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Aims: We propose using glomerular filtration rate (GFR) as the physiological basis for distinguishing components of renal clearance. Methods: Gentamicin, amikacin and vancomycin are thought to be predominantly excreted by the kidneys. A mixed-effects joint model of the pharmacokinetics of these drugs was developed, with a wide dispersion of weight, age and serum creatinine. A dataset created from 18 sources resulted in 27,338 drug concentrations from 9,901 patients. Body size and composition, maturation and renal function were used to describe differences in drug clearance and volume of distribution. Results: This study demonstrates that GFR is a predictor of two distinct components of renal elimination clearance: (1) GFR clearance associated with normal GFR and (2) non-GFR clearance not associated with normal GFR. All three drugs had GFR clearance estimated as a drug-specific percentage of normal GFR (gentamicin 39%, amikacin 90% and vancomycin 57%). The total clearance (sum of GFR and non-GFR clearance), standardized to 70 kg total body mass, 176 cm, male, renal function 1, was 5.58 L/h (95% confidence interval [CI] 5.50-5.69) (gentamicin), 7.77 L/h (95% CI 7.26-8.19) (amikacin) and 4.70 L/h (95% CI 4.61-4.80) (vancomycin). Conclusions: GFR provides a physiological basis for renal drug elimination. It has been used to distinguish two elimination components. This physiological approach has been applied to describe clearance and volume of distribution from premature neonates to elderly adults with a wide dispersion of size, body composition and renal function. Dose individualization has been implemented using target concentration intervention.

Primary central nervous system lymphoma (PCNSL) occurring following organ transplantation (post-transplantation lymphoproliferative disorder [PTLD]) is a highly aggressive non-Hodgkin lymphoma. It is typically treated with high-dose methotrexate-based regimens. Outcomes are dismal and clinical trials are lacking. It is almost always Epstein–Barr virus (EBV) associated. Two patients (CA1-2) presented with EBV-associated PCNSL after renal transplant. CA1 was on hemodialysis and had prior disseminated cryptococcus and pseudomonas bronchiectasis, precluding treatment with methotrexate. CA2 was refractory to methotrexate. Both were treated off-label with the first-generation Bruton's tyrosine kinase inhibitor ibrutinib for 12 months. Cerebrospinal fluid penetration at therapeutic levels was confirmed in CA1 despite hemodialysis. Both patients entered remission by 2 months. Sequencing confirmed absence of genetic aberrations in human leukocyte antigen (HLA) class I/II and antigen-presentation/processing genes, indicating retention of the ability to present EBV-antigens. Between Weeks 10 and 13, they received third-party EBV-specific T cells for consolidation with no adverse effects. They remain in remission ≥34 months since therapy began. The strength of these findings led to an ongoing phase I study (ACTRN12618001541291).

De två sista författarna delar sistaförfattarskapet

De två sista författarna delar sistaförfattarskapet

De två sista författarna delar sistaförfattarskapet

De två sista författarna delar sistaförfattarskapet

De två sista författarna delar sistaförfattarskapet

Background and purpose: Students find clinical pharmacokinetics and pharmacodynamics courses challenging, partly due to their mathematical nature. This study aimed to retrospectively evaluate the impact of “feedback quizzes” on the experiences and academic performance of undergraduate pharmacy students at an Australian university. Educational activity and setting: Formative paper-based quizzes were introduced into tutorials in an intermediate third-year pharmacokinetics course, and summative online quizzes were introduced into a subsequent advanced fourth-year course that included a pharmacokinetics component. Experience data were drawn from institutional student evaluation surveys, and academic performance was obtained from exam results. Student experiences and academic performance were compared pre- and post-intervention using the Test of Equal Proportions and Mann–Whitney–Wilcoxon, respectively. Findings: A greater proportion of students in both quiz cohorts were satisfied with the overall course experience compared to the pre-curricular change cohort (intermediate: 87% vs. 78%; advanced: 63% vs. 50%). Students who received quizzes in both years performed better in the clinical pharmacokinetics component of the advanced course compared to a prior cohort who had no quizzes (85.7% vs. 77.8%). Feedback quizzes, whether formative or summative, administered in-class or outside class, can enhance learning and performance and lead to improvements in student satisfaction with clinical pharmacokinetics courses. Scaffolding of feedback quizzes across year levels can provide students with added confidence when attempting assessment. Collaboration between research-focused and teaching-focused staff can lead to increased scholarship of teaching and learning activities.

