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Gastine S, Morse JD, Leung MT, Wong ICK, Howard RF, Harrop E, Liossi C, Standing JF, Jassal SS, Hain RD, Skene S, Oulton K, Law SL, Quek WT, Anderson BJ. Diamorphine pharmacokinetics and conversion factor estimates for intranasal diamorphine in paediatric breakthrough pain:systematic review. BMJ Support Palliat Care 2024; 13:e485-e493. [PMID: 35184039 DOI: 10.1136/bmjspcare-2021-003461] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/26/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Intranasal diamorphine is a potential treatment for breakthrough pain but few paediatric data are available to assist dose estimation. AIM To determine an intranasal diamorphine dose in children through an understanding of pharmacokinetics. DESIGN A systematic review of the literature was undertaken to seek diamorphine pharmacokinetic parameters in neonates, children and adults. Parenteral and enteral diamorphine bioavailability were reviewed with respect to formation of the major metabolite, morphine. Clinical data quantifying equianalgesic effects of diamorphine and morphine were reviewed. REVIEW SOURCES PubMed (1960-2020); EMBASE (1980-2020); IPA (1973-2020) and original human research studies that reported diacetylmorphine and metabolite after any dose or route of administration. RESULTS The systematic review identified 19 studies: 16 in adults and 1 in children and 2 neonatal reports. Details of study participants were extracted. Age ranged from premature neonates to 67 years and weight 1.4-88 kg. Intranasal diamorphine bioavailability was predicted as 50%. The equianalgesic intravenous conversion ratio of morphine:diamorphine was 2:1. There was heterogeneity between pharmacokinetic parameter estimates attributed to routes of administration, lack of size standardisation, methodology and pharmacokinetic analysis. Estimates of the pharmacokinetic parameters clearance and volume of distribution were reduced in neonates. There were insufficient paediatric data to characterise clearance or volume maturation of either diamorphine or its metabolites. CONCLUSIONS We estimate equianalgesic ratios of intravenous morphine:diamorphine 2:1, intravenous morphine:intranasal diamorphine 1:1 and oral morphine:intranasal diamorphine of 1:3. These ratios are based on adult literature, but are reasonable for deciding on an initial dose of 0.1 mg/kg in children 4-13 years.
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Affiliation(s)
- Silke Gastine
- Great Ormond St Institute of Child Health, University College London, London, UK
| | - James D Morse
- Department of Pharmacology & Clinical Pharmacology, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Miriam Ty Leung
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, Hong Kong
| | - Ian Chi Kei Wong
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
| | - Richard F Howard
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Christina Liossi
- School of Psychology, University of Southampton, Southampton, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Joseph F Standing
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Department of Immunity and Inflammation, University College London, London, UK
| | - Satbir Singh Jassal
- Palliative Care, Rainbows Hospice for Children and Young Adults, Loughborough, UK
| | - Richard D Hain
- All-Wales Managed Clinical Network in Paediatric Palliative Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Simon Skene
- Faculty of Arts and Human Sciences, Surrey Clinical Trials Unit, University of Surrey, Guildford, UK
| | - Kate Oulton
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Siew L Law
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
| | - Wan T Quek
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
| | - Brian J Anderson
- Department of Anaesthesiology, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
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Harrop E, Liossi C, Jamieson L, Gastine S, Oulton K, Skene SS, Howard RF, Johnson M, Boyce K, Mitchell L, Jassal S, Anderson AK, Hain RDW, Hills M, Bayliss J, Soman A, Laddie J, Vickers D, Mellor C, Warlow T, Wong IC. Oral morphine versus transmucosal diamorphine for breakthrough pain in children: methods and outcomes: UK (DIPPER study) consensus. BMJ Support Palliat Care 2024; 13:e1019-e1028. [PMID: 34903585 PMCID: PMC10850727 DOI: 10.1136/bmjspcare-2021-003278] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/04/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVES No randomised controlled trials have been conducted for breakthrough pain in paediatric palliative care and there are currently no standardised outcome measures. The DIPPER study aims to establish the feasibility of conducting a prospective randomised controlled trial comparing oral and transmucosal administration of opioids for breakthrough pain. The aim of the current study was to achieve consensus on design aspects for a small-scale prospective study to inform a future randomised controlled trial of oral morphine, the current first-line treatment, versus transmucosal diamorphine. METHODS The nominal group technique was used to achieve consensus on best practice for mode of administration, dose regimen and a range of suitable pain intensity outcome measures for transmucosal diamorphine in children and young people with breakthrough pain. An expert panel of ten clinicians in paediatric palliative care and three parent representatives participated. Consensus was achieved when agreement was reached and no further comments from participants were forthcoming. RESULTS The panel favoured the buccal route of administration, with dosing according to the recommendations in the Association for Paediatric Palliative Medicine formulary (fifth Edition, 2020). The verbal Numerical Rating Scale was selected to measure pain in children 8 years old and older, the Faces Pain Scale-Revised for children between 4 and 8 years old, and Face, Legs, Activity, Cry and Consolability (FLACC)/FLACC-Revised as the observational tools. CONCLUSIONS The nominal group technique allowed consensus to be reached for a small-scale, prospective, cohort study and provided information to inform the design of a randomised controlled trial.
