Population pharmacokinetics and Bayesian forecasting of vancomycin in neonates requiring intensive care

PURPOSE The primary objective of this investigation was to develop a population-based pharmacokinetic model of vancomycin in neonates that can be utilized in the individualization of drug therapy. The second objective was to evaluate the accuracy and precision of a Bayesian forecasting method, based on an optimum population pharmacokinetic model, for predicting serum vancomycin concentrations in neonates. METHODS Patients All neonates with a post-conceptional age (PCA) of < 44 weeks admitted to the special care nursery (SCN) of Children's and Women's Health Centre of British Columbia (C & W) between January 01, 1996 and December 31, 1999 and prescribed vancomycin by their attending physicians were eligible for enrollment. Population Pharmacokinetic Modeling Population pharmacokinetic models, using an iterative stepwise approach, were developed for vancomycin with data from 185 patients using a nonlinear mixed effects modeling program (NONMEM). Significant covariates were those that resulted in a decrease in the minimum value of the objective function (MOF) of > 6.6 points. Final one- and twocompartment models were evaluated with data from a naive cohort of 65 patients. Following model validation, combined population pharmacokinetic models were fully developed using data from all 250 patients. As with the original model development, an iterative process was implemented to generate base, full, and final models. Bayesian Forecasting Serum vancomycin concentration predictions based on Bayesian estimates were provided in a NONMEM generated output using the POSTHOC function. Vancomycin concentrations were independently supplied as feedback observations to the final, one-and two-compartment models to obtain case-specific predictions of vancomycin peak and trough concentrations.' The precision and accuracy of Bayesian predictions were assessed using mean absolute error and mean error, respectively, and compared using 95% confidence intervals. RESULTS At all sequential stages, the one-compartment model appeared inferior to the twocompartment model. The minimum values of the objective function (MOF) from the onecompartment unadjusted, base model and revised model, were respectively, 438.52 and 29.84 points greater than the comparable two-compartment values. Weight and PCA (relative to term gestation), modeled as power functions, yielded significant reductions in the MOF when included as covariates on vancomycin clearance. Dopamine exposure was associated with a 34% decrease in vancomycin clearance. Patient weight was modeled as a linear function on the central volume of distribution. Chronic lung disease was associated with a 276% increase in the peripheral volume (Vp). The Vp represented 50% of the volume of distribution at steady-state in the youngest patients, but only 9% in the oldest patients. Model validation demonstrated better accuracy of the two-compartment model. The final, combined models were similar, except that indomethacin was associated with a 16% decrease in vancomycin clearance in the twocompartment model. The two-compartment model was more accurate than the one-compartment model in the Bayesian prediction of initial peak and trough concentrations in neonates < 36 weeks PCA. Bayesian predictions using trough samples as feedback yielded relative mean errors of < 3% for both initial and future peak concentrations. Relative mean absolute error was 6% and 12% for initial and future peak concentrations, respectively. CONCLUSIONS The two-compartment model was superior to the one-compartment model, particularly in neonates < 36 weeks PCA. The better specified two-compartment model also generated more accurate Bayesian predictions of peak and trough concentrations in neonates < 36 weeks PCA. Single trough samples using the two-compartment model and Bayesian forecasting appear to be clinically useful for therapeutic drug monitoring of vancomycin in the SCN population.Pharmaceutical Sciences, Faculty ofGraduat

Inhibition of Mycelial Growth by Methotrexate in Neurospora crassa Wild Type and Mutants Deficient in Folylpolyglutamate Synthase

Summary In mammalian cells, folylpolyglutamate synthase (FPGS) catalyzes the polyglutamylation of methotrexate (MTX), a reaction that significantly enhances the cellular retention and cytotoxicity of this antifolate. In contrast, MTX is a poor substrate for the cytosolic FPGS of Neurospora crassa. The present study has therefore examined the effect of MTX on growth of N. crassa wild type (FGSC 853 ) and two mutants (met-6, FGSC 1330 and mac, FGSC 3609) that have lesions affecting FPGS expression. Mycelial dry weights after growth in MTX-supplemented media, suggested that met-6 and mac were more sensitive to the antifolate than the wild type (WT). MTX concentrations resulting in 50% inhibition of growth (ICso values) were 5.5 11M, 6.0 11M and 87.5 11M for met-6, mac, and WT, respectively. When MTX treatment was followed by transfer to 50 11M folinic acid-supplemented media, growth of both mutants was enhanced by ca. 20% while that of WT increased by ca. 8%. [3H]-MTX pulse-chase experiments demonstrated that all three strains had limited or no ability to form polyglutamates (MTXGlun ) of the antifolate. In WT cultures, supplied with 1 I-tM [3H]-MTX for 24 hr and then grown in MTX-free media for another 24 hr, over 95% of the recovered label was in MTX; MTXGlu2 and MTXGlu3 accounting for only 2% and 1% respectively. MTXGlun derivatives were not detected in mac but low levels of MTXGlu2 were generated by met-6. In all three strains, the level of expression of dihydrofolate reductase (DHFR) was similar. DHFR was purified to apparent homogeneity (21.6 kDa) from extracts of each strain using a protocol of ammonium sulfate fractionation, gel filtration and Matrex Green A chromatography. It is concluded that in Neurospora, MTX polyglutamylation is not a major factor in the cytotoxicity of this antifolate.</jats:p

