In silico evaluation of limited sampling strategies for individualized dosing of extended half-life factor IX concentrates in hemophilia B patients

PURPOSE: Hemophilia B is a bleeding disorder, caused by a factor IX (FIX) deficiency. Recently, FIX concentrates with extended half-life (EHL) have become available. Prophylactic dosing of EHL-FIX concentrates can be optimized by assessment of individual pharmacokinetic (PK) parameters. To determine these parameters, limited sampling strategies (LSSs) may be applied. The study aims to establish adequate LSSs for estimating individual PK parameters of EHL-FIX concentrates using in silico evaluation. METHODS: Monte Carlo simulations were performed to obtain FIX activity versus time profiles using published population PK models for N9-GP (Refixia), rFIXFc (Alprolix), and rIX-FP (Idelvion). Fourteen LSSs, containing three or four samples taken within 8 days after administration, were formulated. Bayesian analysis was applied to obtain estimates for clearance (CL), half-life (t(1/2)), time to 1% (Time(1%)), and calculated weekly dose (Dose(1%)). Bias and precision of these estimates were assessed to determine which LSS was adequate. RESULTS: For all PK parameters of N9-GP, rFIXFc and rIX-FP bias was generally acceptable (range: −5% to 5%). For N9-GP, precision of all parameters for all LSSs was acceptable (< 25%). For rFIXFc, precision was acceptable for CL and Time(1%), except for t(1/2) (range: 27.1% to 44.7%) and Dose(1%) (range: 12% to 29.4%). For rIX-FP, all LSSs showed acceptable bias and precision, except for Dose(1%) using LSS with the last sample taken on day 3 (LSS 6 and 10). CONCLUSION: Best performing LSSs were LSS with samples taken at days 1, 5, 7, and 8 (N9-GP and rFIXFc) and at days 1, 4, 6, and 8 (rIX-FP), respectively

A pilot study on the immunogenicity of dendritic cell vaccination during adjuvant oxaliplatin/capecitabine chemotherapy in colon cancer patients

Contains fulltext : 87604.pdf (publisher's version ) (Closed access)BACKGROUND: Dendritic cell (DC) vaccination has been shown to induce anti-tumour immune responses in cancer patients, but so far its clinical efficacy is limited. Recent evidence supports an immunogenic effect of cytotoxic chemotherapy. Pre-clinical data indicate that the combination of chemotherapy and immunotherapy may result in an enhanced anti-cancer activity. Most studies have focused on the immunogenic aspect of chemotherapy-induced cell death, but only few studies have investigated the effect of chemotherapeutic agents on the effector lymphocytes of the immune system. METHODS: Here we investigated the effect of treatment with oxaliplatin and capecitabine on non-specific and specific DC vaccine-induced adaptive immune responses. Stage III colon cancer patients receiving standard adjuvant oxaliplatin/capecitabine chemotherapy were vaccinated at the same time with keyhole limpet haemocyanin (KLH) and carcinoembryonic antigen (CEA)-peptide pulsed DCs. RESULTS: In 4 out of 7 patients, functional CEA-specific T-cell responses were found at delayed type hypersensitivity (DTH) skin testing. In addition, we observed an enhanced non-specific T-cell reactivity upon oxaliplatin administration. KLH-specific T-cell responses remained unaffected by the chemotherapy, whereas B-cell responses were diminished. CONCLUSION: The results strongly support further testing of the combined use of specific anti-tumour vaccination with oxaliplatin-based chemotherapy

Defining Early Human NK Cell Developmental Stages in Primary and Secondary Lymphoid Tissues

