Point of care assay for blood aripiprazole concentrations: development, validation and utility.

BACKGROUND: The antipsychotic aripiprazole is often used in the treatment of first-episode psychosis. Measuring aripiprazole blood levels provides an objective measure of treatment adherence, but this currently involves taking a venous blood sample and sending to a laboratory for analysis. AIMS: To detail the development, validation and utility of a new point of care (POC) test for finger-stick capillary blood concentrations of aripiprazole. METHOD: Analytical performance (sensitivity, precision, recovery and linearity) of the assay were established using spiked whole blood and control samples of varying aripiprazole concentration. Assay validation was performed over a 14-month period starting in July 2021. Eligible patients were asked to provide a finger-stick capillary sample in addition to their usual venous blood sample. Capillary blood samples were tested by the MyCare™ Insite POC analyser, which provided measurement of aripiprazole concentration in 6 min, and the venous blood sample was tested by the standard laboratory method. RESULTS: A total of 101 patients agreed to measurements by the two methods. Venous blood aripiprazole concentrations as assessed by the laboratory method ranged from 17 to 909 ng/mL, and from 1 to 791 ng/mL using POC testing. The correlation coefficient between the two methods (r) was 0.96 and there was minimal bias (slope 0.91, intercept 4 ng/ml). CONCLUSIONS: The MyCare Insite POC analyser is sufficiently accurate and reliable for clinical use. The availability of this technology will improve the assessment of adherence to aripiprazole and the optimising of aripiprazole dosing.

All Optimal Dosing Roads Lead to Therapeutic Drug Monitoring-Why Take the Slow Lane.

This Viewpoint discusses therapeutic drug monitoring as a necessary treatment paradigm and the need for regulatory agencies to provide the conditions to make it happen.

Paclitaxel exposure-toxicity analysis reveals a pharmacokinetic determinant for dose-limiting neutropenia in East-Asian solid tumor patients: results from two prospective, phase II studies.

PURPOSE: The time of a paclitaxel (PTX) concentration remains above 0.05 µM (Tc > 0.05) has been associated with PTX-induced adverse effects in Caucasians, while limited studies were reported in Asians. This study was aimed to explore the characteristics of Tc > 0.05 and the relationship between PTX exposure and toxicity in East-Asian patients. METHODS: This study was based on two prospective phase II clinical trials and patients with advanced nasopharyngeal cancer (NPC) and non-small cell lung cancer (NSCLC) who were naïve to PTX were included independently. Eligible patients receive PTX (175 mg/m2) and carboplatin (AUC = 5) treatment every 3 weeks. PTX pharmacokinetic analysis was accessed. The relationship between PTX exposure and toxicities after first cycle as well as clinical efficacy was evaluated. RESULTS: A total of 93 NPC and 40 NSCLC patients were enrolled. PTX exposure was consistent in two trials with average Tc > 0.05 duration of 38.8 h and 38.4 h, respectively. Average Tc > 0.05 in patients with grade 3/4 neutropenia was significantly higher than those without severe neutropenia in NPC patients (P = 0.003) and NSCLC patients (P = 0.007). Cut-off value of Tc > 0.05 were identified from the NPC cohort and then verified in the NSCLC cohort, dividing patients into high exposure Tc > 0.05 group (> 39 h) and low exposure group (≤ 39 h). Incidence of grade 3/4 neutropenia were significantly higher in the high exposure group in NPC cohort (43.3% vs 10.0%, P < 0.001) and NSCLC cohort (42.1% vs 9.5%, P = 0.028). No significant relationship between Tc > 0.05 and efficacy were observed. CONCLUSION: Patients with PTX Tc > 0.05 duration above 39 h experience more severe neutropenia than those under 39 h. Prospective studies are needed to verify this threshold.

Therapeutic drug monitoring in oncology: International Association of Therapeutic Drug Monitoring and Clinical Toxicology consensus guidelines for imatinib therapy.