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Affiliation(s)
- Emily Harrop
- Helen and Douglas House Hospice, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Christina Liossi
- School of Psychology, University of Southampton, Southampton, UK
- Department of Psychology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Liz Jamieson
- Research Dept of Practice & Policy, University College London School of Pharmacy, London, UK
- UCLH-UCL Centre for Medicines Optimisation Research and Education, London, UK
| | - Silke Gastine
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Kate Oulton
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Simon S Skene
- Surrey Clinical Trials Unit, University of Surrey, Guildford, UK
- School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Richard F Howard
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Margaret Johnson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Katherine Boyce
- Helen and Douglas House Hospice, Oxford, UK
- Flexicare Oxford & Abingdon, Oxford, UK
| | | | - Satbir Jassal
- Rainbows Hospice for Children and Young People, Loughborough, UK
| | - Anna-Karenia Anderson
- Paediatrics, Royal Marsden Hospital, Sutton, UK
- Shooting Star Children's Hospice, Guildford, UK
| | - Richard D W Hain
- All-Wales Managed Clinical Network in Paediatric Palliative Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Michelle Hills
- Martin House Hospice for Children and Young People, Boston Spa, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Julie Bayliss
- The Louis Dundas Centre, Oncology Outreach and Palliative Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Archana Soman
- Sheffield Children's Hospital, Sheffield, UK
- Bluebell Wood Children's Hospice, North Anston, UK
| | | | - David Vickers
- Medical Director, Cambridgeshire Community Services NHS Trust, St Ives, UK
- East Anglia's Children's Hospices, Cambridgeshire, UK
| | | | - Tim Warlow
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Naomi House and Jacksplace, Winchester, UK
| | - Ian Ck Wong
- Research Dept of Practice & Policy, University College London School of Pharmacy, London, UK
- UCLH-UCL Centre for Medicines Optimisation Research and Education, London, UK
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Pok Fu Lam, Hong Kong
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Kane Z, Cheng I, McGarrity O, Chiesa R, Klein N, Cortina-Borja M, Standing JF, Gastine S. Model Based Estimation of Posaconazole Tablet and Suspension Bioavailability in Hospitalized Children Using Real-World Therapeutic Drug Monitoring Data in Patients Receiving Intravenous and Oral Dosing. Antimicrob Agents Chemother 2023; 67:e0007723. [PMID: 37260401 PMCID: PMC10353366 DOI: 10.1128/aac.00077-23] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/18/2023] [Indexed: 06/02/2023] Open
Abstract
Invasive fungal infections are a major cause of morbidity and mortality for immunocompromised patients. Posaconazole is approved for treatment and prophylaxis of invasive fungal infection in adult patients, with intravenous, oral suspension, and gastroresistant/delayed-released tablet formulations available. In Europe, until very recently, posaconazole was used off-label in children, although a new delayed-release suspension approved for pediatric use is expected to become available soon. A population pharmacokinetic model was developed which uses posaconazole therapeutic drug monitoring data following intravenous and oral dosing in hospitalized children, thus enabling estimation of pediatric suspension and tablet oral bioavailability. In total, 297 therapeutic drug monitoring plasma levels from 104 children were included in this analysis. The final model was a one-compartment model with first-order absorption and nonlinear elimination. Allometric scaling on clearance and volume of distribution was included a priori. Tablet bioavailability was estimated to be 66%. Suspension bioavailability was estimated to decrease with increasing doses, ranging from 3.8% to 32.2% in this study population. Additionally, concomitant use of proton pump-inhibitors was detected as a significant covariate, reducing suspension bioavailability by 41.0%. This is the first population pharmacokinetic study to model posaconazole data from hospitalized children following intravenous, tablet, and suspension dosing simultaneously. The incorporation of saturable posaconazole clearance into the model has been key to the credible joint estimation of tablet and suspension bioavailability. To aid rational posaconazole dosing in children, this model was used alongside published pharmacodynamic targets to predict the probability of target attainment using typical pediatric dosing regimen.
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Affiliation(s)
- Zoe Kane
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Iek Cheng
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Department of Pharmacy, Great Ormond Street Hospital, London, United Kingdom
| | - Orlagh McGarrity
- Department of Pharmacy, Great Ormond Street Hospital, London, United Kingdom
| | - Robert Chiesa
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital, London, United Kingdom
| | - Nigel Klein
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Mario Cortina-Borja
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Joseph F. Standing
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Department of Pharmacy, Great Ormond Street Hospital, London, United Kingdom
| | - Silke Gastine
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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Smith TA, Hoyo-Vadillo C, Adom AA, Favari-Perozzi L, Gastine S, Dehbi HM, Villegas-Lara B, Mateos E, González YSP, Navarro-Gualito MD, Cruz-Carbajal AS, Cortes-Vazquez MA, Bekker-Méndez C, Aguirre-Alvarado C, Aguirre-Gil G, Delgado-Pastelin L, Owen A, Lowe D, Standing J, Escobedo J. Correction: Favipiravir and/or nitazoxanide: a randomized, double-blind, placebo-controlled trial of early therapy in COVID-19 in health workers, their household members, and patients treated at IMSS (FANTAZE). Trials 2023; 24:347. [PMID: 37218017 PMCID: PMC10201498 DOI: 10.1186/s13063-023-07364-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David Lowe
- Division of Infection and Immunity, UCL, London, UK
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Grandits M, Grünwald-Gruber C, Gastine S, Standing JF, Reljic R, Teh AYH, Ma JKC. Improving the efficacy of plant-made anti-HIV monoclonal antibodies for clinical use. Front Plant Sci 2023; 14:1126470. [PMID: 36923134 PMCID: PMC10009187 DOI: 10.3389/fpls.2023.1126470] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 02/01/2023] [Indexed: 06/18/2023]
Abstract
Introduction Broadly neutralising antibodies are promising candidates for preventing and treating Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS), as an alternative to or in combination with antiretroviral therapy (ART). These mAbs bind to sites on the virus essential for virus attachment and entry, thereby inhibiting entry into the host cell. However, the cost and availability of monoclonal antibodies, especially combinations of antibodies, hampers implementation of anti-HIV bNAb therapies in low- to middle- income countries (LMICs) where HIV-1 prevalence is highest. Methods We have produced three HIV broadly neutralizing antibodies (bNAbs), 10-1074, VRC01 and 3BNC117 in the Nicotiana benthamiana transient expression system. The impact of specific modifications to enhance potency and efficacy were assessed. To prolong half-life and increase bioavailability, a M252Y/S254T/T256E (YTE) or M428L/N434S (LS) mutation was introduced. To increase antibody dependent cellular cytotoxicity (ADCC), we expressed an afucosylated version of each antibody using a glycoengineered plant line. Results The majority of bNAbs and their variants could be expressed at yields of up to 47 mg/kg. Neither the expression system nor the modifications impacted the neutralization potential of the bNAbs. Afucosylated bNAbs exhibit enhanced ability to bind to FcγRIIIa and trigger ADCC, regardless of the presence of Fc amino acid mutations. Lastly, we demonstrated that Fc-modified variants expressed in plants show enhanced binding to FcRn, which results in a favourable in vivo pharmacokinetic profile compared to their unmodified counterparts. Conclusion Tobacco plants are suitable expression hosts for anti-HIV bNAbs with increased efficacy and an improved pharmacokinetic profile.
