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Ter Avest M, Langemeijer SMC, Blijlevens NMA, van de Kar NCAJ, Ter Heine R. Development of a target concentration intervention to individualize paroxysmal nocturnal hemoglobinuria treatment with pegcetacoplan. Ann Hematol 2024:10.1007/s00277-024-05699-8. [PMID: 38453703 DOI: 10.1007/s00277-024-05699-8] [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: 05/31/2023] [Accepted: 03/03/2024] [Indexed: 03/09/2024]
Abstract
Pegcetacoplan (Aspaveli®/Empaveli™) is a factor C3 inhibitor that is approved for the treatment of paroxysmal nocturnal hemoglobinuria. An individualized dosing strategy might be useful to improve patient-friendliness and cost-effectiveness of this very expensive drug. Therefore, the aim of this study was to develop an individualized treatment regimen for pegcetacoplan based on the pharmacokinetic-pharmacodynamic data of the manufacturer. We conducted a clinical trial simulation with the approved dosing regimen of 1080 mg twice-weekly and a target concentration intervention-based dosing regimen in patients with and without prior eculizumab use. For eculizumab-naïve patients, the target concentration intervention-based dosing regimen resulted in a comparable fraction of patients with LDH normalization (LDH < 226 U/L) and hemoglobulin normalization (> 12 g/dL) compared to the approved regimen (LDH 50.2% and 50.0% respectively and hemoglobulin 45.6% and 44.4%). A modest dose reduction of ~ 5% was possible with target concentration intervention-based dosing. An intensified dosing interval was necessary in 2.3% of the patients however an interval prolongation was possible in 28.2% of the patients. Similar results were obtained for patients prior treated with eculizumab. In this study we show the potential of an individualized dosing regimen of pegcetacoplan with can improve patient friendliness in approximately 30% of the patients and improve therapy in approximately 2% of the patients at slightly reduced costs.
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Affiliation(s)
- Mendy Ter Avest
- Department of Pharmacy, Radboud University Medical Centre, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands.
| | | | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Nicole C A J van de Kar
- Department of Pediatric Nephrology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud University Medical Centre, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands
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Ter Avest M, Langemeijer SMC, Blijlevens NMA, van de Kar NCAJ, Ter Heine R. Dose optimalization of subcutaneous ravulizumab is predicted to yield significant savings and to improve patient friendliness. Br J Clin Pharmacol 2023; 89:1211-1215. [PMID: 36394176 DOI: 10.1111/bcp.15602] [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: 09/02/2022] [Revised: 11/01/2022] [Accepted: 11/07/2022] [Indexed: 11/18/2022] Open
Abstract
Ravulizumab is an expensive complement C5-inhibitor for the treatment of paroxysmal nocturnal haemoglobinuria. Recently, a subcutaneous formulation has entered the market, for which the approved dosing regimen results in supratherapeutic ravulizumab concentrations in the majority of patients in the registration studies. Therefore, we explored alternative dosing regimens in silico based on the registration data of the manufacturer. Extending the interval from 1 to 2 weeks or individualized dosing based on therapeutic drug monitoring resulted in therapeutic ravulizumab concentrations and comparable predicted efficacy in terms of lactate dehydrogenase normalization, with dose reductions up to 64%. We here show that with an individualized dose, a substantial dose reduction for subcutaneous ravulizumab might be possible with improved patient-friendliness.
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Affiliation(s)
- Mendy Ter Avest
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Nicole M A Blijlevens
- Department of Haematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Nicole C A J van de Kar
- Deparment of Paediatric Nephrology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
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Karssemeijer EGA, van der Heijden CDCC, Wolters TLC, Te Boekhorst B, Ter Avest M, Kramers C. [Don't stop medication too abruptly: advice about the discontinuation of medication]. Ned Tijdschr Geneeskd 2021; 165:D6039. [PMID: 34854616] [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] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Polypharmacy may result in interactions and side effects that lead to morbidity and mortality. Therefore, it is important to evaluate on a regular basis the possibility to stop medication. Sometimes it is necessary to temporarily discontinue certain medication, for example when a patient is unable to swallow or suffers from a delirium. Not all drugs can be stopped abruptly, since this can result in a rebound-effect or withdrawal symptoms Especially drugs that act on the central nervous system (e.g. psychotropic drugs, dopaminergic drugs, opioids) are known to cause (severe) withdrawal symptoms when stopped abruptly In addition, beta-blockers, corticosteroids and proton-pump inhibitors cause symptoms when stopped without tapering. Gradually tapering off these medicines is needed, sometimes under guidance from a specialist. Moreover, it is important to realize that stopping medication can also introduce interactions.
