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Thanukrishnan H, Venkataramanan R, Mehta RB, Jorgensen D, Sood P. The combination of exposure to Tacrolimus, mycophenolic acid, Inosine 5'-Monophosphate Dehydrogenase activity and inhibition in the first week define early histological outcomes in renal transplant recipients. Clin Transplant 2022; 36:e14830. [PMID: 36177865 DOI: 10.1111/ctr.14830] [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: 09/06/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 12/27/2022]
Abstract
Therapeutic drug monitoring is routine for Tacrolimus, while levels are not routinely monitored for mycophenolic acid (MPA). This study investigated the effect of early post-transplant pharmacokinetics (PK) of MPA and Tacrolimus along with the pharmacodynamics (PD) of MPA on biopsy-proven acute rejection (BPAR) after renal transplantation. A prospective PK/PD study with limited sampling (three blood samples) was conducted in renal transplant recipients on week 1, around Day 6 (n = 42) and at the 3rd-month biopsy on Day 90 (n = 23). The partial exposures (area under curve [AUC]0-3.5 h ) of both MPA and Tacrolimus obtained during the first week were more predictive of rejection (combined clinical and subclinical rejection) by Day 90 than their trough concentrations or Day 90 exposures. Patients with rejection had significantly worse renal function (eGFR) and a comparatively lower exposure to MPA during the first post-transplant week. The lower MPA exposure was also associated with sub-optimal inosine monophosphate dehydrogenase (IMPDH) inhibition in patients with rejection, and the probability of rejection was higher in the presence of an increased pre-transplant IMPDH activity. A composite of parameters, including MPA exposure and IMPDH activity was found to predict acute rejection and may be beneficial along with tacrolimus monitoring early after renal transplantation.
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Affiliation(s)
| | - Raman Venkataramanan
- School of Pharmacy and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rajil B Mehta
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dana Jorgensen
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Puneet Sood
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Thanukrishnan H, Corcoran TE, Iasella CJ, Moore CA, Nero JA, Morrell MR, McDyer JF, Hussain S, Nguyen MH, Venkataramanan R, Ensor CR. Aerosolization of Second-generation Triazoles: In Vitro Evaluation and Application in Therapy of Invasive Airway Aspergillosis. Transplantation 2020; 103:2608-2613. [PMID: 31343565 DOI: 10.1097/tp.0000000000002697] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND A lung transplant patient with invasive aspergillosis (IA) manifested symptoms of voriconazole-induced transaminitis with systemic voriconazole and progression of IA after switching to oral posaconazole. With limited options for standard triazole therapy, aerosolized delivery with one of the second-generation triazoles was considered. METHODS Feasibility for aerosolized delivery was evaluated using cascade impactor and analysis of physicochemical characteristics of voriconazole (10 mg/mL) and posaconazole (6, 12 mg/mL) solutions. RESULTS Both triazoles showed favorable characteristics for aerosol delivery with mass median aerodynamic diameter, geometric standard deviation, respirable fraction (<5.4 µm) of 2.8 µm, 2.0, 86%; 3.4 µm, 2.4, 78%; and 3.0 µm, 2.3, 79% for voriconazole and 6, 12 mg/mL of posaconazole, respectively. Aspergillus fumigatus isolate from the patient was more susceptible to voriconazole, and hence aerosolized voriconazole was introduced around the third month posttransplant at 40 mg TID for 1 week, 40 mg BID for 1 week, followed by 40 mg daily thereafter, along with IV caspofungin (50 mg/d) and liposomal amphotericin B (300 mg/d). The aerosol regimen was well tolerated by the patient with undetectable trough plasma levels of voriconazole. Bronchoscopy at the fourth month revealed improvement in anastomotic plaques with reduction in bronchoalveolar lavage galactomannan values (7.48-2.15 ng/mL). This consolidated aerosolized and intravenous regimen was maintained until 2.97 years posttransplant. CONCLUSIONS The intravenous solutions of both second-generation triazoles showed characteristics that were suitable for aerosol delivery. Our report further adds to the therapeutic experience with the use of aerosolized voriconazole for IA in a lung transplant patient.
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Affiliation(s)
- Harisudhan Thanukrishnan
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Timothy E Corcoran
- Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, PA.,Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA
| | - Carlo J Iasella
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Cody A Moore
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Joseph A Nero
- Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, PA
| | - Matthew R Morrell
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - John F McDyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Shahid Hussain
- Multi-Organ Transplant Program, Division of Infectious Diseases, Transplant Infectious Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON
| | - M Hong Nguyen
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA.,Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Christopher R Ensor
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
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Al Ahdab OG, Ali A, Almarsdóttir AB, Annemans L, Ashoush N, Baker DE, Blondal AB, Brennan E, Brown L, Buffington D, Calabrese S, Chaiyakunapruk N, Chilkoti DC, Choon WY, Cooper JC, Costa de Sousa I, Dankó D, Davis A, Decerbo M, Decker BS, Dilokthornsakul P, Efendie B, Feturi FG, Gajraj E, Gharat M, Granas AG, Herman RA, Hiligsmann M, Hill A, Hill LH, Hoefer C, John D, Jones EP, Joseph S, Joshi S, Junaid T, Khakurel B, Khalifa S, Kisor DF, Klika C, Kruger J, Kumar K, Lee SWH, Lega F, Leong C, Li H, Lockman K, Suresh Madhavan S, Maine LL, Marriott J, Miah MK, Naeem S, New JP, Osipenko L, Paulino E, Picone MF, Pilch NA, Rajendran N, Raut A, Ray ME, Roberts JA, Rouse MJ, Sambandan G, Scheckelhoff D, Shaik IH, Shrestha R, Sokn E, Steinke DT, Tarn YH(T, Thanukrishnan H, Thomas D, Tian S, Tsui VW, Turcu-Stiolica A, Vadlamudi R, Vaida AJ, Vaidya R, Van Cuyk MP, Venkataramanan R, Vlasses PH, Vos SS, Weeda ER, Wisniewski CS, Woods DJ, Wu X, Zachariah S, Zarembski DG. List of Contributors. Clinical Pharmacy Education, Practice and Research 2019:xvii-xix. [DOI: 10.1016/b978-0-12-814276-9.01002-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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