Compliance lebertransplantierter Patienten mit dem Immunsuppressivum Tacrolimus bei 2x täglicher im Vergleich zu 1x täglicher Einnahme

Compliance lebertransplantierter Patienten mit der immunsuppressiven Therapie ist unerlässlich für den lang-fristigen Erfolg der Lebertransplantation. Aus Non-Compliance mit der immunsuppressiven Therapie können Abstoßungsreaktionen, Organverlust oder sogar Tod resultieren. Hauptziel der vorliegenden Studie war die erstmalige Evaluation der Compliance bei Einnahme von Prograf® (zweimal tägliche Einnahme von Tacrolimus) im Vergleich zur Einnahme von Advagraf® (einmal tägliche Einnahme von Tacrolimus). Von Interesse war außerdem die Fragestellung, ob sich die Compliance bezüglich der immunsuppressiven Therapie mit dem Zeitabstand zur Transplantation verändert. rnDie Compliancemessung wurde offen mittels MEMS® (Aardex Ltd., Schweiz) durchgeführt, der Patient war also über die Compliancekontrolle informiert. Mittels MEMS® konnten Datum und Uhrzeit der Dosisentnahme dokumentiert und damit zuverlässig das gesamte Compliancemuster über im Durchschnitt 176 Tage mit der zweimal täglichen Einnahme und 188 Tage mit der einmal täglichen Einnahme pro Patient erfasst werden. 65 Patienten mit dem Basisimmunsuppressivum Prograf® wurden in die prospektive, nicht-interventionelle Studie eingeschlossen und nach Per Protokoll-Analyse konnten die Daten von 63 in Mainz lebertransplantierten Patienten ausgewertet werden (Prograf®: Gruppe 1: 15 Patienten (Pat.), Gruppe 2: 23 Pat., Gruppe 3: 22 Pat., Drop-outs: 3 Pat.; Advagraf®: Gruppe 1: 16 Pat., Gruppe 2: 23 Pat., Gruppe 3: 23 Pat., Drop-outs: 1 Pat.). Die Dosing Compliance (DC), definiert als Prozent der Tage, an denen der MEMS®-Behälter korrekt geöffnet und die Dosis höchstwahrscheinlich korrekt eingenommen wurde, war der primäre Zielparameter. Weitere Methoden der Compliancemessung, wie der Pill Count, mehrere Fragebögen (Selbsteinschätzung, Patientenwissen-, Morisky-, MESI-, HADS-, SF-36- und Patientenzufriedenheit-Fragebogen) sowie die Blutspiegelmessung wurden eingesetzt, um die Compliance der Patienten umfassend charakterisieren zu können. rnDer Median der DC mit der zweimal täglichen Einnahme betrug 97% bei Pat. > 6 m.p.t. < 2 y.p.t., 97% bei Pat. > 2 y.p.t. < 5 y.p.t. und 98% bei Pat. > 5 y.p.t. (p=0,931; Kruskal-Wallis-Test). Der Median der DC von Tacroli-mus bei einmal täglicher Einnahme (Advagraf®) betrug 99% bei Pat. > 6 m.p.t. < 2 y.p.t., 98% bei Pat. > 2 y.p.t. < 5 y.p.t. und 97% bei Pat. > 5 y.p.t. (p=0,158; Kruskal-Wallis-Test). Insgesamt zeigten die Patienten während des gesamten Beobachtungszeitraums von 12 Monaten eine gute Compliance für die Einnahme ihres Immun-suppressivums. Die Timing Compliance (TiC)-raten lagen auf einem niedrigeren Niveau als die Dosing- und Taking Compliance (TC)-raten. Die Complianceraten der drei Subgruppen unterschieden sich nicht signifikant. Die Patienten mit dem geringsten Abstand zur Transplantation zeigten bei beinahe allen Messmethoden die höchste Compliance im Gegensatz zur etwas