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Affiliation(s)
| | | | | | | | - Mendy Ter Avest
- Canisius Wilhelmina Ziekenhuis, afd. Klinische Farmacie, Nijmegen
| | - C Kramers
- Radboudumc, afd. Farmacologie-Toxicologie, Nijmegen
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Ter Avest M, Langemeijer SMC, Schols SEM, Burger DM, van de Kar NCAJ, Blijlevens NMA, Kievit W, Ter Heine R. The potential of individualized dosing of ravulizumab to improve patient-friendliness of paroxysmal nocturnal haemoglobinuria treatment at reduced costs. Br J Clin Pharmacol 2021; 87:3359-3363. [PMID: 33512711 PMCID: PMC8359320 DOI: 10.1111/bcp.14748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 12/24/2020] [Accepted: 01/18/2021] [Indexed: 01/10/2023] Open
Abstract
Ravulizumab is a very expensive complement C5‐inhibitor for the treatment of paroxysmal nocturnal haemoglobinuria, with a fixed‐dosing interval of 8 weeks. For lifelong treatment, a cost‐effective and patient‐friendly dosing strategy is preferred. We therefore explored alternative ravulizumab dosing regimens in silico based on the thorough dose‐finding studies of the manufacturer. Extending the interval to 10 weeks or individually extending the interval to a mean of 12.8 weeks based on pharmacokinetic monitoring resulted in noninferior efficacy in terms of lactate dehydrogenase normalization, with drug cost savings up to 37%. We here show the potential of individualized ravulizumab dosing to improve patient‐friendliness at reduced costs.
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Affiliation(s)
- Mendy Ter Avest
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Nicole C A J van de Kar
- Deparment of Pediatric Nephrology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Wietske Kievit
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
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Bouwmeester RN, Ter Avest M, Wijnsma KL, Duineveld C, Ter Heine R, Volokhina EB, Van Den Heuvel LPWJ, Wetzels JFM, van de Kar NCAJ. Case Report: Variable Pharmacokinetic Profile of Eculizumab in an aHUS Patient. Front Immunol 2021; 11:612706. [PMID: 33519821 PMCID: PMC7843372 DOI: 10.3389/fimmu.2020.612706] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 09/30/2020] [Accepted: 12/01/2020] [Indexed: 12/31/2022] Open
Abstract
Background With the introduction of eculizumab, a C5-inhibitor, morbidity and mortality improved significantly for patients with atypical hemolytic uremic syndrome (aHUS). In view of the high costs, actual needs of the drug, and increasing evidence in literature, aHUS patients can be treated according to a restrictive eculizumab regimen. We retrospectively analyzed the pharmacokinetic and dynamic parameters of eculizumab in one patient in time, emphasizing various factors which could be taken into account during tapering of treatment. Case Presentation A nowadays 18-year-old male with a severe, frequently relapsing form of atypical HUS due to a hybrid CFH/CFHR1 gene in combination with the homozygous factor H haplotype, required chronic plasma therapy (PT), including periods with plasma infusion, from the age of onset at 5 months until initiation of eculizumab at the age of 11 years. A mild but stable chronic kidney disease (CKD) and 9 years of disease remission enabled prolongation of eculizumab interval. At the age of 15 years, a sudden yet multifactorial progression of chronic kidney disease (CKD) was observed, without any signs of disease recurrence. However, an acquired glomerulocystic disease, a reduced left kidney function, and abnormal abdominal venous system of unknown etiology were found. In addition, after an aHUS relapse, an unexpected increase in intra-patient variability of eculizumab concentrations was seen. Retrospective pharmacokinetic analysis revealed a change in eculizumab clearance, associated with a simultaneous increase in proteinuria. Conclusion High intra-patient variability of eculizumab pharmacokinetics were observed over time, emphasizing the necessity for adequate and continuous therapeutic drug monitoring in aHUS patients. Eculizumab serum trough levels together with complement activation markers (CH50) should be frequently assessed, especially during tapering of drug therapy and/or changing clinical conditions in the patient. In addition, an increase in proteinuria could result in urinary eculizumab loss, indicating that urinary monitoring of eculizumab may be important in aHUS patients with an unexplained decline in serum concentrations.
