Validation and clinical evaluation of an ultra-performance liquid chromatography with ultraviolet detector method for plasma quantification of micafungin.

BACKGROUND: Factors associated with interindividual variability in the pharmacokinetics of micafungin have been identified. This variability can cause underexposure and loss of drug efficacy. For this reason, a simple, fast, cost-effective and sensitive ultra-performance liquid chromatography ultraviolet detector (UPLC-UV) method was developed and validated for the quantification of micafungin. METHODS: The method involves simple plasma precipitation by UPLC with a reversed phase C18 column at 40°C coupled with ultraviolet detection set at a wavelength of 264 nm. The mobile phase consisted of a mixture 42/58 of potassium phosphate 20 mm and acetonitrile. RESULTS: The method was validated over the concentration range of 0.25-15.0 mg/L and proved to be reliable and reproducible with an average percentage of recoveries of 101.59 ± 3.93% and inter and intraday variation coefficients lower than 15% in all cases. The method was successfully applied in determining 30 samples from 10 patients being treated with micafungin. CONCLUSIONS: The method proposed could be useful to facilitate the implementation of therapeutic drug monitoring for personalizing micafungin treatment in invasive fungal infections.

Long-term effectiveness and pharmacokinetics of the infliximab biosimilar CT-P13 after switching from the originator during the treatment of inflammatory bowel disease.

OBJECTIVE: Switching patients from the originator infliximab to a biosimilar is a measure to expand access to treatments and counteract its negative impact on healthcare budgets. However, industry-independent long-term studies on the effect of switching in real life to support the lack of switch-related problems in inflammatory bowel disease (IBD) patients are sparse, as are studies addressing infliximab pharmacokinetic behaviour. The objectives were to investigate the effectiveness and the pharmacokinetics of CT-P13 after switching from originator infliximab in a real-world population of IBD patients with a follow-up of 2 years. METHOD: Prospective, single-centre, observational 2 year study conducted in IBD adult patients with stable disease treated with the originator infliximab who were switched to CT-P13. Four time points were defined for follow-up: prior to the switch, 4-8 weeks after the switch, 8 months later, and 2 years later. Outcome measures were the proportion of patients with clinical, endoscopic and biochemical remission, and changes in biochemical inflammation markers (albumin, C-reactive protein, faecal calprotectin) and infliximab clearance. RESULTS: 42 IBD patients were switched, of which 36 (85.7%) remained on CT-P13 throughout the 2 year study period. Only two patients discontinued CT-P13 due to loss of response. The proportion of patients who displayed clinical, endoscopic and biochemical remission were unchanged during the follow-up (p<0.05) and no statistically significant changes were observed in the biochemical markers of disease activity. The median (IQR) clearance estimated for the infliximab originator before the change was 0.364 (0.321-0.415) L/day, and for the CT-P13 biosimilar it was 0.361 (0.323-0.415) L/day 4-8 weeks after the change, and 0.370 (0.334-0.419) L/day 2 years after (p=0.395). CONCLUSION: Switching from originator infliximab to biosimilar CT-P13 did not affect the long-term clinical outcomes or the pharmacokinetic behaviour. This information provides the clinician more evidence for the success of switching and supports non-medical switching in adult IBD patients.

Population pharmacokinetics of a posaconazole tablet formulation in transplant adult allogeneic stem cell recipients.

BACKGROUND: Posaconazole is an antifungal agent extensively used as a prophylaxis for invasive fungal infections (IFIs) in allogeneic stem cell transplant (SCT) recipients. Low posaconazole concentrations have been associated with reduced clinical response. The aim of this study was to develop a population pharmacokinetic (popPK) model of a posaconazole tablet formulation in allogeneic SCT adult recipients for supporting model-informed precision dosing (MIPD). MATERIALS AND METHOD: Prospective observational study performed in adult allogeneic SCT recipients receiving posaconazole as prophylaxis for IFIs and followed up by a therapeutic drug monitoring (TDM) program. Posaconazole plasma concentrations were quantified using an ultra-high-performance liquid chromatography (UPLC) with UV detector. A popPK model was developed using NONMEM v.7.4.0. Deterministic and stochastic simulations were carried out with the final model to evaluate the differences across physiological variables with impact on drug exposure. RESULTS: A one-compartment model with sequential absorption (zero and first order) and first order elimination described adequately 55 posaconazole concentrations from 36 patients. Higher doses of posaconazole were found to be required by males and patients with lower values of total serum proteins. A nomogram to estimate the posaconazole daily dose based on pharmacokinetic/pharmacodynamic (PKPD) criterion for males and females for different values of total proteins was developed. CONCLUSIONS: Gender and total serum proteins have been identified as covariates influencing posaconazole CL/F in adult allogeneic SCT recipients receiving the delay-released tablet formulation. Additional studies are required to better characterize the absorption of posaconazole and implications on dosage recommendations together with potential safety concerns.

