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AIMS: Paraquat poisoning is a medical problem in many parts of Asia and the Pacific. The mortality rate is extremely high as there is no effective treatment. We analyzed data collected during an ongoing cohort study on self-poisoning and from a randomized controlled trial assessing the efficacy of immunosuppressive therapy in hospitalized paraquat-intoxicated patients. The aim of this analysis was to characterize the toxicokinetics and toxicodynamics of paraquat in this population. METHODS: A non-linear mixed effects approach was used to perform a toxicokinetic/toxicodynamic population analysis in a cohort of 78 patients. RESULTS: The paraquat plasma concentrations were best fitted by a two compartment toxicokinetic structural model with first order absorption and first order elimination. Changes in renal function were used for the assessment of paraquat toxicodynamics. The estimates of toxicokinetic parameters for the apparent clearance, the apparent volume of distribution and elimination half-life were 1.17 l h-1, 2.41 kg-1 and 87 h, respectively. Renal function, namely creatinine clearance, was the most significant covariate to explain between patient variability in paraquat clearance. This model suggested that a reduction in paraquat clearance occurred within 24 to 48 h after poison ingestion, and afterwards the clearance was constant over time. The model estimated that a paraquat concentration of 429 μg l-1 caused 50% of maximum renal toxicity. The immunosuppressive therapy tested during this study was associated with only 8% improvement of renal function. CONCLUSION: The developed models may be useful as prognostic tools to predict patient outcome based on patient characteristics on admission and to assess drug effectiveness during antidote drug development. [ABSTRACT FROM AUTHOR]

Aim To predict simultaneously the area under the concentration−time curve during one dosing interval [ AUC(0,12 h)] for mycophenolic acid ( MPA) and tacrolimus ( TAC), when concomitantly used during the first month after transplantation, based on common blood samples. Methods Data were from two different sources, real patient pharmacokinetic ( PK) profiles from 65 renal transplant recipients and 9000 PK profiles simulated from previously published models on MPA or TAC in the first month after transplantation. Multiple linear regression ( MLR) and Bayesian estimation using optimal samples were performed to predict MPA and TAC AUC(0,12 h) based on two concentrations. Results The following models were retained: AUC(0,12 h) = 16.5 + 4.9 × C1.5 + 6.7 × C3.5 ( r2 = 0.82, r RMSE = 9%, with simulations and r2 = 0.66, r RMSE = 24%, with observed data) and AUC(0,12 h) = 24.3 + 5.9 × C1.5 + 12.2 × C3.5 ( r2 = 0.94, r RMSE = 12.3%, with simulations r2 = 0.74, r RMSE = 15%, with observed data) for MPA and TAC, respectively. In addition, Bayesian estimators were developed including parameter values from final models and values of concentrations at 1.5 and 3.5 h after dose. Good agreement was found between predicted and reference AUC(0,12 h) values: r2 = 0.90, r RMSE = 13% and r2 = 0.97, r RMSE = 5% with simulations for MPA and TAC, respectively and r2 = 0.75, r RMSE = 11% and r2 = 0.83, r RMSE = 7% with observed data for MPA and TAC, respectively. Conclusion Statistical tools were developed for simultaneous MPA and TAC therapeutic drug monitoring. They can be incorporated in computer programs for patient dose individualization. [ABSTRACT FROM AUTHOR]

Background and Objective Mycophenolate mofetil is a prodrug of mycophenolic acid (MPA), an immunosuppressive agent used in combination with corticosteroids and calcineurin inhibitors or sirolimus for the prevention of acute rejection after solid organ transplantation. Although MPA has a rather narrow therapeutic window and its pharmacokinetics show considerable intra- and interindividual variability, dosing guidelines recommend a standard dosage regimen of 0.5-1.0 g twice daily in adult renal, liver and cardiac transplant recipients. The main objective of the present study was to develop a method to predict the MPA area under the plasma concentration-time curve during one 12-hour dosing interval (AUC12) by using multiple linear regression models and maximum a posteriori (MAP) Bayesian estimation methods in patients co-medicated with ciclosporin or sirolimus, aiming to individualize the dosage regimen of mycophenolate mofetil. Patients and Methods Pharmacokinetic profiles of MPA and mycophenolic acid glucuronide (MPAG), the main metabolite of MPA, were obtained from 40 stable adult renal allograft recipients on three different occasions: the day before switching from ciclosporin to sirolimus co-medication (±7.4 months post-transplantation; period I) and at 60 days and 270 days after the switch (periods II and III). Blood samples for determination of MPA and MPAG concentrations in plasma were taken at 0 hours (pre-dose) and at 0.33, 0.66, 1.25, 2, 4, 6, 8 and 12 hours after oral intake of mycophenolate mofetil. The MPA AUC12 was calculated by the trapezoidal method (the observed AUC12). Patients were randomly divided into (i) a model-building test group (n=27); and (ii) a model-validation group (n=13). Multiple linear regression models were developed, based on three sampling times after drug administration. Subsequently, a population pharmacokinetic model describing MPA and MPAG plasma concentrations was developed using nonlinear mixed-effects modelling and a Bayesian estimator based on the population pharmacokinetic model was used to predict the MPA AUC12 based on three sampling times taken within 2 hours following dosing. Results Fifty-two percent of the observed AUC12 values (three periods) in the 40 patients receiving a fixed dose of mycophenolate mofetil 750 mg twice daily were outside the recommended therapeutic range (30-60μg•h/mL). The failure of the standard dose to yield an AUC12 value within the therapeutic range was especially pronounced during the first study period. Of the multiple linear regression models that were tested, the equation based on the 0-hour (pre-dose), 0.66- and 2-hour sampling times showed the best predictive performance in the validation group: r2=0.79, relative root mean square error (rRMSE)=14% and mean relative prediction error (MRPE)=0.9%.… [ABSTRACT FROM AUTHOR]

