Expert opinion on drug metabolism & toxicology最新文献

Introduction: Due to its role in absorption and metabolism, the kidney is an important target for drug toxicity. Drug-induced nephrotoxicity (DIN) presents a significant challenge in clinical practice and drug development. Conventional methods for assessing nephrotoxicity have limitations, highlighting the need for innovative approaches. In recent years, in silico methods have emerged as promising tools for predicting DIN.

Areas covered: A literature search was performed using PubMed and Web of Science, from 2013 to February 2023 for this review. This review provides an overview of the current progress and pitfalls in the in silico prediction of DIN, which discusses the principles and methodologies of computational models.

Expert opinion: Despite significant advancements, this review identified issues accentuates the pivotal imperatives of data fidelity, model optimization, interdisciplinary collaboration, and mechanistic comprehension in sculpting the vista of DIN prediction. Integration of multiple data sources and collaboration between disciplines are essential for improving predictive models. Ultimately, a holistic approach combining computational, experimental, and clinical methods will enhance our understanding and management of DIN.

Introduction: Cefepime/enmetazobactam is a novel β-lactam/β-lactamase inhibitor (BL-BLI) combination with broad Gram-positive and -negative activity. Cefepime is relatively resistant to hydrolysis by AmpC, and enmetazobactam inhibits all Ambler Class A extended spectrum β-lactamases (ESBLs). Hence, the combination is resistant to hydrolysis by many ESBLs. Important spectrum gaps are MRSA, enterococci, Acinetobacter spp. and anaerobes. There is no completely reliable activity against carbapenem-resistant organisms.

Areas covered: We describe the chemistry, pharmacodynamics, pharmacokinetics, toxicities, drug-drug interactions, clinical efficacy, and current regulatory position of cefepime/enmetazobactam, following a review of available published literature relating to cefepime/enmetazobactam.

Expert opinion: The main potential role for cefepime/enmetazobactam is as a carbapenem-sparing agent for the treatment of infections caused by ESBL-producing Enterobacterales to prevent the use of carbapenems and to avoid the toxicities of non-β-lactam alternatives.There may be potential uses for cefepime/enmetazobactam for the treatment of reproductive tract infections, abdominal infections and neonatal sepsis, given the spectrum of activity and pharmacokinetic properties. However, additional non-clinical and clinical studies are required before use in these settings.

Introduction: Rezafungin, formerly SP3025 and CD101, is a next-generation echinocandin, chemically related to anidulafungin, with differentiated pharmacokinetic characteristics, including a prolonged half-life allowing extended-interval dosing.

Areas covered: Herein, we discuss the role of rezafungin in the treatment of candidemia and invasive candidiasis, with a specific focus on pharmacokinetics considerations.

Expert opinion: Rezafungin exhibits potent in vitro activity against most wild-type and azole-resistant Candida species, including Candida auris. The differentiated PK characteristics of rezafungin which enables once weekly dosing could reduce catheter overuse and provide a rapid transition to outpatient treatment for Candida infections in which azoles cannot be used, due to resistance or drug-drug interactions. Besides weekly dosing, other potential pharmacokinetic/pharmacodynamic advantages of rezafungin are its good penetration into anatomically challenging sites and a potentially reduced probability of local resistance promotion, making it an attractive option also for deep-seated infections that could warrant dedicated clinical investigation.

Background: p-cresol and indole are uremic compounds which undergo sulfonation to generate the highly toxic p-cresol sulfate (pCS) and indoxyl sulfate (IxS). They are also subjected to glucuronidation to produce the less toxic p-cresol glucuronide (pCG) and indoxyl glucuronide (IG). We developed and validated an assay to quantify these metabolites in HepaRG cells. We also tested the effects of mefenamic acid on their in-situ formations in relation to the development of cellular necrosis.

Research design and methods: HepaRG cells were exposed to p-cresol or indole (0-1 mM) with mefenamic acid (0-3000 nM) for 24 hours to generate uremic metabolites. Cells were also exposed to 0.5 mM p-cresol or indole with/without 30 nM mefenamic acid to characterize lactate dehydrogenase (LDH) release.

Results: The assay exhibited high sensitivity and wide calibration ranges covering human concentrations. HepaRG cells also generated physiologically-relevant concentrations of each metabolite. Mefenamic acid inhibited pCS formation in a concentration-dependent manner without affecting pCG, IxS, or IG. Mefenamic acid also reduced LDH release from p-cresol (by 50.12±5.86%) or indole (56.26±3.58%).

Conclusions: This novel assay is capable of quantifying these metabolites in HepaRG cells. Our novel findings suggest that mefenamic acid can be potentially utilized therapeutically to attenuate pCS-associated toxicities.

Introduction: Migraine is a complex disorder, and its etiology is not yet fully understood. In the last 40 years, calcitonin gene-related peptide (CGRP) has been central to the understanding of migraine pathophysiology, leading to the development of new molecules targeting the CGRPergic system. These new molecules, such as gepants and monoclonal antibodies, are effective, well-tolerated, and safe, and are approved for clinical use.

Areas covered: By searching multiple electronic scientific databases, this narrative review examined: (i) the role of CGRP in migraine; and (ii) the current knowledge on the effects of CGRPergic antimigraine pharmacotherapies, including a brief analysis of their pharmacodynamic and pharmacokinetic characteristics.