geringeren Compliance der Patienten mit größerem Abstand zur Transplantation. Die während der Advagraf®-Phase mittels MEMS® gemessenen DC-, TC- und TiC-raten fielen höher aus als bei Einnahme von Prograf® (p(DC)=0,003; p(TC)=0,077; p(TiC)=0,003; Wilcoxon Vorzeichen-Rang-Test). Dieses Ergebnis untermauert die in anderen Indikationen gefundene Complianceverbesserung durch die einmal tägliche Arzneimittelgabe im Vergleich zur zweimal täglichen Gabe. Die Auswertung der Drug Holidays ergab für die Advagraf®-Phase hingegen niedrigere Complianceraten als für die Prograf®-Phase. Dieses Ergebnis ist auf die Definition des Drug Holidays (keine Arzneimitteleinnahme über 48 h) zurück zu führen. Die Chance Advagraf® einmal pro Tag zu vergessen ist doppelt so hoch, als Prograf® dreimal aufeinander fol-gend zu vergessen. Mit einer verhältnismäßigeren Definition von Drug Holidays (Einnahmepause von 72 Stun-den bei einmal täglicher Einnahme von Advagraf® entsprechend drei ausgelassenen Dosen von Prograf®) ist die Compliancerate 81%. Die Ergebnisse des Pill Counts waren sowohl bei Einnahme von Prograf® als auch von Advagraf® mit der jeweils gemessenen TC vergleichbar, was die Zuverlässigkeit der Messergebnisse bes-tätigt. rnDie zusätzlich eingesetzten Methoden verifizierten das Ergebnis der höheren Compliance mit der einmal tägli-chen Einnahme. Die während der Advagraf®-Phase beantworteten Fragebögen zeigten einen Trend zu besserer Compliance und Lebensqualität. Lediglich die Ergebnisse des MESI-Fragebogens und der Blutspiegelmessungen wichen sowohl während der Prograf®- als auch während der Advagraf®-Phase stark von den Ergebnis-sen der anderen Methoden ab. rnUnter Einbeziehung aller mittels MEMS® und Pill Count objektiv gemessenen Complianceparameter konnten während der Prograf®-Einnahme 54 von 60 Pat. (90%) und während der Advagraf®-Phase 59 von 62 Pat. (95%) als compliant eingestuft werden. Aufgrund subjektiver Compliancemessungen waren 49 von 58 Pat. (84%) während der Prograf®- und 54 von 59 Pat. (92%) während der Advagraf®-Phase als compliant einzustufen. Es wurde beobachtet, dass die zeitlich korrekte Einnahme der Morgendosis einfacher und bei Einmalgabe zu bevorzugen ist. Die wochentagsbezogene Auswertung ergab erwartungsgemäß, dass am Wochenende (Samstag und Sonntag) am häufigsten Dosen ausgelassen wurden. rnDie Umstellung von Prograf® auf Advagraf® stellte kein Problem dar. Beinahe alle Patienten waren dankbar und zufrieden mit der Reduzierung der Dosierungsfrequenz und der größeren Unabhängigkeit durch die entfallene abendliche Einnahme. Der positive Einfluss der geringeren Dosierungshäufigkeit auf die Langzeitcompliance der Patienten, ist ein hinreichender Grund die Entwicklung von Formulierungen zur einmal täglichen Ein-nahme für weitere Immunsuppressiva zu fordern. Insbesondere bei den häufig eingesetzten Kombinationstherapien von Immunsuppressiva würde der Effekt der Complianceverbesserung noch verstärkt werden, wenn alle eingesetzten Immunsuppressiva zur einmal täglichen Gabe geeignet wären.

