Pharmacokinetic monitoring of mycophenolic acid in heart transplant patients: correlation the side-effects and rejections with pharmacokinetic parameters.

BACKGROUND: Mycophenolate mofetil is a commonly used immunosuppressant in heart transplantation but pharmacokinetic monitoring is not routinely done. We performed a prospective pilot multi-center trial in de-novo heart transplant recipients to evaluate the pharmacokinetics (PK) of mycophenolic acid (MPA) at multiple time points in the first year following transplant.
MATERIAL/METHODS: MPA trough and estimated area-under-the-curve (AUC) values were obtained at multiple visits from 21 enrolled patients. We attempted to correlate the side-effects and rejections with PK parameters.
RESULTS: MPA AUC and trough levels increased modestly over 12 months with substantial inter and intra patient variability. Cardiac rejection was associated with low MPA AUC values with a threshold of <36.2 mg×h/L during the first two post-transplant weeks. A threshold of 2-weeks average MPA trough level of 1.43 mg/L provided a sensitivity 82% and a specificity of 60%.
CONCLUSIONS: Adequate MPA levels are associated with decreased risk of allograft rejection. For patients with Cyclosporine co-immunosuppression, we propose an MPA trough of 1.4 mg/L and an MPA AUC of 36 mg × h/L as threshold values for dose adjustments. We recommend monitoring MPA levels at 1, 2 and 4 weeks, 6 months, 1 year and whenever an unexplained side-effect or allograft rejection occurs. Additional MPA AUC measurements are recommended when trough levels do not explain the clinical picture.

Development of a predictive limited sampling strategy for estimation of mycophenolic acid area under the concentration time curve in patients receiving concomitant sirolimus or cyclosporine.

Limited sampling strategies for estimation of the area under the concentration time curve (AUC) for mycophenolic acid (MPA) co-administered with sirolimus (SRL) have not been previously evaluated. The authors developed and validated 68 regression models for estimation of MPA AUC for two groups of patients, one with concomitant SRL (n = 24) and the second with concomitant cyclosporine (n=14), using various combinations of time points between 0 and 4 hours after drug administration. To provide as robust a model as possible, a dataset-splitting method similar to a bootstrap was used. In this method, the dataset was randomly split in half 100 times. Each time, one half of the data was used to estimate the equation coefficients, and the other half was used to test and validate the models. Final models were obtained by calculating the median values of the coefficients. Substantial differences were found in the pharmacokinetics of MPA between these groups. The mean MPA AUC as well as the standard deviation was much greater in the SRL group, 56.4 +/- 23.5 mg.h/L, compared with 30.4 +/- 11.0 mg.h/L in the cyclosporine group (P < 0.001). Mean maximum concentration was also greater in the SRL group: 16.4 +/- 7.7 mg/L versus 11.7 +/- 7.1mg/L (P < 0.005). The second absorption peak in the pharmacokinetic profile, presumed to result from enterohepatic recycling of glucuronide MPA, was observed in 70% of the profiles in the SRL group and in 35% of profiles from the cyclosporine group. Substantial differences in the predictive performance of the regression models, based on the same time points, were observed between the two groups. The best model for the SRL group was based on 0 (trough) and 40 minutes and 4 hour time points with R2, root mean squared error, and predictive performance values of 0.82, 10.0, and 78%, respectively. In the cyclosporine group, the best model was 0 and 40 minutes and 2 hours, with R2, RMSE, and predictive performance values of 0.86, 4.1, and 83%, respectively. The model with 2 hours as the last time point is also recommended for the SRL group for practical reasons, with the above parameters of 0.77, 11.3, and 69%, respectively.

N-acetylcysteine prevents the deleterious effect of tumor necrosis factor-(alpha) on calcium transients and contraction in adult rat cardiomyocytes.

BACKGROUND: The negative effect of tumor necrosis factor-alpha (TNF-alpha) on heart contraction, which is mediated by sphingosine, is a major component in heart failure. Because the cellular level of glutathione may limit sphingosine production via the inhibition of the Mg-dependent neutral sphingomyelinase (N-SMase), we hypothesized that cardiac glutathione status might determine the negative contractile response to TNF-alpha. METHODS AND RESULTS: We examined the effects of TNF-alpha in isolated cardiomyocytes obtained from control rats or rats that were given the glutathione precursor N-acetylcysteine (NAC, 100 mg IP per animal). In cardiomyocytes obtained from control rats, 25 ng/mL TNF-alpha increased reactive oxygen species generation and N-SMase activity (500% and 34% over basal, respectively) and decreased the amplitude of [Ca(2+)](i) in response to electrical stimulation (22% below basal). NAC treatment increased cardiac glutathione content by 42%. In cardiomyocytes obtained from NAC-treated rats, 25 ng/mL TNF-alpha had no effect on reactive oxygen species production or N-SMase activity but increased the amplitude of [Ca(2+)](i) transients and contraction in response to electrical stimulation by 40% to 50% over basal after 20 minutes. This was associated with a hastened relaxation (20% reduction in t(1/2) compared with basal) and an increased phosphorylation of both Ser(16)- and Thr(17)-phospholamban residues (260% and 115% of maximal isoproterenol effect, respectively). CONCLUSIONS: It is concluded that cardiac glutathione status, by controlling N-SMase activation, determines the severity of the adverse effects of TNF-alpha on heart contraction. Glutathione supplementation may therefore provide therapeutic benefits for vulnerable hearts.

Arachidonic acid mediates dual effect of TNF-alpha on Ca2+ transients and contraction of adult rat cardiomyocytes.

Tumor necrosis factor (TNF)-alpha has a biphasic effect on heart contractility and stimulates phospholipase A2 (PLA2) in cardiomyocytes. Because arachidonic acid (AA) exerts a dual effect on intracellular Ca2+ concentration ([Ca2+]i) transients, we investigated the possible role of AA as a mediator of TNF-alpha on [Ca2+]i transients and contraction with electrically stimulated adult rat cardiac myocytes. At a low concentration (10 ng/ml) TNF-alpha produced a 40% increase in the amplitude of both [Ca2+]i transients and contraction within 40 min. At a high concentration (50 ng/ml) TNF-alpha evoked a biphasic effect comprising an initial positive effect peaking at 5 min, followed by a sustained negative effect leading to 50-40% decreases in [Ca2+]i transients and contraction after 30 min. Both the positive and negative effects of TNF-alpha were reproduced by AA and blocked by arachidonyltrifluoromethyl ketone (AACOCF3), an inhibitor of cytosolic PLA2. Lipoxygenase and cyclooxygenase inhibitors reproduced the high-dose effects of TNF-alpha and AA. The negative effects of TNF-alpha and AA were also reproduced by sphingosine and were abrogated by the ceramidase inhibitor n-oleoylethanolamine. These results point out the key role of the cytosolic PLA2/AA pathway in mediating the contractile effects of TNF-alpha.

Effect of high-fat diet on sarcoplasmic reticulum Ca(++)-ATPase activity in different types of rat skeletal muscle.

The aim of the present study was to examine the effect of a high-fat diet on the Ca(2+)-ATPase activity in the sarcoplasmic reticulum of the flexor digitorum longus (fast-twitch, glycolytic muscle) and the soleus (slow-twitch, oxidative muscle). The enzyme activity in the extensor digitorum longus was several-fold higher than in the soleus. The high-fat diet increased the enzyme activity by 22% (p < 0.05) in the soleus but it had no effect in the flexor digitorum longus. It is concluded that a high-fat diet increases the activity of only one isoform of the enzyme, namely the one which is present in the slow-twitch oxidative fibers.