Full Text, Thesis (PhD Doctorate), Doctor of Philosophy (PhD), School of Pharmacy and Pharmac, Griffith Health, Most patients at advanced stages of cancer experience moderate to severe pain [1, 2]. Despite increased research and attempts on estimation and management, pain continues to be a predominant symptom in patients with cancer [1]. In general, cancer pain is treated with pharmacological agents, specifically using opioids alone or in combination with adjuvant analgesics [3]. Methadone is administered to patients with cancer pain not responsive to morphine or other strong opioids when intractable opioid adverse effects appear [4]. The inherent properties of methadone, including high oral bioavailability, rapid onset of analgesic effect, long half-life resulting in infrequent dosing regimens, lack of active metabolites, low rate of induction of tolerance, low cost, and perceived benefit in difficult pain control scenarios such as neuropathic pain, facilitates its use in in the management of pain in profoundly ill patients [5, 6]. Methadone is also considered as the first strong opioid analgesic in patients with renal impairment [4]. However, in clinical practice the use of methadone is highly restricted due to the narrow therapeutic window between efficacy and toxicity accompanied with large inter- and intra-individual variability in response [2]. Understanding the pharmacokinetics (PK) and pharmacodynamics (PD) of methadone could help determine appropriate opioid selection for individual patients with advanced cancer. In clinical practice, methadone is administered as a racemic mixture of l-and d-methadone and the analgesic properties are mostly attributed to the l-enantiomer. Clinical studies have also indicated the disposition of methadone to be enantioselective [7-9]. Evaluation of the PK profile of the methadone enantiomers requires accurate quantitation of each enantiomer. The use of saliva as a surrogate to plasma samples has been evidenced by strong correlations reported for analgesics such as paracetamol [10] and hydromorphone [11], with mixed results for methadon

Background Pharmacy students do not typically enjoy studying pharmacokinetics because of its mathematical nature and perceived lack of relevance to clinical practice. To improve teaching at our institution, quizzes were introduced into an intermediate and advanced course in this discipline in 2013 and 2014 respectively. Aims To retrospectively evaluate the impact of two different approaches, of introducing ‘feedback quizzes’ to enhance teaching of clinical pharmacokinetics, on the experiences and academic performance of undergraduate pharmacy students. Methods Formative paper-based quizzes were introduced into tutorials in the intermediate course and summative online quizzes were introduced into the advanced course. Academic performance (based on student marks) and student experience data (based on the proportion of students who agreed or strongly agreed with statements in an institutional evaluation survey) were compared pre- and post-curricular change using a Mann–Whitney–Wilcoxon test and Test of Equal Proportions, respectively. Results Statistically significant increases in academic performance were noted in both courses; from 75.0 to 77.0% (p = 0.033) for the median weighted mark in the intermediate course, and from 77.8 to 85.7% (p =0.002) for the median mark in the pharmacokinetic component of the final exam in the advanced course. A non-significant trend towards increased overall course satisfaction was seen in both courses compared with the previous cohort (intermediate 87% vs 78% (p=0.3), advanced 63% vs 50%, (p=0.35)). Conclusion Our study demonstrated that quizzes, whether formative or summative, administered in-class or outside class, can enhance learning and lead to modest improvements in students’ satisfaction of pharmacokinetics courses.

OBJECTIVES: Extensive but fragmented data from existing studies were used to describe the drug-drug interaction between rifabutin and HIV PIs and predict doses achieving recommended therapeutic exposure for rifabutin in patients with HIV-associated TB, with concurrently administered PIs. METHODS: Individual-level data from 13 published studies were pooled and a population analysis approach was used to develop a pharmacokinetic model for rifabutin, its main active metabolite 25-O-desacetyl rifabutin (des-rifabutin) and drug-drug interaction with PIs in healthy volunteers and patients who had HIV and TB (TB/HIV). RESULTS: Key parameters of rifabutin affected by drug-drug interaction in TB/HIV were clearance to routes other than des-rifabutin (reduced by 76%-100%), formation of the metabolite (increased by 224% in patients), volume of distribution (increased by 606%) and distribution to the peripheral compartment (reduced by 47%). For des-rifabutin, clearance was reduced by 35%-76% and volume of distribution increased by 67%-240% in TB/HIV. These changes resulted in overall increased exposure to rifabutin in TB/HIV patients by 210% because of the effects of PIs and 280% with ritonavir-boosted PIs. CONCLUSIONS: Given together with non-boosted or ritonavir-boosted PIs, rifabutin at 150 mg once daily results in similar or higher exposure compared with rifabutin at 300 mg once daily without concomitant PIs and may achieve peak concentrations within an acceptable therapeutic range. Although 300 mg of rifabutin every 3 days with boosted PI achieves an average equivalent exposure, intermittent doses of rifamycins are not supported by current guidelines.