Although therapeutic drug monitoring (TDM) is an important tool in guiding drug dosing for other areas of medicine including infectious diseases, cardiology, psychiatry and transplant medicine, it has not gained wide acceptance in oncology. For imatinib and other tyrosine kinase inhibitors, a flat dosing approach is utilised for management of oral chemotherapy. There are many published studies examining the correlation of blood concentrations with clinical effects of imatinib. The International Association of Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT) determined that there was a need to examine the published literature regarding utility of TDM in imatinib therapy and to develop consensus guidelines for TDM based on the available data. This article summarises the scientific evidence regarding TDM of imatinib, as well as the consensus guidelines developed by the IATDMCT.

The cost-effectiveness of therapeutic drug monitoring for the prescription drug-based treatment of chronic myeloid leukemia.

BACKGROUND: A recent study demonstrating the use of Therapeutic Drug Monitoring (TDM) in patients with chronic myeloid leukemia (CML) resulted in a higher response rate with imatinib (IM) than demonstrated in second-generation tyrosine kinase inhibitor studies. The cost-effectiveness of TDM combined with IM (IM TDM) in first-line CML treatment has not yet been studied. OBJECTIVES: To determine the cost-effectiveness of IM TDM for the first-line treatment of CML compared to tyrosine kinase inhibitor only treatment. METHODS: A recently published cost-effectiveness model of tyrosine kinase inhibitor-treatment in CML was modified to include IM TDM as a first-line tyrosine kinase inhibitor-based CML treatment option. Efficacy inputs for major molecular response (MMR) rates were taken from previously published studies: IM TDM 65%, dasatinib 52%, nilotinib 53%. Annual tyrosine kinase inhibitor drug prices were derived from the Federal Supply Schedule (FSS) and the average and lowest wholesale acquisition costs (WAC) reported in the Red Book; the annual cost of TDM was $228. Other input costs modeled in the original CML CEA model were updated to 2016 US dollars using the medical service component of the Consumer Price Index. A US payer perspective was used with a 5-year time horizon and a 3.0% discount rate. The model compared first-line IM TDM versus IM alone, nilotinib (NIL) or dasatinib (DAS) in terms of the following outcomes: costs, quality-adjusted life-years (QALYs), and cost-effectiveness (total cost/QALY). Deterministic and probabilistic sensitivity analyses were performed using all key clinical and economic parameters. RESULTS: This study found that IM TDM dominates IM alone with $15,452 to $36,940 in savings and 0.25 higher QALYs. Using FSS, per patient total costs for IM and IM TDM were $270,905 and $233,965, respectively.; Using average WAC, these costs were $461,657 and $446,205, and using lowest WAC, these costs were $366,966 and $350,090. The results comparing first line using of IM TDM to NIL/DAS found that TDM IM had higher QALYs and lower costs (0.08 QALYs lower, and $117,006 to $172,420 savings per patient [varying by price basis]). Thus, in terms of cost-effectiveness, IM TDM dominates NIL/DAS with both lower costs and higher QALYs. CONCLUSIONS: IM TDM is a clinically and economically viable first-line treatment option for CML. DISCLOSURES: This study was funded by Saladax Biomedical. Salamone is an employee of Saladax Biomedical. This study was presented at the IATDMCT Congress, September 2018, Brisbane, Australia.

Evaluation of a Nanoparticle-Based Busulfan Immunoassay for Rapid Analysis on Routine Clinical Analyzers.