Comparison of ultra-performance liquid chromatography and ARK immunoassay for therapeutic drug monitoring of voriconazole.

BACKGROUND: Therapeutic drug monitoring (TDM) of voriconazole is recommended for personalizing doses. The objective of this study was to compare the enzyme immunoassay developed by ARKTM Diagnostics Inc. for the quantification of voriconazole adapted to the Architect C4000 autoanalyzer (Abbott®) with ultra-performance liquid chromatography using ultraviolet detector (UPLC-UV) method. MATERIALS AND METHODS: Linearity, precision and accuracy of both methods were validated according to the Food and Drug Administration (FDA) and European Medicines Agency guidelines. The limit of quantification (LOQ) of the UPLC-UV method was determined experimentally. Both methods were applied to the analysis of 62 samples from patients. Correlation was evaluated by Passing-Bablok analysis and the concordance by the Bland-Altman method. Dosage recommendations were generated; the discordances according to the technique were evaluated. RESULTS: All validation parameters determined for UPLC-UV met the criteria set out and LOQ of 0.1 µg/mL was established. However, when the enzyme immunoassay was used to determine concentrations ≤1 µg/ml, CVs were >20%. A linear correlation between both methods was found. However, an overestimation of immunoassay (systematic error of 0.39 µg/mL) was detected. In 11.3% of the samples, the differences in concentrations when they were determined by different techniques would imply a different therapeutic regime. These samples had concentrations close to 1 µg/mL. CONCLUSION: Although both techniques can be used for TDM of voriconazole, when a value close to the lower limit of the therapeutic range is determined by the ARKTM immunoassay, it would be better to verify the result by a non-automated technique to avoid possible underdosing.

Relationship between vedolizumab serum concentrations in the induction phase and early and sustained response in the first year of treatment in patients with ulcerative colitis.

OBJECTIVE: Evidence on the usefulness of proactive monitoring of vedolizumab serum concentrations during the induction phase of treatment is limited. The objective of our study was to evaluate the effectiveness of measuring such concentrations during this phase in predicting response to  treatment in patients with ulcerative colitis with a view to determining whether  patients would benefit from early monitoring of  edolizumab serum concentrations. METHOD: This was a prospective descriptive study carried out at three public  general hospitals. It included adult patients with ulcerative colitis who were  initiated on vedolizumab at the participating hospitals from June 2019 to June  2020. Vedolizumab serum concentrations were determined  at weeks 6 and 14.  Response to treatment was biologically, clinically, and endoscopically  evaluated at weeks 6, 14, and 52. An analysis was made of the relationship  between vedolizumab serum concentrations at week 6 and early response to  treatment, and of the relationship between the vedolizumab serum  concentrations at weeks 6 and 14 and persistent response at one year. RESULTS: A total of 45 patients were included of whom 22 (49%) were considered non-responsive after one year and required intensification of treatment. The median (interquartile range) vedolizumab serum  oncentrations obtained at 6 weeks was higher in patients who obtained an  early response and in those who maintained the response at one year than  in  those who did not respond to vedolizumab [27.4 (19.0-40.8) µg/mL vs 15.6  (13.4-28.5) µg/mL; p = 0.018] and [29.9 (19.2-43.2) µg/mL vs 18.2 (15.4- 26.9) µg/mL; p = 0.022] respectively. Vedolizumab serum concentrations ≥  17.3 µg/mL at week 6 were predictive of a good early response, and  edolizumab serum concentrations ≥ 26.1 µg/mL at week 6 predicted a  sustained response at one year. No relationship was found between  edolizumab serum concentrations at week 14 and a sustained response. CONCLUSIONS: We observed a relationship between vedolizumab serum concentrations determined at week 6, and early and maintained  esponse to vedolizumab therapy in patients with ulcerative colitis, which  supports early drug monitoring during the induction phase to individualize  treatment and increase effectiveness.

