1
|
Chandra S, Mizuno K, Zhao J, Davies SM, Marsh RA, Fukuda T, Setchell KDR, Vinks AA, Mehta PA. Test-dose pharmacokinetics guided melphalan dose adjustment in reduced intensity conditioning allogeneic transplant for non-malignant disorders. Br J Clin Pharmacol 2021; 88:115-127. [PMID: 34075614 DOI: 10.1111/bcp.14932] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/07/2021] [Accepted: 05/23/2021] [Indexed: 12/16/2022] Open
Abstract
AIMS We studied melphalan pharmacokinetics (PK) and feasibility of melphalan full-dose adjustment based on test-dose PK in children and young adults with non-malignant disorders (NMD) undergoing allogeneic hematopoietic cell transplantation (HCT) using reduced intensity conditioning (RIC) containing alemtuzumab, fludarabine and melphalan. METHODS Patients received test-dose melphalan (10% of planned full-dose) prior to conditioning. Blood samples for PK were obtained around test and full-dose melphalan (140 mg/m2 or 4.7 mg/kg in patients <10 kg). Melphalan concentration was measured by liquid chromatography electrospray ionization tandem mass-spectrometry assay and data were analysed using a population-PK model and Bayesian estimation. Test and full-dose melphalan clearance estimates were evaluated by pairwise Wilcoxon test and Bland-Altman plot. RESULTS Twenty-four patients undergoing 25 transplants were included in the final analysis. Patients received standard full-dose melphalan in 17 transplants, with median area under the concentration-time curve (AUC) of 5.5 mg*h/L (range, 3.0-9.5 mg*h/L). Patients received test-dose melphalan in 23 transplants with a test-dose PK predicted full-dose AUC range of 2.9-16.8 mg*h/L. In seven transplants where patients had baseline organ impairment, test-dose PK predicted higher exposure for standard full-dose (median AUC 13.8 mg*h/L). Melphalan full-dose was adjusted in these patients, with achievement of desired target AUC (3.6-5.4 mg*h/L) and no excess toxicity. Mean ratio of test-dose clearance to full-dose clearance was 1.03. Twenty of 22 patients (91%) were within the 95% confidence intervals of the clearance ratio. CONCLUSION Melphalan test-dose PK reliably predicts full-dose PK and allows for accurate adjustment of full-dose melphalan in RIC-HCT for NMD. This approach can avoid excess toxicity from increased systemic exposure, especially in patients with organ impairment.
Collapse
Affiliation(s)
- Sharat Chandra
- Divisions of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Kana Mizuno
- Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Junfang Zhao
- Pathology & Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Stella M Davies
- Divisions of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Rebecca A Marsh
- Divisions of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Tsuyoshi Fukuda
- Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Kenneth D R Setchell
- Pathology & Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Alexander A Vinks
- Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Parinda A Mehta
- Divisions of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| |
Collapse
|