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Hensel A, Bauer R, Heinrich M, Hempel G, Kelber O, Kraft K, Lehmann B, Medà MM, Nieber K, Roether B, Rollinger JM, Wiebelitz R. Rationalising Optimal Dosing of Phytotherapeutics For Use In Children: Current Status - Potential Solutions - Actions Needed. Planta Med 2024. [PMID: 38527490 DOI: 10.1055/a-2294-5259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
"Children are not small adults with respect to the treatment with medicinal products." This statement of the WHO was the basis for the initiative of the European Commission for the establishment of a paediatric regulation in 2007 to improve the health of children by facilitating the development of medicines for children and adolescents. Seventeen years later, in the field of herbal medicinal products, results are still sobering. Therefore, the Foundation Plants for Health, Society for Medicinal Plants and Natural Products Research, and German Society for Phytotherapy organised a symposium to assess the status quo for the paediatric use of herbal medicinal products (HMPs), to analyse the causes of the current situation, and to discuss strategies for establishing the proof of safe and efficacious HMPs for children.The current situation for HMPs and their use in children is not fulfilling the requirements of legislation. HMPs in paediatrics are effective and safe, but considering the needs of children is necessary. In European countries, the use, registration, and marketing of HMPs are different, depending on the respective national regulations and specific traditions. EU herbal monographs are the best common denominator for such procedures. Emerging safety discussions must be considered. New approaches with real-world data might be a solution. The regulatory framework is to be adapted. Defining rationalised dosing for HMPs can be achieved by the extrapolation of data from adults, by using existing clinical data for children, and by using RWD. Therefore, a strong need for revising restrictions for the use of HMPs in children and rationalising defined dosage regimes is obvious.
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Affiliation(s)
- Andreas Hensel
- Institute of Pharmaceutical Biology and Phytochemistry, University of Münster, Germany
| | - Rudolf Bauer
- Institut für Pharmazeutische Wissenschaften, Pharmakognosie, Universitaet Graz, Austria
| | - Michael Heinrich
- School of Pharmacy, University College London, United Kingdom of Great Britain and Northern Ireland
| | - Georg Hempel
- Pharmaceutical and Medical Chenistry, University of Münster, Germany
| | - Olaf Kelber
- Research and Development, Bayer Consumer Health, Steigerwald Arzneimittelwerk GmbH, Darmstadt, Germany
| | - Karin Kraft
- Centre of Internal Medicine, University Medicine Rostock, Germany
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2
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Bauch T, Hempel G. Proof of concept of physiologically based pharmacokinetic modelling in paediatric acute lymphoblastic leukaemia. Br J Haematol 2024. [PMID: 38494194 DOI: 10.1111/bjh.19410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/23/2024] [Accepted: 03/06/2024] [Indexed: 03/19/2024]
Abstract
Physiologically based pharmacokinetic (PBPK) modelling is an alternative modelling technique that is increasingly used in pharmacokinetics. Due to its nature, it can be complementarily employed to population pharmacokinetics, especially when it comes to small population size. Here, we report the proof of concept of its application to accurately describe the pharmacokinetics of a recombinant L-asparaginase in paediatric patients with acute lymphoblastic leukaemia. Data from two randomized, double-blind, phase II/III clinical studies (MC-ASP.4/ALL; MC-ASP.5/ALL) were included to setup and evaluate the final model, respectively. Final population values for basic pharmacokinetic parameters were calculated (clearance: 0.0569 L/h/19.5 kg, volume of distribution: 1.251 L, half-life: 18.5 h, trough concentration: 140.9 IU/L). Pharmacokinetic parameter prediction as well as predictive performance of the model proofed to be comparable to a separately developed population pharmacokinetic model with 13% deviation in predicted median L-asparaginase trough levels. To the best of our knowledge, this is the first whole-body PBPK model of a non-antibody therapeutic protein.
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Affiliation(s)
- Thomas Bauch
- Department of Clinical Pharmacy, Institute for Pharmaceutical and Medical Chemistry, University of Münster, Münster, Germany
| | - Georg Hempel
- Department of Clinical Pharmacy, Institute for Pharmaceutical and Medical Chemistry, University of Münster, Münster, Germany
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3
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Opitz P, Fobker M, Fabian J, Hempel G. Development and validation of a bioanalytical method for the quantification of methotrexate from serum and capillary blood using volumetric absorptive microsampling (VAMS) and on-line solid phase extraction (SPE) LC-MS. J Chromatogr A 2024; 1715:464610. [PMID: 38157584 DOI: 10.1016/j.chroma.2023.464610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/21/2023] [Accepted: 12/25/2023] [Indexed: 01/03/2024]
Abstract
High-dose methotrexate is part of the polychemotherapy protocols for the treatment of Acute lymphoblastic leukaemia (ALL) with therapeutic drug monitoring (TDM) to adjust leucovorin rescue. An immunoassay is commonly used to analyse serum samples collected via venous blood sampling. However, immunoassays cannot distinguish between the parent drug and its metabolites. Besides, the blood volume required by venous blood sampling is high. Therefore, the aim of this project was to develop a fast, simple, reliable and cost-efficient micro sampling bioanalytical method using capillary blood to minimize the harm of children and to analyse both methotrexate and its metabolites. To achieve this aim, a LC-MS method with on-line solid phase extraction (SPE) for the simultaneous detection of methotrexate and its metabolites from capillary blood using volumetric-absorptive-microsampling (VAMS) technology was developed and fully validated. Besides, the method was also validated and modified for serum samples to compare the results with the immunoassay. A single-quadrupole MS detector was used for detection. Through the use of on-line SPE technology, a lower limit of quantitation of 0.03 µM for MTX and 7-OH-MTX and of 0.05 µM for DAMPA from a 10 μL capillary blood sample was achieved. The accuracy is between 90.0 and 104% and the precision between 4.7 and 12% for methotrexate and its metabolites, respectively. Because of the cross reactivity of the immunoassay a cross-validation was not successful. Besides, a correlation factor of 0.46 for MTX between plasma and whole-blood was found. A fast, simple, reliable and cost-efficient extraction and analysis LC-MS method could be developed and validated, which is applicable in ambulatory and clinical care.
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Affiliation(s)
- Patrick Opitz
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany
| | - Manfred Fobker
- University Hospital Münster - Central facility laboratory, Muenster, Germany
| | - Jörg Fabian
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany.
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Zimbelmann F, Flaute S, Deipenbrock M, Ahlke E, Hempel G, Baumann-Köhler M. [Use of strongly acting sustained-release opioids in pediatrics : Pitfalls and solutions for morphine and hydromorphone]. Schmerz 2024:10.1007/s00482-023-00775-w. [PMID: 38170297 DOI: 10.1007/s00482-023-00775-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND In pediatrics, adequate treatment with potent opioids requires the administration of sustained-release preparations for many patients; however, the dosing and administration of sustained-release morphine and hydromorphone preparations via gastrointestinal tubes confronts providers with a major hurdle, especially as the company Mundipharma GmbH has discontinued the production and distribution of the preparation MST retard granules in 2019, which has been proven for these purposes in pediatrics. The aim of this study was to establish a production technique for available sustained-release opioid preparations, which are particularly suitable for use in the low-dose range required in pediatrics and which can also be administered via gastrointestinal tubes. METHOD Low-dose preparations were produced by opening of morphine and hydromorphone capsules and weighing of the sustained-release pellets. To evaluate the partition, an analysis of the drug content via high performance liquid chromatography (HPLC) was conducted. Moreover, the administration via gastrointestinal tubes (charrière, Ch 8-Ch 10) was examined by an ex vivo experiment. RESULTS The examination showed a practicable method to produce low dosages of sustained-release morphine and hydromorphone. The preparations are in accordance with the test for content uniformity of the European Pharmacopoeia (Ph. Eur.). Furthermore, the pellets were administered to gastrointestinal tubes Ch 8 (morphine) and Ch 10 (hydromorphone) by a syringe application technique and passed the tubes completely. CONCLUSION The production technique can be considered as safe and enables the off-label oral application or application via gastrointestinal tubes of sustained-release opioids in pediatrics.
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Affiliation(s)
- Franziska Zimbelmann
- Institut für Pharmazeutische und Medizinische Chemie, Klinische Pharmazie, Universität Münster, Corrensstraße 48, 48149, Münster, Deutschland.
| | - Sarah Flaute
- Rezeptur/Sterilherstellung, Eberwein & Plassmann OHG, Hohenzollern Apotheke, Münster, Deutschland
| | - Melanie Deipenbrock
- Rezeptur/Sterilherstellung, Eberwein & Plassmann OHG, Hohenzollern Apotheke, Münster, Deutschland
| | - Elvira Ahlke
- Pädiatrische Hämatologie und Onkologie, Zentrum für Kinder- und Jugendmedizin, Universitätsklinikum Münster (UKM), Münster, Deutschland
| | - Georg Hempel
- Institut für Pharmazeutische und Medizinische Chemie, Klinische Pharmazie, Universität Münster, Corrensstraße 48, 48149, Münster, Deutschland
| | - Margit Baumann-Köhler
- Spezialisierte Ambulante Palliativversorgung für Kinder und Jugendliche (SAPV), Pädiatrische Hämatologie und Onkologie, Zentrum für Kinder- und Jugendmedizin, Universitätsklinikum Münster (UKM), Münster, Deutschland
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Gastine SE, Rauwolf KK, Pieper S, Hempel G, Lehrnbecher T, Tragiannidis A, Groll AH. Voriconazole plasma concentrations and dosing in paediatric patients below 24 months of age. Mycoses 2023; 66:969-976. [PMID: 37553971 DOI: 10.1111/myc.13643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/11/2023] [Accepted: 07/28/2023] [Indexed: 08/10/2023]
Abstract
Voriconazole (VCZ) is an important first-line option for management of invasive fungal diseases and approved in paediatric patients ≥24 months at distinct dosing schedules that consider different developmental stages. Information on dosing and exposures in children <24 months of age is scarce. Here we report our experience in children <24 months who received VCZ due to the lack of alternative treatment options. This retrospective analysis includes 50 distinct treatment episodes in 17 immunocompromised children aged between 3 and <24 months, who received VCZ between 2004 and 2022 as prophylaxis (14 patients; 47 episodes) or as empirical treatment (3 patients; 3 episodes) by mouth (46 episodes) or intravenously (4 episodes) based on contraindications, intolerance or lack of alternative options. Trough concentrations were measured as clinically indicated, and tolerability was assessed based on hepatic function parameters and discontinuations due to adverse events (AEs). VCZ was administered for a median duration of 10 days (range: 1-138). Intravenous doses ranged from 4.9 to 7.0 mg/kg (median: 6.5) twice daily, and oral doses from 3.8 to 29 mg/kg (median: 9.5) twice daily, respectively. The median trough concentration was 0.63 mg/L (range: 0.01-16.2; 38 samples). Only 34.2% of samples were in the recommended target range of 1-6 mg/L; 57.9% had lower and 7.9% higher trough concentrations. Hepatic function parameters analysed at baseline, during treatment and at end of treatment did not show significant changes during VCZ treatment. There was no correlation between dose and exposure or hepatic function parameters. In three episodes, VCZ was discontinued due to an AE (6%; three patients). In conclusion, this retrospective analysis reveals no signal for increased toxicity in paediatric patients <24 months of age. Empirical dosing resulted in mostly subtherapeutic exposures which emphasises the need for more systematic study of the pharmacokinetics of VCZ in this age group.
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Affiliation(s)
- Silke E Gastine
- Institute of Pharmaceutical and Medical Chemistry - Department of Clinical Pharmacy, Westphalian Wilhelms University Münster, Münster, Germany
| | - Kerstin K Rauwolf
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital Münster, Münster, Germany
| | - Stephanie Pieper
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital Münster, Münster, Germany
| | - Georg Hempel
- Institute of Pharmaceutical and Medical Chemistry - Department of Clinical Pharmacy, Westphalian Wilhelms University Münster, Münster, Germany
| | - Thomas Lehrnbecher
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Athanasios Tragiannidis
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital Münster, Münster, Germany
- 2nd Department of Pediatrics, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital Münster, Münster, Germany
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Ramadan O, Schatz LM, van den Heuvel I, Masjosthusmann K, Groll AH, Hempel G. Developing a Method for Quantifying Meropenem in Children-Volumetric Adsorptive Microsampling Versus Plasma Sampling. Ther Drug Monit 2023; 45:623-630. [PMID: 37199434 DOI: 10.1097/ftd.0000000000001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/12/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Meropenem is a carbapenem antibiotic often used in pediatric intensive care units due to its broad spectrum of activity. Therapeutic drug monitoring (TDM) is a useful tool to increase the effectiveness of meropenem by adjusting the dose based on plasma levels; however, the relatively large sample volume required for TDM can limit its use in children. Therefore, this study aimed to determine meropenem concentrations and consequently perform TDM effectively using the smallest possible sample volume. Volumetric absorptive microsampling (VAMS) is a sampling technology developed to collect a small, precise volume of blood. For the applicability of VAMS in TDM, plasma concentrations must be reliably calculated from whole blood (WB) collected by VAMS. METHODS VAMS technology using 10 µL of WB was evaluated and compared with EDTA-plasma sampling. High-performance liquid chromatography with UV detection was applied to quantify meropenem in VAMS and plasma samples after the removal of proteins by precipitation. Ertapenem was used as the internal standard. Samples were collected simultaneously from critically ill children receiving meropenem using VAMS and traditional sampling. RESULTS It was found that no consistent factor could be determined to calculate meropenem plasma concentrations from the WB, indicating that VAMS was not reliable in the TDM of meropenem. Therefore, to reduce the required sample amount in pediatric patients, a method for quantifying meropenem from 50 µL of plasma with a lower limit of quantification of 1 mg/L was developed and successfully validated. CONCLUSIONS A simple, reliable, and low-cost method was established using high-performance liquid chromatography-UV to determine the concentration of meropenem in 50 µL of plasma. VAMS using WB does not seem to be suitable for TDM of meropenem.
