Population PKPD of voclosporin in renal allograft patients.

The aims of this population-pharmacokinetic/pharmacodynamic (POP-PKPD) analysis of voclosporin in renal allograft patients were to build a POP-PKPD model for voclosporin and calcineurin activity (CNa) and identify clinically relevant covariates that could assist dosing of the drug. POP-PKPD modeling was performed using a stochastic approximation of the standard expectation maximization (SAEM) algorithm for nonlinear mixed-effects as implemented in Monolix™ 3.2. Voclosporin whole blood concentrations were obtained from de novo renal allograft patients and assayed using a validated LC/MS/MS assay. CNa was measured using a (32)P-radiolabeled assay. A two-compartment model with simultaneous sigmoid inhibitory Emax model was used to describe the PKPD relationship between voclosporin concentration and CNa. The POP-PKPD model was then utilized to simulate an optimal initial dosing strategy. Eighty-seven patients were included in the POP-PKPD study. Population mean estimates (relative standard error, rse) for oral clearance (CL/F) and first compartment volume of distribution (V1), were 717 mL min(-1) (35%) and 2010 mL (17%), respectively. Maximum CNa Inhibition (Imax), effective concentration (C50), and baseline immunosuppression (S0) were 0.87 pmol/min/mg (8.0%), 123 ng/mL (10%), and 1.15 pmol/min/mg (4.0%), respectively. Covariate analyses demonstrated that age and body surface area significantly influenced CL/F: CLi=717(Agei/48.8)-0.57(BSAi/1.99)1.1, while serum triglycerides significantly altered S0: S0i=1.15(TRIGi/1.97)0.15.

Pharmacokinetics of voclosporin in renal impairment and hepatic impairment.

Voclosporin is a novel calcineurin inhibitor intended for prevention of organ graft rejection and treatment of lupus nephritis. These studies evaluated the effect of renal or hepatic impairment on pharmacokinetics of voclosporin. Thirty-three subjects were enrolled into 1 of 4 groups based on renal function as defined by creatinine clearance and 18 subjects were enrolled into 1 of 3 groups based on hepatic function defined by Child-Pugh classes. Voclosporin 0.4 mg/kg was administered orally. Geometric mean ratios (renal/hepatic impairment-to-normal) and 90% confidence intervals for Cmax and AUC were calculated. A default no-effect interval of 80-125% was set. Although 90% confidence intervals exceeded the no-effect intervals for both parameters, individual Cmax and AUC plots indicate almost complete overlapping range of values for mild and moderate renal impairment and normal subjects. Severe renal impairment resulted in a 1.5-fold increase in AUC without an increase in Cmax . Mild to moderate hepatic impairment resulted in a 1.5- to 2-fold increase in voclosporin exposure. Voclosporin can be administered safely to patients with mild to moderate renal impairment without dose modification. Appropriate safety monitoring with concentration-based adjustments in transplantation are recommended for patients with severe renal impairment, and for patients with hepatic impairment.

Requirements for therapeutic drug monitoring of sirolimus, an immunosuppressive agent used in renal transplantation.

BACKGROUND: On September 15, 1999, sirolimus received approval from the US Food and Drug Administration (FDA) for marketing as an immunosuppressive agent. As with any chronically administered medication, the question arises whether therapeutic drug monitoring (TDM) is required for optimal therapy. In the case of sirolimus, there are data to suggest that TDM may be beneficial in some patients. OBJECTIVE: To assess the need for monitoring sirolimus concentrations, this paper reviews the following factors influencing the usefulness of TDM: wide pharmacokinetic variability; toxicity; suspected noncompliance; suspected drug interactions; and specific demographic characteristics. Data supporting the correlation between sirolimus concentration and immunosuppressive efficacy are also discussed. RESULTS: The available literature on sirolimus suggests that TDM may be required in some cases. Studies have shown that there is wide interindividual variability in the pharmacokinetic behavior of drugs in transplant patients; that there is a relationship between blood concentrations of sirolimus and adverse events; and that coadministration of cyclosporine alters the pharmacokinetics of sirolimus. Additionally, the correlation between sirolimus concentration and immunosuppressive efficacy in phase III trials suggests a benefit in transplant patients when sirolimus concentrations reach appropriate levels. Finally, noncompliance is a common occurrence in the transplant population, and monitoring is often necessary in suspected noncompliers. CONCLUSION: Although additional clinical studies are needed, it appears that TDM is an important aspect of treatment with sirolimus.

The monitoring of immunosuppressive drugs: a pharmacodynamic approach.