Abstract: The purpose was to investigate dermal microdialysis (DMD) for the assessment of the bioavailability of a ketoprofen topical gel formulation and to evaluate this technique as a tool for the determination of bioequivalence. Four microdialysis probes were inserted into the dermis on the volar aspect of the forearms of 18 human subjects and the probes were perfused with normal saline for 60min. A ketoprofen (2.5%, m/m) gel formulation (50mg) was applied to the skin directly overlying the probes and samples were collected at 30min intervals for 5h. With the probes still in place in the dermis each site was scanned by ultrasound to determine the implantation depth of these probes. Ketoprofen concentration in dialysates was determined by LC–MS/MS. The area under the curve obtained from the concentration–time profiles from pairs of application sites in each subject was evaluated in order to assess bioequivalence. Ninety percent confidence intervals were calculated using the two one-sided test procedure and limits of 80–125% based on log-transformed data were used as acceptance criteria to declare bioequivalence. The intra-subject variability was 10% between probes whereas inter-subject variability was 68% (n =18). Bioequivalence was confirmed with a power greater than 90%. [Copyright &y& Elsevier]

OBJECTIVES: (i) To evaluate the pupillary response to alfentanil as a surrogate measure of alfentanil pharmacokinetics in cirrhotic patients and to compare the data observed in cirrhotic patients with those found in healthy volunteers (historical control group); and (ii) to compare this test with other liver function tests in cirrhotic patients. METHODS: Six patients with mild cirrhosis (Child-Pugh grade A) and six patients with moderate cirrhosis (Child-Pugh grade B) were studied after a single 15 µg/kg bolus of alfentanil. Alfentanil plasma concentrations were measured by liquid chromatography-tandem mass spectrometry, and pupillary responses were measured with a Pupilscan II pupillometer. Alfentanil pharmacokinetics (plasma concentration, area under the plasma concentration-time curve from time zero to infinity [AUC∞(p)] and from time zero to 2 hours [AUC2(p)], apparent volume of distribution at steady state, clearance and terminal elimination half-life [t½(p)]) and miosis pseudo-kinetic parameters [AUC∞(miosis), AUC2(miosis), t½(miosis)] were determined using a noncompartmental analysis method. In six patients (three Child-Pugh grade A and three Child-Pugh grade B), antipyrine (measure of liver intrinsic activity) and D-sorbitol (measure of liver blood flow) tests were performed. RESULTS: A significant correlation was found between the alfentanil AUC∞(p) and AUC∞(miosis) (r = 0.6, p < 0.05) in cirrhotic patients. This correlation was even more significant if AUC determinations were limited to the first 2 hours after alfentanil administration (r = 0.9, p < 0.01). Statistically significant differences in pharmacokinetics and miosis pseudo-kinetic parameters were observed between cirrhotic patients and healthy volunteers from our previous experiment (historical control group). The correlations were significant between alfentanil clearance and antipyrine clearance (n = 6, r = 0.9, p < 0.05), alfentanil clearance and steady-state hepatic blood clearance [CLH(b)] measured by the D-sorbitol test (n = 6, r = 0.9, p < 0.05). CONCLUSION: Alfentanil pharmacokinetic parameters were correlated with miosis pseudo-kinetic parameters in cirrhotic patients. There was a significant decrease in pharmacokinetics and miosis pseudo-kinetics in cirrhotic patients compared with volunteers from the historical control group. Alfentanil-induced miosis has the advantage of being noninvasive and can be limited to miosis measurements during the first 2 hours after alfentanil administration in cirrhotic patients. We thus propose to substitute the AUC2(miosis) for alfentanil pharmacokinetics in cirrhosis. [ABSTRACT FROM AUTHOR]

To study the distribution of fluconazole in the dermis of the rat, on-line microdialysis using double-site sampling coupled with a microbore HPLC system was developed. The chromatographic conditions consisted of a mobile phase of 20 mM diammonium phosphate–acetonitrile (75:25, v/v, pH 7.0) pumped through a microbore C18 column at 40 μl/min. The eluent was monitored with UV detector with UZ flow cell (30 mm path length) at 210 nm. A microbore 10-port pneumatic valve fitted with two loops of 1 μl was used to collect and directly inject microdialysates from jugular and dermal probes. The retention time was 5.8 min for fluconazole and 10.1 min for its fluorinated analog, UK-54373 used as a retrodialysis marker. The assay was precise, with inter- and intra-assay relative standard deviation values of 0.64 and 0.71%, respectively, and with a good linearity (r=0.999) in the range of 0.15–20 μg/ml with only 1 μl injected onto the column. The LOD and LOQ values for fluconazole were 0.100 and 0.150 μg/ml, respectively. The applicability of the method was demonstrated by studying the disposition of fluconazole in blood and dermis following i.v. bolus at a dose of 10 mg/kg. [Copyright &y& Elsevier]

Background: World Health Organization (WHO) advocates use of weight bands in antiretroviral therapy (ART) guidelines. Allometric scaling could be a more reliable method because it uses a non-linear approach in relating dose to body weight. This study evaluates performance of the allometric ¾ power model in comparison to WHO weight band method in children receiving ART., Methods: Records of children receiving (ABC/3TC) + DTG were reviewed. Paediatric ABC/3TC dose was calculated from the adult dose using the allometric ¾ power model and compared to WHO weight band dose., Results: WHO weight band strategy grouped 50.6% of the children in the 25 kg category and therefore received the adult dose of ABC/3TC (600 mg/300 mg); only 1.1% received this dose with allometric scaling. Mean dose (3.8 tablets) for the WHO weight band dosing method was found to be significantly higher (p<0.0001) than for allometric scaling (1.5 tablets)., Conclusions: WHO weight bands may result in the 25 kg weight category receiving a much higher dose leading to ADRs. Using allometric scaling, we recommend a weight band strategy that could improve paediatric ABC/3TC dosing., (© 2022 Singu BS et al.)