OBJETIVO: La evidencia sobre la utilidad de la monitorización proactiva de las  concentraciones séricas de vedolizumab en la fase de inducción del tratamiento es limitada. El objetivo del estudio ha sido evaluar la capacidad de las concentraciones séricas de vedolizumab determinadas en esta fase para predecir la respuesta al tratamiento en pacientes con colitis ulcerosa, con  el fin de establecer si los pacientes se beneficiarían clínicamente de una  monitorización precoz.Método: Estudio descriptivo, prospectivo, realizado en tres hospitales generales públicos. Incluyó a los pacientes adultos con colitis  ulcerosa, que iniciaron tratamiento con vedolizumab en los centros  participantes desde junio de 2019 a junio de 2020. Se determinaron las  concentraciones séricas de vedolizumab en las semanas 6 y 14 de tratamiento.  La respuesta bioquímica, clínica y endoscópica se evaluó en las  semanas 6, 14 y 52. Se estudió la relación de las concentraciones séricas de  vedolizumab determinadas en la semana 6 con la respuesta temprana al  tratamiento, así como la relación de las concentraciones séricas de  vedolizumab en las semanas 6 y 14 con la persistencia de respuesta al año de  tratamiento. RESULTADOS: Se incluyeron 45 pacientes, de los que 22 (49%) se consideraron no respondedores al cabo de un año y necesitaron intensificar el  tratamiento. Las medianas (rango intercuartílico) de las concentraciones séricas de vedolizumab en la semana 6 fueron superiores,  tanto en los pacientes que presentaron respuesta temprana como en los que  mantuvieron respuesta al cabo de un año, comparadas con las de los pacientes que no respondieron a vedolizumab [27,4 (19,0-40,8) µg/ml vs  15,6 (13,4­28,5) µg/ml; p = 0,018] y [29,9 (19,2-43,2) µg/ml vs 18,2  (15,4­26,9) µg/ml; p = 0,022], respectivamente. Las concentraciones séricas  de vedolizumab ≥ 17,3 µg/ml en la semana 6 predijeron una buena respuesta  temprana, y concentraciones séricas de vedolizumab ≥ 26,1 µg/ml en la  emana 6 predijeron una respuesta mantenida al cabo de un año. No se  encontró relación entre las concentraciones séricas de vedolizumab en la  semana 14 y la respuesta mantenida. CONCLUSIONES: Se ha observado una relación entre las concentraciones séricas  de vedolizumab determinadas en la semana 6 y la  respuesta temprana y mantenida a la terapia en pacientes con colitis ulcerosa,  lo que avala la monitorización precoz durante la fase de inducción, para individualizar el tratamiento y aumentar su eficacia.

Relación entre las concentraciones séricas devedolizumab en fase de inducción y respuesta temprana y mantenida en el primer año de tratamiento en pacientes con colitis ulcerosa / Relationship between vedolizumab serum concentrations in the induction phase and early and sustained response in the first year of treatment in patients with ulcerative colitis

Objetivo: La evidencia sobre la utilidad de la monitorización proactiva delas concentraciones séricas de vedolizumab en la fase de inducción del tratamiento es limitada. El objetivo del estudio ha sido evaluar la capacidad delas concentraciones séricas de vedolizumab determinadas en esta fase parapredecir la respuesta al tratamiento en pacientes con colitis ulcerosa, con el finde establecer si los pacientes se beneficiarían clínicamente de una monitorización precoz.Método: Estudio descriptivo, prospectivo, realizado en tres hospitalesgenerales públicos. Incluyó a los pacientes adultos con colitis ulcerosa, queiniciaron tratamiento con vedolizumab en los centros participantes desdejunio de 2019 a junio de 2020. Se determinaron las concentraciones séricas de vedolizumab en las semanas 6 y 14 de tratamiento. La respuestabioquímica, clínica y endoscópica se evaluó en las semanas 6, 14 y 52.Se estudió la relación de las concentraciones séricas de vedolizumab determinadas en la semana 6 con la respuesta temprana al tratamiento, asícomo la relación de las concentraciones séricas de vedolizumab en lassemanas 6 y 14 con la persistencia de respuesta al año de tratamiento. (AU)

Objective: Evidence on the usefulness of proactive monitoring of vedolizumab serum concentrations during the induction phase of treatment islimited. The objective of our study was to evaluate the effectiveness ofmeasuring such concentrations during this phase in predicting responseto treatment in patients with ulcerative colitis with a view to determiningwhether patients would benefit from early monitoring of vedolizumabserum concentrations.Method: This was a prospective descriptive study carried out at threepublic general hospitals. It included adult patients with ulcerative colitiswho were initiated on vedolizumab at the participating hospitals from June2019 to June 2020. Vedolizumab serum concentrations were determined at weeks 6 and 14. Response to treatment was biologically, clinically,and endoscopically evaluated at weeks 6, 14, and 52. An analysis wasmade of the relationship between vedolizumab serum concentrations atweek 6 and early response to treatment, and of the relationship betweenthe vedolizumab serum concentrations at weeks 6 and 14 and persistentresponse at one year. (AU)

Biomarkers of disease activity and other factors as predictors of adalimumab pharmacokinetics in inflammatory bowel disease.