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Affiliation(s)
- Melanie Grandits
- Molecular Immunology Unit, Institute for Infection and Immunity, St. George's University of London, London, United Kingdom
| | - Clemens Grünwald-Gruber
- Core Facility Mass Spectrometry, University of Natural Resources and Life Sciences, Vienna, Austria
| | - Silke Gastine
- Infection, Immunity and Inflammation Research and Teaching Department, University College London (UCL) Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Joseph F. Standing
- Infection, Immunity and Inflammation Research and Teaching Department, University College London (UCL) Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Rajko Reljic
- Molecular Immunology Unit, Institute for Infection and Immunity, St. George's University of London, London, United Kingdom
| | - Audrey Y-H. Teh
- Molecular Immunology Unit, Institute for Infection and Immunity, St. George's University of London, London, United Kingdom
| | - Julian K-C. Ma
- Molecular Immunology Unit, Institute for Infection and Immunity, St. George's University of London, London, United Kingdom
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6
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Obiero CW, Williams P, Murunga S, Thitiri J, Omollo R, Walker AS, Egondi T, Nyaoke B, Correia E, Kane Z, Gastine S, Kipper K, Standing JF, Ellis S, Sharland M, Berkley JA. Randomised controlled trial of fosfomycin in neonatal sepsis: pharmacokinetics and safety in relation to sodium overload. Arch Dis Child 2022; 107:802-810. [PMID: 35078765 PMCID: PMC9411916 DOI: 10.1136/archdischild-2021-322483] [Citation(s) in RCA: 2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 12/24/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess pharmacokinetics and changes to sodium levels in addition to adverse events (AEs) associated with fosfomycin among neonates with clinical sepsis. DESIGN A single-centre open-label randomised controlled trial. SETTING Kilifi County Hospital, Kenya. PATIENTS 120 neonates aged ≤28 days admitted being treated with standard-of-care (SOC) antibiotics for sepsis: ampicillin and gentamicin between March 2018 and February 2019. INTERVENTION We randomly assigned half the participants to receive additional intravenous then oral fosfomycin at 100 mg/kg two times per day for up to 7 days (SOC-F) and followed up for 28 days. MAIN OUTCOMES AND MEASURES Serum sodium, AEs and fosfomycin pharmacokinetics. RESULTS 61 and 59 infants aged 0-23 days were assigned to SOC-F and SOC, respectively. There was no evidence of impact of fosfomycin on serum sodium or gastrointestinal side effects. We observed 35 AEs among 25 SOC-F participants and 50 AEs among 34 SOC participants during 1560 and 1565 infant-days observation, respectively (2.2 vs 3.2 events/100 infant-days; incidence rate difference -0.95 events/100 infant-days (95% CI -2.1 to 0.20)). Four SOC-F and 3 SOC participants died. From 238 pharmacokinetic samples, modelling suggests an intravenous dose of 150 mg/kg two times per day is required for pharmacodynamic target attainment in most children, reduced to 100 mg/kg two times per day in neonates aged <7 days or weighing <1500 g. CONCLUSION AND RELEVANCE Fosfomycin offers potential as an affordable regimen with a simple dosing schedule for neonatal sepsis. Further research on its safety is needed in larger cohorts of hospitalised neonates, including very preterm neonates or those critically ill. Resistance suppression would only be achieved for the most sensitive of organisms so fosfomycin is recommended to be used in combination with another antimicrobial. TRIAL REGISTRATION NUMBER NCT03453177.
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Affiliation(s)
- Christina W Obiero
- Clinical Research Deptartment, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Global Health, University of Amsterdam, Amsterdam, The Netherlands
| | - Phoebe Williams
- Clinical Research Deptartment, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sheila Murunga
- Clinical Research Deptartment, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Johnstone Thitiri
- Clinical Research Deptartment, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Raymond Omollo
- Global Antibiotic Research and Development Partnership, Nairobi, Kenya
| | | | - Thaddaeus Egondi
- Global Antibiotic Research and Development Partnership, Nairobi, Kenya
| | - Borna Nyaoke
- Global Antibiotic Research and Development Partnership, Nairobi, Kenya
| | - Erika Correia
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
| | - Zoe Kane
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Silke Gastine
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Karin Kipper
- Institute of Chemistry, University of Tartu, Tartu, Estonia.,Analytical Services International (ASI) Ltd, St George's - University of London, London, UK
| | - Joseph F Standing
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Sally Ellis
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, University of London, London, UK
| | - James Alexander Berkley
- Clinical Research Deptartment, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya .,Nuffield Department of Medicine, University of Oxford, Oxford, UK.,The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
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7
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Smith T, Hoyo-Vadillo C, Adom AA, Favari-Perozzi L, Gastine S, Dehbi HM, Villegas-Lara B, Mateos E, González YSP, Navarro-Gualito MD, Cruz-Carbajal AS, Cortes-Vazquez MA, Bekker-Méndez C, Aguirre-Alvarado C, Aguirre-Gil G, Delgado-Pastelin L, Owen A, Lowe D, Standing J, Escobedo J. Favipiravir and/or nitazoxanide: a randomized, double-blind, 2×2 design, placebo-controlled trial of early therapy in COVID-19 in health workers, their household members, and patients treated at IMSS (FANTAZE). Trials 2022; 23:583. [PMID: 35869526 PMCID: PMC9306230 DOI: 10.1186/s13063-022-06533-0] [Citation(s) in RCA: 1] [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: 02/28/2022] [Accepted: 07/08/2022] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The 2020 pandemic of SARS-CoV-2 causing COVID-19 disease is an unprecedented global emergency. COVID-19 appears to be a disease with an early phase where the virus replicates, coinciding with the first presentation of symptoms, followed by a later 'inflammatory' phase which results in severe disease in some individuals. It is known from other rapidly progressive infections such as sepsis and influenza that early treatment with antimicrobials is associated with a better outcome. The hypothesis is that this holds for COVID-19 and that early antiviral treatment may prevent progression to the later phase of the disease. METHODS Trial design: Phase IIA randomised, double-blind, 2 × 2 design, placebo-controlled, interventional trial. RANDOMISATION Participants will be randomised 1:1 by stratification, with the following factors: gender, obesity, symptomatic or asymptomatic, current smoking status presence or absence of comorbidity, and if the participant has or has not been vaccinated. BLINDING Participants and investigators will both be blinded to treatment allocation (double-blind). DISCUSSION We propose to conduct a proof-of-principle placebo-controlled clinical trial of favipiravir plus or minus nitazoxanide in health workers, their household members and patients treated at the Mexican Social Security Institute (IMSS) facilities. Participants with or without symptomatic COVID-19 or who tested positive will be assigned to receive favipiravir plus nitazoxanide or favipiravir plus nitazoxanide placebo. The primary outcome will be the difference in the amount of virus ('viral load') in the upper respiratory tract after 5 days of therapy. Secondary outcomes will include hospitalization, major morbidity and mortality, pharmacokinetics, and impact of antiviral therapy on viral genetic mutation rate. If favipiravir with nitazoxanide demonstrates important antiviral effects without significant toxicity, there will be a strong case for a larger trial in people at high risk of hospitalization or intensive care admission, for example older patients and/or those with comorbidities and with early disease. TRIAL REGISTRATION ClinicalTrials.gov NCT04918927 . Registered on June 9, 2021.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David Lowe
