@phdthesis{Munz2019,
  author    = {Munz, Martin Reinhold},
  title     = {Individualization of drug therapy considering pharmacokinetic and clinical factors},
  doi       = {10.25972/OPUS-17339},
  url       = {http://nbn-resolving.de/urn:nbn:de:bvb:20-opus-173396},
  school      = {Universit{\"a}t W{\"u}rzburg},
  year      = {2019},
  abstract  = {In the „Position Paper of the Division of Clinical Pharmacy of the German Pharmaceutical Society (DPhG)" clinical pharmacy is defined as the science and practice of the rational use of drugs1, which includes the individualization of drug therapy. Clinical pharmacists therefore need a profound knowledge of the pharmacokinetic properties of relevant drugs, and clinical factors that are influencing these properties. Against the background of individualizing drug therapy, pharmacokinetic and clinical factors are studied in this thesis. In order to obtain an overview of the existing data on the pharmacokinetics of imipenem / cilastatin and meropenem in critically ill patients, a literature review for each of these carbapenem antibiotics was performed. These reviews included studies in critically ill patients as well as studies in healthy volunteers. While the reported results of studies in healthy volunteers had a small variability, studies in critically ill patients show significant differences in the resulting pharmacokinetics. These differences were not only between, but also within these studies, resulting in a high variability of the pharmacokinetic parameters of the carbapenems in critically ill patients. Furthermore, the results of studies in critically ill patients indicate that clinical factors and in particular renal function have different effects on the pharmacokinetics of imipenem and cilastatin. A therapeutic drug monitoring (TDM) program for antibiotics was initiated in an intensive care unit. The calculation of the pharmacokinetics of imipenem / cilastatin and meropenem was carried out with a population pharmacokinetic approach (POP-PK) and in addition with a non-compartmental approach (NCA). The POP-PK analysis showed that the pharmacokinetics of imipenem and cilastatin could be described adequately with a 1-compartment model. The resulting mean total body clearance (CL) of imipenem and cilastatin was 11.6 L/h (4.24 to 27.5) and 6.14 L/h (0.520 to 26.6 L/h). The nonrenal clearance was estimated to be 5.30 L / h (24.9\% CV) for imipenem and 0.138 L / h (33.3\% CV) for cilastatin. The results of the NCA were in good agreement with the results of the POP-PK approach, as the NCA resulted in an imipenem clearance of 15.5 ± 7.3 L / hr and cilastatin clearance of 10.1 ± 9.9 L / h. The individual clearances resulting from the different pharmacokinetic approaches were in good correlation showing correlation coefficients (r) of 0.882 (p <0.001) and 0.908 (p <0.001) for imipenem and cilastatin. In summary, this study identified and quantified significant differences between the individual clearance mechanisms of imipenem and cilastatin. This is particularly true for patients with impaired renal function and sepsis. As imipenem / cilastatin is only available in a fixed dose combination, those patients might be treated inadequately with this combination. The great variability in the pharmacokinetics of imipenem and cilastatin in septic patients underscores the importance of a TDM program of both substances. For meropenem, a PK/PD model was developed that predicts the concentration gradients of meropenem, serum creatinine, C-reactive protein and procalcitonin simultaneously. A non-linear relationship between the clearance of creatinine and meropenem was identified and the resulting equation for the calculation of the total body clearance of meropenem (for a 70 kg patient) was: 0.480 L/h + 9.86 L/h. (CLCR/6L/h)0.593, with 0.480 L/h representing the nonrenal clearance of meropenem. The resulting mean meropenem clearance of the NCA was 11.9 ± 8.7 L/h. The individual clearances resulting from the different pharmacokinetic approaches were poorly correlated showing a correlation coefficient (r) of 0.502 (p <0.001). In summary, this study showed a non-linear relationship of meropenem clearance and creatinine clearance. The model shows that the renal function may change rapidly and to a significant extent in patients with sepsis and septic shock, which in turn, underscores that creatinine concentrations are not in steady state in these patients. Conversely, dose adjustment based on creatinine values might lead to inappropriate therapy. This underlines the importance of a TDM program for meropenem in critically ill patients. The two most important considerations when choosing an antibiotic for the prophylaxis of postoperative bone infections are its activity against the whole spectrum of bacteria, which might be involved in bone infections, and its ability to penetrate bone tissue and thus to achieve concentrations above the minimum inhibitory concentration (MIC) of the corresponding pathogens. In order to gain information on this data, a study was conducted which investigated the pharmacokinetics of ampicillin / sulbactam in plasma, cortical and cancellous bone. Pharmacokinetic parameters in plasma were determined using NCA. The bone penetration represents the ratio of the concentration in the bone tissue to plasma concentration at the time of bone removal. The resulting half-life of ampicillin and sulbactam in plasma was 1.60  0.37 h and 1.70  0.42 h. The elimination of both substances was in a good correlation with creatinine clearance and resulted in correlation coefficients (r) of 0.729 (p = 0.003) for ampicillin and 0.699 (p = 