Background: Phenytoin and valproic acid, anticonvulsants, have a low therapeutic index and are highly plasma protein bound, mainly to albumin. Hypoalbuminaemia is common in critically ill patients and increases the unbound drug concentration. Thus, monitoring unbound rather than total plasma drug concentrations is recommended to optimise the dosing of these drugs., Objective: This retrospective study determined unbound plasma concentrations of phenytoin and valproic as a more accurate value of drug levels than total plasma drug concentrations., Methods: Total plasma concentrations were retrieved for 56 Intensive Care Unit patients for phenytoin and 93 for valproic acid. Total drug concentrations were converted to unbound concentrations using a serum albumin-based normalising equation., Results: Total phenytoin plasma concentration was below (41.1% of patients), within (46.4%) or above (12.5%) the therapeutic range (10 μg/mL - 20 μg/mL). However, the predicted unbound plasma concentration of phenytoin was above the therapeutic range (1 μg/mL - 2 μg/mL) in the majority of patients (57.1%). For valproic acid, the total plasma concentration of most patients (87.1%) was below the therapeutic range (50 μg/mL - 100 μg/mL); among remaining patients (12.9%), it was within the therapeutic range. In the majority of patients (91.4%), the predicted unbound plasma concentration of valproic acid was between 2.5 μg/mL and 20 μg/mL., Conclusion: The usefulness of monitoring the total phenytoin or valproic acid levels for dose optimisation is limited as it is an inaccurate indicator of a patient's drug therapeutic state. Thus, the unbound plasma drug concentrations should be quantified experimentally or predicted in resource-limited settings., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2022. The Authors.)

Codeine continues to be widely used as an analgesic, antidiarrhoeal and antitussive agent. Its analgesic effect depends on its biotransformation to morphine, a strong opioid. The highly variable biotransformation of codeine to morphine, catalysed by CYP2D6, underlies the pronounced interindividual variability of its analgesic response. Randomized controlled trials have demonstrated that codeine administered alone has the poorest analgesic effect among all commonly used analgesics in acute postoperative pain. Moreover, it is highly unlikely that the low dose of codeine contributes to the pain-relieving effect of the non-opioid component in combination analgesic products. In addition, there is a lack of reliable clinical evidence to support the use of codeine as an antitussive in acute or chronic cough. Codeine use, through its active metabolite morphine, has the potential to lead to abuse and dependence. The World Health Organization (WHO) removed codeine from the essential medicines list for children in 2011. Based on the available information in the scientific literature on the efficacy and safety of codeine, the WHO should seriously consider removing it also from the list of essential medicines for adults, which would be a strong signal for all health professionals to prescribe and dispense codeine with the utmost caution.

Background: In Namibia, one out of every 25 cases of tuberculosis (TB) is "lost to follow-up" (LTFU). This has impacted negatively on national efforts to end the disease by 2035. The aim of this study was to determine the trends and predictors of LTFU under the directly observed treatment short-course (DOTS) programme in Namibia., Methods: The study involved a retrospective longitudinal analysis of a nationwide cohort of TB cases registered under the DOTS programme in Namibia from 2006 to 2015. The trends and predictors of LTFU among cases in the National Electronic TB Register of the National TB and Leprosy Program were respectively determined by interrupted time series and multivariate logistic regression analyses using R-Studio software., Results: Out of 104 203 TB cases, 3775 (3.6%) were LTFU. A quarter (26%) of cases with poor outcomes were due to LTFU. The annual decline in cases of LTFU was significant between the first (2005-2010) and second (2010-2015) medium-term plan period for TB programme implementation (p=0.002). The independent predictors of LTFU were male sex (p=0.004), 15-24 years age group (p=0.03), provider of treatment (p<0.001), intensive phase (p=0.047) and living in border/transit regions (p<0.001). HIV co-infection and TB regimen were not significant predictors of LTFU., Conclusions: There were declining trends in LTFU in Namibia. DOTS programmes should integrate socioeconomic interventions for young and middle-aged adult male TB cases to reduce LTFU., Competing Interests: Conflict of interest: D. Kibuule has nothing to disclose. Conflict of interest: P. Aises has nothing to disclose. Conflict of interest: N. Ruswa has nothing to disclose. Conflict of interest: T.W. Rennie has nothing to disclose. Conflict of interest: R. Verbeeck has nothing to disclose. Conflict of interest: B. Godman has nothing to disclose. Conflict of interest: M. Mubita has nothing to disclose., (Copyright ©ERS 2020.)