- Division of Infection and Immunity, UCL, London, UK
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8
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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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9
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Morse JD, Anderson BJ, Gastine S, Wong ICK, Standing JF. Pharmacokinetic modeling and simulation to understand diamorphine dose-response in neonates, children, and adolescents. Paediatr Anaesth 2022; 32:716-726. [PMID: 35212432 DOI: 10.1111/pan.14425] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/19/2022] [Accepted: 02/21/2022] [Indexed: 11/28/2022]
Abstract
Pharmacokinetic-pharmacodynamic modeling and simulation can facilitate understanding and prediction of exposure-response relationships in children with acute or chronic pain. The pharmacokinetics of diamorphine (diacetylmorphine, heroin), a strong opioid, remain poorly quantified in children and dose is often guided by clinical acumen. This tutorial demonstrates how a model to describe intranasal and intravenous diamorphine pharmacokinetics can be fashioned from a model for diamorphine disposition in adults and a model describing morphine disposition in children. Allometric scaling and maturation models were applied to clearances and volumes to account for differences in size and age between children and adults. The utility of modeling and simulation to gain insight into the analgesic exposure-response relationship is demonstrated. The model explains reported observations, can be used for interrogation, interpolated to determine equianalgesia and inform future clinical studies. Simulation was used to illustrate how diamorphine is rapidly metabolized to morphine via its active metabolite 6-monoacetylmorphine, which mediates an early dopaminergic response accountable for early euphoria. Morphine formation is then responsible for the slower, prolonged analgesic response. Time-concentration profiles of diamorphine and its metabolites reflected disposition changes with age and were used to describe intravenous and intranasal dosing regimens. These indicated that morphine exposure in children after intranasal diamorphine 0.1 mg.kg-1 was similar to that after intranasal diamorphine 5 mg in adults. A target concentration of morphine 30 μg.L-1 can be achieved by a diamorphine intravenous infusion in neonates 14 μg.kg-1 .h-1 , in a 5-year-old child 42 μg.kg-1 .h-1 and in an 15 year-old-adolescent 33 μg.kg-1 .h-1 .
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Affiliation(s)
- James D Morse
- Department of Pharmacology & Clinical Pharmacology, Auckland University, Auckland, New Zealand
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Silke Gastine
- Infection, Immunity, and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Ian C K Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Joseph F Standing
- Infection, Immunity, and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
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10
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Gastine S, Obiero C, Kane Z, Williams P, Readman J, Murunga S, Thitiri J, Ellis S, Correia E, Nyaoke B, Kipper K, van den Anker J, Sharland M, Berkley JA, Standing JF. Simultaneous pharmacokinetic/pharmacodynamic (PKPD) assessment of ampicillin and gentamicin in the treatment of neonatal sepsis. J Antimicrob Chemother 2022; 77:448-456. [PMID: 35107141 PMCID: PMC8809196 DOI: 10.1093/jac/dkab413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022] Open
Abstract
Objectives This study aimed to simultaneously investigate the pharmacokinetics of ampicillin and gentamicin, currently the WHO standard of care for treating neonatal sepsis. Methods Pharmacokinetic data were collected in 59 neonates receiving ampicillin and gentamicin for suspected or proven sepsis in the NeoFosfo trial (NCT03453177). A panel of 23 clinical Escherichia coli isolates from neonates with sepsis, resistant to either ampicillin, gentamicin or both, were tested for susceptibility using chequerboards. Pharmacokinetic/pharmacodynamic (PKPD) modelling and simulations were used to compare single-agent (EUCAST MIC) and combination (chequerboard MIC) target attainment with standard dosing regimens. Results A model was established that simultaneously estimated parameters of a one-compartment ampicillin model and a two-compartment gentamicin model. A common clearance for both drugs was used (6.89 L/h/70 kg) relating to glomerular filtration (CLGFR), with an additional clearance term added for ampicillin (5.3 L/h/70 kg). Covariate modelling included a priori allometric weight and post-menstrual age scaling of clearance. Further covariate relationships on renal clearance were postnatal age and serum creatinine. Simulation-based PKPD assessments suggest good Gram-positive (MIC ≤ 0.25 mg/L) cover. However, less than one-quarter of neonates were predicted to receive efficacious coverage against Enterobacterales (MIC ≤ 2 mg/L). The benefit of the ampicillin/gentamicin combination was limited, with only 2/23 E. coli clinical strains showing FIC index < 0.5 (synergy) and most in the range 0.5–1 (suggesting additivity). Simulations showed that feasible dosing strategies would be insufficient to cover resistant strains. Conclusions PKPD simulations showed ampicillin and gentamicin combination therapy was insufficient to cover Enterobacterales, suggesting the need for alternative empirical treatment options for neonatal sepsis.
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Affiliation(s)
- Silke Gastine
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
| | | | - Zoe Kane
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK.,Quotient Sciences, Mere Way, Ruddington, Nottingham, UK
| | - Phoebe Williams
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - John Readman
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
| | | | | | - Sally Ellis
- Global Antibiotic Research & Development Partnership (GARDP), Genève, Switzerland
| | - Erika Correia
- Global Antibiotic Research & Development Partnership (GARDP), Genève, Switzerland
| | - Borna Nyaoke
- Drugs for Neglected Diseases Initiative (DNDi), Nairobi, Kenya
| | - Karin Kipper
- Institute of Chemistry, University of Tartu, Tartu, Estonia
| | - John van den Anker
- Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Switzerland.,Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's, University of London, London, UK
| | - James A Berkley
- Quotient Sciences, Mere Way, Ruddington, Nottingham, UK.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Joseph F Standing
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK.,Pharmacy Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
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11
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Frank T, Gastine S, Lindauer K, Speth H, Strougo A, Kovar A. LaTeX tutorial for the standardization and automation of population analysis reports. CPT Pharmacometrics Syst Pharmacol 2021; 10:1310-1322. [PMID: 34478613 PMCID: PMC8592516 DOI: 10.1002/psp4.12705] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/01/2020] [Accepted: 07/01/2021] [Indexed: 11/27/2022] Open
Abstract
Writing population analysis reports that fulfilling the specifications of submission readiness is a time‐consuming process and prone to human error. Thus, there is a need to streamline the creation of these reports through elements of standardization and automation. LaTeX is considered a suitable program package capable of creating long, modular, structured documents, and, because of its typographic quality, includes formula typesetting. The presented automation scripts together with easily adjustable LaTeX templates are designed to enable the reader to understand and reproduce a typical workflow from analysis to reporting. The focus of this tutorial is to use an example of a population pharmacokinetic analysis to show how to work with the proposed automated structures allowing even a reader new to the concept of LaTeX to automatize the reporting workflow and customize the templates for their specific needs.