When performing a population pharmacokinetic modelling analysis covariates are often added to the model. Such additions are often justified by improved goodness of fit and/or decreased in unexplained (random) parameter variability. Increased goodness of fit is most commonly measured by the decrease in the objective function value. Parameter variability can be defined as the sum of unexplained (random) and explained (predictable) variability. Increase in magnitude of explained parameter variability could be another possible criterion for judging improvement in the model. The agreement between these three criteria in diagnosing covariate-parameter relationships of different strengths and nature using stochastic simulations and estimations as well as assessing covariate-parameter relationships in four previously published real data examples were explored. Total estimated parameter variability was found to vary with the number of covariates introduced on the parameter. In the simulated examples and two real examples, the parameter variability increased with increasing number of included covariates. For the other real examples parameter variability decreased or did not change systematically with the addition of covariates. The three criteria were highly correlated, with the decrease in unexplained variability being more closely associated with changes in objective function values than increases in explained parameter variability were. The often used assumption that inclusion of covariates in models only shifts unexplained parameter variability to explained parameter variability appears not to be true, which may have implications for modelling decisions.

Die Funktion der äußeren Haarsinneszellen geht weit über die normale Rezeptoreigenschaft der Kategorie Mechanorezeptor hinaus. Äußere Haarzellen mit ihrer reichhaltigen efferenten Innervierung sind nicht nur für die sensorische Aufnahme mechanischer Bewegung zuständig, sondern ermöglichen aufgrund ihrer motorischen Funktionen die mechanische Verstärkung der Wanderwelle in der Cochlea. Äußere Haarzellen sind eine maßgebliche Komponente des ´cochleären Verstärkers` und ihr Ausfall führt zur Schwerhörigkeit. Beiprodukte des cochleä-ren Verstärkers sind otoakustische Emissionen, deren Messung Aufschluss über aktive mechanische Prozesse im Innenohr gibt. Die äußeren Haarsinneszellen bilden Synapsen mit dem olivo-cochleären efferenten System, welches im Zentrum der vorliegenden Untersuchung steht. Es vermittelt den Einfluss des Zentralnervensystems auf das Corti-Organ des Innenohrs. Über die akustische Reizung des olivo-cochleären Reflexbogens ist man in der Lage, das efferente System zu aktivieren und gleichzeitig die Antworteigenschaften der Cochlea zu verändern. Efferente Modulationen des cochleären Verstärkers können sich z. B. in einer Veränderung des Emissionspegels bemerk-bar machen. Die Fledermausspezies Carollia perspicillata ist aufgrund ihres Echoortungs-systems mit einem sehr sensitiven und hochauflösenden Hörvermögen ausgestattet und eignet sich hervorragend als Modelltier in der Hörforschung, insbesondere auch deshalb, da oto-akustische Emissionen sehr gut messbar sind. Das efferente System von C. perspicillata wurde in dieser Untersuchung durch akustische Stimulation der kontralateralen Cochlea angeregt. Die Stimuli, die nicht nur in ihrem Pegel sondern auch in ihrer Bandbreite und in der Mittelfrequenz in Relation zu den ipsilateralen Stimulusfrequenzen variierten, beeinflussten dabei die Generierung der otoakustischen Emis-sionen (DPOAE, engl: distortion product otoacoustic emissions) im ipsilateralen Ohr: akustische Stimulation der kontralateralen Cochle

Investigate the possibility to directly optimize a clinical trial design for statistical power to detect a drug effect and compare to optimal designs that focus on parameter precision. An improved statistic derived from the general formulation of the Wald approximation was used to predict the statistical power for given trial designs of a disease progression study. The predicted value was compared, together with the classical Wald statistic, to a type I error-corrected model-based power determined via clinical trial simulations. In a second step, a study design for maximal power was determined by directly maximizing the new statistic. The resulting power-optimal designs and their corresponding performance based on empirical power calculations were compared to designs focusing on parameter precision. Comparisons of empirically determined power and the newly developed statistic, showed excellent agreement across all scenarios investigated. This was in contrast to the classical Wald statistic, which consistently over-predicted the reference power with deviations of up to 90 %. Designs maximized using the proposed metric differed from traditional optimal designs and showed equal or up to 20 % higher power in the subsequent clinical trial simulations. Furthermore, the proposed method was used to minimize the number of individuals required to achieve 80 % power through a simultaneous optimization of study size and study design. The targeted power of 80 % was confirmed in subsequent simulation study. A new statistic was developed, allowing for the explicit optimization of a clinical trial design with respect to statistical power.