Objectives: Optimal treatment success rates are critical to end tuberculosis in Namibia. Despite the scale-up of high quality directly observed therapy short-course strategy (DOTS) in Namibia, treatment success falls short of the global target of 90%. The objective of this study was to ascertain the predictors of treatment success rates under DOTS in Namibia to provide future direction., Methods: A nation-wide comparative analysis of predictors of treatment success was undertaken. Tuberculosis cases in the electronic tuberculosis register were retrospectively reviewed over a 10-year period, 2004-2016. The patient, programmatic, clinical, and treatment predictors of treatment success were determined by multivariate logistic regression modeling using R software., Results: 104,603 TB cases were registered at 300 DOTS sites in 37 districts. The 10-year period treatment success rate was 80%, and varied by region (77.2%-89.2%). The patient's sex and age were not significant predictors. The independent predictors for treatment success as were: Region of DOTS implementation (p=0.001), type of directly observed treatment (DOT) supporter (p<0.001), sputum conversion at 2 months (p=0.013), DOT regimen (p<0.001), cotrimoxazole prophylaxis (p=0.002), and HIV co-infection (p=0.001)., Conclusion: Targeted programmatic, clinical and treatment interventions are required to enhance DOTS treatment success in Namibia. These are now ongoing.

Background Therapeutic drug monitoring is frequently used to optimize the gentamicin dose. Objective The study investigated whether a 240 mg once daily standard dose achieves the recommended target serum gentamicin concentrations. Setting The prospective, observational study took place in the 2 major public hospitals in Namibia. Method Twenty-nine female patients receiving a standard dose (240 mg gentamicin once daily) participated in the study. Two blood samples were withdrawn to estimate gentamicin pharmacokinetic parameters. Serum creatinine was used to calculate creatinine clearance with the Cockcroft-Gault formula (CL cr ), and estimate glomerular filtration rate (eGFR) by the Modified Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. Main outcome measure The outcome measure was the proportion of patients receiving 240 mg gentamicin once daily having C max values above 15 mg/L. Results Total body weight (TBW) and body mass index were highly variable: 43-115 kg, and 17.3-41.3 kg/m 2 , respectively. The gentamicin dose normalized for TBW (adjusted body weight for obese patients) was relatively low, i.e. 4.2 ± 0.8 mg/kg (mean SD). Gentamicin C max was 14.4 ± 4.7 mg/L; only 9 patients (31%) had a C max > 15 g/mL. eGFR (MDRD-4) correlated well with CL cr , but eGFR (EPI-CKD) formula showed systematic deviations from CLcr. Conclusions (1) a standard 240 mg dose results in gentamicin C max values below 15 mg/L in the majority of the patients, (2) eGFR formulas to estimate kidney function will have to be evaluated for their usefulness in the Namibian patient population.

Literature data relevant to the decision to allow a waiver of in vivo bioequivalence testing for the marketing authorization of immediate-release, solid oral dosage forms containing enalapril maleate are reviewed. Enalapril, a prodrug, is hydrolyzed by carboxylesterases to the active angiotensin-converting enzyme inhibitor enalaprilat. Enalapril as the maleate salt is shown to be highly soluble, but only 60%-70% of an orally administered dose of enalapril is absorbed from the gastrointestinal tract into the enterocytes. Consequently, enalapril maleate is a Biopharmaceutics Classification System class III substance. Because in situ conversion of the maleate salt to the sodium salt is sometimes used in production of the finished drug product, not every enalapril maleate-labeled finished product actually contains the maleate salt. Enalapril is not considered to have a narrow therapeutic index. With this background, a biowaiver-based approval procedure for new generic products or after major revisions to existing products is deemed acceptable, provided the in vitro dissolution of both test and reference preparation is very rapid (at least 85% within 15 min at pH 1.2, 4.5, and 6.8). Additionally, the test and reference product must contain the identical active drug ingredient., (Copyright © 2017 American Pharmacists Association®. All rights reserved.)

Introduction: Tuberculosis (TB) remains one of the world's deadliest communicable diseases. Although cure rates of the standard four-drug (rifampicin, isoniazid, pyrazinamide, ethambutol) treatment schedule can be as high as 95-98 % under clinical trial conditions, success rates may be much lower in less well resourced countries. Unsuccessful treatment with these first-line anti-TB drugs may lead to the development of multidrug resistant and extensively drug resistant TB. The intrinsic interindividual variability in the pharmacokinetics (PK) of the first-line anti-TB drugs is further exacerbated by co-morbidities such as HIV infection and diabetes., Methods: Therapeutic drug monitoring has been proposed in an attempt to optimize treatment outcome and reduce the development of drug resistance. Several studies have shown that maximum plasma concentrations (C max), especially of rifampicin and isoniazid, are well below the proposed target C max concentrations in a substantial fraction of patients being treated with the standard four-drug treatment schedule, even though treatment's success rate in these studies was typically at least 85 %., Discussion: The proposed target C max concentrations are based on the concentrations of these agents achieved in healthy volunteers and patients receiving the standard doses. Estimation of C max based on one or two sampling times may not have the necessary accuracy since absorption rate, especially for rifampicin, may be highly variable. In addition, minimum inhibitory concentration (MIC) variability should be taken into account to set clinically meaningful susceptibility breakpoints. Clearly, there is a need to better define the key target PK and pharmacodynamic (PD) parameters for therapeutic drug monitoring (TDM) of the first-line anti-TB drugs to be efficacious, C max (or area under the curve (AUC)) and C max/MIC (or AUC/MIC)., Conclusion: Although TDM of first-line anti-TB drugs has been successfully used in a limited number of specialized centers to improve treatment outcome in slow responders, a better characterization of the target PK and/or PK/PD parameters is in our opinion necessary to make it cost-effective.