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Affiliation(s)
- Thomas Frank
- Sanofi‐Aventis Deutschland GmbH R&D Frankfurt Germany
| | - Silke Gastine
- Sanofi‐Aventis Deutschland GmbH R&D Frankfurt Germany
| | | | - Heiner Speth
- Sanofi‐Aventis Deutschland GmbH R&D Frankfurt Germany
| | | | - Andreas Kovar
- Sanofi‐Aventis Deutschland GmbH R&D Frankfurt Germany
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12
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Bentley S, Davies JC, Gastine S, Donovan J, Standing JF. Clinical pharmacokinetics and dose recommendations for posaconazole gastroresistant tablets in children with cystic fibrosis. J Antimicrob Chemother 2021; 76:3247-3254. [PMID: 34458906 PMCID: PMC8598294 DOI: 10.1093/jac/dkab312] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/21/2021] [Indexed: 12/13/2022] Open
Abstract
Objectives To investigate the population pharmacokinetics of posaconazole gastroresistant tablets in children with cystic fibrosis (CF) and perform simulations to recommend optimal doses. Patients and methods Children from a paediatric CF centre who had received posaconazole tablets and underwent therapeutic drug monitoring were identified from pharmacy records. Relevant clinical data were collated from case notes and electronic patient records and used to develop an allometrically scaled population pharmacokinetic model. A stepwise covariate model-building exercise evaluated the influence of interacting medicines and liver function. Results One hundred posaconazole serum concentrations were collected from 37 children with a median age of 14 years (range 7–17). Posaconazole pharmacokinetics were adequately described by a one-compartment model with inter-individual variability on clearance. Dose simulations demonstrated a 77%–83% probability of attaining a trough target of 1 mg/L with a dose of 300 mg every 12 h for two doses then 300 mg once daily (OD) in children aged 6–11 years; and 86%–88% with a dose of 400 mg every 12 h for two doses then 400 mg OD in adolescents aged 12–17 years. This dose scheme also yielded a 90% probability of achieving an AUC of 30 mg·h/L. AUC and trough concentration were highly correlated (r2 = 0.98). Simulations showed that trough concentrations of >0.75 mg/L would exceed an AUC of 30 mg·h/L in 90% of patients. Conclusions A starting dose of 300 mg OD in those aged 6–11 years and 400 mg OD in those aged 12–17 years (following loading doses) yields a 90% probability of attaining an AUC of 30 mg·h/L.
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Affiliation(s)
- Siân Bentley
- Pharmacy Department, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Jane C Davies
- National Heart and Lung Institute, Imperial College London, London, UK.,Paediatric Respiratory Medicine Department, Royal Brompton Hospital, London, UK
| | - Silke Gastine
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Jackie Donovan
- Clinical Biochemistry Department, Royal Brompton Hospital, London, UK
| | - Joseph F Standing
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK.,Pharmacy Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
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13
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Gastine S, Pang J, Boshier FA, Carter SJ, Lonsdale DO, Cortina‐Borja M, Hung IF, Breuer J, Kloprogge F, Standing JF. Systematic Review and Patient-Level Meta-Analysis of SARS-CoV-2 Viral Dynamics to Model Response to Antiviral Therapies. Clin Pharmacol Ther 2021; 110:321-333. [PMID: 33641159 PMCID: PMC8014833 DOI: 10.1002/cpt.2223] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/22/2021] [Indexed: 12/13/2022]
Abstract
Severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) viral loads change rapidly following symptom onset, so to assess antivirals it is important to understand the natural history and patient factors influencing this. We undertook an individual patient-level meta-analysis of SARS-CoV-2 viral dynamics in humans to describe viral dynamics and estimate the effects of antivirals used to date. This systematic review identified case reports, case series, and clinical trial data from publications between January 1, 2020, and May 31, 2020, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A multivariable Cox proportional hazards (Cox-PH) regression model of time to viral clearance was fitted to respiratory and stool samples. A simplified four parameter nonlinear mixed-effects (NLME) model was fitted to viral load trajectories in all sampling sites and covariate modeling of respiratory viral dynamics was performed to quantify time-dependent drug effects. Patient-level data from 645 individuals (age 1 month to 100 years) with 6,316 viral loads were extracted. Model-based simulations of viral load trajectories in samples from the upper and lower respiratory tract, stool, blood, urine, ocular secretions, and breast milk were generated. Cox-PH modeling showed longer time to viral clearance in older patients, men, and those with more severe disease. Remdesivir was associated with faster viral clearance (adjusted hazard ratio (AHR) = 9.19, P < 0.001), as well as interferon, particularly when combined with ribavirin (AHR = 2.2, P = 0.015; AHR = 6.04, P = 0.006). Combination therapy should be further investigated. A viral dynamic dataset and NLME model for designing and analyzing antiviral trials has been established.
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Affiliation(s)
- Silke Gastine
- Infection, Immunity and Inflammation Research and Teaching DepartmentGreat Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - Juanita Pang
- Division of Infection and ImmunityUniversity College LondonLondonUK
| | | | - Simon J. Carter
- Infection, Immunity and Inflammation Research and Teaching DepartmentGreat Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - Dagan O. Lonsdale
- Department of Clinical PharmacologySt George’s University of LondonLondonUK
- Department of Intensive CareSt George’s University Hospitals NHS Foundation TrustLondonUK
| | - Mario Cortina‐Borja
- Population, Policy and Practice Research and Teaching DepartmentGreat Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - Ivan F.N. Hung
- Division of Infectious DiseasesDepartment of MedicineThe University of Hong KongHong KongChina
| | - Judy Breuer
- Division of Infection and ImmunityUniversity College LondonLondonUK
| | - Frank Kloprogge
- Institute for Global HealthUniversity College LondonLondonUK
| | - Joseph F. Standing
- Infection, Immunity and Inflammation Research and Teaching DepartmentGreat Ormond Street Institute of Child HealthUniversity College LondonLondonUK
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14
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Kane Z, Gastine S, Obiero C, Williams P, Murunga S, Thitiri J, Ellis S, Correia E, Nyaoke B, Kipper K, van den Anker J, Sharland M, Berkley JA, Standing JF. IV and oral fosfomycin pharmacokinetics in neonates with suspected clinical sepsis. J Antimicrob Chemother 2021; 76:1855-1864. [PMID: 33855449 PMCID: PMC8212774 DOI: 10.1093/jac/dkab083] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/20/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Fosfomycin has the potential to be re-purposed as part of a combination therapy to treat neonatal sepsis where resistance to current standard of care (SOC) is common. Limited data exist on neonatal fosfomycin pharmacokinetics and estimates of bioavailability and CSF/plasma ratio in this vulnerable population are lacking. OBJECTIVES To generate data informing the appropriate dosing of IV and oral fosfomycin in neonates using a population pharmacokinetic analysis of plasma and CSF data. METHODS The NeoFosfo study (NCT03453177) was a randomized trial that examined the safety and pharmacokinetics of fosfomycin comparing SOC versus SOC plus fosfomycin. Sixty-one neonates received fosfomycin (100 mg/kg IV q12h for 48 h) and then they converted to oral therapy at the same dose. Two plasma pharmacokinetic samples were taken following the first IV and oral doses, sample times were randomized to cover the whole pharmacokinetic profile and opportunistic CSF pharmacokinetic samples were collected. A population pharmacokinetic model was developed in NONMEM and simulations were performed. RESULTS In total, 238 plasma and 15 CSF concentrations were collected. A two-compartment disposition model, with an additional CSF compartment and first-order absorption, best described the data. Bioavailability was estimated as 0.48 (95% CI = 0.347-0.775) and the CSF/plasma ratio as 0.32 (95% CI = 0.272-0.409). Allometric weight and postmenstrual age (PMA) scaling was applied; additional covariates included postnatal age (PNA) on clearance and CSF protein on CSF/plasma ratio. CONCLUSIONS Through this analysis a population pharmacokinetic model has been developed that can be used alongside currently available pharmacodynamic targets to select a neonatal fosfomycin dose based on an infant's PMA, PNA and weight.
