 4.1 min and 3.1 +/- 0.26 min, respectively (mean +/- SEM, n = 24) and no significant differences were noted between the three formulations (P > 0.05). In one patient receiving propofol 6% SAZN, in two patients receiving propofol 1% SAZN and in three patients receiving Diprivan-10, the level of sedation was inadequate and additional sedative medication had to be given. In all other 18 patients, the level of sedation was adequate. The mean propofol concentration in these six inadequately sedated patients was lower than the adequately sedated patients (P = 0.015). The serum triglyceride concentrations were not significantly different between the groups studied. No adverse events occurred in any of the patients. CONCLUSIONS The pharmacokinetics, pharmacodynamics and safety characteristics of propofol 6% SAZN are in good agreement with those of the 1% formulations. Propofol 6% SAZN therefore provides a useful alternative to the commercially available 1% formulation for short-term sedation in the intensive care unit. Expected advantages in long-term sedation of the 6% over 1% formulation are the subject of an ongoing study.
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Affiliation(s)
- C A Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.
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Knibbe CA, Koster VS, Aarts LP, Langemeijer HJ, Danhof M. Pilot study in humans on the pharmacokinetics and safety of propofol 6% SAZN. Pharm World Sci 1999; 21:239-40. [PMID: 10550850 DOI: 10.1023/a:1008701004814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
In a pilot study on the first application of Propofol 6% SAZN in humans, the pharmacokinetics and safety of the new product seem to be similar to those of Propofol 1% SAZN and Diprivan-10 after bolus injection. The results will have to be confirmed in a larger clinical study in order to develop Propofol 6% SAZN as an alternative for Diprivan-10.
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Affiliation(s)
- C A Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
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Knibbe CA, Voortman HJ, Aarts LP, Kuks PF, Lange R, Langemeijer HJ, Danhof M. Pharmacokinetics, induction of anaesthesia and safety characteristics of propofol 6% SAZN vs propofol 1% SAZN and Diprivan-10 after bolus injection. Br J Clin Pharmacol 1999; 47:653-60. [PMID: 10383543 PMCID: PMC2014258 DOI: 10.1046/j.1365-2125.1999.00942.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AIMS In order to avoid the potential for elevated serum lipid levels as a consequence of long term sedation with propofol, a formulation of propofol 6% in Lipofundin(R) MCT/LCT 10% (Propofol 6% SAZN) has been developed. The pharmacokinetics, induction of anaesthesia and safety characteristics of this new formulation were investigated after bolus injection and were compared with the commercially available product (propofol 1% in Intralipid(R) 10%, Diprivan-10) and propofol 1% in Lipofundin(R) MCT/LCT 10% (Propofol 1% SAZN). METHODS In a randomised double-blind study, 24 unpremedicated female patients received an induction dose of propofol of 2.5 mg kg-1 over 60 s which was followed by standardized balanced anaesthesia. The patients were randomized to receive propofol as Propofol 6% SAZN, Propofol 1% SAZN or Diprivan-10. RESULTS For all formulations the pharmacokinetics were adequately described by a tri-exponential equation, as the propofol concentrations collected early after the injection suggested an additional initial more rapid phase. The average values for clearance (CL), volume of distribution at steady-state (Vd,ss ), elimination half-life (t1/2,z ) and distribution half-life (t1/2, lambda2) observed in the three groups were 32+/-1.5 ml kg-1 min-1, 2. 0+/-0.18 l kg-1, 95+/-5.6 min and 3.4+/-0.20 min, respectively (mean+/-s.e.mean, n=24) and no significant differences were noted between the three formulations (P >0.05). The half-life of the additional initial distribution phase (t1/2,lambda1 ) in all subjects ranged from 0.1 to 0.6 min. Anaesthesia was induced successfully and uneventfully in all cases, and the quality of induction was adequate in all 24 patients. The induction time did not vary between the three formulations and the average induction time observed in the three groups was 51+/-1.3 s which corresponded to an induction dose of propofol of 2.1+/-0.06 mg kg-1 (mean+/-s.e. mean, n=24). The percentage of patients reporting any pain on injection did not vary between the formulations and was 17% for the three groups. No postoperative phlebitis or other venous sequelae of the vein used for injection occurred in any of the patients at recovery of anaesthesia nor after 24 h. CONCLUSIONS From the above results, we conclude that the alteration of the type of emulsion and the higher concentration of propofol in the new parenteral formulation of propofol does not affect the pharmacokinetics and induction characteristics of propofol, compared with the currently available product. Propofol 6% SAZN can be administered safely and has the advantage of a reduction of the load of fat and emulsifier which may be preferable when long term administration of propofol is required.