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Affiliation(s)
- Ola Ramadan
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Münster, Münster, Germany
| | - Lea Marie Schatz
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Münster, Münster, Germany
| | - Ingeborg van den Heuvel
- Department of General Paediatrics, University Children's Hospital Münster, Münster, Germany; and
| | - Katja Masjosthusmann
- Department of General Paediatrics, University Children's Hospital Münster, Münster, Germany; and
| | - Andreas H Groll
- Department of Pediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Münster, Münster, Germany
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Mecklenburg L, Lenz S, Hempel G. How important are concurrent vehicle control groups in (sub)chronic non-human primate toxicity studies conducted in pharmaceutical development? An opportunity to reduce animal numbers. PLoS One 2023; 18:e0282404. [PMID: 37535533 PMCID: PMC10399820 DOI: 10.1371/journal.pone.0282404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/19/2023] [Indexed: 08/05/2023] Open
Abstract
Safety assessment of human pharmaceuticals demands extensive animal experiments before a compound can be tested in patients or released on the market. Such experiments typically include concurrent vehicle control groups. Reconsidering the need for concurrent controls could support the strive to reduce the use of animals for scientific purposes. We reviewed reports from 20 (sub)chronic toxicity studies that were conducted in non-human primates (NHP) to characterize hazards of novel human pharmaceuticals. Firstly, we determined the toxicological endpoints that were identified to characterize the hazard. Secondly, we evaluated if the hazard could have been identified without reference to the concurrent controls. Thirdly, we employed an alternative statistical method to test for any significant change related to dose level or time. We found that toxicologically relevant hazards were identifiable without reference to concurrent controls, because individual measurements could be compared with pre-dosing values or because individual measurements could be compared to historical reference data. Effects that could not be evaluated without reference to concurrent controls were clinical observations and organ weights for which appropriate historical reference data was not available, or immune responses that could not be compared to pre-dosing measurements because their magnitude would change over time. Our investigation indicates that concurrent control groups in (sub)chronic NHP toxicity studies are of limited relevance for reaching the study objective. Under certain conditions, regulatory (sub)chronic NHP toxicity studies represent a good starting point to implement virtual control groups rather than concurrent control groups in nonclinical safety testing.
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Affiliation(s)
| | - Sarah Lenz
- Labcorp Early Development Services GmbH, Muenster, Germany
- Institute for Pharmaceutical and Medicinal Chemistry, Westphalian Wilhelms University, Muenster, Germany
| | - Georg Hempel
- Institute for Pharmaceutical and Medicinal Chemistry, Westphalian Wilhelms University, Muenster, Germany
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Schatz LM, Brinkmann A, Röhr A, Frey O, Greppmair S, Weinelt F, Zoller M, Scharf C, Hempel G, Liebchen U. Systematic Evaluation of Pharmacokinetic Models for Model-Informed Precision Dosing of Meropenem in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy. Antimicrob Agents Chemother 2023; 67:e0010423. [PMID: 37125925 DOI: 10.1128/aac.00104-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
The altered pharmacokinetics of renally cleared drugs such as meropenem in critically ill patients receiving continuous renal replacement therapy (CRRT) might impact target attainment. Model-informed precision dosing (MIPD) is applied to individualize meropenem dosing. However, most population pharmacokinetic (PopPK) models developed to date have not yet been evaluated for MIPD. Eight PopPK models based on adult CRRT patients were identified in a systematic literature research and encoded in NONMEM 7.4. A data set of 73 CRRT patients from two different study centers was used to evaluate the predictive performance of the models using simulation and prediction-based diagnostics for i) a priori dosing based on patient characteristics only and ii) Bayesian dosing by including the first measured trough concentration. Median prediction error (MPE) for accuracy within |20%| (95% confidence intervals including zero) and median absolute prediction error (MAPE) for precision ≤ 30% were considered clinically acceptable. For a priori dosing, most models (n = 5) showed accuracy and precision MPE within |20%| and MAPE <35%. The integration of the first measured meropenem concentration improved the predictive performance of all models (median MAPE decreased from 35.4 to 25.0%; median MPE decreased from 21.8 to 4.6%). The best predictive performance for intermittent infusion was observed for the O'Jeanson model, including residual diuresis as covariate (a priori and Bayesian dosing MPE within |2%|, MAPE <30%). Our study revealed the O'Jeanson model as the best-predicting model for intermittent infusion. However, most of the selected PopPK models are suitable for MIPD in CRRT patients when one therapeutic drug monitoring sample is available.
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Affiliation(s)
- Lea Marie Schatz
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany
| | - Alexander Brinkmann
- Department of Anaesthesiology and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Anka Röhr
- Department of Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Otto Frey
- Department of Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Sebastian Greppmair
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Ferdinand Weinelt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
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Rosser SPA, McLachlan AJ, Hempel G, Chung J, Shaw PJ, Keogh SJ, Nath CE. Validation of a liquid chromatography-tandem mass spectrometry method for simultaneous quantification of N,N-dimethylacetamide and N-monomethylacetamide in pediatric plasma. J Sep Sci 2023; 46:e2201003. [PMID: 36879545 DOI: 10.1002/jssc.202201003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/07/2023] [Accepted: 03/04/2023] [Indexed: 03/08/2023]
Abstract
N,Na-dimethylacetamide is an excipient used in intravenous busulfan formulations, a drug used in hematopoietic stem cell transplantation conditioning. The aim of this study was to develop and validate a liquid chromatography-tandem mass spectrometry method for simultaneous quantification of N,N-dimethylacetamide, and its metabolite N-monomethylacetamide in plasma from children receiving busulfan. A 4 μl aliquot of patient plasma was extracted using 196 μl 50% methanol solution and quantified against calibrators prepared in the extraction solvent given negligible matrix effects across three concentrations. 9 [H2 ]-N,N-dimethylacetamide was used as an internal standard. Separation of N,N-dimethylacetamide and N-monomethylacetamide was achieved using a Kinetex EVO C18 stationary phase (100 mm × 2.1 mm × 2.6 μm) running an isocratic mobile phase of 30% methanol containing 0.1% formic acid at a flow of 0.2 ml/min over 3.0 min. The injection volume was 1 μl. Calibration curves for N,N-dimethylacetamide and N-monomethylacetamide were linear up to 1200 and 200 μg/L, respectively, with a lower limit of quantification 1 μg/L for both analytes. Calibrator accuracy and precision were within ± 10% of the test parameters across four concentration levels. Analytes were stable over 14 days at three different storage conditions. This method was successfully applied to measure N,N-dimethylacetamide and N-monomethylacetamide concentrations in a total of 1265 plasma samples from 77 children.
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Affiliation(s)
- Sebastian P A Rosser
- The Children's Hospital at Westmead Clinical School, University of Sydney, Sydney, Australia.,Department of Biochemistry, The Children's Hospital at Westmead, Sydney, Australia.,Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Georg Hempel
- Institute for Pharmaceutical and Medicinal Chemistry and Clinical Pharmacy, University of Münster, Sydney, Germany
| | - Jason Chung
- The Children's Hospital at Westmead Clinical School, University of Sydney, Sydney, Australia.,Department of Biochemistry, The Children's Hospital at Westmead, Sydney, Australia
| | - Peter J Shaw
- The Children's Hospital at Westmead Clinical School, University of Sydney, Sydney, Australia.,Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
| | - Steven J Keogh
- Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
| | - Christa E Nath
- Department of Biochemistry, The Children's Hospital at Westmead, Sydney, Australia.,Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, Australia.,Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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10
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Maierhöfer S, Waltering I, Jacobs M, Würthwein G, Appelrath M, Koling S, Hempel G. Decision support software-guided medication reviews in elderly patients with polypharmacy: a prospective analysis of routine data from community pharmacies (OPtiMed study protocol). J Pharm Policy Pract 2022; 15:100. [PMID: 36494764 PMCID: PMC9732986 DOI: 10.1186/s40545-022-00495-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/17/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pharmacist-led medication reviews are considered a valuable measure to address risks of polypharmacy. The software Medinspector® is used in community pharmacies to assist the performance of this complex service by structuring the medication review process and supporting pharmacists in their decision-making with targeted clinical knowledge. Key feature is a computerized risk assessment of both the initial and adjusted medication regimen of a patient in multiple domains, thus aiming to support the identification and solving of drug-related problems. This study will examine the effects of medication reviews performed with the clinical decision support system in daily routine practice on medication-related and patient-reported outcomes in elderly patients with polypharmacy. METHODS A prospective, before-after observational study is conducted in German community pharmacies aiming to include 148 patients aged 65 or older, who chronically use five or more active pharmaceutical substances with systemic effects and utilize the software-supported medication review service. The study is based on routine documentation within the software over the course of the medication review, including a patient's baseline medication, the medication proposed by pharmacists, and the final medication regimen. A software-implemented questionnaire comprising self-developed and literature-derived instruments is used to collect patient-reported outcome data at baseline and follow-up. Primary outcome is the appropriateness of medication measured with an adapted version of the Medication Appropriateness Index (MAI). Secondary medication-related outcomes are medication underuse, exposition towards anticholinergic/sedative drugs, number of drugs in long-term use and the implementation of pharmacist-proposed medication adjustments by the physicians. Secondary patient-reported outcomes are symptom burden, medication-related quality of life, adherence, fulfillment of medication review-related goals, and perception of the service. DISCUSSION With the recently introduced remuneration of community pharmacist-led MR in Germany, the demand for digital tools supporting the MR process is assumed to rise. The OPtiMed-study is expected to create evidence on the effects of a novel tool on patient care in a vulnerable patient population. Trial registration German Clinical Trials Register, DRKS00027410. Registered 22 December 2021, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00027410 . Also available on the WHO meta-registry: https://trialsearch.who.int/?TrialID=DRKS00027410.
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Affiliation(s)
- Stefan Maierhöfer
- grid.5949.10000 0001 2172 9288Department of Pharmaceutical and Medicinal Chemistry — Clinical Pharmacy, Westfaelische Wilhelms-University, Muenster, Germany
| | - Isabell Waltering
- grid.5949.10000 0001 2172 9288Department of Pharmaceutical and Medicinal Chemistry — Clinical Pharmacy, Westfaelische Wilhelms-University, Muenster, Germany
| | | | - Gudrun Würthwein
- grid.5949.10000 0001 2172 9288Department of Pharmaceutical and Medicinal Chemistry — Clinical Pharmacy, Westfaelische Wilhelms-University, Muenster, Germany
| | | | - Susanne Koling
- Clinic for Pediatrics and Adolescent Medicine — Evangelical Hospital Hamm, Hamm, Germany
| | - Georg Hempel
- grid.5949.10000 0001 2172 9288Department of Pharmaceutical and Medicinal Chemistry — Clinical Pharmacy, Westfaelische Wilhelms-University, Muenster, Germany
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Gastine S, Hempel G, Neely MN, Walsh TJ, Groll AH. Pharmacokinetic modelling of caspofungin to develop an extended dosing regimen in paediatric patients. J Antimicrob Chemother 2022; 77:2209-2216. [PMID: 35696555 DOI: 10.1093/jac/dkac182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Echinocandins are commonly used in treatment and prophylaxis of invasive fungal diseases. Intravenous daily dosing for prophylaxis in the outpatient setting can however become a hurdle for adequate compliance in the paediatric population. OBJECTIVES Simulations were performed to assess extended twice-weekly dosing for antifungal prophylaxis using caspofungin. METHODS A population pharmacokinetic model was developed based on previously published data from children aged 3 months to 17 years. Using the final model, Monte Carlo simulations were performed to assess the dose needed for adequate exposure in a twice-weekly setting. Mean weekly AUC0-24 h/MIC together with reported AUC0-24 h from previously reported paediatric trials were used to guide adequate exposure. RESULTS AND CONCLUSIONS A two-compartment model with linear elimination and allometric scaling using fixed exponents was found most adequate to describe the given paediatric populations. Simulations showed that a 200 mg/m2 twice-weekly regimen with maximal 200 mg total dose should result in exposures matching registered daily dosing as well as commonly used pharmacokinetic/pharmacodynamic targets.
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Affiliation(s)
- Silke Gastine
- Institute of Pharmaceutical and Medical Chemistry, Deptartment of Clinical Pharmacy, Westfälische Wilhelms-Universität Münster, Münster, Germany.,Department of Infection, Immunity & Inflammation Research & Teaching, GOS Institute of Child Health, University College London, London, UK
| | - Georg Hempel
- Institute of Pharmaceutical and Medical Chemistry, Deptartment of Clinical Pharmacy, Westfälische Wilhelms-Universität Münster, Münster, Germany
| | - Michael N Neely
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany
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12
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Krämer J, Nolte K, Zupanc L, Schnitker S, Roos A, Göpel C, Cid JS, Eichler K, Hooven TVD, Hempel G, Pavenstädt HJ, Klaas C, Gosheger G, Raschke MJ, Wiendl H, Duning T. Structured delirium management in the hospital—a randomized controlled trial. Deutsches Ärzteblatt international 2022; 119:188-194. [PMID: 35197189 PMCID: PMC9229581 DOI: 10.3238/arztebl.m2022.0131] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/04/2021] [Accepted: 02/01/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Delirium is a common and serious complication of inpatient hospital care in older patients. The current approaches to prevention and treatment followed in German hospitals are inconsistent. The aim of this study was to test the effectiveness of a standardized multiprofessional approach to the management of delirium in inpatients. METHODS The patients included in the study were all >65 years old, were treated for at least 3 days on an internal medicine, trauma surgery, or orthopedic ward at Münster University Hospital between January 2016 and December 2017, and showed cognitive deficits on standardized screening at the time of admission (a score of ≤=25 on the Montreal Cognitive Assessment [MoCA] test). Patients in the intervention group received standardized delirium prevention and treatment measures; those in the control group did not. The primary outcomes measured were the incidence and duration of delirium during the hospital stay; the secondary outcomes measured were cognitive deficits relevant to daily living at 12 months after discharge (MoCA and Instrumental Activities of Daily Living [I-ADL]). RESULTS The data of 772 patients were analyzed. Both the rate and the duration of delirium were lower in the intervention group than in the control group (6.8% versus 20.5%, odds ratio 0.28, 95% confidence interval [0.18; 0.45]; 3 days [interquartile range, IQR 2-4] versus 6 days [IQR 4-8]). A year after discharge, the patients with delirium in the intervention group showed fewer cognitive deficits relevant to daily living than those in the control group (I-ADL score 2.5 [IQR 2-4] versus 1 [IQR 1-2], P = 0.02). CONCLUSION Structured multiprofessional management reduces the incidence and duration of delirium and lowers the number of lasting cognitive deficits relevant to daily living after hospital discharge.