BACKGROUND: Busulfan is an alkylating agent used in allogeneic hematopoietic stem cell transplantation for various malignant and nonmalignant disorders. Therapeutic drug monitoring of busulfan is common because busulfan exposure has been linked to veno-occlusive disease, disease relapse, and failed engraftment. The authors developed an automated immunoassay, along with stable calibrators and controls, and quantified busulfan in sodium heparin plasma. METHODS: The authors evaluated a homogenous nanoparticle immunoassay, the MyCare Oncology Busulfan Assay Kit (Saladax Biomedical, Inc), for precision, sensitivity, accuracy, and linearity on an open channel clinical chemistry analyzer; they compared the method with 2 mass spectrometry methods (liquid chromatography-tandem mass spectrometry and gas chromatography/mass spectrometry), using anonymized, remnant patient samples. RESULTS: The coefficients of variation for repeatability and within-laboratory precision were ≤9.0%. The linear range was 150-2000 ng/mL; samples up to 6000 ng/mL can be measured with sample dilution. Measured values deviated by ≤14% from assigned values. Comparison between validated mass spectrometry methods resulted in a correlation coefficient R ≥ 0.995. CONCLUSIONS: The MyCare Busulfan Assay Kit shows the precision, accuracy, linearity, and test range for performing busulfan concentration measurements in sodium heparin plasma on routine clinical chemistry analyzers.

The Alzheimer's Association international guidelines for handling of cerebrospinal fluid for routine clinical measurements of amyloid ß and tau.

The core cerebrospinal fluid (CSF) Alzheimer's disease (AD) biomarkers amyloid beta (Aß42 and Aß40), total tau, and phosphorylated tau, have been extensively clinically validated, with very high diagnostic performance for AD, including the early phases of the disease. However, between-center differences in pre-analytical procedures may contribute to variability in measurements across laboratories. To resolve this issue, a workgroup was led by the Alzheimer's Association with experts from both academia and industry. The aim of the group was to develop a simplified and standardized pre-analytical protocol for CSF collection and handling before analysis for routine clinical use, and ultimately to ensure high diagnostic performance and minimize patient misclassification rates. Widespread application of the protocol would help minimize variability in measurements, which would facilitate the implementation of unified cut-off levels across laboratories, and foster the use of CSF biomarkers in AD diagnostics for the benefit of the patients.

Point-of-care measurement of clozapine concentration using a finger-stick blood sample.

BACKGROUND: The use of clozapine demands regular monitoring of clozapine plasma concentrations and of white blood cell parameters. The delay between sending blood samples for analysis and receiving the results hinders clinical care. Point-of-care testing (POCT) can provide drug assay results within a few minutes. AIM: This study aimed to investigate the utility of a novel point-of-care device that can measure clozapine concentrations using capillary blood samples collected via a finger stick. METHOD: During a five-week period starting in June 2019 eligible patients were asked to provide a finger-stick capillary sample in addition to their usual venous blood sample. Samples were analysed by the novel point-of-care device and by the standard laboratory method. Capillary blood samples were tested by the MyCare™ Insite POCT analyser, and a quantitative measurement of clozapine concentration was provided within six minutes. RESULTS: A total of 309 patients agreed to measurements by the two methods. Analysis revealed clozapine concentrations in venous blood as determined by the laboratory method ranged from 20 to 1310 ng/mL and by POCT from 7 to 1425 ng/mL. There was a strong positive correlation (R = 0.89) between the results from the venous and the capillary sample methods. The slope of the association between standard assay and MyCare™ Insite was 1.0 with an intercept of -21 ng/mL, indicating minimal bias. CONCLUSION: Clozapine concentrations can be accurately measured at the point of care using capillary blood samples collected via a finger stick. This approach may be more acceptable than venous sampling to patients and, with almost instant results available, more useful to clinicians.

Inversion algorithm for Lamb-wave-based depth characterization of acoustic emission sources in plate-like structures.