Modeling and Simulation Analysis of Aprepitant Pharmacokinetics in Pediatric Patients With Postoperative or Chemotherapy-Induced Nausea and Vomiting

OBJECTIVESAprepitant is effective for the prevention of chemotherapy-induced or postoperative nausea and vomiting (CINV/PONV). The aim of this study was to develop a population pharmacokinetic (PK) model of aprepitant in pediatric patients and to support dosing recommendations for oral aprepitant in pediatric patients at risk of CINV.METHODSA population PK model was constructed based on data from 3 clinical studies in which children (6 months to 12 years) and adolescents (12–19 years) were treated with a 3-day regimen of oral aprepitant (capsules or suspension), with or without intravenous fosaprepitant on day 1 (CINV), or a single dose of oral aprepitant (capsules or suspension; PONV). Nonlinear mixed-effects modeling was used for model development, and a stepwise covariate search determined factors influencing PK parameters. Simulations were performed to guide final dosing strategies of aprepitant in pediatric patients.RESULTSThe analysis included 1326 aprepitant plasma concentrations from 147 patients. Aprepitant PK was described by a 2-compartment model with linear elimination and first-order absorption, with allometric scaling for central and peripheral clearance and volume using body weight, and a cytochrome P450 3A4 maturation component for the effect of ontogeny on systemic clearance. Simulations established that application of a weight-based (for those &amp;lt;12 years) and fixed-dose (for those 12–17 years) dosing regimen results in comparable exposures to those observed in adults.CONCLUSIONSThe developed population PK model adequately described aprepitant PK across a broad pediatric population, justifying fixed (adult) dosing for adolescents and weight-based dosing of oral aprepitant for children.</jats:sec

1558. A Population Pharmacokinetic Model for Posaconazole Intravenous Solution and Oral Powder for Suspension Formulations in Pediatric Patients With Neutropenia

Abstract Background Posaconazole is approved in adults for prophylaxis and treatment of invasive fungal disease. Two formulations that offer weight-based dosing—intravenous (IV) and oral powder for suspension (PFS)—are being evaluated in children. A population pharmacokinetic (popPK) approach was used to characterize and predict the PK exposure of posaconazole PFS and IV formulations in children to identify dosages associated with achieving a target PK of 1200 ng/mL as the mean Cavg and individual Cavg ≥500 ng/mL and &lt;2500 ng/mL in ~90% of patients. Methods A popPK model was developed through nonlinear mixed-effects modeling using data obtained from a trial in children with neutropenia (ClinicalTrials.gov, NCT02452034; Merck protocol, MK-5592-097). Three dose cohorts (3.5, 4.5, and 6 mg/kg/day [≤300 mg/day]) were studied in two age groups (2–&lt;7 years and 7–17 years). Posaconazole IV was administered twice on day 1 then once daily through at least day 10, followed by PFS once daily through day 28 at clinician discretion. A compartmental model, including both formulations, was fit to the data. Model selection was based on the Log-Likelihood Criterion, goodness-of-fit plots, and scientific plausibility. Significance of the covariates was assessed in a stepwise forward inclusion/backward procedure. An additional assessment characterized the impact of different food covariates on bioavailability. Results An open one-compartmental PK model with first-order absorption and estimated bioavailability, as well as allometrically scaled effects of body weight on clearance and volume, adequately described the PK of posaconazole IV and PFS formulations. Model predictions are shown in the Table. Effects of the different food covariates were not statistically significant. Simulations indicated that for the 6-mg/kg/d dose, model-predicted Cavg generally met PK targets. Model-predicted Cavg was ≥500 ng/mL in &gt;90% of subjects in all cohorts. The 1200-ng/mL target geometric mean Cavg was achieved for all but the 2–&lt;7 years cohort receiving the PFS formulation. Conclusion This popPK-based analysis demonstrated that the 6-mg/kg/d dose of IV or PFS posaconazole formulation (≤300 mg/days) is appropriate for children (2–17 years) and that PFS can be administered without regard to food. Disclosures All authors: No reported disclosures. </jats:sec