Purpose: The therapeutic equivalence of multiple registered fenofibrate formulations, several of which are suprabioavailable and therefore marketed at lower dosage strengths than their reference products, is based on the results of bioequivalence studies. Most of these formulations show a higher bioavailability when taken with a high-fat meal. The relative bioavailability of two of these formulations, the 200 mg Lidose hard capsules and the 145 mg nanoparticle tablets, was assessed when taken with a high-fat meal., Methods: In this single dose, 2-way, randomized, crossover study, 24 healthy subjects received a 200 mg fenofibrate Lidose hard capsule (Test) and a 145 mg nanoparticle tablet (Reference) under high-fat fed conditions. Plasma concentrations of fenofibric acid were measured up to 72 hours by using a validated LC-MS/MS method., Results: The geometric mean ratios (Test/Reference) and the 90% confidence intervals for AUC0-t and Cmax were 1.37 (131.58 - 142.88) and 1.38 (124.60 - 152.93), respectively. The median (range) Tmax- values of fenofibric acid were 4.5 h (3.0 - 8.0 h) and 3.25 h (1.0 - 6.5 h) after administration of the Lidose hard capsule and the nanoparticle tablet, respectively., Conclusion: Under high-fat fed conditions the extent of fenofibrate absorption was 37% higher for the 200 mg Lidose hard capsule compared to the 145 mg nanoparticle tablet, which is exactly as expected based on a mg-to-mg weight basis. The results of the present study underline the importance of assessing bioequivalence of fenofibrate formulations under identical fed conditions, and preferentially after a high-fat meal as this condition represents the worst-case scenario. Furthermore, the results of this study demonstrate that the 145 mg nanoparticle tablet is not bioequivalent to the 200 mg Lidose hard capsule when administered under high-fat meal conditions.

Background: Tacrolimus (TAC) pharmacokinetics (PKs) show considerable unexplained variability, particularly in the early period after transplantation. Therefore, TAC is a good candidate for therapeutic drug monitoring. The main objective of the present work was to propose a robust PK model for TAC in the early period after transplantation, with the final goal to provide practitioners with a tool for dose individualization in pediatric patients., Methods: TAC concentration data were obtained from 82 pediatric liver allograft recipients during the first 2 weeks after transplantation. Previously published models, and a model recently developed by our group for pediatrics early after pediatric liver transplantation, were fitted to the data and their predictive performance compared with the performances of a model developed using the data from 82 pediatric patients., Results: During the data-driven analysis, the PKs of TAC were best described by a 1-compartment model with time-varying first order elimination. Apparent volume of distribution and blood clearance estimates were 283 L and 10 L/h, respectively. The absorption was also considered to be a first order process, with a first order rate fixed to 4.45 hours. Parameters were estimated with good precision and accuracy. Although hematocrit levels, time after transplantation, liver weight, and body weight influenced the clearance, body weight was the only covariate retained on volume of central and peripheral compartments. Two of the 5 previous models showed acceptable predictive performances using the observed data., Conclusions: Time after transplantation, body weight, and hematocrit levels were shown to influence TAC PK in the early pediatric post-liver transplantation period and should be considered, besides therapeutic drug monitoring, by clinicians for the TAC posology prescription and adaptation.

This study aimed at investigating the contribution of CYP2C9 and VKORC1 genetic polymorphisms to inter-individual variability of acenocoumarol pharmacokinetics and pharmacodynamics in Black Africans from Benin. Fifty-one healthy volunteers were genotyped for VKORC1 1173C>T polymorphism. All of the subjects had previously been genotyped for CYP2C9*5, CYP2C9*6, CYP2C9*8, CYP2C9*9 and CYP2C9*11 alleles. Thirty-six subjects were phenotyped with a single 8 mg oral dose of acenocoumarol by measuring plasma concentrations of (R)- and (S)-acenocoumarol 8 and 24 h after the administration using chiral liquid-chromatography tandem mass-spectrometry. International normalized ratio (INR) values were determined prior to and 24 h after the drug intake. The allele frequency of VKORC1 variant (1173C>T) was 1.96% (95% CI 0.0-4.65%). The INR values did not show statistically significant difference between the CYP2C9 genotypes, but were correlated with body mass index and age at 24 h post-dosing (P < 0.05). At 8 h post dose, the (S)-acenocoumarol concentrations in the CYP2C9*5/*8 and CYP2C9*9/*11 genotypes were about 1.9 and 5.1 fold higher compared with the CYP2C9*1/*1 genotype and 2.2- and 6.0-fold higher compared with the CYP2C9*1/*9 group, respectively. The results indicated that pharmacodynamic response to acenocoumarol is highly variable between the subjects. This variability seems to be associated with CYP2C9*5/*8 and *9/*11 variant and demographic factors (age and weight) in Beninese subjects. Significant association between plasma (S)-acenocoumarol concentration and CYP2C9 genotypes suggested the use of (S)-acenocoumarol for the phenotyping purpose. Larger number of subjects is needed to study the effect of VKORC1 1173C>T variant due to its low frequency in Beninese population.