Generalized, pruritic, ulcerating maculopapular rash necessitating cessation of sirolimus in a liver transplantation patient

The use of sirolimus as an alternative to calcineurin antagonists has enabled the continuation of immunosuppression in patients with renal impairment with preservation of kidney function. Sirolimus is generally well tolerated, with the main causes of cessation of therapy related to its effect on blood lipid profile as well as leukopenia and thrombocytopenia. We report a case of a debilitating ulcerating maculopapular rash necessitating cessation of the drug in a liver transplantation patient. A 56-year-old Caucasian liver transplantation patient presented with a diffuse, debilitating rash attributed to sirolimus use. This ultimately necessitated cessation of the immunosuppressant with subsequent resolution of her symptoms. From a review of the current literature, this is a highly unusual adverse reaction to sirolimus.

A pilot study to evaluate the self-medication system for liver transplant patients at the Queen Elizabeth Hospital in Birmingham

Background and Objective: Medication non-compliance is a considerable obstacle in achievinga therapeutic goal, whichcan result in poorerhealthcare outcomes, increased expenditure, wastage and potential for medication resistance. The UK Government’s Audit Commission’s publication ‘A Spoonful of Sugar’1 addresses these issues and promotes self-medication systems as a possible solution. The self-medication system within the Liver Transplant Unit (LTU) was implemented to induct patients onto new post- transplantation medication regimes ready for discharge. The system involves initial consultations with both the Liver Transplant Pharmacist and Trans- plant Co-ordinator, supported with additional advice as and when necessary. Design: Following ethical approval, evaluation of the self-medication sys- tem for liver transplant patients was conducted between January and March 2004 via two methods: audit and structured post-transplantation interview. The audit enabled any discrepancies between current Hospital guidelines and Liver Transplant Unit (LTU) practices to be highlighted. Patient interviews generated a retrospective insight into patient acceptance of the self-medication system. Setting: LTU, Queen Elizabeth Hospital, Birmingham, England. Main Outcome Measures: LTU compliance with Hospital self-medication guidelines and patient insight into self-medication system. Results: A total of seven patients were audited. Findings illustrated that self- medication by transplant patients is a complex process which was not fully addressed by current Hospital self-medication guidelines. Twenty-three patients were interviewed, showing an overwhelming positive attitude to- wards participating in their own care and a high level of understanding towards their individual medication regimes. Following a drugs counselling session, 100% of patients understood why they were taking their medica- tion, and their doses, 95% understood how to take their medication and 85% were aware of potential side effects. Conclusions: From this pilot evaluation it can be stated that the LTU self-medication system is appreciated by patients and assists them in fully understanding their medication regimes. There appear to be no major defects in the system. However areas such as communication barriers and on-going internet education were illustrated as areas for possible future investigation. References: 1. Audit Commission. A spoonful of sugar – medicines management in NHS hospitals. London: Audit Commission; 2001.

An open-label, comparative study of the efficacy and safety of once-daily dose of enoxaparin versus unfractionated heparin in the treatment of proximal lower limb deep-vein thrombosis

Background: Treatment of deep-vein thrombosis (DVT) with a once-daily regimen of enoxaparin, rather than a continuous infusion of unfractionated heparin (UFH) is more convenient and allows for home care in some patients. This study was designed to compare the efficacy and safety of these two regimens for the treatment of patients with proximal lower limb DVT. Methods: 201 patients with proximal lower limb DVT from 13 centers in Brazil were randomized in an open manner to receive either enoxaparin [1.5 mg/kg subcutaneous (s.c.) OD] or intravenous (i.v.) UFH (adjusted to aPTT 1.5-2.5 times control) for 5-10 days. All patients also received warfarin (INR 2-3) for at least 3 months. The primary efficacy endpoint Was recurrent DVT (confirmed by venography or ultrasonography), and safety endpoints included bleeding and serious adverse events. The rate of pulmonary embolism (PE) was also collected. Hospitalization was at the physician's discretion. Results: Baseline patient characteristics were comparable between groups. The duration of hospital stay was significantly shorter with enoxaparin than with UFH (3 versus 7 days). In addition, 36% of patients receiving enoxaparin did not need to be hospitalized, whereas all of the patients receiving UFH were! hospitalized. The treatment duration was slightly longer with enoxaparin (8 versus 7 days). There was a nonsignificant trend toward a reduction in the rate of recurrent DVT with enoxaparin versus UFH, and similar safety. Conclusions: A once-daily regimen of enoxaparin 1.5 mg/kg subcutaneous is at least as effective and safe as conventional treatment with a continuous intravenous infusion of UFH. However, the once daily enoxaparin regimen is easier to administer (subcutaneous versus intravenous), does not require aPTT monitoring, and leads to both a reduced number of hospital admissions and an average 4-day-shorter hospital stay. (C) 2004 Elsevier Ltd. All rights reserved.

Antibiotic treatment for intermittent bladder catheterisation with once daily prophylaxis (the AnTIC study) : Study protocol for a randomised controlled trial

Funder statement This article/paper/report presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the UK Government’s Department of Health. Acknowledgements We would like to acknowledge Dr Graeme MacLennan, Mr Simon Skene, Mr Julian Shah and Dr Nadine Dougall (past member) for their valuable contribution to the study as DMC members. We would like to thank Professor Chris Butler, Dr Emma Hall, Mr Roland Morley, Mr Dan Wood, Ms Jane Laws and Ms Sarah Bittlestone for their oversight of the AnTIC study as members of the TSC, and we would like to thank Ms Heather Armstrong for her contributions as a patient group representative. We thank all Principal Investigators and site staff for their commitment in recruitment for the AnTIC study. Finally, we would like to thank Hazel Wilde for secretarial support. The trial is funded by the NIHR Health Technology Assessment Programme (project reference: 11-72-01) and will be published in full in the Health Technology Assessment journal series. The authors also acknowledge the support of the National Institute for Health Research through the Comprehensive Clinical Research Network.