Pharmacodynamic monitoring measures biologic response to a drug, which, alone or coupled with pharmacokinetics, provides a novel method for the optimization of drug dosing. Pharmacodynamic monitoring has been investigated by us and other investigators on primarily five immunosuppressive drugs: cyclosporine (CsA), mycophenolate mofetil (MMF), rapamycin (RAPA), azathioprine (AZA), and methylprednisolone (MP). The pharmacodynamic monitoring of CsA and MMF involves measurement of the activity of the enzymes calcineurin and inosine monophosphate dehydrogenase, respectively. The pharmacodynamics of AZA are assessed by measurement of the activity of thiopurine methyl transferase (TPMT), which is induced by a metabolite of AZA, 6-mercaptopurine. The pharmacodyamics for RAPA involve the measurement of a P70 S6 kinase activity within lymphocytes, whereas that for MP involves the measurement of the endogenous synthesis of cortisol by the suppression of the hypothalamic pituitary axis. To date, the most detailed studies have been performed involving pharmacodynamic monitoring of CsA and MMF. Similarities exist in the pharmacodynamic response to CsA and MMF in patients who undergo renal transplantation. At trough concentrations in blood, both drugs result in only a 50% reduction in activity of their target enzymes; however, there is considerable interpatient variability. Throughout the dosing interval, enzyme activity parallels that of drug concentrations. Renal transplant recipients who are treated with AZA and who exhibit an increase in TPMT activity from the time of transplantation experience fewer episodes of active rejection. Renal transplant recipients who are administered MP and in whom suppression of endogenous synthesis of cortisol is greatest exhibit the least incidence of steroid-induced side effects. Additional clinical trials relating pharmacokinetics and pharmacodynamic parameters to clinical response are under way to ascertain which provides the best guide for dosing. Pharmacodynamic monitoring may provide an alternative approach to traditional drug level measurement.

Pharmacodynamic monitoring of immunosuppressive drugs.

Pharmacodynamic (PD) monitoring measures the biological response to a drug, which alone--or coupled with pharmacokinetics--provides a novel method for optimization of drug dosing. PD monitoring has been investigated by us and other investigators primarily for four immunosuppressive drugs: cyclosporine (CsA), azathioprine (AZA), mycophenolate mofetil (MMF), and rapamycin (RAPA). PD monitoring of CsA and MMF involves measuring the activity of the enzymes calcineurin and inosine monophosphate dehydrogenase, respectively. The PD of AZA is assessed by measuring the activity of thiopurine methyltransferase, which is induced by a metabolite of AZA, 6-mercaptopurine. The PD for RAPA involves measuring the activity of a P70 S6 kinase in lymphocytes. To date, the most detailed studies have been performed with PD monitoring of CsA and MMF. Similarities exist in the PD responses to CsA and MMF in renal-transplant patients. At trough concentrations in blood, both drugs reduce the activity of their target enzymes by only 50%; however, considerable interpatient variability is evident. Throughout the dosing interval, the enzyme activities parallel the respective drug concentrations. AZA treatment of renal-transplant patients who exhibited an increase in thiopurine methyltransferase activity from time of transplantation resulted in fewer episodes of active rejection. Additional clinical trials are currently underway to relate various pharmacokinetics and PD parameters to clinical response, to ascertain which provides the best guide for dosing. PD monitoring may provide an alternative approach to additional measurements of drug concentrations.

Determination of p-trifluoromethylphenol, a metabolite of fluoxetine, in tissues and body fluids using an electron-capture gas chromatographic procedure.

An electron-capture gas chromatographic procedure was developed for the analysis of p-trifluoromethylphenol, an O-dealkylated metabolite of fluoxetine, in biological samples. A basic extraction of the biological sample was employed, followed by derivatization with pentafluorobenzenesulfonyl chloride. The internal standard, 2,4-dichlorophenol, was added to all samples used in the procedure to aid in quantitation. The practical limit of detection (signal-to-noise ratio>3) for p-trifluoromethylphenol was <5 ng/ml in human plasma samples, <10 ng/g of rat brain tissue, <25 ng/g of rat liver tissue and <25 ng/ml in human and rat urine samples. In the rat, the levels of free p-trifluoromethylphenol in the liver were 10-fold higher than those in the brain, and a substantial amount was excreted in the urine. Human urine samples contained levels of free p-trifluoromethylphenol approximately 30-fold higher than those found in human plasma samples. The procedure described is useful for the detection and quantitation of free p-trifluoromethylphenol in humans and rats treated with fluoxetine.