Objective: The aim of the present study was to compare the pharmacokinetic properties, bioavailability and tolerability of artesunate (AS) and amodiaquine (AQ) administered as a fixed-dose combination (Amonate FDC tablets; Dafra Pharma, Turnhout, Belgium) or as a non-fixed dose combination of separate AS tablets (Arsuamoon; Guilin Pharmaceutical Co, Shanghai, China) and AQ tablets (Flavoquine; Sanofi-Aventis, Paris, France)., Methods: This was a randomized, open label, two-period, two-treatment, two-sequence, cross-over study in which 60 healthy male Indian volunteers were given a single total oral dose of 100 mg AS and 400 mg AQ hydrochloride either as two tablets of Amonate FDC (AS 50 mg and AQ hydrochloride 200 mg) or as two AS tablets of the co-blister Arsuamoon (50 mg AS) together with two Flavoquine tablets (200 mg AQ hydrochloride). Plasma AS and blood AQ concentrations, as well as those of their respective active metabolites dihydroartemisinin (DHA) and desethylamodiaquine (DEAQ), were measured by high-performance liquid chromatography-tandem spectrometry. The pharmacokinetic parameters of AS, DHA, AQ and DEAQ were determined by non-compartmental analysis. Bioequivalence assessment was performed by analysis of variance (ANOVA), and calculation of the 90% confidence intervals of the geometric mean ratio test (fixed)/reference (non-fixed) for AUC(0-t) and C(max) for AS, AQ, DHA and DEAQ., Results: Interim analysis showed that both treatments were not bioequivalent; therefore, statistical analysis was carried out on the results of all subjects for whom blood/plasma concentrations were available for all four analytes (n=26). The C(max) (maximum plasma/blood concentration) of AS was 67.0 ± 37.1 and 154.8 ± 116.2 ng/mL for the fixed-dose and non-fixed dose administration, respectively. The AUC(0-t) (area under the plasma concentration-time curve from time zero to the last measurable concentration) of AS was 60.1 ± 27.5 and 81.8 ± 44.3 ng h/mL for the fixed-dose and non-fixed dose administration, respectively. The 90% confidence intervals for C(max) and AUC(0-t) of AS were outside the 80-125% acceptance range: 37.02-61.62% and 70.10-83.47%, respectively. The C(max) of AQ was 33.8 ± 13.6 and 31.4 ± 14.1 ng/mL for the fixed-dose and non-fixed dose administration, respectively. The AUC(0-t) of AQ was 332.3 ± 116.6 and 329.8 ± 99.5 ng h/mL for the fixed and non-fixed dose administration, respectively. For AQ, the 90% CIs for C(max) and AUC(0-t) were within the 80-125% acceptance range: 99.17-121.71 and 89.53-107.35%, respectively. Bioequivalence assessment based on the active metabolite data supported the bioequivalence conclusions based on the parent compound data. Both the fixed-dose and non-fixed dose administration of 100 mg AS and 400 mg AQ were well tolerated., Conclusion: Bioequivalence of the fixed-dose AS/AQ formulation with the non-fixed dose combination of the same drugs was not demonstrated for AS, but it was shown for AQ for both C(max) and AUC(0-t). The results obtained on the active metabolites support this conclusion. Overall, the fixed-dose 50 mg AS/200 mg AQ tablets were not technically bioequivalent with 50 mg AS tablets and 200 mg AQ tablets administered separately. The difference cannot be explained by the pharmaceutical properties of the tablets and seems to be biologically related.

Objectives: The study aims to develop empirical models able to predict the pharmacokinetics (PK) of four beta-lactams using the amikacin (AMK) therapeutic drug monitoring (TDM), in order to optimize their dosage regimens., Design and Methods: 69 critically ill septic patients were included. All received a first dose of AMK combined with piperacillin/tazobactam, ceftazidime, cefepime or meropenem. A multivariate analysis was performed to predict the beta-lactam PK using AMK PK parameters estimated from TDM and using pathophysiological variables., Results: An optimal prediction model was identified for each PK parameter of each beta-lactam. The best predictor of each model was one of the AMK PK parameters estimated from TDM. Other variables included colloid solution, renal and hepatic biomarkers, age and body weight., Conclusion: PK of the four beta-lactams could be easily and rapidly predicted in critically ill septic patients using the AMK TDM. These predictions could improve the beta-lactam dosages in clinical practice., (Copyright 2009 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.)

Introduction: Chronic kidney disease is a common, progressive illness that is becoming a global public health problem. In patients with kidney dysfunction, the renal excretion of parent drug and/or its metabolites will be impaired, leading to their excessive accumulation in the body. In addition, the plasma protein binding of drugs may be significantly reduced, which in turn could influence the pharmacokinetic processes of distribution and elimination. The activity of several drug-metabolizing enzymes and drug transporters has been shown to be impaired in chronic renal failure. In patients with end-stage renal disease, dialysis techniques such as hemodialysis and continuous ambulatory peritoneal dialysis may remove drugs from the body, necessitating dosage adjustment., Methods: Inappropriate dosing in patients with renal dysfunction can cause toxicity or ineffective therapy. Therefore, the normal dosage regimen of a drug may have to be adjusted in a patient with renal dysfunction. Dosage adjustment is based on the remaining kidney function, most often estimated on the basis of the patient's glomerular filtration rate (GFR) estimated by the Cockroft-Gault formula. Net renal excretion of drug is a combination of three processes: glomerular filtration, tubular secretion and tubular reabsorption. Therefore, dosage adjustment based on GFR may not always be appropriate and a re-evaluation of markers of renal function may be required., Discussion: According to EMEA and FDA guidelines, a pharmacokinetic study should be carried out during the development phase of a new drug that is likely to be used in patients with renal dysfunction and whose pharmacokinetics are likely to be significantly altered in these patients. This study should be carried out in carefully selected subjects with varying degrees of renal dysfunction. In addition to this two-stage pharmacokinetic approach, a population PK/PD study in patients participating in phase II/phase III clinical trials can also be used to assess the impact of renal dysfunction on the drug's pharmacokinetics and pharmacodynamics., Conclusion: In conclusion, renal dysfunction affects more that just the renal handling of drugs and/or active drug metabolites. Even when the dosage adjustment recommended for patients with renal dysfunction are carefully followed, adverse drug reactions remain common.