An inversion algorithm (termed AEDep) is proposed for estimating the depth of acoustic emission (AE) sources in plate-like structural components. The work is motivated by the need for characterizing early-stage fatigue crack growth in such components. The algorithm achieves depth estimation by automatically extracting the depth-dependent amplitude ratio between the fundamental Lamb modes which comprise the AE signals. A finite element model is designed to study the frequency-dependent forward problem of Lamb wave motion due to a given source, from which the relation between source depth and amplitude ratio is established. Elastodynamic theory is used to validate the model in the frequency domain, as well as to derive a sensor tuning factor which may be incorporated into the solution. The proposed algorithm was tested on two plate-like specimens: a 6061-T6 aluminum plate and a 2025-T6 aluminum aircraft fuselage panel. Validation of the algorithm was achieved by generating controlled AE sources at various depths along the edges of the specimens, in the form of Hsu-Nielsen pencil lead breaks. Good agreement was found in the aluminum plate between the true and estimated source depths. A slight decrease in accuracy was found in the fuselage panel between the true values and their estimations. However, both experimental cases demonstrated the ability to distinguish between sources originating near the mid-plane of a plate-like structure from those near the surface. Lastly, the fast computation of the inversion algorithm shows strong potential for real-time monitoring applications.

Randomized study of individualized pharmacokinetically-guided dosing of paclitaxel compared with body-surface area dosing in Chinese patients with advanced non-small cell lung cancer.

AIMS: This prospective, randomized study was initiated to assess the impact of pharmacokinetically (PK)-guided paclitaxel (PTX) dosing on toxicity and efficacy compared with body-surface area (BSA)-based dosing in Chinese non-small cell lung cancer patients. METHODS: A total of 319 stage IIIB/IV non-small cell lung cancer patients receiving first-line chemotherapy were enrolled. Patients were randomized to receive 3-weekly carboplatin plus PTX at a starting dose of 175 mg/m2 with subsequent PTX dosing based on either BSA or PK-guided dosing targeting time above a PTX plasma concentration of 0.05 µmol/L (PTXTc > 0.05 ) between 26 and 31 hours. The primary safety endpoint was grade 4 haematological toxicity. The secondary endpoints were neuropathy, objective response rate, progression-free survival and overall survival. RESULTS: In total, 275 (86%) patients completed ≥2 cycles of chemotherapy (140 in BSA arm and 135 in PK arm). In cycle 1, with the same PTX dose, average PTXTc > 0.05 was 37 hours (range = 18-57 hours). Over cycles 2-4, patients in the PK arm had significantly lower average PTX doses and exposure compared with the BSA arm (128 vs 161 mg/m2 , P < .0001 and 29 vs 35 hours, P < .0001). PK-guided dosing significantly reduced the cumulative incidence of grade 4 haematological toxicity (15% vs 24%, P = .004), grade 4 neutropenia (15% vs 23%, P = .009) and grade ≥ 2 neuropathy (8% vs 21%, P = .005). Objective response rate (32% vs 26%, P = .28) and overall survival (21.0 vs 24.0 months, P = .815) were similar in PK and BSA arms. Progression-free survival was slightly improved in PK arm (4.67 vs 4.17 months, P = .026). CONCLUSION: PK-guided PTX dosing significantly reduced grade 4 haematological toxicities and grade ≥ 2 neuropathy without an adverse impact on clinical outcomes.

The role of shape disorder in the collective behaviour of aligned fibrous matter.

We study the compression of bundles of aligned macroscopic fibers with intrinsic shape disorder, as found in human hair and in many other natural and man-made systems. We show by a combination of experiments, numerical simulations and theory how the statistical properties of the shapes of the fibers control the collective mechanical behaviour of the bundles. This work paves the way for designing aligned fibrous matter with purposed-designed properties from large numbers of individual strands of selected geometry and rigidity.

Computation of propagating and non-propagating guided modes in nonuniformly stressed plates using spectral methods.

This paper presents a numerical approach based on spectral methods for the computation of guided ultrasonic wave modes (i.e., Lamb and shear horizontal) in nonuniformly stressed plates. In particular, anisotropic elastic plates subjected to a normal stress profile, which varies nonuniformly over their thickness, are considered. The proposed approach computes the modeshapes and the full three-dimensional dispersion spectrum (i.e., real frequency, complex wavenumber). It therefore includes both propagating (real wavenumber) and non-propagating (complex wavenumber) modes. Furthermore, an approach for robustly post-processing the dispersion spectra in order to compute the group velocity of propagating modes is presented, which is based on a spectral quadrature method. Numerical results are presented for two case studies: (1) a bending profile in a fiber-reinforced graphite/epoxy plate, and (2) an exponential profile in a silver plate. The results show the computational efficiency (i.e., spectral convergence) of the proposed method compared to other existing approaches such as the sublayering and finite element methods.