Background and Objectives While several studies have examined the pharmacokinetics of tobramycin in patients with cystic fibrosis (CF), there is no consensus on whether they differ in patients with and without CF. The objectives of this study were to identify covariates which explain pharmacokinetic variability and to examine whether having the disease CF in itself alters these relationships and drug dose requirements. Methods To investigate this issue, a population pharmacokinetic meta-analysis of data from eight centres was undertaken. NONMEM (R) 7.2 was used to analyse the data, which comprised 4,514 concentration-time measurements from 465 adults and children with CF and 1,095 concentration-time measurements from 267 adults and children without CF. Results Tobramycin disposition was well described by a two-compartment model with first-order elimination. Patient age, fat-free mass, serum creatinine concentration and sex were identified as significant covariates in the final model. Fat-free mass was superior to total bodyweight as a descriptor of clearance, volume of distribution of the central and peripheral compartments and inter-compartmental clearance. CF as an independent disease-specific factor had no significant influence on the pharmacokinetics of tobramycin at any stage during covariate model building. An optimal dose of 11 mg/kg every 24 h was defined for CF patients using a utility function approach. Conclusion The pharmacokinetics of tobramycin do not differ significantly in CF patients compared with patients without CF when subject age, fat-free mass, sex and renal function are taken into consideration. Variations in tobramycin dosing between CF and non-CF patients should therefore reflect target concentrations or exposures based on differences in expected pathogen sensitivity and not the presence of CF.

Phenytoin is regularly employed in the critically ill for prophylaxis against or treatment of seizure disorders. No prior studies have examined current dosing practices in an Australasian intensive care unit (ICU) setting. The aims of this study were to: a) describe the adequacy of contemporary dosing in respect to free and total serum phenytoin concentrations; b) identify factors associated with therapeutic drug concentrations; and c) examine the accuracy of predictive equations that estimate free concentrations in this setting. All patients receiving a loading dose of phenytoin in a tertiary-level ICU were eligible for enrolment; 53 patients were enrolled in the study. Serum samples to determine free and total phenytoin concentrations (measured by high performance liquid chromatography) were then drawn prior to the following dose. Free concentrations below the recommended target (<1 mg/l) were considered as suboptimal. The most common indication for phenytoin loading was traumatic brain injury (49%) and the mean administered dose was 14.5 (3.66) mg/kg. Twenty-six patients (49%) had suboptimal trough free concentrations, although this subgroup was significantly heavier and therefore received a lower per kilogram dose (12.8 [3.1] vs 16.3 [3.4] mg/kg, P=0.001). In multivariate analysis, larger weight adjusted doses (P=0.018), higher albumin concentration (P=0.034) and receiving phenytoin for an indication other than seizure (P=0.035), were associated with a greater likelihood of adequate concentrations. In conclusion, phenytoin dosing remains complex in critically ill patients, although lower per kilogram loading doses are strongly associated with free concentrations below the desired target.

Several developments have facilitated the practical application and increased the general use of optimal design for nonlinear mixed effects models. These developments include new methodology for utilizing advanced pharmacometric models, faster optimization algorithms and user friendly software tools. In this paper we present the extension of theoptimal design software PopED, which incorporates many of these recent advances into aneasily useable enhanced GUI. Furthermore, we present new solutions to problems related to the design of experiments such as: faster and more robust FIM calculations and optimizations, optimizing over cost/utility functions and diagnostic tools and plots to evaluate designperformance. Examples for; (i) Group size optimization and efficiency translation, (ii) Cost/constraint optimization, (iii) Optimizations with different FIM approximations and (iv) optimization with parallel computing demonstrate the new features in PopED and underline the potential use of this tool when designing experiments.