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13
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Barnett S, Hellmann F, Parke E, Makin G, Tweddle DA, Osborne C, Hempel G, Veal GJ. Vincristine dosing, drug exposure and therapeutic drug monitoring in neonate and infant cancer patients. Eur J Cancer 2021; 164:127-136. [PMID: 34657763 PMCID: PMC8914346 DOI: 10.1016/j.ejca.2021.09.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/02/2021] [Accepted: 09/16/2021] [Indexed: 01/12/2023]
Abstract
Background The anticancer drug vincristine is associated with potentially dose-limiting side-effects, including neurotoxicity and myelosuppression. However, there currently exists a lack of published clinical pharmacology data relating to its use in neonate and infant patients. We report a study investigating vincristine dosing and drug exposure, alongside the feasibility and impact of a therapeutic drug monitoring treatment approach, in this challenging patient population. Patients and methods Vincristine pharmacokinetic data from a total of 57 childhood cancer patients, including 26 neonates and infants, were used to characterise a population pharmacokinetic model. Vincristine was administered at doses of 0.02–0.05 mg/kg or 0.75–1.5 mg/m2 in neonates and infants aged <1 year or ≤12 kg and doses of 1.5 mg/m2 in older children. Results A two-compartment model provided the best fit for the population analysis. There was no significant difference in vincristine clearance normalised for body surface area between neonates/infants and older children. Lower doses administered to neonates and infants resulted in significantly lower drug exposures (area under the curve [AUC]), compared with older children (p = 0.047). Vincristine doses of <0.05 mg/kg in neonates and infants resulted in significantly lower AUC values than observed in those receiving doses of ≥0.05 mg/kg (p ≤ 0.0001). Therapeutic drug monitoring was shown to be feasible, effective and well tolerated in neonates and infants experiencing suboptimal drug exposures. Conclusion Doses of <0.05 mg/kg should not be used in neonate and infant patients because of a high risk of patients experiencing potentially suboptimal drug exposures. Therapeutic drug monitoring approaches in neonates and infants are supported by the data generated, with a proposed target therapeutic window of 50–100 μg/l∗h. Vincristine dosing and drug exposure was investigated in neonates and infants. Vincristine concentrations were quantified in 210 plasma samples from 57 children. Lower drug exposures were observed in infants and neonates compared with older children. Therapeutic drug monitoring can be used to avoid suboptimal vincristine drug exposures. Vincristine dosing guidance is provided for treatment of neonate and infant patients.
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Affiliation(s)
- Shelby Barnett
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
| | - Farina Hellmann
- Department of Pharmaceutical and Medical Chemistry, University of Münster, Münster, Germany
| | - Elizabeth Parke
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
| | - Guy Makin
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Royal Manchester Children's Hospital, Manchester, UK
| | - Deborah A Tweddle
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK; Great North Children's Hospital, Newcastle, UK
| | - Caroline Osborne
- Pharmacy Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, University of Münster, Münster, Germany
| | - Gareth J Veal
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK.
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14
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Waltering I, Schwalbe O, Hempel G. Identification of factors for a successful implementation of medication reviews in community pharmacies: Using Positive Deviance in pharmaceutical care. Int J Clin Pharm 2021; 44:79-89. [PMID: 34357475 PMCID: PMC8866257 DOI: 10.1007/s11096-021-01315-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 07/28/2021] [Indexed: 12/04/2022]
Abstract
Background Pharmacists in community pharmacies worldwide successfully conduct an increasing number of medication reviews (MR). Since June 2012 MR are incorporated in the German ordinance on the operation of pharmacies as pharmaceutical service. In November 2014, a German guideline for MR was established. Different teaching programmes for MR were implemented since. Despite these favorable conditions, only few pharmacies conduct MR regularly. Objective: Identification of factors necessary for a successful implementation of MR in community pharmacies. Setting: Community pharmacies located in the area of the Pharmacists’ Chamber Westphalia-Lippe (Part of Northrhine-Westphalia, Germany). Method: Following a Positive-Deviance approach, telephone interviews were conducted in community pharmacies with pharmacy-owners, MR-trained employed pharmacists, and technicians. Data evaluation was performed using qualitative content analysis. Main outcome results: Successful strategies for implementing MR in community pharmacies. Results: Forty-four interviews were conducted and analysed. Thirty-three success factors were identified. Data analysis revealed two groups of success-factors important for implementation of MR; organisational (n = 25) and individual factors (n = 8). Relevant organisational success-factor were involvement of the entire team with active involvement of technicians, documentation of results in the pharmacy software and training in patient-identification and communication. Restructuring of workflows increased time-periods for MR. Important individual success-factors were: motivation and identification with the service, routine in execution to enhance self-esteem, and specialisation in pharmacotherapy of particular diseases. Pharmacy-owners play a pivotal role as motivators. Professional healthcare attitude, exhibited in daily routine, leads to increased acceptance by patients and practitioners and thus increases implementation-rates considerably. Conclusion: We were able to define strategies for successful implementation of MR in community pharmacies.
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Affiliation(s)
- Isabell Waltering
- Institute of Pharmaceutical and Medicinal Chemistry, Clinical Pharmacy, Westfaelische Wilhelms-University Muenster, Corrensstrasse 48, 48149, Muenster, Germany.
| | - Oliver Schwalbe
- Department of Education and Training, Pharmacists' Chamber of Westphalia-Lippe, Bismarckallee 25, 48151, Muenster, Germany
| | - Georg Hempel
- Institute of Pharmaceutical and Medicinal Chemistry, Clinical Pharmacy, Westfaelische Wilhelms-University Muenster, Corrensstrasse 48, 48149, Muenster, Germany
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15
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Weissenbacher A, Bolz R, Zimmermann A, Donaubauer B, Stehr SN, Hempel G. [Mentoring and workplace-based assessments for final year medical students : An effective way to increase satisfaction and competence?]. Anaesthesist 2021; 70:486-496. [PMID: 33315142 PMCID: PMC8189941 DOI: 10.1007/s00101-020-00902-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 08/30/2020] [Accepted: 11/18/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The final year of medical training in Germany is one of the least structured and standardized years of medical school. Medical students often complain about a lack of guidance, supervision and feedback. They are mostly asked to perform delegable nonmedical tasks even though student experiences in this period critically determine future decisions for certain medical specialties. Consequently, right from the beginning many young professionals feel overburdened especially by the time pressure of everyday clinical practice. The planned amendment of the medical licensing regulations will make competence-based training even more important. This article therefore aims to examine the extent to which a mentoring-based curriculum with workplace-based examinations during the final year of medical studies can make a valuable contribution to this. METHODS After a needs assessment (structured literature search, results evaluation and focus groups with both students and medical specialists), a mentoring-based curriculum for final year medical students was developed following the Kern cycle. In 2 work sessions 10 discipline-specific competencies for the fields of anesthesiology, critical care, emergency and pain medicine were established and prioritized, which had to be mastered by every student independently at the end of the training period. Assessment of these competencies was performed on a regular basis by trained mentors in the form of workplace-based assessments (mini-clinical evaluation exercise, mini-CEX, direct observation of procedural skills, DOPS). Multiperspective evaluation was and is the foundation of continuous program development. By September 2019 a total of 40 students had completed the modified curriculum and were subsequently interviewed online about various aspects of the tertial. RESULTS The response rate to the survey was 80% (n = 32). The gender ratio was balanced (male = 50%, female = 50%). Prioritization and assessment of 10 competencies by trained mentors enabled a focused, demand-driven and high-quality training of final year medical students. Surveyed students found the section mentoring and feedback to be very positive and it supported their learning success (grade 1.5). Despite firmly established feedback structures, in retrospect almost half (51.6%) wanted more structured feedback. Workplace-based assessments were mostly previously unknown (64.6%) but were experienced as helpful and meaningful (76.7%). Students felt confident and prepared for the final state examination (81.3%) and their career start (71.0%) after being part of the program. These findings were accompanied by a high level of satisfaction (grade 1.7) as well as a high recommendation rate for this institution (as a training program for final year medical students and as a career start for residents, both with 93.7%). Thus, the good evaluation results of the department before the start of the project could again be slightly improved. CONCLUSION A demand-driven, mentoring-based curriculum with integrated workplace-based assessments not only led to high overall student satisfaction but also promoted the quality of teaching in an effective and resource-saving way. Mentoring promotes learning success mainly through feedback and individual learning support and also supports the communicative and social skills of students and mentors alike.
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Affiliation(s)
- A Weissenbacher
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
| | - R Bolz
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
| | - A Zimmermann
- Lernklinik Leipzig - Skills- und Simulationszentrum, Universität Leipzig, Leipzig, Deutschland
| | - B Donaubauer
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
| | - S N Stehr
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
| | - G Hempel
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland.
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16
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Spiegler V, Greiffer L, Jacobtorweihen J, Asase A, Lanvers-Kaminsky C, Hempel G, Agyare C, Hensel A. In vitro screening of plant extracts traditionally used as cancer remedies in Ghana - 15-Hydroxyangustilobine A as the active principle in Alstonia boonei leaves. J Ethnopharmacol 2021; 265:113359. [PMID: 32891813 DOI: 10.1016/j.jep.2020.113359] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/21/2020] [Accepted: 08/29/2020] [Indexed: 06/11/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Cancer represents a major health burden and drain on the global healthcare systems. Traditional African medicine widely use a variety of plant species for treatment of different kinds of cancer. A previous systematic survey by traditional healers in the Ashanti region of Ghana revealed a good overview on the plant species and herbal materials used for the different types of cancer. AIMS OF THE STUDY The following study aimed to investigate 18 herbal materials from 10 plant species based on the cancer survey in Ghana regarding potential cytotoxicity against different cancer cell lines under in vitro conditions followed by subsequent bioassay-guided fractionation towards the active principle. MATERIALS AND METHODS Ethanol-water (1:1) extracts were tested (1-100 μg/mL) against a panel of cancer cell lines according to their respective traditional use. Selected extracts with relevant cytotoxicity in this screening were also tested against common pediatric malignancies (leukemias (HL-60, REH) and Ewing sarcoma (RD-ES and CADO-ES1)). Bioassay-guided fractionation of the hydroalcoholic extract from Alstonia boonei was performed by liquid-liquid chromatography and preparative HPLC. Preliminary mechanistic studies on the mode of action were performed by flow cytometric cell cycle analysis as well as apoptosis and necrosis staining. RESULTS Screening of plant extracts revealed relevant cytotoxicity against all tested cancer cell lines for Alstonia boonei leaves and stem of Paulinia pinnata. The A. boonei extract was additionally found to be active against common pediatric tumor types (leukemias and Ewing sarcoma). Bioassay-guided fractionation of the A. boonei extract revealed the presence of 15-hydroxyangustilobine A 1 as the active principle (IC50 26 μM against MCF-7 cells). This is the first report of this compound in A. boonei. 1 was shown to lead to cell cycle arrest in the G2/M-phase (MCF-7 cells), triggering cells at least partially into apoptosis. CONCLUSION In summary, an appreciable in vitro activity was revealed for the leaf extract from A. boonei and the isolated vallesamine type indole alkaloid 1, which has to be investigated in future studies towards a potential clinical use.
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Affiliation(s)
- Verena Spiegler
- University of Münster, Institute for Pharmaceutical Biology and Phytochemistry, Corrensstrasse 48, D-48149, Münster, Germany.
| | - Luise Greiffer
- University of Münster, Institute for Pharmaceutical Biology and Phytochemistry, Corrensstrasse 48, D-48149, Münster, Germany
| | - Joshua Jacobtorweihen
- University of Münster, Institute for Pharmaceutical Biology and Phytochemistry, Corrensstrasse 48, D-48149, Münster, Germany
| | - Alex Asase
- Department of Plant and Environmental Biology, University of Ghana, Legon, Accra, Ghana
| | - Claudia Lanvers-Kaminsky
- University Children's Hospital Münster - Pediatric Hematology and Oncology, Albert Schweitzer-Campus 1A1, University Hospital Münster, Germany
| | - Georg Hempel
- University of Münster, Institute for Pharmaceutical and Medicinal Chemistry - Clinical Pharmacy, Corrensstrasse 48, D-48149, Münster, Germany
| | - Christian Agyare
- Department of Pharmaceutics, Faculty of Pharmacy and Pharmaceutical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Andreas Hensel
- University of Münster, Institute for Pharmaceutical Biology and Phytochemistry, Corrensstrasse 48, D-48149, Münster, Germany
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17
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Jalusic KO, Hempel G, Arnemann PH, Spiekermann C, Kampmeier TG, Ertmer C, Gastine S, Hessler M. Population pharmacokinetics of vancomycin in patients with external ventricular drain-associated ventriculitis. Br J Clin Pharmacol 2020; 87:2502-2510. [PMID: 33202067 DOI: 10.1111/bcp.14657] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 07/15/2020] [Revised: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To determine the distribution of vancomycin into the cerebrospinal fluid (CSF) in patients with external ventricular drain (EVD)-associated ventriculitis, the pharmacokinetics of vancomycin were evaluated and covariate relationships explored. METHODS For the population pharmacokinetic model patients were recruited in a neurocritical care unit at the University Hospital of Muenster in the period between January 2014 and June 2015. All patients had a clinical evidence of EVD-associated ventriculitis. Population pharmacokinetic analysis of vancomycin was performed using NONMEM. RESULTS A total of 184 blood and 133 CSF samples were collected from 29 patients. The final population pharmacokinetic model is a three-compartment model with linear elimination. Creatinine clearance (ClCr ) and CSF-lactate were detected as significant covariates, showing that the total vancomycin plasma clearance (Cl) depends on ClCr and furthermore the clearance (Cldif ) between the central and CSF compartment correlates with CSF lactate concentration. Based on the final model, the following values were estimated by NONMEM: Cl = 5.15 L/h, Q (intercompartmental clearance) = 3.31 L/h, Cldif = 0.0031 L/h, Vcentral = 42.1 L, VCSF = 0.32 L and the value of Vperipheral was fixed to 86.2 L. With the developed pharmacokinetic model, area under the curve (AUC) values as well as CSF trough levels were simulated. CONCLUSION Based on our analysis, the dosing of vancomycin should be referred to the degree of inflammation (derived from the CSF lactate concentration) and renal function (derived from ClCr ).