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Affiliation(s)
- Romy N Bouwmeester
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Mendy Ter Avest
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Kioa L Wijnsma
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Caroline Duineveld
- Department of Nephrology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Elena B Volokhina
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lambertus P W J Van Den Heuvel
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jack F M Wetzels
- Department of Nephrology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nicole C A J van de Kar
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
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Ter Avest M, Veringa A, van den Heuvel ER, Kosterink JGW, Schölvinck EH, Tissing WJE, Alffenaar JWC. The effect of inflammation on voriconazole trough concentrations in children. Br J Clin Pharmacol 2016; 83:678-680. [PMID: 27862167 PMCID: PMC5306482 DOI: 10.1111/bcp.13151] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 10/01/2016] [Accepted: 10/05/2016] [Indexed: 11/28/2022] Open
Affiliation(s)
- Mendy Ter Avest
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Anette Veringa
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Edwin R van den Heuvel
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Jos G W Kosterink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Department of Pharmacy, Section Pharmacotherapy and Pharmaceutical Care, University of Groningen, Groningen, the Netherlands
| | - Elisabeth H Schölvinck
- Department of Pediatrics (Infection/Immunology), University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Wim J E Tissing
- Department of Pediatrics (Oncology/Hematology), University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jan-Willem C Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Veringa A, Ter Avest M, Span LFR, van den Heuvel ER, Touw DJ, Zijlstra JG, Kosterink JGW, van der Werf TS, Alffenaar JWC. Voriconazole metabolism is influenced by severe inflammation: a prospective study. J Antimicrob Chemother 2016; 72:261-267. [PMID: 27601292 DOI: 10.1093/jac/dkw349] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/19/2016] [Accepted: 07/26/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND During an infection or inflammation, several drug-metabolizing enzymes in the liver are down-regulated, including cytochrome P450 iso-enzymes. Since voriconazole is extensively metabolized by cytochrome P450 iso-enzymes, the metabolism of voriconazole can be influenced during inflammation via reduced clearance of the drug, resulting in higher voriconazole trough concentrations. OBJECTIVE To investigate prospectively the influence of inflammation on voriconazole metabolism and voriconazole trough concentrations. METHODS A prospective observational study was performed at the University Medical Center Groningen. Patients were eligible for inclusion if they were ≥18 years old and treated with voriconazole. Voriconazole and voriconazole-N-oxide concentrations were determined in discarded blood samples. To determine the degree of inflammation, C-reactive protein (CRP) concentrations were used. Subsequently, a longitudinal data analysis was performed to assess the effect of inflammation on the metabolic ratio and voriconazole trough concentration. RESULTS Thirty-four patients were included. In total 489 voriconazole trough concentrations were included in the longitudinal data analysis. This analysis showed that inflammation, reflected by CRP concentrations, significantly influenced the metabolic ratio, voriconazole trough concentration and voriconazole-N-oxide concentration (all P < 0.001), when corrected for other factors that could influence voriconazole metabolism. The metabolic ratio was decreased by 0.99229N and the voriconazole-N-oxide concentration by 0.99775N, while the voriconazole trough concentration was increased by 1.005321N, where N is the difference in CRP units (in mg/L). CONCLUSIONS This study shows that voriconazole metabolism is decreased during inflammation, resulting in higher voriconazole trough concentrations. Therefore, frequent monitoring of voriconazole serum concentrations is recommended during and following severe inflammation.
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Affiliation(s)
- Anette Veringa
- University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
| | - Mendy Ter Avest
- University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
| | - Lambert F R Span
- University Medical Center Groningen, Department of Hematology, University of Groningen, Groningen, the Netherlands
| | - Edwin R van den Heuvel
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Daan J Touw
- University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
| | - Jan G Zijlstra
- University Medical Center Groningen, Department of Critical Care, University of Groningen, Groningen, the Netherlands
| | - Jos G W Kosterink
- University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands.,University of Groningen, Department of Pharmacy, Section of Pharmacotherapy and Pharmaceutical Care, Groningen, the Netherlands
| | - Tjip S van der Werf
- University Medical Center Groningen, Department of Internal Medicine, University of Groningen, Groningen, the Netherlands.,University Medical Center Groningen, Department of Pulmonary Diseases and Tuberculosis, University of Groningen, Groningen, the Netherlands
| | - Jan-Willem C Alffenaar
- University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
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