Inflammatory bowel disease (IBD) is commonly treated with adalimumab. The main objective of the study was to develop a population pharmacokinetic model of adalimumab in IBD patients evaluating the potential biomarkers of disease activity and other factors and its implications in adalimumab dosing. A prospective observational study was performed in adult patients diagnosed with Crohn's disease and ulcerative colitis treated with adalimumab and following a proactive therapeutic drug monitoring of serum concentrations. Adalimumab serum concentrations (ASC) were quantified mainly prior the administration using an enzyme-linked immunosorbent assay (ELISA). A population pharmacokinetic model was developed based on 303 ASC data of 104 IBD patients using non-linear mixed effect modelling approach. Sixty-five ASC from 20 additional patients were randomly selected as an external validation group. A one-compartment model with first order absorption and elimination best describe the ASC time course. Body mass index (BMI), faecal calprotectin (FCP), unexplained decline in ASC and the specific administration pen device exhibited significant influence on apparent clearance (p-value < 0.001). FCP was the inflammatory activity biomarker showing the most relevant impact on adalimumab exposure, higher than C-reactive protein and albumin, and may be useful for adalimumab dosing adjustment. The population-based pharmacokinetic model developed adequately characterized adalimumab exposure in IBD patients. The unexplained decline in ASC, FCP, BMI and the specific administration pen device were identified as meaningful variables significantly influencing adalimumab pharmacokinetics.

A 3-year prospective study of a multidisciplinary early proactive therapeutic drug monitoring programme of infliximab treatments in inflammatory bowel disease.

AIMS: Therapeutic drug monitoring (TDM) of trough serum infliximab concentrations has been mainly used in case of loss of response in patients with inflammatory bowel disease (IBD). The aim of this study was to evaluate the effectiveness and safety of a multidisciplinary early proactive TDM (mep-TDM) programme for dose adjustment. METHODS: A 3-year prospective study was conducted based on a sample of 81 patients who started treatment and were subsequently subjected to mep-TDM with the first control at week 14. Data of a historical control group of 72 patients treated with infliximab and managed with empirical dosing were included. Effectiveness variables were treatment failure, IBD-related surgery and IBD-related hospitalization. Safety variables were serious infusion reactions (SIRs) and adverse reactions. Cox regression was used for survival analysis. RESULTS: In the mep-TDM study group, compared to the control group, there was a significant reduction in the risk of treatment failure (hazard ratio [HR]: 0.51; 95% confidence interval [CI]: 0.27-0.92; P = .037), IBD-related surgery (HR: 0.14; 95% CI: 0.03-0.65; P = .012) and hospitalization (HR: 0.38; 95% CI: 0.17-0.87; P = .022). SIRs were lower in the mep-TDM group (2.5% vs 10.4%; P < .050); the incidence of adverse reactions was similar (3.7% vs 3.9%; p > .999). CONCLUSION: This study found that compared to empirical dosing, mep-TDM is associated with improved efficacy and safety of infliximab therapy, reduced IBD-related hospitalization and surgery and incidence of SIRs, and increasing long-term durability of treatment effects.

Earliest floral grave lining from 13,700-11,700-y-old Natufian burials at Raqefet Cave, Mt. Carmel, Israel.

Flowering plants possess mechanisms that stimulate positive emotional and social responses in humans. It is difficult to establish when people started to use flowers in public and ceremonial events because of the scarcity of relevant evidence in the archaeological record. We report on uniquely preserved 13,700-11,700-y-old grave linings made of flowers, suggesting that such use began much earlier than previously thought. The only potentially older instance is the questionable use of flowers in the Shanidar IV Neanderthal grave. The earliest cemeteries (ca. 15,000-11,500 y ago) in the Levant are known from Natufian sites in northern Israel, where dozens of burials reflect a wide range of inhumation practices. The newly discovered flower linings were found in four Natufian graves at the burial site of Raqefet Cave, Mt. Carmel, Israel. Large identified plant impressions in the graves include stems of sage and other Lamiaceae (Labiatae; mint family) or Scrophulariaceae (figwort family) species; accompanied by a plethora of phytoliths, they provide the earliest direct evidence now known for such preparation and decoration of graves. Some of the plant species attest to spring burials with a strong emphasis on colorful and aromatic flowers. Cave floor chiseling to accommodate the desired grave location and depth is also evident at the site. Thus, grave preparation was a sophisticated planned process, embedded with social and spiritual meanings reflecting a complex preagricultural society undergoing profound changes at the end of the Pleistocene.