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Affiliation(s)
- Kris Oliver Jalusic
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany.,Institute of Epidemiology and Social Medicine, Faculty of Medicine, University of Muenster, Muenster, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany
| | - Philip-Helge Arnemann
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Christina Spiekermann
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Tim-Gerald Kampmeier
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Christian Ertmer
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Silke Gastine
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany.,Infection, Immunity & Inflammation Research & Teaching Department, GOS Institute of Child Health, University College London, London, UK
| | - Michael Hessler
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
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18
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Khalil A, Würthwein G, Golitsch J, Hempel G, Fobker M, Gerss J, Möricke A, Zimmermann M, Smisek P, Zucchetti M, Nath C, Attarbaschi A, Von Stackelberg A, Gökbuget N, Rizzari C, Conter V, Schrappe M, Boos J, Lanvers-Kaminsky C. Pre-existing antibodies against polyethylene glycol reduce asparaginase activities on first administration of pegylated E. coli asparaginase in children with acute lymphocytic leukemia. Haematologica 2020; 107:49-57. [PMID: 33299233 PMCID: PMC8719085 DOI: 10.3324/haematol.2020.258525] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Indexed: 11/09/2022] Open
Abstract
Antibodies against polyethylene glycol (PEG) in healthy subjects raise concerns about the efficacy of pegylated drugs. We evaluated the prevalence of antibodies against PEG among patients with acute lymphoblastic leukemia (ALL) prior to and/or immediately after their first dose of pegylated E.coli asparaginase (PEG-ASNase). Serum samples of 701 children, 673 with primary ALL, 28 with relapsed ALL, and 188 adults with primary ALL were analyzed for anti-PEG IgG and IgM. Measurements in 58 healthy infants served as reference to define cut-points for antibody-positive and -negative samples. Anti-PEG antibodies were detected in ALL patients prior the first PEG-ASNase with a prevalence of 13.9% (anti-PEG IgG) and 29.1% (anti-PEG IgM). After administration of PEG-ASNase the prevalence of anti-PEG antibodies decreased to 4.2% for anti-PEG IgG and to 4.5% for anti-PEG IgM. Pre-existing anti-PEG antibodies did not inhibit PEG-ASNase activity but significantly reduced PEGASNase activity levels in a concentration dependent manner. Although pre-existing anti-PEG antibodies did not boost, pre-existing anti-PEG IgG were significantly associated with firstexposure hypersensitivity reactions (CTCAE grade 2) (p
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Affiliation(s)
- Alaeddin Khalil
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster
| | - Gudrun Würthwein
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster
| | - Jana Golitsch
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster
| | - Manfred Fobker
- Center of Laboratory Medicine, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University of Muenster
| | - Anja Möricke
- Department of Pediatrics, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel
| | - Martin Zimmermann
- Department of Pediatric Hematology and Oncology, Medical School Hannover
| | - Petr Smisek
- Department of Pediatric Hematology and Oncology, University Hospital Motol, Praha, Czech Republic
| | - Massimo Zucchetti
- Laboratory of Cancer Pharmacology, Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan
| | - Christa Nath
- Departments of Biochemistry and Oncology, The Children's Hospital at Westmead, Sydney Pharmacy School, University of Sydney, Sydney
| | - Andishe Attarbaschi
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna
| | - Arend Von Stackelberg
- Departments of Pediatric Oncology/Hematology and of General Pediatrics, Charité - University Medicine Berlin, Berlin
| | | | - Carmelo Rizzari
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, ASST-Monza, Monza
| | - Valentino Conter
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, ASST-Monza, Monza
| | - Martin Schrappe
- Department of Pediatrics, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel
| | - Joachim Boos
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster
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19
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Dellinger JK, Pitzer S, Schaffler-Schaden D, Schreier MM, Fährmann LS, Hempel G, Likar R, Osterbrink J, Flamm M. Improving medication appropriateness in nursing homes via structured interprofessional medication-review supported by health information technology: a non-randomized controlled study. BMC Geriatr 2020; 20:506. [PMID: 33243145 PMCID: PMC7690110 DOI: 10.1186/s12877-020-01895-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 11/12/2020] [Indexed: 11/10/2022] Open
Abstract
Background In nursing home residents (NHRs), polypharmacy is widespread, accompanied by elevated risks of medication related complications. Managing medication in NHRs is a priority, but prone to several challenges, including interprofessional cooperation. Against this background, we implemented and tested an interprofessional intervention aimed to improve medication appropriateness for NHRs. Methods A non-randomized controlled study (SiMbA; “Sicherheit der Medikamentherapie bei AltenheimbewohnerInnen”, Safety of medication therapy in NHRs) was conducted in six nursing homes in Austria (2016–2018). Educational training, introduction of tailored health information technology (HIT) and a therapy check process were combined in an intervention aimed at healthcare professionals. Medication appropriateness was assessed using the Medication Appropriateness Index (MAI). Data was collected before (t0), during (t1, month 12) and after (t2, month 18) intervention via self-administered assessments and electronic health records. Results We included 6 NHs, 17 GPs (52.94% female) and 240 NHRs (68.75% female; mean age 85.0). Data of 159 NHRs could be included in the analysis. Mean MAI-change was − 3.35 (IG) vs. − 1.45 (CG). In the subgroup of NHRs with mean MAI ≥23, MAI-change was − 10.31 (IG) vs. −3.52 (CG). The intervention was a significant predictor of improvement in MAI when controlled for in a multivariable regression model. Conclusions Improvement of medication appropriateness was clearest in residents with inappropriate baseline MAI-scores. This improvement was independent of variances in certain covariates between the intervention and the control group. We conclude that our intervention is a feasible approach to improve NHRs’ medication appropriateness. Trial registration DRKS Data Management, ID: DRKS00012246. Registered 16.05.2017 – Retrospectively registered.
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Affiliation(s)
| | - Stefan Pitzer
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Dagmar Schaffler-Schaden
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | - Laura Sandre Fährmann
- Institute of Pharmaceutic and Medical Chemistry, University of Münster, Münster, Germany
| | - Georg Hempel
- Institute of Pharmaceutic and Medical Chemistry, University of Münster, Münster, Germany
| | - Rudolf Likar
- Klinikum Klagenfurt am Wörthersee, Klagenfurt am Wörthersee, Austria
| | - Jürgen Osterbrink
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Maria Flamm
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria
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Rimmler C, Lanckohr C, Mittrup M, Welp H, Würthwein G, Horn D, Fobker M, Ellger B, Hempel G. Population pharmacokinetic evaluation of cefuroxime in perioperative antibiotic prophylaxis during and after cardiopulmonary bypass. Br J Clin Pharmacol 2020; 87:1486-1498. [PMID: 32959896 DOI: 10.1111/bcp.14556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 08/30/2020] [Accepted: 09/09/2020] [Indexed: 11/27/2022] Open
Abstract
AIMS The purpose of this study was to explore pharmacokinetic and pharmacodynamic aspects of a contemporary dosing scheme of cefuroxime as perioperative prophylaxis in cardiac surgery using cardiopulmonary bypass (CPB). METHODS Cefuroxime plasma concentrations were measured in 23 patients. A 1.5-g dose of cefuroxime was administered at start of surgery and CPB, followed by 3 additional doses every 6 hours postoperative. Drug levels were used to build a population pharmacokinetic model. Target attainment for Staphylococcus aureus (2-8 mg/L) and Escherichia coli (8-32 mg/L) were evaluated and dosing strategies for optimization were investigated. RESULTS A dosing scheme of 1.5 g cefuroxime preoperatively with a repetition at start of CPB achieves plasma unbound concentrations of 8 mg/L in almost all patients during surgery. The second administration is critical to provide this level of coverage. Simulations indicate that higher unbound concentrations up to 32 mg/L are reached by a continuous infusion rate of 1 g/h after a bolus of 1 g. In the postoperative phase, most patients do not reach unbound concentrations above 2 mg/L. To improve target attainment up to 8 mg/L, the continuous application of cefuroxime with infusion rates of 0.125-0.25 g/h is simulated and shown to be an alternative to bolus dosing. CONCLUSION Dosing recommendations for cefuroxime as perioperative antibiotic prophylaxis in cardiac surgery are sufficient to reach plasma unbound concentration to cover S. aureus during the operation. Target attainment is not achieved in the postoperative period. Continuous infusion of cefuroxime may optimize target attainment.
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Affiliation(s)
- Christer Rimmler
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
| | - Christian Lanckohr
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Miriam Mittrup
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Henryk Welp
- Department of Cardiac Surgery, University Hospital Muenster, Muenster, Germany
| | - Gudrun Würthwein
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
| | - Dagmar Horn
- Department of Pharmacy, University Hospital of Muenster, Muenster, Germany
| | - Manfred Fobker
- Center for Laboratory Medicine, University Hospital Muenster, Muenster, Germany
| | - Björn Ellger
- Department of Anesthesiology, Intensive Care and Pain Medicine, Klinikum Westfalen, Dortmund, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
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21
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Zubiaur P, Kneller LA, Ochoa D, Mejía G, Saiz-Rodríguez M, Borobia AM, Koller D, García IG, Navares-Gómez M, Hempel G, Abad-Santos F. Evaluation of Voriconazole CYP2C19 Phenotype-Guided Dose Adjustments by Physiologically Based Pharmacokinetic Modeling. Clin Pharmacokinet 2020; 60:261-270. [PMID: 32939689 DOI: 10.1007/s40262-020-00941-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Controversy exists regarding dose adjustment in patients treated with voriconazole due to the severity of the infections for which it is prescribed. The Dutch Pharmacogenetics Working Group (DPWG) recommends a 50% dose increase or decrease for cytochrome P450 (CYP) 2C19 ultrarapid (UM) or poor (PM) metabolizers, respectively. In contrast, for the previous phenotypes, the Clinical Pharmacogenetics Implementation Consortium (CPIC) voriconazole guideline only recommends a change of treatment. Based on observed data from single-dose bioequivalence studies and steady-state observed concentrations, we aimed to investigate voriconazole dose adjustments by means of physiologically based pharmacokinetic (PBPK) modeling. METHODS PBPK modeling was used to optimize voriconazole single-dose models for each CYP2C19 phenotype, which were extrapolated to steady state and evaluated for concordance with the therapeutic range of voriconazole. Based on optimized models, dose adjustments were evaluated for better adjustment to the therapeutic range. RESULTS Our models suggest that the standard dose may only be appropriate for normal metabolizers (NM), although they would benefit from a 50-100% loading dose increase. Intermediate metabolizers (IMs) and PMs required a daily dose reduction of 50 and 75%, respectively. Rapid metabolizers (RMs) and UMs required a daily dose increase of 100% and 300%, respectively. CONCLUSION The prescription of voriconazole in clinical practice should be personalized according to the CYP2C19 phenotype, followed by therapeutic drug monitoring of plasma concentrations to guide dose adjustment.
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Affiliation(s)
- Pablo Zubiaur
- Clinical Pharmacology Department, La Princesa University Hospital, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), C/Diego de León, 62, 28006, Madrid, Spain
- UICEC Hospital Universitario de La Princesa, Plataforma SCReN (Spanish Clinical Research Network), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
| | - Lisa A Kneller
- Institute of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Münster, Münster, Germany
| | - Dolores Ochoa
- Clinical Pharmacology Department, La Princesa University Hospital, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), C/Diego de León, 62, 28006, Madrid, Spain
- UICEC Hospital Universitario de La Princesa, Plataforma SCReN (Spanish Clinical Research Network), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
| | - Gina Mejía
- Clinical Pharmacology Department, La Princesa University Hospital, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), C/Diego de León, 62, 28006, Madrid, Spain
- UICEC Hospital Universitario de La Princesa, Plataforma SCReN (Spanish Clinical Research Network), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
| | - Miriam Saiz-Rodríguez
- Clinical Pharmacology Department, La Princesa University Hospital, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), C/Diego de León, 62, 28006, Madrid, Spain
- Research Unit, Fundación Burgos Por La Investigación de La Salud, Hospital Universitario de Burgos, Burgos, Spain
| | - Alberto M Borobia
- School of Medicine, Clinical Pharmacology Department, La Paz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Dora Koller
- Clinical Pharmacology Department, La Princesa University Hospital, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), C/Diego de León, 62, 28006, Madrid, Spain
| | - Irene García García
- School of Medicine, Clinical Pharmacology Department, La Paz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Marcos Navares-Gómez
- Clinical Pharmacology Department, La Princesa University Hospital, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), C/Diego de León, 62, 28006, Madrid, Spain
| | - Georg Hempel
- Institute of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Münster, Münster, Germany
| | - Francisco Abad-Santos
- Clinical Pharmacology Department, La Princesa University Hospital, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), C/Diego de León, 62, 28006, Madrid, Spain.
- UICEC Hospital Universitario de La Princesa, Plataforma SCReN (Spanish Clinical Research Network), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain.
- School of Medicine, Clinical Pharmacology Department, La Paz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
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22
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Hensel A, Bauer R, Heinrich M, Spiegler V, Kayser O, Hempel G, Kraft K. Challenges at the Time of COVID-19: Opportunities and Innovations in Antivirals from Nature. Planta Med 2020; 86:659-664. [PMID: 32434254 PMCID: PMC7356065 DOI: 10.1055/a-1177-4396] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/05/2020] [Accepted: 05/13/2020] [Indexed: 05/03/2023]
Abstract
As viral infections are an increasing threat to human societies, the need for new therapeutic strategies is becoming even more obvious. As no vaccine is available for COVID-19, the development of directly acting antiviral agents and preventive strategies have to be considered. Nature provides a huge reservoir of anti-infectious compounds, from which we can deduce innovative ideas, therapies, and products. Anti-adhesive natural products interact with the receptor-mediated recognition and early interaction of viruses with the host cells, leading to a reduced internalisation of the virus and reduced infections (e.g., procyanidin-B-2-di-O-gallate against influenza and herpes virus). Lignans like podophyllotoxin and bicyclol show strong antiviral activities against different viruses, and essential oils can directly interact with viral membranes and reduce the host's inflammatory responses (e.g., 1,8-cineol). Echinacea extracts stimulate the immune system, and bioavailable alkamides are key players by interacting with immunomodulating cannabinoid receptors. COVID-19 and SARS-CoV-2 infections have, in part, successfully been treated in China by preparations from traditional Chinese medicine and, while it is too early to draw conclusions, some promising data are available. There is huge potential, but intensified research is needed to develop evidence-based medicines with a clearly defined chemical profile. Intensified research and development, and therefore funding, are needed for exploiting nature's reservoir against viral infections. Combined action for basic research, chemistry, pharmacognosy, virology, and clinical studies, but also supply chain, sustainable sourcing, and economic aspects have to be considered. This review calls for intensified innovative science on natural products for the patients and for a healthier world!