The liver plays a central role in the pharmacokinetics of the majority of drugs. Liver dysfunction may not only reduce the blood/plasma clearance of drugs eliminated by hepatic metabolism or biliary excretion, it can also affect plasma protein binding, which in turn could influence the processes of distribution and elimination. Portal-systemic shunting, which is common in advanced liver cirrhosis, may substantially decrease the presystemic elimination (i.e., first-pass effect) of high extraction drugs following their oral administration, thus leading to a significant increase in the extent of absorption. Chronic liver diseases are associated with variable and non-uniform reductions in drug-metabolizing activities. For example, the activity of the various CYP450 enzymes seems to be differentially affected in patients with cirrhosis. Glucuronidation is often considered to be affected to a lesser extent than CYP450-mediated reactions in mild to moderate cirrhosis but can also be substantially impaired in patients with advanced cirrhosis. Patients with advanced cirrhosis often have impaired renal function and dose adjustment may, therefore, also be necessary for drugs eliminated by renal exctretion. In addition, patients with liver cirrhosis are more sensitive to the central adverse effects of opioid analgesics and the renal adverse effects of NSAIDs. In contrast, a decreased therapeutic effect has been noted in cirrhotic patients with beta-adrenoceptor antagonists and certain diuretics. Unfortunately, there is no simple endogenous marker to predict hepatic function with respect to the elimination capacity of specific drugs. Several quantitative liver tests that measure the elimination of marker substrates such as galactose, sorbitol, antipyrine, caffeine, erythromycin, and midazolam, have been developed and evaluated, but no single test has gained widespread clinical use to adjust dosage regimens for drugs in patients with hepatic dysfunction. The semi-quantitative Child-Pugh score is frequently used to assess the severity of liver function impairment, but only offers the clinician rough guidance for dosage adjustment because it lacks the sensitivity to quantitate the specific ability of the liver to metabolize individual drugs. The recommendations of the Food and Drug Administration (FDA) and the European Medicines Evaluation Agency (EMEA) to study the effect of liver disease on the pharmacokinetics of drugs under development is clearly aimed at generating, if possible, specific dosage recommendations for patients with hepatic dysfunction. However, the limitations of the Child-Pugh score are acknowledged, and further research is needed to develop more sensitive liver function tests to guide drug dosage adjustment in patients with hepatic dysfunction.

Ageing affects drugs metabolism influencing the therapeutic efficacy and safety of drugs. By using the experimental model of aged male rats, we investigated the influence of ageing on some CYP2C isoforms, the most important CYP450 sub-family in rats. The activity of the male specific CYP2C11 is decreased by 55% in senescent male rats. This correlates with a significant reduction of both protein content (80%) and mRNA (60%) indicating a demasculinization process. The expression of CYP2C12, a female specific isoform, is induced in senescent male rats indicating a feminization process. Neither the activity nor the expression of CYP2C6, a female predominant isoform, is modified in senescent male rats. Thereafter, certain putative GH mediators like some liver enriched transcription factors (LETFs) or STAT5b were investigated. The amount of HNF3beta mRNA, a transcription factor involved in the up-regulation of CYP2C12, has been shown to increase by about three-fold in senescent male rats. With regard to STAT5b, which has been reported to be involved in the male specific regulation of CYP2C11, large amounts of phosphorylated STAT5 were observed in the liver of senescent male rats. These results indicate that while the induction of CYP2C12 during ageing could be due, at least partially, to the enhanced HNF3beta expression, the decline of CYP2C11 is unlikely related to a decrease of STAT5 activation.

The effect of ageing on CYP2E1 activity and its protein and mRNA contents was investigated in both adult (9 months) and senescent (24 months) male Wistar rats. The CYP2E1 activity (as measured by chlorzoxazone hydroxylation) was significantly decreased by 36% in senescent rats as compared to adult rats. However, this decrease of activity was not associated with a loss of protein content because the amount of both CYP2E1 protein and CYP2E1 mRNA did not decrease in senescent rats but rather increased, by 79% and 64% respectively, as compared to adult rats. Lipid peroxidation was increased significantly by 140% with ageing. The decrease in CYP2E1 activity could be explained by post-translational modification of CYP2E1 proteins, due to an increase in oxidative stress in senescent animals, leading to a loss of their functionality. However, no changes in the extent of protein carbonyls were observed in the adult versus senescent rats (16.2 +/- 9.6 vs. 12.7 +/- 7.3 nmol/mg prot) and the major proteasome activity remained unchanged. With regards to the increase of CYP2E1 expression, our results showed that the amount of hepatocyte nuclear factor 1alpha mRNA, a transcription factor that positively regulates CYP2E1, was strongly increased (154%) in senescent rats.

The effect of ageing on CYP3A2, a male specific isoform, was examined in adult (9 months) and senescent (24 months) male rats. A significant decrease (65%) of CYP3A2-related activity (midazolam oxidation) was observed in all senescent rats. Half of these rats still express CYP3A2 suggesting that decreased activities in these rats are due to post-translational modifications. The other senescent male rats did not express CYP3A2 anymore, indicating an impairment of transcription. These transcriptional modifications are due to the previously shown continuous secretion of GH in senescent male rats. GH also regulates HNF4alpha, a hepatocyte nuclear factor, essential for the basal transcriptional activation of the CYP3A2 gene. In senescent rats, a drastic reduction (76%) of HNF4alpha protein content and a decrease in DNA binding activity were observed. When these parameters were assessed in male and female rats of the same age (3 months), a higher HNF4alpha DNA binding activity and a higher HNF4alpha protein content (38%) were observed in female rats. Our results show that in male senescent rats (1) the decrease of HNF4alpha is not consistent with the continuous secretion of GH, and (2) the suppression of CYP3A2 expression is not dependent to the HNF4alpha binding activity.