Modification of the EMIT immunoassay for the measurement of unbound mycophenolic acid in plasma.

OBJECTIVES: Evaluation of the performance of a modified Enzyme Multiplied Immunoassay Technique for therapeutic drug monitoring of plasma free mycophenolic acid (fMPA) concentrations. DESIGN AND METHODS: A fMPA assay was developed on a Viva-E analyzer. A study of prior ultrafiltration conditions and analytical validation of the EMIT assay were performed. RESULTS: The method was reliable and reproducible. CONCLUSIONS: fMPA levels can be monitored using this EMIT assay with the advantage of being an automated method.

Reduced-intensity conditioning allogeneic transplantation from unrelated donors: evaluation of mycophenolate mofetil plus cyclosporin A as graft-versus-host disease prophylaxis.

In the current study, we have analyzed the efficacy of cyclosporine A (CSA) plus mycophenolate mofetil (MMF) as graft-versus-host disease (GVHD) prophylaxis in the fludarabine plus melphalan or busulfan reduced intensity regimen (RIC) setting in a series of 44 patients receiving allogeneic transplantation from an unrelated donor. Only 23% were in the first complete remission at the time of transplant. Cumulative incidence of grades II-IV and III-IV acute GVHD (aGVHD) was 53% and 23%, respectively. Fifty-six percent had equal to or greater than grade 2 gut involvement. Cumulative incidence of overall and extensive chronic GVHD (cGVHD) was 93% and 63%, respectively. Ninety-two percent of patients who were evaluable +100 days after transplant were in complete remission. Relapse rate was 25% at 2 years. Event free (EFS) and overall survival (OS) at 2 years were 52%. Pharmacokinetic assays of mycophenolic acid (MPA) showed a therapeutic area under the curve (AUC) at the dosage of 3 g daily, although a large inter- and intraindividual variations of MPA plasma levels were found. In conclusion, the combination of CSA plus MMF in the fludarabine plus melphalan or busulfan RIC setting is feasible. Regarding GVHD, this combination allowed to control aGVHD but lead to a high incidence of cGVHD, so that newer strategies are required, especially in trying to decrease gastrointestinal involvement.

Carriers involved in targeting the cytostatic bile acid-cisplatin derivatives cis-diammine-chloro-cholylglycinate-platinum(II) and cis-diammine-bisursodeoxycholate-platinum(II) toward liver cells.

Molecular bases for targeting bile acid-cisplatin derivatives Bamet-R2 [cis-diammine-chloro-cholylglycinate-platinum(II)] and Bamet-UD2 [cis-diammine-bisursodeoxycholate-platinum(II)] toward liver cells were investigated. Carriers for bile acids [human Na(+)-taurocholate cotransporting polypeptide (NTCP)], organic anions [organic anion transporting polypeptide (OATP)], and organic cations [organic cation transporter (OCT)] were expressed in Xenopus laevis oocytes (XO) and Chinese hamster ovary (CHO) cells. Drug uptake was measured by flameless atomic absorption of platinum. Rat Oatp1- or rat Ntcp-transfected CHO cells were able to take up Bamets, but not cisplatin, severalfold more efficiently than wild-type cells. This uptake was enhanced by butyrate-induced expression of both carriers. Uptake of both Bamets by Ntcp-transfected CHO cells was stimulated by extracellular sodium. The amount of Bamets, but not cisplatin, taken up by XO was enhanced when expressing OATP-A, OATP-C, NTCP, OCT1, or OCT2, a nonhepatic OCT isoform used for comparative purposes. Bamet uptake by XO was inhibited by known substrates of these carriers (glycocholate for NTCP and OATP-C, ouabain for OATP-A, and quinine for OCT1 and OCT2). Drug uptake versus substrate concentration revealed saturation kinetics (K(m) was in the 8-58 microM range), with the following order of efficiency of transport (V(max)/K(m)) for Bamet-R2: OATP-C > OCT2 > OATP-A > NTCP > OCT1; and the following order of efficiency of transport for Bamet-UD2: OATP-C > OCT2 > OATP-A > OCT1 > NTCP. Increasing the generation of cationic forms of Bamets by incubation in the absence of chloride increased drug uptake by OATP-A, OCT1, and OCT2 but reduced that achieved by NTCP and OATP-C. These results suggest a role for carriers of organic anions and cations in Bamet-R2 and Bamet-UD2 uptake, which may determine their ability to accumulate in liver tumor cells and/or be taken up and efficiently excreted by hepatocytes.