A better understanding of human NK cell development in vivo is crucial to exploit NK cells for immunotherapy. Here, we identified seven distinctive NK cell developmental stages in bone marrow of single donors using 10-color flow cytometry and found that NK cell development is accompanied by early expression of stimulatory co-receptor CD244 in vivo. Further analysis of cord blood (CB), peripheral blood (PB), inguinal lymph node (inLN), liver lymph node (liLN) and spleen (SPL) samples showed diverse distributions of the NK cell developmental stages. In addition, distinctive expression profiles of early development marker CD33 and C-type lectin receptor NKG2A between the tissues, suggest that differential NK cell differentiation may take place at different anatomical locations. Differential expression of NKG2A and stimulatory receptors (e.g. NCR, NKG2D) within the different subsets of committed NK cells demonstrated the heterogeneity of the CD56brightCD16+/− and CD56dimCD16+ subsets within the different compartments and suggests that microenvironment may play a role in differential in situ development of the NK cell receptor repertoire of committed NK cells. Overall, differential in situ NK cell development and trafficking towards multiple tissues may give rise to a broad spectrum of mature NK cell subsets found within the human body

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Cross-evaluation of Pharmacokinetic-Guided Dosing Tools for Factor VIII

Background Patients with severe and moderate haemophilia A are treated prophylactically with factor VIII (FVIII) concentrate. Individualization of prophylaxis can be achieved by pharmacokinetic (PK)-guided dosing. Aim In this study, the performance of three PK tools (myPKFiT, Web-Accessible Population Pharmacokinetic Service-Hemophilia [WAPPS] and NONMEM) is compared. Methods In 39 patients, with severe or moderate haemophilia A, blood samples were collected 4, 24 and 48 hours after administration of 50 IU kg -1 of recombinant FVIII (Advate [ n = 30] or Kogenate [ n = 9]). FVIII dose, FVIII activity and patient characteristics were entered into the three PK tools. Obtained PK parameters and dosing advises were compared. Results myPKFiT provided PK parameters for 24 of 30 patients receiving Advate, whereas WAPPS and NONMEM provided estimates for all patients. Half-life was different among the three methods: medians were 12.6 hours (n = 24), 11.2 hours (n = 30) and 13.0 hours (n = 30) for myPKFiT, WAPPS and NONMEM (p < 0.001), respectively. To maintain a FVIII trough level of 0.01 IU mL -1 after 48 hours, doses for myPKFiT and NONMEM were 15.1 and 11.0 IU kg -1 (p < 0.01, n = 11) and for WAPPS and NONMEM were 9.0 and 8.0 IU kg -1 (p < 0.01, n = 23), respectively. In nine patients receiving Kogenate, WAPPS and NONMEM produced different PK-parameter estimates; half-life was 15.0 and 12.3 hours and time to 0.05 IU mL -1 was 69.2 and 60.8 hours, respectively (p < 0.01, n = 9). However, recommended doses to obtain these levels were not different. Conclusion The three evaluated PK tools produced different PK parameters and doses for recombinant FVIII. Haematologists should be aware that recommended doses may be influenced by the choice of PK tool

In silico evaluation of limited blood sampling strategies for individualized recombinant factor IX prophylaxis in hemophilia B patients

Background Patients with severe hemophilia B regularly administer prophylactic intravenous doses of clotting factor IX concentrate to maintain a trough level of at least 0.01 IU mL(-1) in order to prevent joint bleeds. Assessment of individual pharmacokinetic (PK) parameters allows individualization of the recombinant factor IX (rFIX) dose. Aim To evaluate the predictive performance of limited sampling strategies (LSSs) with one to three samples to estimate individual PK parameters of rFIX. Methods Monte Carlo simulations were performed to obtain 5000 concentration-time profiles by the use of population PK parameters for rFIX from literature. Eleven LSSs were developed with one, two or three samples taken within an 80-h interval following administration of 100 IU kg(-1) rFIX. Clearance (CL), half-life (t(1/2)), time to 1% and steady-state distribution volume (V-ss) were estimated for each simulated individual by the use of Bayesian analysis. Results For each LSS, average bias was small for CL (range - 1.5% to 1.4%), t(1/2) (range - 4.5% to - 0.7%), time to 1% (range - 2.9% to 0%), and V-ss (range - 3.7% to 0.3%). Imprecision for these parameters ranged from 6.4% to 11.9%, from 10.3% to 15.6%, from 7.3% to 10.9%, and from 9% to 20.1%, respectively. The best predictive performance was achieved with one sample taken between 10 min and 3 h and two samples taken between 48 h and 56 h after administration of rFIX. Conclusions This study demonstrates that limited sampling strategies, used for individualized dosing of rFIX in hemophilia B patients, can be developed and evaluated by in silico simulatio