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Affiliation(s)
- Andreas Hensel
- Institute of Pharmaceutical Biology and Phytochemistry, University of Münster, Münster, Germany
| | - Rudolf Bauer
- Institute of Pharmaceutical Sciences, University of Graz, Graz, Austria
| | - Michael Heinrich
- Pharmacognosy and Phytotherapy, UCL School of Pharmacy, London, UK
| | - Verena Spiegler
- Institute of Pharmaceutical Biology and Phytochemistry, University of Münster, Münster, Germany
| | - Oliver Kayser
- Technical Biochemistry, TU Dortmund University, Dortmund, Germany
| | - Georg Hempel
- Institute of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Münster, Münster, Germany
| | - Karin Kraft
- University Medicine Rostock, Chair of Complementary Medicine, Rostock, Germany
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23
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Waltering I, Scheppe S, Kurth V, Hempel G, Jaehde U. [Quality indicators for medication reviews in community pharmacies]. Z Evid Fortbild Qual Gesundhwes 2020; 153-154:44-53. [PMID: 32482507 DOI: 10.1016/j.zefq.2020.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/27/2020] [Accepted: 03/28/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Medication reviews conducted in community pharmacies are a measure to reduce drug-related problems and to increase medication safety. Since 2014, a guideline for medication reviews has been available in Germany. However, the sole existence of a guideline does not guarantee a high quality of this novel service. Quality indicators can contribute to ensure appropriate quality standards. So far, no such indicators have been available in Germany. This project therefore aims at developing suitable indicators to assess the quality of medication reviews type 2a in community pharmacies. METHODS Based on a literature review, potential quality indicators were generated. Using a two-step Delphi method applying the RUMBA criteria, a set of structure, process, and outcome indicators was developed. RESULTS The literature review identified 23 potential indicators. Nine further indicators derived from the guideline for medication reviews and expert opinion were amended. After discussion in a focus group, the 32 indicators were reduced to a preliminary set of twelve indicators used for the Delphi survey. Following two Delphi rounds, a final indicator set consisting of three structure indicators, one process indicator and two outcome indicators, was generated. DISCUSSION The set of quality indicators is potentially suitable for measuring the quality of medication reviews in German community pharmacies. In the next step, these indicators need to be evaluated with regard to their validity and applicability in daily routine.
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Affiliation(s)
- Isabel Waltering
- Institut für Pharmazeutische und Medizinische Chemie, Westfälische Wilhelms-Universität Münster, Münster, Deutschland.
| | - Sophie Scheppe
- Pharmazeutisches Institut, Abteilung Klinische Pharmazie, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Deutschland
| | - Verena Kurth
- Pharmazeutisches Institut, Abteilung Klinische Pharmazie, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Deutschland
| | - Georg Hempel
- Institut für Pharmazeutische und Medizinische Chemie, Westfälische Wilhelms-Universität Münster, Münster, Deutschland
| | - Ulrich Jaehde
- Pharmazeutisches Institut, Abteilung Klinische Pharmazie, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Deutschland
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24
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Siebel C, Würthwein G, Lanvers-Kaminsky C, André N, Berthold F, Castelli I, Chastagner P, Doz F, English M, Escherich G, Frühwald MC, Graf N, Groll AH, Ruggiero A, Hempel G, Boos J. Can we optimise doxorubicin treatment regimens for children with cancer? Pharmacokinetic simulations and a Delphi consensus procedure. BMC Pharmacol Toxicol 2020; 21:37. [PMID: 32466789 PMCID: PMC7254632 DOI: 10.1186/s40360-020-00417-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 05/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite its cardiotoxicity doxorubicin is widely used for the treatment of paediatric malignancies. Current treatment regimens appear to be suboptimal as treatment strategies vary and do not follow a clear pharmacological rationale. Standardisation of dosing strategies in particular for infants and younger children is required but is hampered by scarcely defined exposure-response relationships. The aim is to provide a rational dosing concept allowing for a reduction of variability in systemic therapy intensity and subsequently unforeseen side effects. METHODS Doxorubicin plasma concentrations in paediatric cancer patients were simulated for different treatment schedules using a population pharmacokinetic model which considers age-dependent differences in doxorubicin clearance. Overall drug exposure and peak concentrations were assessed. Simulation results were used to support a three round Delphi consensus procedure with the aim to clarify the pharmacological goals of doxorubicin dosing in young children. A group of 28 experts representing paediatric trial groups and clinical centres were invited to participate in this process. RESULTS Pharmacokinetic simulations illustrated the substantial differences in therapy intensity associated with current dosing strategies. Consensus among the panel members was obtained on a standardised a priori dose adaptation that individualises doxorubicin doses based on age and body surface area targeting uniform drug exposure across children treated with the same protocol. Further, a reduction of peak concentrations in very young children by prolonged infusion was recommended. CONCLUSIONS An approach to standardise current dose modification schemes in young children is proposed. The consented concept takes individual pharmacokinetic characteristics into account and involves adaptation of both the dose and the infusion duration potentially improving the safety of doxorubicin administration.
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Affiliation(s)
- Christian Siebel
- Department of Paediatric Haematology and Oncology, University Children's Hospital Muenster, Albert-Schweitzer-Campus 1, A1, 48149, Muenster, Germany
| | - Gudrun Würthwein
- Department of Paediatric Haematology and Oncology, University Children's Hospital Muenster, Albert-Schweitzer-Campus 1, A1, 48149, Muenster, Germany
| | - Claudia Lanvers-Kaminsky
- Department of Paediatric Haematology and Oncology, University Children's Hospital Muenster, Albert-Schweitzer-Campus 1, A1, 48149, Muenster, Germany
| | - Nicolas André
- Department of Paediatric Haematology-Oncology, La Timone University Hospital of Marseille, Marseille, France
| | - Frank Berthold
- Department of Paediatric Oncology and Haematology, University Children's Hospital Cologne, Cologne, Germany
| | - Ilaria Castelli
- Department of Paediatrics, University of Milano-Bicocca, Hospital S Gerardo, Monza, Italy
| | - Pascal Chastagner
- Department of Paediatric Oncology, CHRU Nancy, Vandoeuvre Les Nancy, France
| | - François Doz
- Oncology Center SIREDO, Institut Curie and University Paris Descartes, Paris, France
| | - Martin English
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Gabriele Escherich
- University Medical Centre Eppendorf, Clinic of Paediatric Haematology and Oncology, Hamburg, Germany
| | - Michael C Frühwald
- Swabian Children's Cancer Centre, University Children's Hospital Augsburg, Augsburg, Germany
| | - Norbert Graf
- Department of Paediatric Haematology/Oncology, Saarland University, Homburg/Saar, Germany
| | - Andreas H Groll
- Department of Paediatric Haematology and Oncology, University Children's Hospital Muenster, Albert-Schweitzer-Campus 1, A1, 48149, Muenster, Germany
| | - Antonio Ruggiero
- Division of Paediatric Oncology, Catholic University of Rome, Rome, Italy
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry - Clinical Pharmacy, University of Muenster, Muenster, Germany
| | - Joachim Boos
- Department of Paediatric Haematology and Oncology, University Children's Hospital Muenster, Albert-Schweitzer-Campus 1, A1, 48149, Muenster, Germany.
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25
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Berning P, Hennemann C, Tulotta C, Schaefer C, Lechtape B, Hotfilder M, El Gourari Y, Jürgens H, Snaar-Jagalska E, Hempel G, Dirksen U, Potratz J. The Receptor Tyrosine Kinase RON and Its Isoforms as Therapeutic Targets in Ewing Sarcoma. Cancers (Basel) 2020; 12:cancers12040904. [PMID: 32272784 PMCID: PMC7226494 DOI: 10.3390/cancers12040904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 03/29/2020] [Accepted: 04/04/2020] [Indexed: 11/16/2022] Open
Abstract
The receptor tyrosine kinase (RTK) RON is linked to an aggressive metastatic phenotype of carcinomas. While gaining interest as a therapeutic target, RON remains unstudied in sarcomas. In Ewing sarcoma, we identified RON among RTKs conferring resistance to insulin-like growth factor-1 receptor (IGF1R) targeting. Therefore, we explored RON in pediatric sarcoma cell lines and an embryonic Tg(kdrl:mCherry) zebrafish model, using an shRNA-based approach. To examine RON–IGF1R crosstalk, we employed the clinical-grade monoclonal antibody IMC-RON8, alone and together with the IGF1R-antibody IMC-A12. RON silencing demonstrated functions in vitro and in vivo, particularly within micrometastatic cellular capacities. Signaling studies revealed a unidirectional IGF1-mediated cross-activation of RON. Yet, IMC-A12 failed to sensitize cells to IMC-RON8, suggesting additional mechanisms of RON activation. Here, RT-PCR revealed that childhood sarcomas express short-form RON, an isoform resistant to antibody-mediated targeting. Interestingly, in contrast to carcinomas, treatment with DNA methyltransferase inhibitor did not diminish but increased short-form RON expression. Thus, this first report supports a role for RON in the metastatic progression of Ewing sarcoma. While principal molecular functions appear transferrable between carcinomas, Ewing sarcoma and possibly more common sarcoma subtypes, RON highlights that specific regulations of cellular networks and isoforms require better understanding to successfully transfer targeting strategies.
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Affiliation(s)
- Philipp Berning
- Department of Medicine A, Hematology, Oncology and Pneumology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Carolin Hennemann
- Department of Pediatric Hematology and Oncology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
- Department of General Pediatrics, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Claudia Tulotta
- Institute of Biology, Leiden University, Gorlaeus Laboratories, Einsteinweg 55, 2333 CC Leiden, The Netherlands
| | - Christiane Schaefer
- Department of Pediatric Hematology and Oncology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Birgit Lechtape
- Department of Pediatric Hematology and Oncology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Marc Hotfilder
- Department of Pediatric Hematology and Oncology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Yassmine El Gourari
- Department of General Pediatrics, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Heribert Jürgens
- Department of Pediatric Hematology and Oncology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Ewa Snaar-Jagalska
- Institute of Biology, Leiden University, Gorlaeus Laboratories, Einsteinweg 55, 2333 CC Leiden, The Netherlands
| | - Georg Hempel
- Institute of Pharmaceutical and Medical Chemistry, Westfälische Wilhelms-Universität Münster, Corrensstraße 48, 48149 Münster, Germany
| | - Uta Dirksen
- Division of Hematology and Oncology, Department of Pediatrics III, West German Cancer Centre, University Hospital Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Jenny Potratz
- Department of Pediatric Hematology and Oncology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
- Department of General Pediatrics, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
- Correspondence:
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Stern M, Giebels M, Fey T, Lübking M, Alferink J, Hempel G. 24 Clinical validation study to derive conversion factors from capillary blood concentration to plasma concentration for venlafaxine and desvenlafaxine. PHARMACOPSYCHIATRY 2020. [DOI: 10.1055/s-0040-1710132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- M Stern
- Institut für Pharmazeutische und Medizinische Chemie – Klinische Pharmazie, Westfälische Wilhelms-Universität
| | - M Giebels
- Gerontopsychiatrie, LWL-Klinik Münster
| | - T Fey
- Gerontopsychiatrie, LWL-Klinik Münster
| | - M Lübking
- Damian-Klinik, Alexianer Münster GmbH
| | | | - G Hempel
- Institut für Pharmazeutische und Medizinische Chemie – Klinische Pharmazie, Westfälische Wilhelms-Universität
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27
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Lücht UR, Geiben AK, Brune S, Scholz WU, Hempel G. 16 Using physiologically based pharmacokinetic (PBPK) modelling and SCHOLZ databank’s MDDI calculator (SDB-MDDI) to predict potential drug-drug interactions (DDI) of psychopharmaceuticals. PHARMACOPSYCHIATRY 2020. [DOI: 10.1055/s-0040-1710124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- UR Lücht
- Department of Pharmaceutical and Medicinal Chemistry Muenster
| | | | | | | | - G Hempel
- Department of Pharmaceutical and Medicinal Chemistry Muenster
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28
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Kneller LA, Hempel G. 14 Physiologically based pharmacokinetic modelling of risperidone and 9-hydroxyrisperidone to determine cytochrome P450 2D6 phenotypes in schizophrenia patients. PHARMACOPSYCHIATRY 2020. [DOI: 10.1055/s-0040-1710122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- LA Kneller
- Institute of Pharmaceutical and Medicinal Chemistry, Clinical Pharmacy, Westfälische Wilhelms-Universität Münster
| | - G Hempel
- Institute of Pharmaceutical and Medicinal Chemistry, Clinical Pharmacy, Westfälische Wilhelms-Universität Münster
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Krisch L, Mahlknecht A, Bauer U, Nestler N, Hempel G, Osterbrink J, Flamm M. The challenge to define a relevant change in medication appropriateness index score in older adults - An approach. Br J Clin Pharmacol 2020; 86:398-399. [PMID: 31930550 PMCID: PMC7015747 DOI: 10.1111/bcp.14167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/25/2019] [Accepted: 10/28/2019] [Indexed: 11/30/2022] Open
Affiliation(s)
- Laura Krisch
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Angelika Mahlknecht
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Ulrike Bauer
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Nadja Nestler
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry - Clinical Pharmacy, Westfaelische Wilhelms-University, Muenster, Germany
| | - Jürgen Osterbrink
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Maria Flamm
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria
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30
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Hempel G. Pharmacotherapy in Children and Adolescents: Oncology. Handb Exp Pharmacol 2020; 261:415-440. [PMID: 31792677 DOI: 10.1007/164_2019_306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Pharmacotherapy in paediatric oncology is a difficult task. It is challenging to determine the optimal dose in children of different age groups. In addition, anticancer drugs display severe side effects reducing the quality of life. Late effects like secondary tumours and cardiotoxicity can be apparent years after treatment and must be taken into account when planning treatment schedules. Classical cytoreducing agents are still of great importance in treating children with leukaemia and solid tumours. In addition, drugs developed by rational drug design (targeted drugs) are a very important part of many treatment protocols, and newer drugs are emerging in several types of cancer. Unfortunately, there is only limited experience with newer drugs in children, because new drugs are mostly developed for adults. Complicated therapy regimens require a solid knowledge of the pharmacology of the drugs applied. This chapter attempts to introduce some pharmacological knowledge for the most important anticancer drugs in children with a focus on side effects and age-specific considerations.
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Affiliation(s)
- Georg Hempel
- Westfälische Wilhelms-Universität Münster, Institut für Pharmazeutische und Medizinische Chemie, Klinische Pharmazie, Münster, Germany.