0.005) for sulbactam. The mean clearance and the mean volume of distribution of ampicillin and sulbactam were 10.7  3.9 and 10.3  3.3 L/h, and 23.9  7.9 and 24.3  6.8 L. The mean concentrations of ampicillin in the cortical and cancellous bone were 6.60  4.22 and 10.15  7.40 µg/g, resulting in bone penetration ratios of 9.1  5.7 and 16.2  16.9 \%. For sulbactam the corresponding concentrations were 3.91  2.52 and 5.73  4.20 µg/g, resulting in bone penetration ratios of 10.6  6.3 and 17.5  16.1 \%. In summary, this study shows that the bone penetration of both substances is on average rather unsatisfactory and has a high variability, which can lead to inadequate bone concentrations for the prophylaxis of bone infections. One factor that could be identified for the penetration of both substances into cancellous bone was the period between the application of the drug and the removal of the bone. Therefore, a time interval between the administration of the antibiotic and the incision should be considered. Immunosuppression is a risk factor for the development of various malignancies, including hematologic diseases. While the relationship between the use of immunosuppressive therapy with methotrexate and the development of an Epstein-Barr virus (EBV) associated lymphoproliferative disease (LPD) has been well established, this connection is less evident for immunosuppressive therapy with azathioprine. The patient presented by us was immunosuppressed with azathioprine for autoimmune hepatitis. The development of an EBV-associated Hodgkin-like lymphoma under this immunosuppressive therapy and especially the regression of the lymphoma after cessation of azathioprine confirms the relationship between this immunosuppressant, EBV-infection and the development of Hodgkin-like lymphoma. Therefore, albeit in rare cases, azathioprine-related lymphomas may respond to mere cessation of immunosuppressive therapy without need for chemotherapy. Apart from viral infections, drugs are a major cause of acute liver failure. Due to the lack of specific symptoms or tests, it is difficult to diagnose a drug-induced liver injury. We report a case of a young patient in whom different antibiotics, the analgesic and antipyretic acetaminophen or a combination of these drugs may have led to DILI resulting in life-threatening ALF. Based on this case report, we describe a procedure to exclude non-drug related causes and discuss the hepatotoxic potential of the involved drugs in this case.},
  subject      = {Pharmakokinetik},
  language  = {en}
}
@phdthesis{JakobRodamer2014,
  author    = {Jakob-Rodamer, Verena},
  title     = {Development and validation of LC-MS/MS methods to determine PK/PD parameters of anti-infectives},
  url       = {http://nbn-resolving.de/urn:nbn:de:bvb:20-opus-109215},
  school      = {Universit{\"a}t W{\"u}rzburg},
  year      = {2014},
  abstract  = {In the present thesis the development and validation of bioanalytical LC-MS/MS methods for the quantification of erythromycin A, erythromycin ethylsuccinate, roxithromycin, clarithromycin, 14 hydroxy clarithromycin, flucloxacillin, piperacillin and moxifloxacin in human plasma and human urine (piperacillin) is introduced. All methods were applied to analyze human plasma and urine samples from clinical trials and therefore, have been validated according to international guidelines. The methods were reliable in these studies and fulfilled all regulatory requirements known at the time of the study conduct. Moreover, the validation data of the macrolides were compared on three different mass spectrometers (API III Plus, API 3000™, API 5000™). The new innovations in the ion source (horizontal versus vertical electrospray), the ionpath (skimmer, QJet) and the diameter of the orifice resulted in better sensitivity and a larger linearity range for the majority of the analytes. Sensitivity was improved up to a factor of 12 (for clarithromycin) between API III Plus to API 3000™ and up to a factor of 8 (for erythromycin and roxithromycin) between API 3000™ and API 5000™, keeping the accuracy and precision data at about the same level. The high sensitivity was a benefit for example for the flucloxacillin study, because concentrations from all subject samples were detectable up to approximately eight half-lives, i.e. no concentrations needed to be reported below the quantification limit. Also the linearity range were extended from two orders of magnitude to up to four orders of magnitude, which increases the likelihood to allow to analyze all samples from a pharmacokinetic study in the same run. This is especially useful if a large concentration range needs to be analysed, for example, if the method shall be applied in an ascending dose study. Then, all low concentrations from the beginning of the study can be determined, as well as all high concentrations, without the need to dilute and analyse single samples repeatedly. The pharmacokinetic data were compared to previously reported literature data and correlated graphically with MIC values of popular microorganisms which might be a starting point for further PK/PD investigations. The PK/PD theory is a very helpful tool for prediction of the efficacy of given drugs against certain micro-organisms. Depending on the pharmacodynamic processes, e. g. the mode of action, three classes of drugs have been identified. In the same way this applies to adverse effects, which need to be minimised by reducing plasma concentrations. These coherences are not well-investigated, yet, and are not discussed further in this thesis. Still, a lot of research has to be done in this interdisciplinary field to minimise uncertainty in single values, like an AUC/MIC. These include: Improve accuracy and precision of bioanalytical methods determining total and free concentration data in biological matrices for calculation of AUC and Cmax These parameters are related to the MIC in pharmacodynamic considerations. Since the determination of the MIC often underlies significant variations and also differences between microbiological laboratories, the determination of concentrations of anti-infectives is particular important, being achievable by scientific exact techniques. Finally, from the volume of distribution of antibiotics can be used to derive information about intracellular concentrations and effectivity of antiinfectives.},
