Institute of Pharmaceutical and Medical Chemistry-Department of Clinical Pharmacy, Westfälische Wilhelms-Universität Münster, Münster, Germany.
Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt, Germany.
Antimicrob Agents Chemother. 2017 Dec 21;62(1). doi: 10.1128/AAC.01194-17. Print 2018 Jan.
The pharmacokinetic variability of voriconazole (VCZ) in immunocompromised children is high, and adequate exposure, particularly in the first days of therapy, is uncertain. A population pharmacokinetic model was developed to explore VCZ exposure in plasma after alternative dosing regimens. Concentration data were obtained from a pediatric phase II study. Nonlinear mixed effects modeling was used to develop the model. Monte Carlo simulations were performed to test an array of three-times-daily (TID) intravenous dosing regimens in children 2 to 12 years of age. A two-compartment model with first-order absorption, nonlinear Michaelis-Menten elimination, and allometric scaling best described the data (maximal kinetic velocity for nonlinear Michaelis-Menten clearance [] = 51.5 mg/h/70 kg, central volume of distribution [] = 228 liters/70 kg, intercompartmental clearance [] = 21.9 liters/h/70 kg, peripheral volume of distribution [] = 1,430 liters/70 kg, bioavailability [] = 59.4%, = fixed value of 1.15 mg/liter, absorption rate constant = fixed value of 1.19 h). Interindividual variabilities for , , , and were 63.6%, 45.4%, 67%, and 1.34% on a logit scale, respectively, and residual variability was 37.8% (proportional error) and 0.0049 mg/liter (additive error). Monte Carlo simulations of a regimen of 9 mg/kg of body weight TID simulated for 24, 48, and 72 h followed by 8 mg/kg two times daily (BID) resulted in improved early target attainment relative to that with the currently recommended BID dosing regimen but no increased rate of accumulation thereafter. Pharmacokinetic modeling suggests that intravenous TID dosing at 9 mg/kg per dose for up to 3 days may result in a substantially higher percentage of children 2 to 12 years of age with adequate exposure to VCZ early during treatment. Before implementation of this regimen in patients, however, validation of exposure, safety, and tolerability in a carefully designed clinical trial would be needed.
伏立康唑(VCZ)在免疫功能低下儿童中的药代动力学变异性较高,其充分暴露,尤其是在治疗初期,尚不确定。本研究旨在建立群体药代动力学模型,以探索不同给药方案后儿童患者血浆中的 VCZ 暴露情况。从一项儿科 II 期研究中获取浓度数据。采用非线性混合效应模型建立模型。通过蒙特卡罗模拟对 2 至 12 岁儿童的三种每日三次(TID)静脉滴注给药方案进行测试。一个两室模型,采用一级吸收、非线性米氏消除和比例缩放来描述数据(非线性米氏消除的最大动力学速度 [ ] = 51.5 mg/h/70 kg,中央分布容积 [ ] = 228 升/70 kg,隔室间清除率 [ ] = 21.9 升/小时/70 kg,外周分布容积 [ ] = 1430 升/70 kg,生物利用度 [ ] = 59.4%, [ ] = 固定值 1.15 mg/l,吸收速率常数 [ ] = 固定值 1.19 h)。 [ ]、[ ]、[ ]和 [ ] 的个体间变异性分别为 63.6%、45.4%、67%和 1.34%(以对数值表示),残差变异性为 37.8%(比例误差)和 0.0049 mg/l(加性误差)。对 9 mg/kg 体重 TID 方案(24、48 和 72 h),随后 8 mg/kg 每日两次(BID)的模拟方案进行 Monte Carlo 模拟,结果表明与目前推荐的 BID 给药方案相比,早期目标实现率有所提高,但此后无蓄积率增加。药代动力学模型表明,连续 3 天每天 9 mg/kg 的静脉 TID 给药可能会使 2 至 12 岁儿童在治疗早期充分暴露于 VCZ 的比例大大提高。然而,在患者中实施该方案之前,需要在精心设计的临床试验中验证其暴露量、安全性和耐受性。