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Rimmler C, Lanckohr C, Akamp C, Horn D, Fobker M, Wiebe K, Redwan B, Ellger B, Koeck R, Hempel G. Physiologically based pharmacokinetic evaluation of cefuroxime in perioperative antibiotic prophylaxis. Br J Clin Pharmacol 2019; 85:2864-2877. [PMID: 31487057 PMCID: PMC6955413 DOI: 10.1111/bcp.14121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/19/2019] [Accepted: 08/30/2019] [Indexed: 12/18/2022] Open
Abstract
Aims Adequate plasma concentrations of antibiotics during surgery are essential for the prevention of surgical site infections. We examined the pharmacokinetics of 1.5 g cefuroxime administered during induction of anaesthesia with follow‐up doses every 2.5 hours until the end of surgery. We built a physiologically based pharmacokinetic model with the aim to ensure adequate antibiotic plasma concentrations in a heterogeneous population. Methods A physiologically based pharmacokinetic model (PK‐Sim®/MoBi®) was developed to investigate unbound plasma concentrations of cefuroxime. Blood samples from 25 thoracic surgical patients were analysed with high‐performance liquid chromatography. To evaluate optimized dosing regimens, physiologically based pharmacokinetic model simulations were conducted. Results Dosing simulations revealed that a standard dosing regimen of 1.5 g every 2.5 hours reached the pharmacokinetic/pharmacodynamic target for Staphylococcus aureus. However, for Escherichia coli, >50% of the study participants did not reach predefined targets. Effectiveness of cefuroxime against E. coli can be improved by administering a 1.5 g bolus immediately followed by a continuous infusion of 3 g cefuroxime over 3 hours. Conclusion The use of cefuroxime for perioperative antibiotic prophylaxis to prevent staphylococcal surgical site infections appears to be effective with standard dosing of 1.5 g preoperatively and follow‐up doses every 2.5 hours. In contrast, if E. coli is relevant in surgeries, this dosing regimen appears insufficient. With our derived dose recommendations, we provide a solution for this issue.
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Affiliation(s)
- Christer Rimmler
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
| | - Christian Lanckohr
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Ceren Akamp
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Dagmar Horn
- Department of Pharmacy, University Hospital of Muenster, Muenster, Germany
| | - Manfred Fobker
- Center for Laboratory Medicine, University Hospital Muenster, Muenster, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery and Lung Transplantation, University Hospital Muenster, Muenster, Germany
| | - Bassam Redwan
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery and Lung Transplantation, University Hospital Muenster, Muenster, Germany
| | - Bjoern Ellger
- Department of Anesthesiology, Intensive Care and Pain Medicine, Klinikum Westfalen, Dortmund, Germany
| | - Robin Koeck
- Institute of Hygiene, DRK Kliniken Berlin Westend, Berlin, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
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Gastine S, Lanckohr C, Blessou M, Horn D, Fobker M, Bause D, Hempel G, Ellger B. Pharmacokinetics of Micafungin in Critically Ill Patients. Sci Rep 2019; 9:17741. [PMID: 31780687 PMCID: PMC6882900 DOI: 10.1038/s41598-019-53093-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 10/18/2019] [Indexed: 12/12/2022] Open
Abstract
We investigated covariates of pharmacokinetics of micafungin in critically ill patients. After application of micafungin, plasma samples were collected. Non-linear mixed effects modelling (NONMEM 7.3) was used to develop the pharmacokinetic model. Using this model, the adequacy of a fixed 100 mg dosing regimen was evaluated in the study cohort. A two-compartment model with linear elimination was found to describe the obtained data. SOFA score was identified as a significant covariate on both clearance and central volume of distribution, respectively. Patients in highly critical condition, represented by a SOFA above 10 showed a 30.8% lower central volume of distribution than the less critically ill patients. For patients with bilirubin levels above 4 mg/dl, clearance was decreased by 21.1%. Renal replacement therapy (RRT) did not influence micafungin clearance or the volumes of distribution. In a posthoc evaluation of the modeled population, 100 mg micafungin was suitable when assessing the PKPD targets (AUC/MIC) for C. albicans and C. glabrata, with insufficient target attainment for C. parapsilosis. Micafungin pharmacokinetics appear not to be influenced by the status of RRT. A dose of 100 mg micafungin is suitable for infections with C. albicans and C. glabrata in critically ill patients.
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Affiliation(s)
- Silke Gastine
- Institute of Pharmaceutical and Medical Chemistry - Department of Clinical Pharmacy, Westfälische Wilhelms-Universität Münster, Münster, Germany
| | - Christian Lanckohr
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany.
| | - Magalie Blessou
- Institute of Pharmaceutical and Medical Chemistry - Department of Clinical Pharmacy, Westfälische Wilhelms-Universität Münster, Münster, Germany
| | - Dagmar Horn
- Department of Pharmacy, University Hospital Münster, Münster, Germany
| | - Manfred Fobker
- Center for Laboratory Medicine, University Hospital Münster, Münster, Germany
| | - Daniela Bause
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Georg Hempel
- Institute of Pharmaceutical and Medical Chemistry - Department of Clinical Pharmacy, Westfälische Wilhelms-Universität Münster, Münster, Germany
| | - Björn Ellger
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Klinikum Westfalen, Dortmund, Germany
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Jackson RK, Liebich M, Berry P, Errington J, Liu J, Parker C, Moppett J, Samarasinghe S, Hough R, Rowntree C, Goulden NJ, Vora A, Kearns PR, Saha V, Hempel G, Irving JAE, Veal GJ. Impact of dose and duration of therapy on dexamethasone pharmacokinetics in childhood acute lymphoblastic leukaemia-a report from the UKALL 2011 trial. Eur J Cancer 2019; 120:75-85. [PMID: 31499383 DOI: 10.1016/j.ejca.2019.07.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/01/2019] [Accepted: 07/23/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The use of dexamethasone in acute lymphoblastic leukaemia therapy contributes to short- and long-term toxicities. The UKALL 2011 randomised trial investigated whether a more intense dexamethasone dose (10 mg/m2/d x 14d, short vs 6 mg/m2/d x 28d, standard) would lead to a more rapid cytoreduction and reduced adverse effects associated with longer durations of steroids in induction. The impact of dose and duration on dexamethasone pharmacokinetics was investigated. METHODS Blood samples were obtained on one of the first three and last three days of induction dexamethasone dosing at time points up to 8 h after oral administration. Plasma dexamethasone levels were quantified in 1084 plasma samples obtained from 174 children and a population pharmacokinetic model developed. RESULTS Drug exposure varied significantly between patients, with a >12-fold variation in AUC0-12h values and a marked overlap in dexamethasone exposures between dose levels. Intuitively, AUC0-12h was significantly higher with short dosing (10 mg/m2/d), but cumulative exposure was significantly higher with standard dosing over 28 days, after a higher cumulative dose. Concomitant rasburicase administration was associated with a 60% higher dexamethasone clearance. Day 8 bone marrow response was comparable between dosing arms, but those with <5% blast count exhibited a greater mean dexamethasone exposure than those with >5%. No statistical differences were observed between arms in terms of steroid-related toxicity or minimal residual disease at the end of induction. CONCLUSION The potential significance of dexamethasone AUC0-12h on early response and higher cumulative exposure on the standard arm suggest that duration of therapy and exposure may be more important factors than absolute dose from a clinical pharmacology perspective.
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Affiliation(s)
- Rosanna K Jackson
- Northern Institute for Cancer Research, Newcastle University, Newcastle Upon Tyne, UK
| | - Martina Liebich
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Münster, Germany
| | - Philip Berry
- Northern Institute for Cancer Research, Newcastle University, Newcastle Upon Tyne, UK
| | - Julie Errington
- Northern Institute for Cancer Research, Newcastle University, Newcastle Upon Tyne, UK
| | - Jizhong Liu
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | - Catriona Parker
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | - John Moppett
- Department of Paediatric Haematology and Oncology, Bristol Royal Hospital for Children, UK
| | - Sujith Samarasinghe
- Department of Haematology, Great Ormond Street Hospital for Children, London, UK
| | | | | | - Nick J Goulden
- Department of Haematology, Great Ormond Street Hospital for Children, London, UK
| | - Ajay Vora
- Department of Paediatric Haematology, Great Ormond Street Hospital, UK
| | - Pamela R Kearns
- Cancer Research UK Clinical Trials Unit, National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Cancer and Genomic Studies, University of Birmingham, UK
| | - Vaskar Saha
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK; Tata Translational Cancer Research Centre, Tata Medical Center, Kolkata, India
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Münster, Germany
| | - Julie A E Irving
- Northern Institute for Cancer Research, Newcastle University, Newcastle Upon Tyne, UK
| | - Gareth J Veal
- Northern Institute for Cancer Research, Newcastle University, Newcastle Upon Tyne, UK.
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Mahlknecht A, Krisch L, Nestler N, Bauer U, Letz N, Zenz D, Schuler J, Fährmann L, Hempel G, Flamm M, Osterbrink J. Impact of training and structured medication review on medication appropriateness and patient-related outcomes in nursing homes: results from the interventional study InTherAKT. BMC Geriatr 2019; 19:257. [PMID: 31533630 PMCID: PMC6749664 DOI: 10.1186/s12877-019-1263-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 08/29/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Uncoordinated interprofessional communication in nursing homes increases the risk of polypharmacy and inappropriate medication use. This may lead to augmented frequency of adverse drug events, hospitalizations and mortality. The aims of this study were (1) to improve interprofessional communication and medication safety using a combined intervention and thus, (2) to improve medication appropriateness and health-related outcomes of the included residents. METHODS The single-arm interventional study (2014-2017) was conducted in Muenster, Germany and involved healthcare professionals and residents of nursing homes. The intervention consisted of systematic education of participating healthcare professionals and of a structured interprofessional medication review which was performed via an online communication platform. The primary endpoint was assessed using the Medication Appropriateness Index MAI. Secondary endpoints were: cognitive performance, delirium, agitation, mobility, number of drugs, number of severe drug-drug interactions and appropriateness of analgesics. Outcomes were measured before, during and after the intervention. Data were analyzed using descriptive and inference-statistical methods. RESULTS Fourteen general practitioners, 11 pharmacists, 9 nursing homes and 120 residents (n = 83 at all testing times) participated. Overall MAI sum-score decreased significantly over time (mean reduction: -7.1, CI95% -11.4 - - 2.8; median = - 3.0; dCohen = 0.39), especially in cases with baseline sum-score ≥ 24 points (mean reduction: -17.4, CI95% -27.6 - - 7.2; median = - 15.0; dCohen = 0.86). MAI sum-score of analgesics also decreased (dCohen = 0.45). Mean number of severe drug-drug interactions rose slightly over time (dCohen = 0.17). The proportion of residents showing agitated behavior diminished from 83.9 to 67.8%. Remaining secondary outcomes were without substantial change. CONCLUSION Medication appropriateness increased particularly in residents with high baseline MAI sum-scores. Cognitive decline of participating residents was seemingly decelerated when compared with epidemiologic studies. A controlled trial is required to confirm these effects. Interprofessional interaction was structured and performance of medication reviews was facilitated as the online communication platform provided unlimited and consistent access to all relevant and updated information. TRIAL REGISTRATION DRKS Data Management, ID: DRKS00007900 , date of registration: 2015-09-02 (retrospectively registered i.e. 6 weeks after commencement of the first data collection).
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Affiliation(s)
- Angelika Mahlknecht
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria.
| | - Laura Krisch
- Institute of Nursing Science and Practice, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
| | - Nadja Nestler
- Institute of Nursing Science and Practice, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
| | - Ulrike Bauer
- Institute of Nursing Science and Practice, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
| | - Nina Letz
- Institute of Nursing Science and Practice, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
| | - Daniel Zenz
- smart-Q Softwaresysteme GmbH, BioMedizinZentrum Bochum, Universitätsstraße 136, 44799, Bochum, Germany
| | - Jochen Schuler
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
| | - Laura Fährmann
- Department of Pharmaceutical and Medical Chemistry - Clinical Pharmacy, Westfaelische Wilhelms-University, Corrensstraße 48, 48149, Muenster, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry - Clinical Pharmacy, Westfaelische Wilhelms-University, Corrensstraße 48, 48149, Muenster, Germany
| | - Maria Flamm
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
| | - Jürgen Osterbrink
- Institute of Nursing Science and Practice, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
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Dallmann A, Ince I, Coboeken K, Eissing T, Hempel G. A Physiologically Based Pharmacokinetic Model for Pregnant Women to Predict the Pharmacokinetics of Drugs Metabolized Via Several Enzymatic Pathways. Clin Pharmacokinet 2019; 57:749-768. [PMID: 28924743 DOI: 10.1007/s40262-017-0594-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Physiologically based pharmacokinetic modeling is considered a valuable tool for predicting pharmacokinetic changes in pregnancy to subsequently guide in-vivo pharmacokinetic trials in pregnant women. The objective of this study was to extend and verify a previously developed physiologically based pharmacokinetic model for pregnant women for the prediction of pharmacokinetics of drugs metabolized via several cytochrome P450 enzymes. METHODS Quantitative information on gestation-specific changes in enzyme activity available in the literature was incorporated in a pregnancy physiologically based pharmacokinetic model and the pharmacokinetics of eight drugs metabolized via one or multiple cytochrome P450 enzymes was predicted. The tested drugs were caffeine, midazolam, nifedipine, metoprolol, ondansetron, granisetron, diazepam, and metronidazole. Pharmacokinetic predictions were evaluated by comparison with in-vivo pharmacokinetic data obtained from the literature. RESULTS The pregnancy physiologically based pharmacokinetic model successfully predicted the pharmacokinetics of all tested drugs. The observed pregnancy-induced pharmacokinetic changes were qualitatively and quantitatively reasonably well predicted for all drugs. Ninety-seven percent of the mean plasma concentrations predicted in pregnant women fell within a twofold error range and 63% within a 1.25-fold error range. For all drugs, the predicted area under the concentration-time curve was within a 1.25-fold error range. CONCLUSION The presented pregnancy physiologically based pharmacokinetic model can quantitatively predict the pharmacokinetics of drugs that are metabolized via one or multiple cytochrome P450 enzymes by integrating prior knowledge of the pregnancy-related effect on these enzymes. This pregnancy physiologically based pharmacokinetic model may thus be used to identify potential exposure changes in pregnant women a priori and to eventually support informed decision making when clinical trials are designed in this special population.