Higher order longitudinal guided wave modes in axially stressed seven-wire strands.

This paper investigates the effect of axial stress on higher order longitudinal guided modes propagating in individual wires of seven-wire strands. Specifically, an acoustoelastic theory for a rod is used to predict the effect of stress on the phase velocity of guided modes in a strand. To this end, the exact acoustoelastic theory for an axially stressed rod is adapted for small deformations. Aside from the exact theory, approximate phase velocity changes (derived from both theory and experiment) are proposed, without the need to solve for dispersion curves. To validate the use of rod theories for strands, a custom-built prestressing bed was designed to apply axial load (up to 50% of yield) to a strand while conducting guided wave measurements. Higher order modes were excited in individual wires, and their phase velocity change under stress is compared to the exact acoustoelastic theory. Furthermore, it is shown that the proposed approximate phase velocity changes derived from theory and experiment only differ by roughly 2% from their exact counterparts. Higher order modes are shown to have stable stress dependence near their peak group velocity, which is beneficial for stress measurement. Additionally, linear stress dependence is observed, which is predicted by rod theories. Due to the unavailability of third order elastic constants for the steel strand, constants for a steel with similar Carbon content (0.6% C Hecla 17) were used as representative values in the theory. Using the Hecla 17 constants, roughly 15% mismatch in the slope of the linear stress dependence was observed when compared to the measurements on a steel strand.

Validation of a Commercial Assay and Decision Support Tool for Routine Paclitaxel Therapeutic Drug Monitoring (TDM).

BACKGROUND: The value of therapeutic drug monitoring (TDM) for paclitaxel (PTX) was recently demonstrated in the largest TDM trial ever conducted in oncology. The trial demonstrated significant reduction in neuropathy when using TDM. Dose adjustment for PTX was based on time above a threshold concentration (Tc>0.05). Tc>0.05 must be calculated with a pharmacokinetic model and complex nonlinear mixed-effects software. The use of the software and chromatographic methods to measure PTX requires specialized expertise. User-friendly methods to quantitate PTX and calculate Tc>0.05 could simplify the introduction of TDM into routine clinical practice. METHODS: The immunoassay (MyPaclitaxel) was used to quantitate PTX in samples from the clinical trial; the results were used to calculate Tc>0.05 using a stand-alone computer program with a simple, friendly graphical user interface for nonlinear mixed-effects pharmacokinetic calculations (MyCare Drug Exposure Calculator). The resulting dose recommendations from the calculated Tc>0.05 were compared with those using liquid chromatography-ultraviolet detection and NONMEM to examine the efficacy of the simpler tools for TDM. RESULTS: There was a good agreement between the immunoassay and liquid chromatography-ultraviolet detection: Passing-Bablok regression slope was 1.045 and intercept was -6.00, R was 0.9757, and mean bias was -1.77 ng/mL (-2.07 nmol/L). Dosing recommendations were identical for 70% of the cycles and within 10% for 89% of the samples. All Tc>0.05 values were at the same or adjacent medical decision points. CONCLUSIONS: MyPaclitaxel assay and MyCare Drug Exposure Calculator are convenient, user-friendly tools that may be suitable for routine TDM of PTX in clinical care.

Rapid Homogeneous Immunoassay to Quantify Gemcitabine in Plasma for Therapeutic Drug Monitoring.