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Affiliation(s)
- C A Knibbe
- Department of Clinical Pharmacy, St Antonius Hospital, P.O. Box 2500, 3430 EM Nieuwegein, The Netherlands
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Knibbe CA, Koster VS, Deneer VH, Stuurman RM, Kuks PF, Lange R. Determination of propofol in low-volume samples by high-performance liquid chromatography with fluorescence detection. J Chromatogr B Biomed Sci Appl 1998; 706:305-10. [PMID: 9551817 DOI: 10.1016/s0378-4347(97)00571-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In order to determine propofol in rat whole-blood samples of 50 microl, we developed a rapid, simple and reliable method which is characterized by precipitation of blood elements with acetonitrile and submission of the supernatant to HPLC analysis with fluorescence detection. The method described is linear from 0.4 to 40 mg/l and the relative standard deviations in this concentration range are less than 10%. The limit of quantification proved to be 0.4 mg/l. Blood constituents do not interfere with the assay.
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Affiliation(s)
- C A Knibbe
- Department of Clinical Pharmacy, St. Anonius Hospital, Nieuwegein, The Netherlands
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Cox EH, Knibbe CA, Koster VS, Langemeijer MW, Tukker EE, Lange R, Kuks PF, Langemeijer HJ, Lie-A-Huen L, Danhof M. Influence of different fat emulsion-based intravenous formulations on the pharmacokinetics and pharmacodynamics of propofol. Pharm Res 1998; 15:442-8. [PMID: 9563075 DOI: 10.1023/a:1011980432646] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The influence of different intravenous formulations on the pharmacokinetics and pharmacodynamics of propofol was investigated using the effect on the EEG (11.5-30 Hz) as pharmacodynamic endpoint. METHODS Propofol was administered as an intravenous bolus infusion (30 mg/kg in 5 min) or as a continuous infusion (150 mg/kg in 5 hours) in chronically instrumented male rats. Propofol was formulated as a 1% emulsion in an Intralipid 10%-like fat emulsion (Diprivan-10, D) or as a 1%- or 6% emulsion in Lipofundin MCT/LCT-10% (P1% and P6%, respectively). EEG was recorded continuously and arterial blood samples were collected serially for the determination of propofol concentrations using HPLC. RESULTS Following bolus infusion, the pharmacokinetics of the various propofol emulsions could adequately be described by a two-compartmental pharmacokinetic model. The average values for clearance (Cl), volume of distribution at steady-state (Vd,ss) and terminal half-life (t1/2, lambda 2) were 107 +/- 4 ml/min/kg, 1.38 +/- 0.06 l/kg and 16 +/- 1 min, respectively (mean +/- S.E. n = 22). No significant differences were observed between the three propofol formulations. After continuous infusion these values were 112 +/- 11 ml/min/kg, 5.19 +/- 0.41 l/kg and 45 +/- 3 min, respectively (mean +/- S.E., n = 20) with again no statistically significant differences between the three propofol formulations. Comparison between the bolus- and the continuous infusion revealed a statistically significant difference for both Vd,ss and t1/2, lambda 2 (p < 0.05), whereas Cl remained unchanged. In all treatment groups infusion of propofol resulted in a burst-suppression type of EEG. A profound hysteresis loop was observed between blood concentrations and EEG effect for all formulations. The hysteresis was minimized by a semi-parametric method and resulted in a biphasic concentration-effect relationship of propofol that was described non-parametrically. For P6% a larger rate constant onset of drug effect (t1/2,keo) was observed compared to the other propofol formulations (p < 0.05). CONCLUSIONS The pharmacokinetics and pharmacodynamics of propofol are not affected by to a large extent the type of emulsion nor by the concentration of propofol in the intravenous formulation.
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Affiliation(s)
- E H Cox
- Division of Pharmacology, University of Leiden, Sylvius Laboratory, The Netherlands
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