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Affiliation(s)
- André Dallmann
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, Westfälische Wilhelms-University Münster, 48149, Münster, Germany.
| | - Ibrahim Ince
- Clinical Pharmacometrics, Bayer AG, 51368, Leverkusen, Germany
| | - Katrin Coboeken
- Clinical Pharmacometrics, Bayer AG, 51368, Leverkusen, Germany
| | - Thomas Eissing
- Clinical Pharmacometrics, Bayer AG, 51368, Leverkusen, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, Westfälische Wilhelms-University Münster, 48149, Münster, Germany
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Freundt JK, Frommeyer G, Spieker T, Wötzel F, Grotthoff JS, Stypmann J, Hempel G, Schäfers M, Jacobs AH, Eckardt L, Lange PS. Histone deacetylase inhibition by Entinostat for the prevention of electrical and structural remodeling in heart failure. BMC Pharmacol Toxicol 2019; 20:16. [PMID: 30841920 PMCID: PMC6404297 DOI: 10.1186/s40360-019-0294-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 02/26/2019] [Indexed: 12/14/2022] Open
Abstract
Background The development of heart failure is accompanied by complex changes in cardiac electrophysiology and functional properties of cardiomyocytes and fibroblasts. Histone deacetylase (HDAC) inhibitors hold great promise for the pharmaceutical therapy of several malignant diseases. Here, we describe novel effects of the class I HDAC inhibitor Entinostat on electrical and structural remodeling in an in vivo model of pacing induced heart failure. Methods Rabbits were implanted a pacemaker system, subjected to rapid ventricular pacing and treated with Entinostat or placebo, respectively. Following stimulation, rabbit hearts were explanted and subsequently subjected to electrophysiological studies and further immunohistological analyses of left ventricles. Results In vivo, rapid ventricular stimulation caused a significant prolongation of monophasic action potential duration compared to sham hearts (from 173 ± 26 ms to 250 ± 41 ms; cycle length 900 ms; p < 0.05) and an increased incidence of Early afterdepolarisations (+ 150%), while treatment with Entinostat in failing hearts could partially prevent this effect (from 250 ± 41 ms to 170 ± 53 ms, p < 0.05; reduction in EAD by 50%). Entinostat treatment partially restored KCNH2 and Cav1.3 gene expressions in failing hearts, and inhibited the development of cardiac fibrosis in vivo. Conclusion In a rabbit model of heart failure, Entinostat diminishes heart failure related prolongation of repolarization and partially restores KCNH2 and Cav1.3 expression. In addition, Entinostat exerts antifibrotic properties both in vitro and in vivo. Thus, Entinostat might be an interesting candidate for the pharmaceutical therapy of heart failure directed against structural and electrical remodeling. Electronic supplementary material The online version of this article (10.1186/s40360-019-0294-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Johanna K Freundt
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Gerrit Frommeyer
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Tilmann Spieker
- Department of Pathology, University Hospital Münster, Münster, Germany
| | - Fabian Wötzel
- Department of Pathology, University Hospital Münster, Münster, Germany
| | | | - Jörg Stypmann
- Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany
| | - Georg Hempel
- Institute for Pharmaceutical and Medical Chemistry, University of Münster, Münster, Germany
| | - Michael Schäfers
- European Institute for Molecular Imaging, University Hospital Münster, Münster, Germany.,Department of Nuclear Medicine, University Hospital Münster, Münster, Germany
| | - Andreas H Jacobs
- European Institute for Molecular Imaging, University Hospital Münster, Münster, Germany
| | - Lars Eckardt
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Philipp S Lange
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany.
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Ellermann I, Bueckmann A, Eveslage M, Buddendick H, Latal T, Niehoff D, Geissler RG, Hempel G, Kerkhoff A, Berdel WE, Roeder N, Van Aken HK, Zarbock A, Steinbicker AU. Treating Anemia in the Preanesthesia Assessment Clinic. Anesth Analg 2018; 127:1202-1210. [DOI: 10.1213/ane.0000000000003583] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Dallmann A, Ince I, Solodenko J, Meyer M, Willmann S, Eissing T, Hempel G. Physiologically Based Pharmacokinetic Modeling of Renally Cleared Drugs in Pregnant Women. Clin Pharmacokinet 2018; 56:1525-1541. [PMID: 28391404 DOI: 10.1007/s40262-017-0538-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [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: 01/04/2023]
Abstract
BACKGROUND Since pregnant women are considerably underrepresented in clinical trials, information on optimal dosing in pregnancy is widely lacking. Physiologically based pharmacokinetic (PBPK) modeling may provide a method for predicting pharmacokinetic changes in pregnancy to guide subsequent in vivo pharmacokinetic trials in pregnant women, minimizing associated risks. OBJECTIVES The goal of this study was to build and verify a population PBPK model that predicts the maternal pharmacokinetics of three predominantly renally cleared drugs (namely cefazolin, cefuroxime, and cefradine) at different stages of pregnancy. It was further evaluated whether the fraction unbound (f u) could be estimated in pregnant women using a proposed scaling approach. METHODS Based on a recent literature review on anatomical and physiological changes during pregnancy, a pregnancy population PBPK model was built using the software PK-Sim®/MoBi®. This model comprised 27 compartments, including nine pregnancy-specific compartments. The PBPK model was verified by comparing the predicted maternal pharmacokinetics of cefazolin, cefuroxime, and cefradine with observed in vivo data taken from the literature. The proposed scaling approach for estimating the f u in pregnancy was evaluated by comparing the predicted f u with experimentally observed f u values of 32 drugs taken from the literature. RESULTS The pregnancy population PBPK model successfully predicted the pharmacokinetics of cefazolin, cefuroxime, and cefradine at all tested stages of pregnancy. All predicted plasma concentrations fell within a 2-fold error range and 85% of the predicted concentrations within a 1.25-fold error range. The f u in pregnancy could be adequately predicted using the proposed scaling approach, although a slight underestimation was evident in case of drugs bound to α1-acidic glycoprotein. CONCLUSION Pregnancy population PBPK models can provide a valuable tool to predict a priori the pharmacokinetics of predominantly renally cleared drugs in pregnant women. These models can ultimately support informed decision making regarding optimal dosing regimens in this vulnerable special population.
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Affiliation(s)
- André Dallmann
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Westfälische Wilhelm-University Münster, 48149, Münster, Germany
| | - Ibrahim Ince
- Bayer AG, Drug Discovery, Pharmaceuticals, Systems Pharmacology & Medicine I, Kaiser-Wilhelm-Allee, 51373, Leverkusen, Germany.
| | - Juri Solodenko
- Bayer AG, ET-TD-ET Systems Pharmacology ONC, 51368, Leverkusen, Germany
| | - Michaela Meyer
- Bayer AG, DD-CS Clinical Pharmacometrics, 42113, Wuppertal, Germany
| | - Stefan Willmann
- Bayer AG, DD-CS Clinical Pharmacometrics, 42113, Wuppertal, Germany
| | - Thomas Eissing
- Bayer AG, Drug Discovery, Pharmaceuticals, Systems Pharmacology & Medicine I, Kaiser-Wilhelm-Allee, 51373, Leverkusen, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Westfälische Wilhelm-University Münster, 48149, Münster, Germany
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Würthwein G, Lanvers-Kaminsky C, Hempel G, Gastine S, Möricke A, Schrappe M, Karlsson MO, Boos J. Population Pharmacokinetics to Model the Time-Varying Clearance of the PEGylated Asparaginase Oncaspar ® in Children with Acute Lymphoblastic Leukemia. Eur J Drug Metab Pharmacokinet 2018; 42:955-963. [PMID: 28349335 DOI: 10.1007/s13318-017-0410-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND OBJECTIVES The pharmacokinetics of the polyethylene glycol (PEG)-conjugated asparaginase Oncaspar® are characterized by an increase in elimination over time. The focus of our analysis is the better understanding of this time-dependency. METHODS In paediatric acute lymphoblastic leukemia therapy (AIEOP-BFM ALL 2009), two administrations of Oncaspar® (2500 U/m2 intravenously) in induction phase (14-day interval) and one single administration in reinduction were followed by weekly monitoring of asparaginase activity. Non-linear mixed-effects modeling techniques (NONMEM) were used. Samples indicating immunological inactivation were excluded to describe the pharmacokinetics under standard conditions. Models with time-constant or time-varying clearance (CL) as well as transit compartment models with an increase in CL over a chain of compartments were investigated. RESULTS Models with time-constant elimination could not adequately describe 6107 asparaginase activities from 1342 patients. Implementing a time-varying CL improved the fit. Modeling an increase of CL over time after dose (Emax- and Weibull-functions) were superior to models with an increase of CL over time after the first administration. However, a transit compartment model came out to be the best structural model. CONCLUSION The increase in elimination of PEGylated asparaginase appears to be driven by physicochemical processes that are drug-related. The observed hydrolytically in vitro instability of the drug leads to the hypothesis that this increase in CL might be due to an in vivo hydrolysis of the instable ester bond between PEG and the enzyme combined with an increased elimination of the partly de-PEGylated enzyme (Trial registered at www.clinicaltrials.gov , NCT0111744).
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Affiliation(s)
- Gudrun Würthwein
- Paediatric Haematology and Oncology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany
| | - Claudia Lanvers-Kaminsky
- Paediatric Haematology and Oncology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Corrensstraße 48, 48149, Muenster, Germany
| | - Silke Gastine
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Corrensstraße 48, 48149, Muenster, Germany
| | - Anja Möricke
- Department of Pediatrics, Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Schwanenweg 20, 24105, Kiel, Germany
| | - Martin Schrappe
- Department of Pediatrics, Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Schwanenweg 20, 24105, Kiel, Germany
| | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala University, P.O. Box 591, 75124, Uppsala, Sweden
| | - Joachim Boos
- Paediatric Haematology and Oncology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany.
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Dallmann A, Ince I, Meyer M, Willmann S, Eissing T, Hempel G. Gestation-Specific Changes in the Anatomy and Physiology of Healthy Pregnant Women: An Extended Repository of Model Parameters for Physiologically Based Pharmacokinetic Modeling in Pregnancy. Clin Pharmacokinet 2018; 56:1303-1330. [PMID: 28401479 DOI: 10.1007/s40262-017-0539-z] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [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: 12/11/2022]
Abstract
BACKGROUND In the past years, several repositories for anatomical and physiological parameters required for physiologically based pharmacokinetic modeling in pregnant women have been published. While providing a good basis, some important aspects can be further detailed. For example, they did not account for the variability associated with parameters or were lacking key parameters necessary for developing more detailed mechanistic pregnancy physiologically based pharmacokinetic models, such as the composition of pregnancy-specific tissues. OBJECTIVES The aim of this meta-analysis was to provide an updated and extended database of anatomical and physiological parameters in healthy pregnant women that also accounts for changes in the variability of a parameter throughout gestation and for the composition of pregnancy-specific tissues. METHODS A systematic literature search was carried out to collect study data on pregnancy-related changes of anatomical and physiological parameters. For each parameter, a set of mathematical functions was fitted to the data and to the standard deviation observed among the data. The best performing functions were selected based on numerical and visual diagnostics as well as based on physiological plausibility. RESULTS The literature search yielded 473 studies, 302 of which met the criteria to be further analyzed and compiled in a database. In total, the database encompassed 7729 data. Although the availability of quantitative data for some parameters remained limited, mathematical functions could be generated for many important parameters. Gaps were filled based on qualitative knowledge and based on physiologically plausible assumptions. CONCLUSION The presented results facilitate the integration of pregnancy-dependent changes in anatomy and physiology into mechanistic population physiologically based pharmacokinetic models. Such models can ultimately provide a valuable tool to investigate the pharmacokinetics during pregnancy in silico and support informed decision making regarding optimal dosing regimens in this vulnerable special population.
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Affiliation(s)
- André Dallmann
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, Westfälische Wilhelm-University Münster, Münster, Germany
| | - Ibrahim Ince
- ET-TD-ET Systems Pharmacology CV, Bayer AG, Leverkusen, Germany.
| | - Michaela Meyer
- DD-CS Clinical Pharmacometrics, Bayer AG, Wuppertal, Germany
| | - Stefan Willmann
- DD-CS Clinical Pharmacometrics, Bayer AG, Wuppertal, Germany
| | - Thomas Eissing
- ET-TD-ET Systems Pharmacology CV, Bayer AG, Leverkusen, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, Westfälische Wilhelm-University Münster, Münster, Germany
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Agyare C, Spiegler V, Asase A, Scholz M, Hempel G, Hensel A. An ethnopharmacological survey of medicinal plants traditionally used for cancer treatment in the Ashanti region, Ghana. J Ethnopharmacol 2018; 212:137-152. [PMID: 29066406 DOI: 10.1016/j.jep.2017.10.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/09/2017] [Accepted: 10/19/2017] [Indexed: 06/07/2023]
Abstract
AIMS Cancer represents a major health burden and drain on healthcare resources in the world. The majority of the people of Africa still patronize traditional medicine for their health needs, including various forms of cancer. The aim of the following study is the identification of medicinal plants used for cancer treatment by the traditional healers in the Ashanti area of Ghana and to cross-reference the identified plant species with published scientific literature. METHODOLOGY Validated questionnaires were administered to 85 traditional healers in 10 communities within Ashanti region. For cross-validation, also 7 healers located outside Ashanti region were investigated to evaluate regional differences. Interviews and structured conversations were used to administer the questionnaires. Selected herbal material dominantly used by the healers was collected and identified. RESULTS The ethnopharmacological survey revealed 151 plant species used for cancer treatment. Identified species were classified into different groups according to their frequency of use, resulting in the "top-22" plants. Interestingly group I (very frequent use) contained 5 plant species (Khaya senegalensis, Triplochiton scleroxylon, Azadirachta indica, Entandrophragma angolense, Terminalia superba), three of which belong to the plant family Meliaceae, phytochemically mainly characterized by the presence of limonoids. Cross-referencing of all plants identified by current scientific literature revealed species which have not been documented for cancer therapy until now. Special interest was laid on use of plants for cancer treatment of children. CONCLUSION A variety of traditionally used anti-cancer plants from Ghana have been identified and the widespread use within ethnotraditional medicine is obvious. Further in vitro and clinical studies will be performed in the near future to rationalize the phytochemical and functional scientific background of the respective extracts for cancer treatment.