BACKGROUND: Gemcitabine (2',2'-difluoro-2'-deoxycytidine) is a nucleoside analog used as a single agent and in combination regimens for the treatment of a variety of solid tumors. Several studies have shown a relationship between gemcitabine peak plasma concentration (Cmax) and hematological toxicity. An immunoassay for gemcitabine in plasma was developed and validated to facilitate therapeutic drug monitoring (TDM) by providing an economical, robust method for automated chemistry analyzers. METHODS: A monoclonal antibody was coated on nanoparticles to develop a homogenous agglutination inhibition assay. To prevent ex vivo degradation of gemcitabine in blood, tetrahydrouridine was used as a sample stabilizer. Validation was conducted for precision, recovery, cross-reactivity, and linearity on a Beckman Coulter AU480. Verification was performed on an AU5800 in a hospital laboratory. A method comparison was performed with (LC-MS/MS) liquid chromatography tandem mass spectrometry using clinical samples. Selectivity was demonstrated by testing cross-reactivity of the major metabolite, 2',2'-difluorodeoxyuridine. RESULTS: Coefficients of variation for repeatability and within-laboratory precision were <8%. The deviation between measured and assigned values was <3%. Linear range was from 0.40 to 33.02 µ/mL (1.5-125.5 µM). Correlation with validated LC-MS/MS methods was R = 0.977. The assay was specific for gemcitabine: there was no cross-reactivity to 2',2'-difluorodeoxyuridine, chemotherapeutics, concomitant, or common medications tested. Tetrahydrouridine was packaged in single-use syringes. Gemcitabine stability in whole blood was extended to 8 hours (at room temperature) and in plasma to 8 days (2-8°C). CONCLUSIONS: The assay demonstrated the selectivity, test range, precision, and linearity to perform reliable measurements of gemcitabine in plasma. The addition of stabilizer improved the sample handling. Using general clinical chemistry analyzers, gemcitabine could be measured for TDM.

The effect of applied stress on the phase and group velocity of guided waves in anisotropic plates.

This paper presents an analytical formulation for the phase and group velocity of acoustoelastic guided waves in anisotropic plates. Uniform in-plane applied stress is considered, with both arbitrary propagation and stress directions. An expression for the energy velocity in a stressed anisotropic plate is derived, from which the group velocity is computed. Since the wavefront and group velocity directions generally differ, the deviation angle between the two is also studied. A method is proposed for verifying the consistency of the formulation, based on the correspondence between a direct and an indirect formulation. Analytical results are presented for a unidirectional fiber-reinforced graphite/epoxy composite plate. The plate is considered homogeneous for large wavelength to fiber diameter ratios. Results for the phase velocity, group velocity, and deviation angle are presented for two uniaxial applied loading cases. These are used to study the effect of stress for various propagation and stress directions. The linearity of the deviation angle with respect to stress is also demonstrated. Exact correspondence between the direct and indirect formulations is observed, which verifies consistency. The importance of accounting for shear strain in the indirect formulation is also demonstrated, which has not been noted in previous guided wave studies.

Effect of pressurization on helical guided wave energy velocity in fluid-filled pipes.

The effect of pressurization stresses on helical guided waves in a thin-walled fluid-filled pipe is studied by modeling leaky Lamb waves in a stressed plate bordered by fluid. Fluid pressurization produces hoop and longitudinal stresses in a thin-walled pipe, which corresponds to biaxial in-plane stress in a plate waveguide model. The effect of stress on guided wave propagation is accounted for through nonlinear elasticity and finite deformation theory. Emphasis is placed on the stress dependence of the energy velocity of the guided wave modes. For this purpose, an expression for the energy velocity of leaky Lamb waves in a stressed plate is derived. Theoretical results are presented for the mode, frequency, and directional dependent variations in energy velocity with respect to stress. An experimental setup is designed for measuring variations in helical wave energy velocity in a thin-walled water-filled steel pipe at different levels of pressure. Good agreement is achieved between the experimental variations in energy velocity for the helical guided waves and the theoretical leaky Lamb wave solutions.