Expert opinion: Current anti-CGRPergic medications, although effective, have limitations, such as side effects and lack of antimigraine efficacy in some patients. The existence of patients with medication-resistant migraine may be due to the: (i) complex migraine pathophysiology, in which several systems appear to be deregulated before, during, and after a migraine attack; and (ii) pharmacodynamic and pharmacokinetic properties of antimigraine medications. As envisioned here, although seminal studies support the notion that CGRP plays a key role in migraine headache, the dysfunction of CGRPergic transmission does not seem to be relevant in all cases.

Introduction: Vasomotor symptoms (VMS) affect the majority of menopausal women, with possible negative impact on several domains of quality of life (QoL). Although menopausal hormone therapy (MHT) represents an effective treatment, the risk-benefit profile is not favorable for every woman. Non-hormonal options are limited in number and efficacy.

Areas covered: Fezolinetant is a novel oral non-hormonal drug recently approved for the treatment of moderate-severe VMS. It acts as an antagonist of neurokinin 3 receptor (NK3R), the main target of neurokinin B (a tachykinin over-expressed by kisspeptin/neurokinin B/dynorphin [KNDy] neurons after menopausal hypoestrogenism), involved in the modulation of the thermoregulatory hypothalamic center. Here, we report pharmacodynamics and pharmacokinetic properties of fezolinetant as well as its efficacy and safety data from available clinical trials.

Expert opinion: Fezolinetant has shown efficacy in reducing the frequency and severity of VMS with a positive impact on sleep- and health-related QoL and acceptable safety and tolerability profile. Given the limited availability of effective non-hormonal options for VMS, fezolinetant could potentially represent a game-changer for care of menopausal women, especially when relative or absolute contraindications to MHT use are present. Further studies to gain more information about the safety profile and potential extra-VMS benefits or disadvantages are warranted in real-life clinical practice.

Background: Limited data exist on how continuous renal replacement therapy (CRRT) affects antimicrobial dosing in pediatric patients. This study examined the impact of pediatric CRRT parameters on the pharmacokinetics (PK) of meropenem, piperacillin, and tazobactam using an in vitro CRRT model.

Research design and methods: An in vitro CRRT model with a pediatric ST60 circuit was used to assess antimicrobial clearance during continuous veno-venous hemodialysis (CVVHD) or hemofiltration (CVVH). Antimicrobials were administered intermittently or continuously, with samples taken pre- and post-filter, and from the effluent. The model tested two conditions: 1) off treatment (0 mL/kg/h), and 2) an elimination phase, with CRRT flow rates ranging from 40 to 400 mL/kg/h.

Results: Clearance of meropenem, piperacillin, and tazobactam increased significantly with higher dialyzate/ultrafiltration flow rates (p < 0.001). Median clearance rates differed significantly by CRRT flow rates and modality (p < 0.001). Under CVVHD, the saturation coefficient (Sa) decreased with increasing dialyzate flow rates, while under CVVH, the sieving coefficient (Sc) remained stable regardless of ultrafiltration rates.

Conclusions: The clearance of low protein-binding, low molecular weight antimicrobials increases with higher CRRT effluent flow rates, with modality-specific differences in clearance dynamics.

Introduction: In ovarian steroid-dependent diseases such as uterine fibroids, endometriosis and adenomyosis, oral GnRH antagonists have emerged as new therapeutic alternatives. These oral GnRH antagonists offer key advantages, including oral administration, dose-dependent estrogen suppression and rapid reversibility.

Areas covered: This review examines the pharmacological, clinical and therapeutic profiles of the latest non-peptide oral GnRH antagonists, through an analysis of clinical evidence and randomized clinical trials, to provide a comprehensive and up-to-date overview of their clinical applications and potential benefits.

Expert opinion: The clinical trials examined demonstrated significant efficacy in reducing heavy menstrual bleeding in women with fibroids and pelvic pain in women with endometriosis, with more than 70% of patients achieving primary endpoints. The use of add-back therapy minimized bone mass density loss, ensuring long-term safety. Adverse events were dose-dependent but generally well tolerated. In our opinion, the strength of oral GnRH antagonists lies in their pharmacological properties. Oral administration increases convenience, allows adjustable dosing and ensures a dose-dependent effect. These drugs provide an immediate antagonistic effect without the flare-up phenomenon. Furthermore, they are expected to act on ectopic endometrial and smooth muscle cell receptors, potentially providing additional anti-proliferative effects. However, further research is needed: long term clinical trials must compare them with existing treatments.

Background: Immune-mediated liver injury caused by immune checkpoint inhibitors (ILICI) and autoimmune hepatitis (AIH) are both related to the distorted immune system. However, ILICI differs from AIH in several distinct ways. We aimed to study the differences between ILICI and AIH.

Research design and methods: This is a retrospective study collecting clinical data of ILICI (2016.1-2024.2) and AIH (2002.1-2023.6) patients. Demographic, clinicopathological, radiological characteristics, treatment and outcomes were analyzed.

Results: A total of 71 ILICI and 158 AIH cases were included. ILICI group had older patients and fewer females (age: 66 vs. 56 years, gender: 28.2% vs. 85.4%, p < 0.001). They had lower ALT, AST, TBil, IgG levels, and lower titers of ANA. Some ILICI patients exhibited bile duct edema and dilation, while AIH patients typically had liver fibrosis in CT/MRI. Histologically, ILICI showed bile duct injury, inflammatory cells infiltration with fewer plasma cells. Glucocorticoid treatment was less common, but ALT level recovery was faster in ILICI patients (41 vs. 140 days, p < 0.001).

Conclusions: ILICI generally affects older patients without a female predilection and is linked to milder, acute liver injury. High ANA titers, elevated IgG, and prominent plasma cell infiltration were less common. Liver function normalizes more quickly in ILICI.