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Affiliation(s)
- Zoe Kane
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK.,Quotient Sciences, Mere Way, Ruddington, Nottingham, UK
| | - Silke Gastine
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
| | | | - Phoebe Williams
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | - Sally Ellis
- GARDP-Global Antibiotic Research & Development Partnership, Genève, Switzerland
| | - Erika Correia
- GARDP-Global Antibiotic Research & Development Partnership, Genève, Switzerland
| | - Borna Nyaoke
- DNDi-Drugs for Neglected Diseases initiative, Nairobi, Kenya
| | - Karin Kipper
- Institute of Chemistry, University of Tartu, Tartu, Estonia
| | - John van den Anker
- Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland.,Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - James A Berkley
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Joseph F Standing
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK.,Pharmacy Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
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15
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Westermann I, Gastine S, Müller C, Rudolph W, Peters F, Bloos F, Pletz M, Hagel S. Population pharmacokinetics and probability of target attainment in patients with sepsis under renal replacement therapy receiving continuous infusion of meropenem: Sustained low-efficiency dialysis and continuous veno-venous haemodialysis. Br J Clin Pharmacol 2021; 87:4293-4303. [PMID: 33818823 DOI: 10.1111/bcp.14846] [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: 11/21/2020] [Revised: 03/16/2021] [Accepted: 03/27/2021] [Indexed: 01/01/2023] Open
Abstract
AIMS To describe the population pharmacokinetics (PK) and probability of target attainment (PTA) of continuous infusion (CI) of meropenem in septic patients receiving renal replacement therapy (RRT). METHODS Fifteen patients without RRT, 13 patients receiving sustained low-efficiency dialysis and 12 patients receiving continuous veno-venous haemodialysis were included. Population PK analysis with Monte Carlo simulations for different dosing regimens was performed. For minimum inhibitory concentration 2 mg/L was chosen. The target was set as 50% time ≥4× minimum inhibitory concentration. RESULTS The PK of meropenem was best described by a 1-compartment model with linear elimination. Serum creatinine, residual diuresis and time on RRT, with no difference between sustained low-efficiency dialysis and continuous veno-venous haemodialysis, were found to be significant covariates affecting clearance, explaining >20% of the clearance between subject variability. PTA analysis showed that in patients with RRT, 2 g/24 h, meropenem CI achieved a PTA of 95%. In patients without RRT, the target was achieved with 3 g/24 h CI or prolonged infusion of 1 g meropenem over 8 hours but not with bolus application of 1 g meropenem for 8 hours. Only 2 patients (both without RRT) had meropenem concentrations below the target level. However, approximately half of the patients with RRT receiving CI 3 g/24 h meropenem had toxic concentrations. CONCLUSION We found relevant PK variability for meropenem CI in septic patients with or without RRT, leading to a substantial risk for overdosing in patients with RRT. This finding highlights the strong demand for personalized dosing in critically ill patients.
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Affiliation(s)
- Isabella Westermann
- Department of Anesthesiology and Intensive Care Therapy, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany.,Center for Sepsis Control and Care - Friedrich Schiller University Jena, Jena, Germany
| | - Silke Gastine
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Carsten Müller
- Centre of Pharmacology, Department of Therapeutic Drug Monitoring, University of Cologne, Cologne, Germany
| | - Wiebke Rudolph
- Institute of Forensic Medicine, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany
| | - Frank Peters
- Institute of Forensic Medicine, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany
| | - Frank Bloos
- Department of Anesthesiology and Intensive Care Therapy, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany.,Center for Sepsis Control and Care - Friedrich Schiller University Jena, Jena, Germany
| | - Mathias Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany
| | - Stefan Hagel
- Center for Sepsis Control and Care - Friedrich Schiller University Jena, Jena, Germany.,Institute for Infectious Diseases and Infection Control, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany
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16
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Gastine S, Hsia Y, Clements M, Barker CI, Bielicki J, Hartmann C, Sharland M, Standing JF. Variation in Target Attainment of Beta-Lactam Antibiotic Dosing Between International Pediatric Formularies. Clin Pharmacol Ther 2021; 109:958-970. [PMID: 33521971 PMCID: PMC8358626 DOI: 10.1002/cpt.2180] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/15/2021] [Indexed: 12/26/2022]
Abstract
As antimicrobial susceptibility of common bacterial pathogens decreases, ensuring optimal dosing may preserve the use of older antibiotics in order to limit the spread of resistance to newer agents. Beta-lactams represent the most widely prescribed antibiotic class, yet most were licensed prior to legislation changes mandating their study in children. As a result, significant heterogeneity persists in the pediatric doses used globally, along with quality of evidence used to inform dosing. This review summarizes dosing recommendations from the major pediatric reference sources and tries to answer the questions: Does beta-lactam dose heterogeneity matter? Does it impact pharmacodynamic target attainment? For three important severe clinical infections-pneumonia, sepsis, and meningitis-pharmacokinetic models were identified for common for beta-lactam antibiotics. Real-world demographics were derived from three multicenter point prevalence surveys. Simulation results were compared with minimum inhibitory concentration distributions to inform appropriateness of recommended doses in targeted and empiric treatment. While cephalosporin dosing regimens are largely adequate for target attainment, they also pose the most risk of neurotoxicity. Our review highlights aminopenicillin, piperacillin, and meropenem doses as potentially requiring review/optimization in order to preserve the use of these agents in future.