Effect of assay methodology on pharmacokinetic differences between cyclosporine Neoral and Sandimmune formulations.

The new oral formulation of cyclosporine (CsA), Neoral (CsA-N), results in increased area under the curve (AUC) and decreased intra- and interindividual variation in blood concentrations and other pharmacokinetic (PK) parameters when compared with the current Sand-immune (CsA-S) formulation. The present study examines the effect of assay methodology on variability in blood concentrations and PK parameters for renal transplant patients receiving CsA-N and CsA-S and whether this variation is reduced with CsA-N. The results show that interindividual variations in PK parameters for patients receiving CsA-N were less than those for patients receiving CsA-S. Both blood concentrations and dose of CsA better correlated with abbreviated (4-h) AUC after administration of CsA-N. For both CsA-S and CsA-N, blood concentrations at 4 h postdose exhibited the best correlation with AUC. All samples were analyzed by three common procedures: HPLC, RIA, and fluorescence polarization immunoassay (FPIA). There were no significant differences observed in blood concentrations or PK parameters obtained from FPIA and RIA. HPLC results, however, were lower because of specificity of this method for the parent drug. The assay methodology did not have an effect on interindividual variability, indicating that the cross-reactivity of metabolites in commonly used immunoassays for CsA does not contribute to the PK variability observed in renal transplant patients.

The effects of desipramine and iprindole on levels of enantiomers of fluoxetine in rat brain and urine.

The antidepressant fluoxetine (FLU) and its N-demethylated metabolite, norfluoxetine (NFLU), each contains a chiral center. The combination of FLU and desipramine (DMI), another antidepressant, has been reported to be useful in treatment of depression, to dramatically increase plasma levels of DMI and also to produce more rapid beta-adrenergic receptor down-regulation in brain than caused by DMI alone. We have now begun studies on the effects of this drug combination on the levels of FLU and NFLU enantiomers in the rat. In addition, the combination of FLU and iprindole (IPR) was also investigated. Male Sprague-Dawley rats were treated intraperitoneally with either normal saline vehicle, DMI (5 mg/kg/day), (R,S)-FLU (10 mg/kg/day) or DMI (5 mg/kg/day) + (R,S)-FLU (10 mg/kg/day) for 4 days. Following the last treatment, 24 h urine samples were collected. Rats were sacrificed and brains were removed. For the IPR study, rats were pretreated with either saline or IPR-HCl (11.2 mg/kg) and then treated 1 h later with (R,S)-FLU. After 5 h, the rats were sacrificed and brains were removed. Brain and urine samples were analyzed by gas chromatography with electron-capture detection for free (R)-and (S)-FLU and (R)- and (S)-NFLU after extraction and reaction with (-)-(S)-N-(trifluoroacetyl)prolyl chloride. The results from the brains of the rats treated with DMI/FLU indicate that levels of enantiomers of both FLU and NFLU were significantly increased over those seen in the animals receiving (R,S)-FLU alone.(ABSTRACT TRUNCATED AT 250 WORDS)

A gas chromatographic procedure for separation and quantitation of the enantiomers of the antidepressant tranylcypromine.

A novel assay procedure has been developed that allows for the separation and quantification of the enantiomers of the monoamine oxidase inhibitor tranylcypromine (TCP) in brain and liver of rats. The analytical method involves extraction of the drug from rat tissue with an organic solvent. TCP is then derivatized with S-(-)-N-(trifluoroacetyl)-prolyl chloride to allow gas chromatographic analysis of the resulting diastereoisomers. Conditions for analysis by a gas chromatograph equipped with a nitrogen-phosphorus detector and a capillary column are described. The method has been applied to the separation and quantification of the enantiomers of TCP in samples of brain and liver of rats that had been injected with this drug alone and after pretreatment with iprindole, a drug known to block aromatic ring hydroxylation.

Simultaneous determination of fluoxetine and norfluoxetine enantiomers in biological samples by gas chromatography with electron-capture detection.

An electron-capture gas chromatographic procedure was developed for the simultaneous analysis of the enantiomers of fluoxetine and norfluoxetine. The assay involves basic extraction of these enantiomers from the biological samples, followed by their conversion to diastereoisomers using the chiral derivatizing reagent (S)-(-)-N-trifluoroacetylprolyl chloride. The method was utilized to detect and measure the quantity of these enantiomers in plasma and urine of patients and in liver and brain tissue of rats treated with (R,S)-fluoxetine.