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Affiliation(s)
- Christian Agyare
- Department of Pharmaceutics, Faculty of Pharmacy and Pharmaceutical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Verena Spiegler
- University of Münster, Institute for Pharmaceutical Biology and Phytochemistry, Corrensstrasse 48, D-48149 Münster, Germany
| | - Alex Asase
- Department of Plant and Environmental Biology, University of Ghana, Legon, Ghana
| | - Michael Scholz
- University of Münster, Institute for Pharmaceutical Biology and Phytochemistry, Corrensstrasse 48, D-48149 Münster, Germany
| | - Georg Hempel
- University of Münster, Institute for Pharmaceutical and Medicinal Chemistry - Clinical Pharmacy, Corrensstrasse 48, D-48149 Münster, Germany
| | - Andreas Hensel
- University of Münster, Institute for Pharmaceutical Biology and Phytochemistry, Corrensstrasse 48, D-48149 Münster, Germany.
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Perego P, Hempel G, Linder S, Bradshaw TD, Larsen AK, Peters GJ, Phillips RM. Cellular pharmacology studies of anticancer agents: recommendations from the EORTC-PAMM group. Cancer Chemother Pharmacol 2017; 81:427-441. [PMID: 29285635 DOI: 10.1007/s00280-017-3502-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 12/17/2017] [Indexed: 02/07/2023]
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Völler S, Pichlmeier U, Zens A, Hempel G. Pharmacokinetics of recombinant asparaginase in children with acute lymphoblastic leukemia. Cancer Chemother Pharmacol 2017; 81:305-314. [DOI: 10.1007/s00280-017-3492-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 11/27/2017] [Indexed: 11/28/2022]
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Weber J, Oberfeld S, Bonse A, Telger K, Lingg R, Hempel G. Validation of a dried blood spot method for therapeutic drug monitoring of citalopram, mirtazapine and risperidone and its active metabolite 9-hydroxyrisperidone using HPLC–MS. J Pharm Biomed Anal 2017; 140:347-354. [DOI: 10.1016/j.jpba.2017.02.061] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/24/2017] [Accepted: 02/04/2017] [Indexed: 02/04/2023]
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Dickschen KJR, Willmann S, Hempel G, Block M. Addressing Adherence Using Genotype-Specific PBPK Modeling-Impact of Drug Holidays on Tamoxifen and Endoxifen Plasma Levels. Front Pharmacol 2017; 8:67. [PMID: 28382001 PMCID: PMC5361661 DOI: 10.3389/fphar.2017.00067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 02/01/2017] [Indexed: 12/30/2022] Open
Abstract
Introduction: Tamoxifen is one of the most common treatment opportunities for hormonal positive breast cancer. Despite its good tolerability, patients demonstrate decreasing adherence over years impacting on therapeutic success. PBPK modeling was applied to demonstrate the impact of drug holidays on plasma levels of tamoxifen and its active metabolite endoxifen for different CYP2D6 genotypes. Materials and Methods: A virtual study with 24,000 patients was conducted in order to investigate the development of tamoxifen steady-state kinetics in patient groups of different CYP2D6 genotypes. The impact of drug holidays on steady-state kinetics was investigated assuming changing drug holiday scenarios. Results: Drug holidays in CYP2D6 extensive and intermediate metabolizers (EMs, IMs) exceeding 1 month lead to a decrease of endoxifen steady-state trough levels below the 5th percentile of the control group. Assuming drug holidays of 1, 2, or 3 months and administering a fixed-dose combination of 20 mg tamoxifen and 3 mg endoxifen EMs demonstrated re-established endoxifen steady-state trough levels after 5, 8, and 9 days. IMs receiving the same fixed-dose combination demonstrated re-established endoxifen steady-state trough levels after 7, 10, and 11 days. Discussion: The PBPK model impressively demonstrates the impact of drug holidays in different CYP2D6 genotypes on PK. Population simulation results indicate that drug holidays of more than 2 weeks cause a tremendous decrease of plasma levels despite the long half-life of tamoxifen. To improve therapeutic success, PBPK modeling allows identifying genotype-specific differences in PK following drug holidays and adequate treatment with loading doses.
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Affiliation(s)
| | - Stefan Willmann
- Clinical Pharmacometrics, Bayer Pharma AG Wuppertal, Germany
| | - Georg Hempel
- Clinical Pharmacy, Department of Pharmaceutical and Medical Chemistry, University of Muenster Muenster, Germany
| | - Michael Block
- Computational Systems Biology, Bayer AG Leverkusen, Germany
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Mahlknecht A, Nestler N, Bauer U, Schüßler N, Schuler J, Scharer S, Becker R, Waltering I, Hempel G, Schwalbe O, Flamm M, Osterbrink J. Effect of training and structured medication review on medication appropriateness in nursing home residents and on cooperation between health care professionals: the InTherAKT study protocol. BMC Geriatr 2017; 17:24. [PMID: 28100176 PMCID: PMC5241939 DOI: 10.1186/s12877-017-0418-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 01/11/2017] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Pharmacotherapy in residents of nursing homes is critical due to the special vulnerability of this population. Medical care and interprofessional communication in nursing homes are often uncoordinated. As a consequence, polypharmacy and inappropriate medication use are common and may lead to hospitalizations and health hazards. The aim of this study is to optimize communication between the involved professional groups by specific training and by establishing a structured medication review process, and to improve medication appropriateness and patient-relevant health outcomes for residents of nursing homes. METHODS/DESIGN The trial is designed as single-arm study. It involves 300 nursing home residents aged ≥ 65 years and the members of the different professional groups practising in nursing home care (15-20 general practitioners, nurses, pharmacists). The intervention consists of interprofessional education on safe medication use in geriatric patients, and a systematic interprofessional therapy check (recording, reviewing and adapting the medication of the participating residents by means of a specific online platform). The intervention period is divided into two phases; total project period is 3 years. Primary outcome measure is the change in medication appropriateness according to the Medication Appropriateness Index. Secondary outcomes are cognitive performance, occurrence of delirium, agitation, tendency of falls, total number of drugs, number of potentially dangerous drug-drug interactions and appropriateness of recorded analgesic therapy regimens according to the Medication Appropriateness Index. Data are collected at t0 (before the start of the intervention), t1 (after the first intervention period) and t2 (after the second intervention period). Cooperation and communication between the professional groups are investigated twice by qualitative interviews. DISCUSSION The project aims to establish a structured system for monitoring of drug therapy in nursing home residents. The newly developed online platform is designed to systematize and to improve the communication between the professional groups and, thus, to enhance quality and safety of drug therapy. Limitations of the study are the lack of a control group and the non-randomly recruited study sample. TRIAL REGISTRATION DRKS Data Management, DRKS-ID: DRKS00007900.
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Affiliation(s)
- Angelika Mahlknecht
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Nadja Nestler
- Institute of Nursing Science and Practice, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Ulrike Bauer
- Institute of Nursing Science and Practice, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Nadine Schüßler
- Institute of Nursing Science and Practice, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Jochen Schuler
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Sebastian Scharer
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Ralf Becker
- Hausärzteverbund Münster/Association of general practitioners of Muenster, Metzer Strasse 59, 48151 Muenster, Germany
| | - Isabel Waltering
- Institut für Pharmazeutische und Medizinische Chemie der Westfälischen Wilhelms-Universität Münster/Institute of Pharmaceutic and Medical Chemistry of the Westfaelische Wilhelms-University, Corrensstraße 48, 48149 Muenster, Germany
| | - Georg Hempel
- Institut für Pharmazeutische und Medizinische Chemie der Westfälischen Wilhelms-Universität Münster/Institute of Pharmaceutic and Medical Chemistry of the Westfaelische Wilhelms-University, Corrensstraße 48, 48149 Muenster, Germany
| | - Oliver Schwalbe
- Apothekerkammer Westfalen-Lippe/Chamber of Pharmacists Westphalia-Lippe, Bismarckallee 25, 48151 Muenster, Germany
| | - Maria Flamm
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Jürgen Osterbrink
- Institute of Nursing Science and Practice, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
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Usman M, Frey OR, Hempel G. Population pharmacokinetics of meropenem in elderly patients: dosing simulations based on renal function. Eur J Clin Pharmacol 2016; 73:333-342. [PMID: 27966034 DOI: 10.1007/s00228-016-2172-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [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: 07/18/2016] [Accepted: 12/02/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate different dosage regimens of meropenem in elderly patients in relation with renal function using a population pharmacokinetic (popPK) model. METHODS The data of 178 elderly patients treated with meropenem was collected from different sources. A popPK model was developed by using NONMEM® and the influence of different covariates on meropenem CL and V1 was observed. Monte Carlo dosing simulations were performed at steady state to observe the % T > MIC for targets of 40, 60 and 80% of dosage intervals at different levels of creatinine clearance (CLCR). RESULTS The data was described by a two-compartment model and the values of parameter estimates for CL, V1, Q and V2 were 5.27 L/h, 17.2 L, 9.92 L/h and 10.6 L, respectively. The CLCR, body weight and centre had a significant influence on meropenem CL while no direct influence of age was observed. Extended infusions had pharmacokinetic and pharmacodynamic (PK/PD) breakpoint one dilution greater than corresponding short infusion regimens for each target of % T > MIC. CONCLUSION Meropenem CL was significantly lower in the elderly compared to CL reported in younger patients due to the reduced renal function. An extended infusion of 1000 mg q8h can be considered for empirical treatment of infections in elderly patients when CLCR is ≤ 50 mL/min. A continuous infusion of 3000 mg daily dose is preferred if CLCR > 50 mL/min. However, a higher daily dose of meropenem would be required for resistant strains (MIC >8 mg/L) of bacteria if CLCR is >100 mL/min.
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Affiliation(s)
- Muhammad Usman
- Department of Pharmaceutical and Medicinal Chemistry - Clinical Pharmacy, University of Muenster, Corrensstr. 48, 48149, Muenster, Germany.,Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Otto R Frey
- Department of Pharmacy, Hospital of Heidenheim, Heidenheim, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medicinal Chemistry - Clinical Pharmacy, University of Muenster, Corrensstr. 48, 48149, Muenster, Germany.
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Krischke M, Hempel G, Völler S, André N, D'Incalci M, Bisogno G, Köpcke W, Borowski M, Herold R, Boddy AV, Boos J. Pharmacokinetic and pharmacodynamic study of doxorubicin in children with cancer: results of a "European Pediatric Oncology Off-patents Medicines Consortium" trial. Cancer Chemother Pharmacol 2016; 78:1175-1184. [PMID: 27770238 PMCID: PMC5114325 DOI: 10.1007/s00280-016-3174-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 10/12/2016] [Indexed: 11/26/2022]
Abstract
Purpose Doxorubicin is a key component in many pediatric oncology treatment regimens; still pharmacology data on which current dosing regimens are based are very limited. Methods We conducted a multinational pharmacokinetic study investigating age dependency of doxorubicin metabolism and elimination in children with cancer. One hundred and one patients treated with doxorubicin according to a cancer-specific national or European therapeutic trial were recruited. Doses of doxorubicin ranged from 10.4 to 57.7 mg/m2. Blood samples for measurement of doxorubicin and its metabolite doxorubicinol were collected after two administrations, with five samples collected in children <3 years and eight in children ≥3 years. A population pharmacokinetic approach was used for analysis, including pharmacogenetic covariates. Natriuretic peptides and cardiac troponins were measured to evaluate their role as early indicators of cardiotoxicity. Results Age dependence of doxorubicin clearance was demonstrated, with children less than 3 years having a statistically significant lower clearance (21.1 ± 5.8 l/h/m2) than older children (26.6 ± 6.7 l/h/m2) (p = 0.0004) after correcting for body surface area. No effect of the investigated genetic polymorphisms on the pharmacokinetics could be observed. Although natriuretic peptides were transiently elevated after each doxorubicin administration and troponin levels increased with increasing doxorubicin exposure, only limited correlation could be observed between their blood levels and doxorubicin pharmacokinetics. Conclusion In the European framework of funding and regulatory support, an add-on study to existing therapeutic trials was developed. The pediatric need concerning missing PK data could be addressed with limited burden for the patients. Empirically used dose adaptations for infants were generally found to be justified based on our PK analyses. Electronic supplementary material The online version of this article (doi:10.1007/s00280-016-3174-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Miriam Krischke
- Pediatric Hematology and Oncology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
- Zentrum für Klinische Studien (ZKS), University Hospital Münster, Von-Esmarch-Straße 62, 48149, Münster, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, Westfälische Wilhelms-Universität Münster, Corrensstraße 48, 48149, Münster, Germany
| | - Swantje Völler
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, Westfälische Wilhelms-Universität Münster, Corrensstraße 48, 48149, Münster, Germany
| | - Nicolas André
- INSERM UMR 911, Centre de Recherche en Oncologie biologique et en Oncopharmacologie, Aix-Marseille University, Marseille, France
- Hematology and Pediatric Oncology Department, La Timone University Hospital of Marseille, Marseille, France
| | - Maurizio D'Incalci
- Department of Oncology, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Via La Masa, 19, 20156, Milan, Italy
| | - Gianni Bisogno
- Dipartimento di Pediatria, Clinica di Oncoematologia, via Giustiniani, 3, 35100, Padua, Italy
| | - Wolfgang Köpcke
- Institute of Biostatistics and Clinical Research, Westfälische Wilhelms-Universität Münster, Schmeddingstraße 56, 48149, Münster, Germany
| | - Matthias Borowski
- Institute of Biostatistics and Clinical Research, Westfälische Wilhelms-Universität Münster, Schmeddingstraße 56, 48149, Münster, Germany
| | - Ralf Herold
- European Medicines Agency (EMA), 30 Churchill Place, Canary Wharf, London, E14 5EU, UK
| | - Alan V Boddy
- Northern Institute for Cancer Research, Newcastle University, Paul O'Gorman Building, Medical School, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
- Faculty of Pharmacy, University of Sydney, Sydney, Australia
| | - Joachim Boos
- Pediatric Hematology and Oncology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
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Ulrici J, Hempel G, Sasse M, Vollrath J, Höhne C. Atemwegskomplikationen bei übergewichtigen und adipösen Kindern. Anaesthesist 2016; 65:911-916. [DOI: 10.1007/s00101-016-0229-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 09/02/2016] [Accepted: 09/06/2016] [Indexed: 11/24/2022]
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Waltering I, Schwalbe O, Hempel G. Informationsgehalt von Medikationsplänen vor dem Hintergrund der Einführung des einheitlichen patientenbezogenen Medikationsplans. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen 2016; 115-116:24-32. [DOI: 10.1016/j.zefq.2016.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 06/07/2016] [Accepted: 06/21/2016] [Indexed: 11/30/2022]
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