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Affiliation(s)
- Silke Gastine
- Infection, Immunity and Inflammation Research and Teaching DepartmentUCL Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - Yingfen Hsia
- School of PharmacyQueen’s University BelfastBelfastUK
| | | | - Charlotte I.S. Barker
- Department of Medical & Molecular GeneticsKing’s College LondonLondonUK
- Paediatric Infectious Diseases Research GroupInstitute for Infection and ImmunitySt George’s University of LondonLondonUK
| | - Julia Bielicki
- Paediatric Infectious Diseases Research GroupInstitute for Infection and ImmunitySt George’s University of LondonLondonUK
- Paediatric Pharmacology GroupUniversity of Basel Children’s HospitalBaselSwitzerland
| | | | - Mike Sharland
- Paediatric Infectious Diseases Research GroupInstitute for Infection and ImmunitySt George’s University of LondonLondonUK
| | - Joseph F. Standing
- Infection, Immunity and Inflammation Research and Teaching DepartmentUCL Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- Department of PharmacyGreat Ormond Street Hospital for ChildrenLondonUK
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17
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Bentley S, Davies J, Gastine S, Standing J. EPS3.10 Clinical pharmacokinetics and dose recommendations for posaconazole gastro-resistant tablets in children with cystic fibrosis. J Cyst Fibros 2021. [DOI: 10.1016/s1569-1993(21)01027-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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18
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Clements MN, Russell N, Bielicki JA, Ellis S, Gastine S, Hsia Y, Standing JF, Walker AS, Sharland M. Global antibiotic dosing strategies in hospitalised children: Characterising variation and implications for harmonisation of international guidelines. PLoS One 2021; 16:e0252223. [PMID: 34043696 PMCID: PMC8159011 DOI: 10.1371/journal.pone.0252223] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/11/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Paediatric global antibiotic guidelines are inconsistent, most likely due to the limited pharmacokinetic and efficacy data in this population. We investigated factors underlying variation in antibiotic dosing using data from five global point prevalence surveys. METHODS & FINDINGS Data from 3,367 doses of the 16 most frequent intravenous antibiotics administered to children 1 month-12 years across 23 countries were analysed. For each antibiotic, we identified standard doses given as either weight-based doses (in mg/kg/day) or fixed daily doses (in mg/day), and investigated the pattern of dosing using each strategy. Factors underlying observed variation in weight-based doses were investigated using linear mixed effects models. Weight-based dosing (in mg/kg/day) clustered around a small number of peaks, and all antibiotics had 1-3 standard weight-based doses used in 5%-48% of doses. Dosing strategy was more often weight-based than fixed daily dosing for all antibiotics apart from teicoplanin, which had approximately equal proportions of dosing attributable to each strategy. No strong consistent patterns emerged to explain the historical variation in actual weight-based doses used apart from higher dosing seen in central nervous system infections, and lower in skin and soft tissue infections compared to lower respiratory tract infections. Higher dosing was noted in the Americas compared to the European region. CONCLUSIONS Antibiotic dosing in children clusters around a small number of doses, although variation remains. There is a clear opportunity for the clinical, scientific and public health communities to consolidate behind a consistent set of global antibiotic dosing guidelines to harmonise current practice and prioritise future research.
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Affiliation(s)
| | - Neal Russell
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George’s University, London, United Kingdom
| | - Julia A. Bielicki
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George’s University, London, United Kingdom
| | - Sally Ellis
- Global Antibiotic Research & Development Partnership, Geneva, Switzerland
| | - Silke Gastine
- Infection, Immunity and Inflammation, Institute of Child Health, University College London, London, United Kingdom
| | - Yingfen Hsia
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George’s University, London, United Kingdom
| | - Joseph F. Standing
- Infection, Immunity and Inflammation, Institute of Child Health, University College London, London, United Kingdom
| | | | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George’s University, London, United Kingdom
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19
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Gonzalez Hernandez F, Carter SJ, Iso-Sipilä J, Goldsmith P, Almousa AA, Gastine S, Lilaonitkul W, Kloprogge F, Standing JF. An automated approach to identify scientific publications reporting pharmacokinetic parameters. Wellcome Open Res 2021; 6:88. [PMID: 34381873 PMCID: PMC8343403 DOI: 10.12688/wellcomeopenres.16718.1] [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] [Accepted: 04/09/2021] [Indexed: 11/29/2022] Open
Abstract
Pharmacokinetic (PK) predictions of new chemical entities are aided by prior knowledge from other compounds. The development of robust algorithms that improve preclinical and clinical phases of drug development remains constrained by the need to search, curate and standardise PK information across the constantly-growing scientific literature. The lack of centralised, up-to-date and comprehensive repositories of PK data represents a significant limitation in the drug development pipeline.In this work, we propose a machine learning approach to automatically identify and characterise scientific publications reporting PK parameters from in vivo data, providing a centralised repository of PK literature. A dataset of 4,792 PubMed publications was labelled by field experts depending on whether in vivo PK parameters were estimated in the study. Different classification pipelines were compared using a bootstrap approach and the best-performing architecture was used to develop a comprehensive and automatically-updated repository of PK publications. The best-performing architecture encoded documents using unigram features and mean pooling of BioBERT embeddings obtaining an F1 score of 83.8% on the test set. The pipeline retrieved over 121K PubMed publications in which in vivo PK parameters were estimated and it was scheduled to perform weekly updates on newly published articles. All the relevant documents were released through a publicly available web interface (https://app.pkpdai.com) and characterised by the drugs, species and conditions mentioned in the abstract, to facilitate the subsequent search of relevant PK data. This automated, open-access repository can be used to accelerate the search and comparison of PK results, curate ADME datasets, and facilitate subsequent text mining tasks in the PK domain.
