Establishment and validation of a LC-MS/MS method for the determination of anlotinib in human plasma: Application to therapeutic drug monitoring.

Anlotinib is a novel small molecule multitarget tyrosine kinase inhibitor for the treatment of several cancers. We developed and validated a highly sensitive, rapid and stable high-performance liquid chromatography-mass spectrometrymethod for the determination of anlotinib in human plasma with anlotinib-d5 as a stable isotopically labeled internal standard (SIL-IS). To explore the feasibility of therapeutic drug monitoring in the treatment of tumors with anlotinib, human plasma samples were prepared by protein precipitation. The mobile phases comprised of (A) 5.0 mm NH4 AC aqueous solution containing 0.1% formic acid and (B) 100% methanol containing 0.1% formic acid. A gradient mobile phase system was adopted for chromatographic separation using a BEH C18 (2.1 × 50 mm, 1.7 µm) column. A positive ion pattern was chosen for quantification under multiple reaction monitoring mode. The ion pairs were detected at m/z 408.2 â†’ 339.1 and m/z 413.4 â†’ 344.3 for anlotinib and anlotinib-d5 (SIL-IS), respectively. The total run time was 5.0 min. The calibration curve was found to be linear within a plasma concentration range of 2-400 ng·ml-1 . The precision and accuracy, matrix effect, extraction recovery and stability were all validated and met the requirements of international guidelines. The proposed methods were successfully applied to support therapeutic drug monitoring in breast and thyroid cancer patients receiving anlotinib for therapy. Clinical data showed that in the 12 mg dose group, the mean plasma concentrations of anlotinib in breast cancer patients and thyroid cancer patients were 87.1 and 118.8 ng·ml-1 , respectively. The data demonstrate that the peak concentration of anlotinib may be related to the different tumor types in patients.

The Role of the Mesencephalic Astrocyte-Derived Neurotrophic Factor in Patients in Intensive Care Units Receiving Voriconazole Therapy.

Recent publications regarding the role of mesencephalic astrocyte-derived neurotrophic factor (MANF) in various metabolic and degenerative disorders suggest that MANF is both a marker of disease and a possible therapeutic agent. We investigate the role of plasma MANF levels in patients in intensive care units (ICUs) receiving voriconazole (VCZ) therapy while also comparing MANF levels in healthy individuals. A single-center prospective study was conducted. The plasma MANF level in patients in ICU was found to have high interindividual variability and was significantly higher than that in healthy controls (P < .01). Compared with patients using VCZ only, patients using both VCZ and amikacin had 3-fold lower MANF concentrations (P < .05). The MANF concentrations also decreased when alkaline phosphatase (ALP) and serum creatinine levels were above the upper limits of the normal range (P < .05) and the estimated glomerular filtration rate (eGFR) was below the lower limit of the normal range (P < .01). Receiver operating characteristic curve analysis indicated that low MANF levels were associated with high ALP levels, high creatinine levels, and low eGFR. The cut-off value of MANF for ALP levels higher than 126 U/L was 0.35 ng/mL (area under curve, AUC = 0.62, 95%CI = 0.50-0.74, P = .044); for serum creatinine levels higher than 104 µmol/L, the cut-off value was 0.41 ng/mL (AUC = 0.74, 95%CI = 0.62-0.87, P = .001); and for eGFR below 80 mL/min, the cut-off value was 0.75 ng/mL (AUC = 0.70, 95%CI = 0.59-0.81, P = .002). Monitoring plasma MANF levels may be of value for clinical decision-making regarding the choice of antibiotics and the prediction of impaired liver function and renal function in patients admitted to an ICU.

Factors influencing plasma concentration of voriconazole and voriconazole- N-oxide in younger adult and elderly patients.

Background: Voriconazole (VCZ) metabolism is influenced by many factors. Identifying independent influencing factors helps optimize VCZ dosing regimens and maintain its trough concentration (C0) in the therapeutic window. Methods: We conducted a prospective study investigating independent factors influencing VCZ C0 and the VCZ C0 to VCZ N-oxide concentration ratio (C0/CN) in younger adults and elderly patients. A stepwise multivariate linear regression model, including the IL-6 inflammatory marker, was used. The receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive effect of the indicator. Results: A total of 463 VCZ C0 were analyzed from 304 patients. In younger adult patients, the independent factors that influenced VCZ C0 were the levels of total bile acid (TBA) and glutamic-pyruvic transaminase (ALT) and the use of proton-pump inhibitors. The independent factors influencing VCZ C0/CN were IL-6, age, direct bilirubin, and TBA. The TBA level was positively associated with VCZ C0 (ρ = 0.176, p = 0.019). VCZ C0 increased significantly when the TBA levels were higher than 10 µmol/L (p = 0.027). ROC curve analysis indicated that when the TBA level ≥4.05 µmol/L, the incidence of a VCZ C0 greater than 5 µg/ml (95% CI = 0.54-0.74) (p = 0.007) increased. In elderly patients, the influencing factors of VCZ C0 were DBIL, albumin, and estimated glomerular filtration rate (eGFR). The independent factors that affected VCZ C0/CN were eGFR, ALT, γ-glutamyl transferase, TBA, and platelet count. TBA levels showed a positive association with VCZ C0 (ρ = 0.204, p = 0.006) and C0/CN (ρ = 0.342, p < 0.001). VCZ C0/CN increased significantly when TBA levels were greater than 10 µmol/L (p = 0.025). ROC curve analysis indicated that when the TBA level ≥14.55 µmol/L, the incidence of a VCZ C0 greater than 5 µg/ml (95% CI = 0.52-0.71) (p = 0.048) increased. Conclusion: TBA level may serve as a novel marker for VCZ metabolism. eGFR and platelet count should also be considered when using VCZ, especially in elderly patients.