Toward better outcomes with tacrolimus therapy: Population pharmacokinetics and individualized dosage prediction in adult liver transplantation

Patient outcomes in transplantation would improve if dosing of immunosuppressive agents was individualized. The aim of this study is to develop a population pharmacokinetic model of tacrolimus in adult liver transplant recipients and test this model in individualizing therapy. Population analysis was performed on data from 68 patients. Estimates were sought for apparent clearance (CL/F) and apparent volume of distribution (V/F) using the nonlinear mixed effects model program (NONMEM). Factors screened for influence on these parameters were weight, age, sex, transplant type, biliary reconstructive procedure, postoperative day, days of therapy, liver function test results, creatinine clearance, hematocrit, corticosteroid dose, and interacting drugs. The predictive performance of the developed model was evaluated through Bayesian forecasting in an independent cohort of 36 patients. No linear correlation existed between tacrolimus dosage and trough concentration (r(2) = 0.005). Mean individual Bayesian estimates for CL/F and V/F were 26.5 8.2 (SD) L/hr and 399 +/- 185 L, respectively. CL/F was greater in patients with normal liver function. V/F increased with patient weight. CL/F decreased with increasing hematocrit. Based on the derived model, a 70-kg patient with an aspartate aminotransferase (AST) level less than 70 U/L would require a tacrolimus dose of 4.7 mg twice daily to achieve a steady-state trough concentration of 10 ng/mL. A 50-kg patient with an AST level greater than 70 U/L would require a dose of 2.6 mg. Marked interindividual variability (43% to 93%) and residual random error (3.3 ng/mL) were observed. Predictions made using the final model were reasonably nonbiased (0.56 ng/mL), but imprecise (4.8 ng/mL). Pharmacokinetic information obtained will assist in tacrolimus dosing; however, further investigation into reasons for the pharmacokinetic variability of tacrolimus is required.

Survival, growth and quality of life in children after orthotopic liver transplantation: A 5 year experience

The aims of this study were to investigate outcome and to evaluate areas of potential ongoing concern after orthotopic liver transplantation (OLT) in children. Actuarial survival in relation to age and degree of undernutrition at the time of OLT was evaluated in 53 children (age 0.58-14.2 years) undergoing OLT for endstage liver disease. Follow-up studies of growth and quality of life were undertaken in those with a minimum follow-up period of 12 months (n = 26). The overall 3 year actuarial survival was 70%. Survival rates did not differ between age groups (actuarial 2 year survival for ages <1, 1-5 and >5 years were 70, 70 and 69% respectively) but did differ according to nutritional status at OLT (actuarial 2 year survival for children with Z scores for weight <-1 was 57%, >-1 was 95%; P = 0.004). Significant catch-up weight gain was observed by 18 months post-transplant, while height improved less rapidly. Quality of life (assessed by Vineland Adaptive Behaviour Scales incorporating socialization, daily living skills, communication and motor skills) was good (mean composite score 91 ± 19). All school-aged children except one were attending normal school. Two children had mild to moderate intellectual handicap related to post-operative intracerebral complications. Satisfactory long-term survival can be achieved after OLT in children regardless of age but the importance of pre-operative nutrition is emphasized. Survivors have an excellent chance of a good quality of life and of satisfactory catch-up weight gain and growth.

A novel, long-acting agonist of glucose-dependent insulinotropic polypeptide suitable for once-daily administration in type 2 diabetes

Glucose-dependent insulinotropic polypeptide (GIP) is a gastrointestinal hormone with a potentially therapeutic role in type 2 diabetes. Rapid degradation by dipeptidylpeptidase IV has prompted the development of enzyme-resistant N-terminally modified analogs, but renal clearance still limits in vivo bioactivity. In this study, we report long-term antidiabetic effects of a novel, N-terminally protected, fatty acid-derivatized analog of GIP, N-AcGIP(LysPAL(37)), in obese diabetic (ob/ob) mice. Once-daily injections of N-AcGIP(LysPAL(37)) over a 14-day period significantly decreased plasma glucose, glycated hemoglobin, and improved glucose tolerance compared with ob/ob mice treated with saline or native GIP. Plasma insulin and pancreatic insulin content were significantly increased by N-AcGIP(LysPAL(37)). This was accompanied by a significant enhancement in the insulin response to glucose together with a notable improvement of insulin sensitivity. No evidence was found for GIP receptor desensitization and the metabolic effects of NAcGIP(LysPAL(37)) were independent of any change in feeding or body weight. Similar daily injections of native GIP did not affect any of the parameters measured. These data demonstrate the ability of once-daily injections of N-terminally modified, fatty acid-derivatized analogs of GIP, such as N-AcGIP(LysPAL(37)), to improve diabetes control and to offer a new class of agents for the treatment of type 2 diabetes.