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Affiliation(s)
| | - Simon J Carter
- Institute of Pharmacy, Uppsala University, Uppsala, Sweden.,Institute for Global Health, University College London, London, UK
| | | | | | | | - Silke Gastine
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Watjana Lilaonitkul
- Institute of Health Informatics, University College London, London, UK.,Health Data Research, London, UK
| | - Frank Kloprogge
- Institute for Global Health, University College London, London, UK
| | - Joseph F Standing
- Great Ormond Street Institute of Child Health, University College London, London, UK
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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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21
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Tragiannidis A, Herbrüggen H, Ahlmann M, Vasileiou E, Gastine S, Thorer H, Fröhlich B, Müller C, Groll AH. Plasma exposures following posaconazole delayed-release tablets in immunocompromised children and adolescents. J Antimicrob Chemother 2020; 74:3573-3578. [PMID: 31504563 DOI: 10.1093/jac/dkz359] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 07/09/2019] [Accepted: 07/18/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Posaconazole is a recommended option for antifungal prophylaxis in paediatric patients >12 years of age. However, little is known about plasma exposures and safety following administration of the delayed-release tablets (DRTs) in children and adolescents. METHODS In a retrospective observational study, we analysed steady-state trough concentrations of posaconazole in all paediatric patients who had received the DRT formulation between May 2015 and December 2018 for antifungal prophylaxis. Dosing was guided by a published population pharmacokinetic model with weight-based dosing. Drug concentrations in plasma were measured by a validated tandem MS method. Liver function and drug discontinuations due to adverse effects were also assessed. RESULTS A total of 34 patients (21 male, 13 female; median age 12 years, range 5-17 years; median body weight 43.5 kg, range 16-84 kg) undergoing treatment for haemato-oncological disorders (n=23) or immunosuppression for polyarthritis (n=1) or post-allogeneic HSCT (n=11) received posaconazole DRTs for a median of 70 days (range 9-391 days). The median first steady-state trough plasma concentration following model-derived dosing was 1607 ng/mL (range 501-8485 ng/mL) with trough concentrations being above the dosing target of ≥700 ng/mL in 32/34 patients (94%). Considering all (first and subsequent) trough concentrations, target attainment was 90% (63/70 samples). Posaconazole was well tolerated without adverse event-related discontinuations or breakthrough infections. CONCLUSIONS Administration of posaconazole DRTs to paediatric patients guided by a population pharmacokinetic-derived dosing algorithm resulted in predictable and potentially effective exposures and was well tolerated over prolonged time periods.
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Affiliation(s)
- Athanasios Tragiannidis
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany.,Hematology Oncology Unit, 2nd Department of Pediatrics, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Heidrun Herbrüggen
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Martina Ahlmann
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Eleni Vasileiou
- Hematology Oncology Unit, 2nd Department of Pediatrics, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Silke Gastine
- Department of Pharmaceutical and Medical Chemistry, University of Münster, Münster, Germany
| | - Heike Thorer
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Birgit Fröhlich
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Carsten Müller
- Department of Pharmacology, University of Cologne, Cologne, Germany
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
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22
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Gastine S, Rashed AN, Hsia Y, Jackson C, Barker CIS, Mathur S, Tomlin S, Lutsar I, Bielicki J, Standing JF, Sharland M. GAPPS (Grading and Assessment of Pharmacokinetic-Pharmacodynamic Studies) a critical appraisal system for antimicrobial PKPD studies - development and application in pediatric antibiotic studies. Expert Rev Clin Pharmacol 2019; 12:1091-1098. [PMID: 31747323 DOI: 10.1080/17512433.2019.1695600] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 12/13/2022]
Abstract
Introduction: There are limited data on optimal dosing of antibiotics in different age groups for neonates and children. Clinicians usually consult pediatric formularies or online databases for dose selection, but these have variable recommendations, are usually based on expert opinion and are not graded based on the existing pharmacokinetic-pharmacodynamic (PKPD) studies. We describe here a potential new tool that could be used to grade the strength of evidence emanating from PKPD studies.Areas covered: A scoring system was developed (GAPPS tool) to quantify the strength of each PK assessment and rate the studies quality in already published articles. GAPPS was evaluated by applying it to pediatric PKPD studies of antibiotics from the 2019 Essential Medicines List for children (EMLC), identified through a search of PubMed.Expert opinion: Evidence for most antibiotic dose selection decisions was generally weak, coming from individual PK studies and lacked PKPD modeling and simulations. However, the quality of evidence appears to have improved over the last two decades.Incorporating a formal grading system, such as GAPPS, into formulary development will provide a transparent tool to support decision-making in clinical practice and guideline development, and guide PKPD authors on study designs most likely to influence guidelines.
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Affiliation(s)
- Silke Gastine
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Asia N Rashed
- Pharmacy Department, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Institute of Pharmaceutical Science, King's College London, London, UK
| | - Yingfen Hsia
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Charlotte Jackson
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Charlotte I S Barker
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Shrey Mathur
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Stephen Tomlin
- Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Irja Lutsar
- Department of Microbiology, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Julia Bielicki
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,Paediatric Pharmacology Group, University of Basel Children's Hospital, Basel, Switzerland
| | - Joseph F Standing
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
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23
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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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24
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Rashed AN, Jackson C, Gastine S, Hsia Y, Bielicki J, Standing JF, Tomlin S, Sharland M. Pediatric pharmacokinetics of the antibiotics in the access and watch groups of the 2019 WHO model list of essential medicines for children: a systematic review. Expert Rev Clin Pharmacol 2019; 12:1099-1106. [PMID: 31760892 DOI: 10.1080/17512433.2019.1693257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 10/25/2022]
Abstract
Introduction: Pharmacokinetic-pharmacodynamic (PK-PD) studies of antibiotics in pediatrics are limited. Pediatric dosing regimens for many antimicrobial drugs have been historically derived from adult pharmacokinetic data. Most pediatric formularies and dosing guidelines globally are expert-based and provide no rationale for the recommended doses, leading to heterogeneous guidance.Areas covered: We systematically reviewed the current dosing for 28 antibiotics listed in the Access and Watch groups of the 2019 World Health Organization (WHO) Essential Medicines List for children (EMLc). PubMed and EMBASE were searched for all PK-PD and pharmacological studies in pediatrics up to May 2018. In total, 262 pediatric related articles were deemed eligible. The most studied drugs were those where therapeutic drug monitoring is routine (aminoglycosides, glycopeptides) and study reporting detail was variable, with only 60.0% using the PK-PD results in make dosing recommendations. Based on this evidence, dose recommendations for each antibiotic were made.Expert opinion: We provide an up-to-date review of the limited available evidence on pediatric dosing for the 28 commonly prescribed antibiotics in the 2019 WHO EMLc. We propose synthesized dosing recommendations for those antibiotics administered systemically for the treatment of serious infections. Further PK-PD studies in children, particularly with underlying conditions, are needed.
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Affiliation(s)
- Asia N Rashed
- Institute of Pharmaceutical Science, King's College London, London, UK.,Pharmacy Department, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Charlotte Jackson
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Silke Gastine
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Yingfen Hsia
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Julia Bielicki
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,Paediatric Pharmacology Group, University of Basel Children's Hospital, Basel, Switzerland
| | - Joseph F Standing
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,Great Ormond Street Institute of Child Health, University College London, London, UK.,Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Stephen Tomlin
- Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
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25
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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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