  subject      = {Antimikrobieller Wirkstoff},
  language  = {en}
}
@phdthesis{Wohlfart2022,
  author    = {Wohlfart, Jonas},
  title     = {Analysis of Drug Impurities by Means of Chromatographic Methods: Targeted and Untargeted Approaches},
  doi       = {10.25972/OPUS-27387},
  url       = {http://nbn-resolving.de/urn:nbn:de:bvb:20-opus-273878},
  school      = {Universit{\"a}t W{\"u}rzburg},
  year      = {2022},
  abstract  = {The presented works aimed on the analysis of new impurities in APIs and medicinal products. Different subtypes of LC were coupled to suitable detection methods, i.e. UV and various MS techniques, depending on the chemical natures of the analytes and the analytical task. Unexpected impurities in medicinal products and APIs caused several scandals in the past, concomitant with fatalities or severe side effects in human and veterinary patients. The detection of nitrosamines in sartans led to the discovery of nitrosamines in various other drugs, of which the antibiotic rifampicin was analyzed in this work. An examination of the synthesis of rifampicin revealed a high potential for the formation of 4-methyl-1-nitrosopiperazine (MeNP). An LC-MS/HRMS method suitable for the quantification of MeNP was applied in the analysis of drugs collected from Brazil, Comoros, India, Nepal, and Tanzania, where a single dose of rifampicin is used in the post-exposure prophylaxis of leprosy. All batches were contaminated with MeNP, ranging from 0.7-5.1 ppm. However, application of rifampicin containing up to 5 ppm MeNP was recommended by the regulatory authorities for the post-exposure prophylaxis of leprosy. In the 1990s the aminoglycoside antibiotic gentamicin attracted attention after causing fatalities in the USA, but the causative agent was never identified unequivocally. The related substance sisomicin was recognized as a lead impurity by the Holzgrabe lab at the University of W{\"u}rzburg: sisomicin was accompanied by a variety of other impurities and batches containing sisomicin had caused the fatalities. In 2016, anaphylactic reactions were reported after application of gentamicin. A contamination of the medicinal products with histamine, an impurity of the raw material fish peptone used upon the production, could be identified as the cause of the adverse effects. Batches of gentamicin sulfate, which had been stored at the University of W{\"u}rzburg since the earlier investigations, were analyzed regarding their contamination with histamine to determine whether the biogenic amine was responsible for the 1990s fatalities as well. Furthermore, a correlation with the lead impurity sisomicin was checked. Histamine could be detected in all analyzed batches, but at a lower level than in the batches responsible for the anaphylactic reactions. Moreover, there is no correlation of histamine with the lead impurity sisomicin. Hence, the causative agent for the 1990s fatalities was not histamine and remains unknown. Another source of impurities is the reaction of APIs with excipients, e.g. the esterification of naproxen with PEG 600 in soft gel capsules. The influence of the formulation's composition on this reaction was investigated by means of LC-UV. Therefore, the impurity naproxen-PEG-ester (NPEG) was synthesized and used for the development of a method suitable for the analysis of soft gel capsule formulations. Different formulations were stressed for 7 d at 60 °C and the relative amount of NPEG was determined. The formation of NPEG was influenced by the concentrations of water and lactic acid, the pH, and the drug load of the formulation, which can easily be explained by the chemistry behind esterification reactions. Keeping in mind the huge variety of sources of impurities, it might be impossible to predict all potential impurities of a drug substance/product. Targeted and untargeted approaches were combined in the impurity profiling of bisoprolol fumarate. Eight versions of an LC-HRMS method were developed to enable the detection of a maximum number of impurities: an acidic and a basic buffered LC was coupled to MS detection applying ESI and APCI, both in positive in negative mode. MS and MS/MS data were acquired simultaneously by information dependent acquisition. In the targeted approach, potential impurities were derived from a reaction matrix based on the synthesis route of the API, while the untargeted part was based on general unknown comparative screening to identify additional signals. 18 and 17 impurities were detected in the targeted and the untargeted approach, respectively. The molecular formulae were assessed based on the exact mass and the isotope pattern. Theoretical fragment spectra generated by in silico fragmentation were matched with experimental data to estimate the plausibility of proposed/elucidated structures. Moreover, the detected impurities were quantified with respect to an internal standard.},
  subject      = {LC-MS},
  language  = {en}
}