Dose-dependent effects of the once-daily GLP-1 receptor agonist lixisenatide in patients with Type 2 diabetes inadequately controlled with metformin:a randomized, double-blind, placebo-controlled trial

To evaluate the dose-response relationship of lixisenatide (AVE0010), a glucagon-like peptide-1 (GLP-1) receptor agonist, in metformin-treated patients with Type 2 diabetes.

Population pharmacokinetic and pharmacogenetic analysis of tacrolimus in paediatric liver transplant patients

Aims: To build a population pharmacokinetic model that describes the apparent clearance of tacrolimus and the potential demographic, clinical and genetically controlled factors that could lead to inter-patient pharmacokinetic variability within children following liver transplantation.

Methods: The present study retrospectively examined tacrolimus whole blood pre-dose concentrations (n = 628) of 43 children during their first year post-liver transplantation. Population pharmacokinetic analysis was performed using the non-linear mixed effects modelling program (nonmem) to determine the population mean parameter estimate of clearance and influential covariates.

Results: The final model identified time post-transplantation and CYP3A5*1 allele as influential covariates on tacrolimus apparent clearance according to the following equation:

TVCL=12.9×(Weight /13.2)^0.75×EXP(-0.00158×TPT)×EXP(0.428×CYP3A5)

where TVCL is the typical value for apparent clearance, TPT is time post-transplantation in days and the CYP3A5 is 1 where*1 allele is present and 0 otherwise. The population estimate and inter-individual variability (%CV) of tacrolimus apparent clearance were found to be 0.977 l h kg (95% CI 0.958, 0.996) and 40.0%, respectively, while the residual variability between the observed and predicted concentrations was 35.4%.

Conclusion: Tacrolimus apparent clearance was influenced by time post-transplantation and CYP3A5 genotypes. The results of this study, once confirmed by a large scale prospective study, can be used in conjunction with therapeutic drug monitoring to recommend tacrolimus dose adjustments that take into account not only body weight but also genetic and time-related changes in tacrolimus clearance. © 2013 The British Pharmacological Society.

One-Year Safety of Olodaterol Once Daily via Respimat® in Patients with GOLD 2-4 Chronic Obstructive Pulmonary Disease: Results of a Pre-Specified Pooled Analysis

The novel long-acting β2-agonist olodaterol demonstrated an acceptable safety profile in short-term phase II clinical studies. This analysis of four randomized, double-blind, placebo-controlled, parallel-group, phase III studies (1222.11, NCT00782210; 1222.12, NCT00782509; 1222.13, NCT00793624; 1222.14, NCT00796653) evaluated the long-term safety of olodaterol once daily (QD) in a large cohort of patients with moderate to very severe (Global initiative for chronic Obstructive Lung Disease 2-4) chronic obstructive pulmonary disease (COPD). The studies compared olodaterol (5 or 10 μg) QD via Respimat®, formoterol 12 μg twice daily (BID) via Aerolizer® (1222.13 and 1222.14), and placebo for 48 weeks. Patients continued receiving background maintenance therapy, with ∼60% receiving concomitant cardiovascular therapy and 25% having a history of concomitant cardiac disease. Pre-specified analyses of pooled data assessed the adverse events (AEs) and serious AEs in the whole population, and in subgroups with cardiac disease, along with in-depth electrocardiogram and Holter monitoring. In total, 3104 patients were included in the safety analysis: 876 received olodaterol 5 μg, 883 received olodaterol 10 μg, 885 received placebos, and 460 received formoterol 12 μg BID. Overall incidence of on-treatment AEs (71.2%), serious AEs (16.1%), and deaths (1.7%) were balanced across treatment groups. Respiratory and cardiovascular AEs, including major adverse cardiac events, were reported at similar frequencies in placebo and active treatment groups. The safety profiles of both olodaterol 5 μg (marketed and registered dose) and 10 μg QD delivered via Respimat® are comparable to placebo and formoterol BID in this population, with no safety signals identified.