Prediction of plasma trough concentration of voriconazole in adult patients using machine learning.

OBJECTIVE: Plasma trough concentration of voriconazole (VCZ) was associated with its toxicity and efficacy. However, the nonlinear pharmacokinetic characteristics of VCZ make it difficult to determine the relationship between clinical characteristics and its concentration. We intended to present a machine learning (ML)-based method to predict toxic plasma trough concentration of VCZ (>5 µg/mL). METHODS: A single center retrospective study was conducted. Three ML algorithms were used to estimate the concentration in adult patients, including random forest (RF), gradient boosting (GB), and extreme gradient boosting (XGBoost). The importance of variables was recognized by the SHapley Additive exPlanations (SHAP) method. In addition, an external validation set was used to validate the robustness of models. RESULTS: A total of 1318 VCZ plasma concentration were included, with 33 variables enrolled in the model. Nine classification models were developed using the RF, GB, and XGBoost algorithms. Most models performed well for both the training set and test set, with an average balanced accuracy (BA) of 0.704 and an average accuracy (ACC) of 0.788. In addition, the average Matthews correlation coefficient value reached 0.484, which indicated the predicted values are meaningful. Based on the average BA and ACC values, the predictive ability of the models can be ranked from best to worst as follows: younger adult models > mixed models > elderly models, and XGBoost models > GBT models > RF models. The SHAP results showed that the top five influencing factors in younger adult patients (<60 years) were albumin, total bile acid (TBA), platelets count, age, and inflammation, while the top five influencing factors in elderly patients were albumin, TBA, aspartate aminotransferase, creatinine, and alanine aminotransferase. Furthermore, the prediction of external validation set for VCZ concentrations verified the high reliability of the models, for the ACC value of 0.822 by the best model. CONCLUSIONS: The ML models can be reliable tools for predicting toxic concentration exposure of VCZ. The SHAP results may provide useful guidelines for dosage adjustment of VCZ.

Inflammation Affects Liver Function and the Metabolism of Voriconazole to Voriconazole-N-Oxide in Adult and Elderly Patients.

Background: The inner association of inflammation with voriconazole (VCZ) metabolism has not been fully investigated. We intend to investigate the effects of inflammation on liver function, VCZ trough concentration (C0), C0/dose ratio and the ratio of VCZ to VCZ-N-oxide concentration (C0/CN) in adult and elderly patients. Methods: A single-center retrospective study was conducted among patients who were treated in our hospital between January 2018 and December 2021. For each eligible patient, demographic details, medical history, laboratory parameters, procalcitonin (PCT), C reactive protein (CRP), and interleukin-6 (IL-6) were collected from the medical chart. VCZ CN, TNF-α, IL-1ß, IL-8, and IL-10 concentrations were detected in blood samples. Results: A total of 356 patients were included in our study, with 195 patients in the adult cohort (<60 years) and 161 patients in the elderly cohort (≥60 years). In adult patients, CRP and IL-8 levels showed moderate association with VCZ C0/CN ratio (CRP: r = 0.512, p < 0.001; IL-8: r = 0.476, p = 0.002). IL-6 level shallowly associated with VCZ C0/CN ratio both in adult and elderly patients (r = 0.355, p = 0.003; r = 0.386, p = 0.001). A significantly higher VCZ C0, C0/dose ratio and C0/CN ratio was observed in adult patients with severe inflammation compared with patients with moderate inflammation and no to mild inflammation, as reflected by PCT levels (p < 0.05). However, there was no significant difference observed among different inflammation degrees in elderly patients. Lower albumin (AL) and higher total bilirubin (TBIL) were observed along with the degree of inflammation in both adult and elderly patients, as reflected by CRP and PCT levels (p < 0.05). Conclusion: Inflammation may affect the metabolism of VCZ to VCZ-N-oxide both in adult and elderly patients, and decreased plasma AL levels and increased TBIL levels under inflammatory conditions may also alter VCZ metabolism.