Comparison of single and dual-platform assay formats for CD34+ haematopoietic progenitor cell enumeration

Most techniques for CD34+ cell enumeration are dual platform assays. That is, they derive absolute numbers of CD34+ cells from either the flow cytometrically assessed per cent (%) CD34+ cells within the nucleated cells and/or the white blood cell count from a haematology cell analyser. Recently, so-called single-platform assays have been developed, in which the absolute number of CD34+ cells is directly derived from a single flow cytometric measurement. The present study aims to compare the variation between eight laboratories in CD34+ cell counts from paired assays of 15 samples using a common single (ProCOUNT) and the local dual-platform method. Six laboratories used the 'SIHON' and two the 'ISHAGE' protocol for CD34+ cell enumeration. Use of the single-platform method reduced the inter-laboratory variation in per cent and absolute numbers of CD34+ cells, as measured by interquartile ranges, by half but did not lead to an appreciable reduction of the inter-laboratory variation in white blood cell counts. Thus, part of the reduced inter-laboratory variation obtained with ProCOUNT may have been a result of the use of standardized procedures and reagents to detect CD34+ cells. In order to eliminate any variation arising from the use of different local protocols for percentage of CD34+ cell assessments, a comparison was made of the ProCOUNT-derived absolute CD34+ cell numbers (i.e. single platform) with the dual-platform absolute CD34+ cell numbers calculated by multiplying ProCOUNT-derived percentage of CD34+ cells and with the corresponding haematology analyser-derived white blood cell count. Regardless, the interquartile ranges of absolute CD34+ cell numbers remained almost a factor of two smaller with the use of the single platform method. Thus, these results suggest that single-platform methodology can reduce the variation in absolute CD34+ cell numbers between laboratorie

Comparison of single and dual-platform assay formats for CD34+ haematopoietic progenitor cell enumeration

Most techniques for CD34+ cell enumeration are dual platform assays. That is, they derive absolute numbers of CD34+ cells from either the flow cytometrically assessed per cent (%) CD34+ cells within the nucleated cells and/or the white blood cell count from a haematology cell analyser. Recently, so-called single-platform assays have been developed, in which the absolute number of CD34+ cells is directly derived from a single flow cytometric measurement. The present study aims to compare the variation between eight laboratories in CD34+ cell counts from paired assays of 15 samples using a common single (ProCOUNT) and the local dual-platform method. Six laboratories used the 'SIHON' and two the 'ISHAGE' protocol for CD34+ cell enumeration. Use of the single-platform method reduced the inter-laboratory variation in per cent and absolute numbers of CD34+ cells, as measured by interquartile ranges, by half but did not lead to an appreciable reduction of the inter-laboratory variation in white blood cell counts. Thus, part of the reduced inter-laboratory variation obtained with ProCOUNT may have been a result of the use of standardized procedures and reagents to detect CD34+ cells. In order to eliminate any variation arising from the use of different local protocols for percentage of CD34+ cell assessments, a comparison was made of the ProCOUNT-derived absolute CD34+ cell numbers (i.e. single platform) with the dual-platform absolute CD34+ cell numbers calculated by multiplying ProCOUNT-derived percentage of CD34+ cells and with the corresponding haematology analyser-derived white blood cell count. Regardless, the interquartile ranges of absolute CD34+ cell numbers remained almost a factor of two smaller with the use of the single platform method. Thus, these results suggest that single-platform methodology can reduce the variation in absolute CD34+ cell numbers between laboratorie