A time and sampling intensive pretransplant test dose design was to be reduced, but at the same time optimized so that there was no loss in the precision of predicting the individual pharmacokinetic (PK) estimates of posttransplant dosing. The following variables were optimized simultaneously: sampling times, ciclosporin dose, time of second dose, infusion duration, and administration order, using a published ciclosporin population PK model as prior information. The original design was reduced from 22 samples to 6 samples/patient and both doses (intravenous oral) were administered within 8 hours. Compared with the prior information given by the published ciclosporin population PK model, the expected standard deviations (SDs) of the individual parameters for clearance and bioavailability could be reduced by, on average, 40% under the optimized sparse designs. The gain of performing the original rich design compared with the optimal reduced design, considering the standard errors of the parameter estimates, was found to be minimal. This application demonstrates, in a practical clinical scenario, how optimal design techniques may be used to improve diagnostic procedures given available software and methods.

A simulation-based comparison study on the relative merits of dose-control trials (DCTs) with exposure-response analysis versus concentration-control trials (CCTs) for drugs with narrow therapeutic index showed that DCT designs are more informative about the exposure-response relationship. The authors revisit the question employing optimal design methodology and propose strategies for designing ethically attractive trials for these drugs, balancing between individual-collective risk and informativeness. An optimal study was performed considering a hypothetical immunosuppressant agent with 2 clinical end points. Different scenarios were optimized applying cost-based designs (unwanted events vs number of sub-jects/trial or maximal individual risk). Dose/exposure targets and number of subjects per trial/arm were optimized. Prior information inclusion on baseline risks was evaluated. DCTs were more informative, needing smaller studies to provide the same information as CCTs. Using the number of unwanted events-rather than subjects-as cost resulted in ethically more attractive designs. Including prior baseline risk information reduced the number of subject/events and allowed the use of targets closer to the optimal. Designing dose-finding trials for some narrow therapeutic index drugs may be improved by using DCTs with exposure-response analysis, cost-based designs, prior information, and optimal design analysis providing information on the ethical trade-off between individual risk and information gain.

Optimal design has been used in the past mainly to optimize sampling schedules for clinical trials. Optimization on design variables other than sampling times has been published in the literature only once before. This study shows, as an example, optimization on the length of treatment periods to obtain reliable estimates of drug effects on longterm disease progression studies. Disease progression studies are high in cost, effort, and time; therefore, optimization of treatment length is highly recommended to avoid failure or loss of information. Results are provided for different drug effects (eg, protective and symptomatic) and for different lengths of studies and sampling schedules. The merits of extending the total study length versus inclusion of more samples per participants are investigated. The authors demonstrate that if no observations are taken during the washout period, a trial can lose up to 40% of its efficiency. Furthermore, when optimization of treatment length is performed using multiple possible drug effect models simultaneously, these studies show high power in discriminating between different drug effect models.

Objective: The objective of the study was to characterise the population pharmacokinetic properties of itraconazole and its active metabolite hydroxyitraconazole in a representative paediatric population of cystic fibrosis and bone marrow transplant (BMT) patients and to identify patient characteristics influencing the pharmacokinetics of itraconazole. The ultimate goals were to determine the relative bioavailability between the two oral formulations (capsules vs oral solution) and to optimise dosing regimens in these patients. Methods: All paediatric patients with cystic fibrosis or patients undergoing BMT at The Royal Children's Hospital, Brisbane, QLD, Australia, who were prescribed oral itraconazole for the treatment of allergic bronchopulmonary aspergillosis (cystic fibrosis patients) or for prophylaxis of any fungal infection (BMT patients) were eligible for the study. Blood samples were taken from the recruited patients as per an empirical sampling design either during hospitalisation or during outpatient clinic visits. ltraconazole and hydroxy-itraconazole plasma concentrations were determined by a validated high-performance liquid chromatography assay with fluorometric detection. A nonlinear mixed-effect modelling approach using the NONMEM software to simultaneously describe the pharmacokinetics of itraconazole and its metabolite. Results: A one-compartment model with first-order absorption described the itraconazole data, and the metabolism of the parent drug to hydroxy-itraconazole was described by a first-order rate constant. The metabolite data also showed one-compartment characteristics with linear elimination. For itraconazole the apparent clearance (CLitraconazole) was 35.5 L/hour, the apparent volume of distribution (V-d(itraconazole)) was 672L, the absorption rate constant for the capsule formulation was 0.0901 h(-1) and for the oral solution formulation was 0.96 h-1. The lag time was estimated to be 19.1 minutes and the relative bioavailability be