Precision-cut liver slices (PCLS) offer a lot of advantages because all heterogeneity and cell-cell interactions within the original tissue matrix are maintained. This in vitro model was used to study the effect of ageing on certain aspects of drug metabolism and liver function in young (3 months), adult (9 months) and old (24 months) Wistar male rats. Protein synthesis, an important liver function, was not modified in young, adult and old rats, suggesting that ageing does not impair liver functionality but it affects some specific targets. Among them, a decrease in total P450 in liver microsomes and the loss of CYP3A23 inducibility in PCLS were clearly observed in old rats as compared to adult rats. Finally, the amount of total paracetamol conjugates was not modified between 9 and 24 months but in old rats, sulfoconjugation of paracetamol, its major route of elimination, was decreased.

Drug biotransformation and its therapeutic effect may be modified during ageing. Among different causative factors of ageing, the impairment of normal cellular functions by free radicals has been evoked as playing a critical role. The effect of age on the expression and activity of CYP2E1 and CYP3A was investigated in male Wistar rats of 3, 8, 11 and 18 months old. The total cytochrome P450 as well as the expression and the activity (midazolam oxidation) of CYP3A isoforms did not change until 18 months of age. Chlorzoxazone hydroxylation (CYP2E1 activity) increased from 3 to 8 months, remained constant between 8 and 11 months and then progressively decreased until 18 months. Interestingly, CYP2E1 microsomal protein followed the same enzyme activity profile from 3 to 8 months, but remained constant thereafter. The level of CYP2E1 mRNA did not change over the whole period. While the amount of proteins did not change after 8 months, their functionality may be affected by oxidative stress (increase in thiobarbituric acid reactive substances, decrease in reduced glutathione level). However, no changes in carbonyl protein content were observed. The decrease in CYP2E1 activity in rats after 11 months is most probably due to post-translational modifications of CYP2E1 proteins. Indeed, it may be correlated with an accumulation of oxidative damage. Since no change was observed in CYP3A activity or in their protein and mRNA content, it seems that such isoforms should be less affected by oxidative stress.

Purpose: To describe the modification of the ropivacaine (R) pharmacokinetics produced by the addition of epinephrine (E)., Methods: After Institutional Review Board approval, 18 ASA I boys received a caudal block (1 mL x kg(-1)) with either plain 0.2% R (Group E-) or with 0.2% R containing E (5 microg x mL(-1); Group E+). Venous blood samples were taken at zero, 15, 30, 60, 90, 120, 180, 240, 420, 720, 1440 min after caudal injection. Total R concentration in plasma was determined by high pressure liquid chromatography. Maximal concentration (C(max)) and time to peak concentration (T(max)) were obtained from the data, terminal half-life (T(1/2z)), clearance (Cl) and volume of distribution (Vd) were estimated by a non-compartmental approach. Subsequently, in order to determine the absorption rate (Ka) and to reduce to number of blood samples, 25 other children, receiving plain R and another group of 25 receiving the E solution were studied using a population approach (NONMEM). A one compartment model with first order absorption was used. The effect of weight, age and E on Cl, Vd and Ka was estimated., Results: C(max) was significantly lower in Group E+ (0.93 mg x L(-1) +/- 0.29 vs 0.61 mg x L(-1) +/- 0.28, P = 0.05) and T(max) occurred later (124 min +/- 53 vs 47 min +/- 16, P = 0.003). Weight was a significant covariate for Cl and Vd while E significantly slowed R Ka [Group I Ka 0.025 min(-1) [coefficient of variation (CV) 21%] vs 0.078 min(-1) (CV 25%) in Group II]., Conclusion: The addition of E significantly modifies the pharmacokinetics of R injected caudally.

Taurine is released by contracting muscles, but its actual role remains unspecified. In this study, we investigated whether the exercise-stimulated release of taurine from muscle into the plasma regulates the modification of osmolality induced by intramuscular osmolyte production. Six subjects performed 90 min of cycling exercise (at 70% maximum power output) on two occasions, with (HC) or without (DC) fluid intake. Taurine content was determined in plasma, blood cells and urine before and after the endurance events, together with plasma osmolality. Plasma osmolality increased by 4% in the DC experiment ( P<0.01), but remained stable in the HC condition. The exercise also induced changes in the mean (SD) plasma taurine content to a greater degree in HC [+63 (26)%] than in DC [+33 (18)%; P<0.05], supporting the hypothesis that taurine is released into the plasma via an osmoregulatory process. However, the higher plasma taurine content in HC was not related to changes in renal taurine. In addition, the increase of taurine in plasma was not related to its release from blood cells since their taurine concentration increased by 70% both in HC [429 (77) to 680 (82) microM; P=0.003] and in DC [451 (57) to 731 (34) microM; P<0.001]. The lack of correlation between plasma volume modification and the mass ratio of taurine would exclude a major role for taurine exchange in plasma volume regulation. Sodium ( R=0.967, P<0.001), chloride ( R=0.917, P<0.001) and osmolality ( R=0.924, P<0.001) seem to be the main regulators of plasma volume changes during exercise. In conclusion, changes in the plasma taurine content during endurance exercise is related to an osmoregulatory process, but this alone does not control plasma volume changes.