Thank you, Nick. I am working with a group that have adults burn patients where they have some pk parameters from q8 dosing of gentamicin- and estimated their once daily gentamicin dose in this population. They will now implement this once daily gentamicin dose and follow serial samples 4-5 samples in a 24 hr period for each patient but it will be a small sample given burn patients are relatively rare vs other adult inpatient populations .
These samples will be part of clinical care as these are acute burn patients in a trauma burn unit and the protocol will of course submitted to REB for review to ensure that our protocol is ethical . We won't sample towards end of 24 hr as it will likely be in detectable, so likely no useful info gained as you have advised. I will follow your leads and advice. Thanks! Winnie - Sent from my iPhone On 2013-10-27, at 20:14, "Nick Holford" <[email protected]> wrote: > Winnie, > Please see below for my comments and suggestions. > Best wishes, > Nick > > On 28/10/2013 8:28 a.m., Winnie Seto wrote: >> >> Hello NONMEM users and Dr. Holford >> >> I am a novice when it comes to pop PK simulations- >> > You refer to pop PK simulations but what you describe below sounds more like > a plan for a pop PK parameter estimation study rather than a pop PK > simulation study. Of course, some simulation would be helpful for planning a > parameter estimation study (see below). > > It would be helpful for know what your objectives are. There must be hundreds > of published aminoglycoside studies so why are you planning another? What are > you hoping to learn? Do you have a hypothesis you want to confirm? If you > don't have a clear idea about what you going to learn or confirm, and a > scientific plan to show you can achieve the objectives, then I would consider > this kind of study unethical. >> >> Our group is planning on a prospective once daily aminoglycoside >> pharmacokinetic study in patients with proposed serial time levels post dose >> with 30min, 2hr, 4hr, 12hr and 24hr post dose drug levels. >> > In typical patients given once daily doses of aminoglycosides such as > gentamicin it is most likely that a 24 h concentration would be less than the > limit of quantification of you laboratory. IMHO a 24 h sample would be > unethical in a typical patient over the age of 1 year because it has some > discomfort and probably $$ cost for the patient and is of almost no value. > This is where some simulation could be helpful. In patients with low > clearance (e.g. due to immaturity in neonates) then a 24 h sample might be > reasonable. You can see a simple simulation example here in slide 17: > http://holford.fmhs.auckland.ac.nz/docs/target-concentration-intervention.pdf > This kind of simulation is easily done in Excel. Just doing it yourself will > help you understand the answers to many questions about PK study design. > >> We will have only a small sample size (less than 50 patients) and some >> patients may not be able to have samples at all these timepoints from >> logistical reasons. >> > The sample size depends on what your objectives are. 50 patients would be > fine to describe the popPK of an aminoglycoside given 5 conc measurements per > subject. If your objective is related to a question about covariates > predicting variability (weight, renal function, maturation, etc) then you may > need a larger sample to get a clear answer. >> >> I would really appreciate some advice on the following: >> >> 1.Is there a number of minimum patients that I need for each sampling time >> point for pop pk analysis? >> > This kind of question about the number of patients, number of samples and > timing of samples is best answered by using an optimal design program. See > http://www.page-meeting.org/pdf_assets/9481-mentre_page07postPage2.pdf for a > review. Most of these programs will have improved since then but some of them > are no longer available). The trade off between these design quantities will > be determined by what your objectives are and how much money and time you > have. >> >> 2.For each time point – is it better to have some variability within the >> sampling time window e.g. 10-12hr with a few patients with samples >> distributed at 10, 11 or 12 hour mark? >> > Yes -- as a general rule your design will be more robust if you use sampling > windows and in real life samples will not be taken at exactly the same time > in every patient. For data analysis it is essential to record the dosing and > sampling times as accurately as possible. >> >> 3.I have learnt only the basics with NONMEM; I have used WIN NONLIN in the >> past - recently I have added their WIN-NLME pop PK software to my >> subscriptions – should I use both NONMEM and NLME to run results ? would >> there be differences? I suspected that NLME may be easier for novice and >> students to catch up during short-student rotations to run simulations then >> to learn NONMEM on a 4 week rotation. Any opinions? >> > For simple popPK problems I don't think there is really much difference in > ease of use between NONMEM and Phoenix NLME. A NM-TRAN control stream is > probably simpler to learn how to write for this kind of very simple PK > problem rather than dealing with the layers of the Phoenix GUI. Phoenix > graphics are better than NONMEM but there are many ways to make graphs from > NONMEM using other tools such as Xpose. There won't be any important > differences in the results. > > If you have a NM-TRAN control stream or Phoenix NLME workflow set up then as > you add more data and want students on rotation to learn the basics of popPK > then running the model again is only a matter of seconds. The real time > required is learning the principles of PK models and population analysis and > how to interpret the results. Software run times are negligible compared with > that. > >> Thank you in advance for your help. >> >> Winnie >> >> Winnie Seto, BScPhm, PharmD, MSc, ACPR, R.Ph. >> >> Therapeutic Drug Monitoring Coordinator & Critical Care Unit Pharmacist >> >> Clinical Manager >> >> Department of Pharmacy >> >> The Hospital for Sick Children >> >> 555 University Avenue >> >> Toronto, Ontario >> >> Canada M5G 1X8 >> >> phone: 416-813-6236 >> >> fax: 416-813-5880 >> >> Confidentiality Notice: This is a medical communication. This e-mail >> message, including any attachments, is for the sole use of the intended >> recipient(s) and may contain privileged and confidential information. >> >> Any unauthorized review, use, copying, saving, re-transmission, disclosure >> or distribution is strictly prohibited. If you are not the intended >> recipient, please contact the author by reply email and destroy all original >> and copies of this email message. >> >> >> ------------------------------------------------------------------------ >> >> This e-mail may contain confidential, personal and/or health >> information(information which may be subject to legal restrictions on use, >> retention and/or disclosure) for the sole use of the intended recipient. Any >> review or distribution by anyone other than the person for whom it was >> originally intended is strictly prohibited. If you have received this e-mail >> in error, please contact the sender and delete all copies. > > -- > Nick Holford, Professor Clinical Pharmacology > Dept Pharmacology & Clinical Pharmacology, Bldg 503 Room 302A > University of Auckland,85 Park Rd,Private Bag 92019,Auckland,New Zealand > office:+64(9)923-6730 mobile:NZ +64(21)46 23 53 > email: [email protected] > http://holford.fmhs.auckland.ac.nz/ > > Holford NHG. Disease progression and neuroscience. Journal of > Pharmacokinetics and Pharmacodynamics. 2013;40:369-76 > http://link.springer.com/article/10.1007/s10928-013-9316-2 > Holford N, Heo Y-A, Anderson B. A pharmacokinetic standard for babies and > adults. J Pharm Sci. 2013: > http://onlinelibrary.wiley.com/doi/10.1002/jps.23574/abstract > Holford N. A time to event tutorial for pharmacometricians. CPT:PSP. 2013;2: > http://www.nature.com/psp/journal/v2/n5/full/psp201318a.html > Holford NHG. Clinical pharmacology = disease progression + drug action. > British Journal of Clinical Pharmacology. 2013: > http://onlinelibrary.wiley.com/doi/10.1111/bcp.12170/abstract > > ________________________________ This e-mail may contain confidential, personal and/or health information(information which may be subject to legal restrictions on use, retention and/or disclosure) for the sole use of the intended recipient. Any review or distribution by anyone other than the person for whom it was originally intended is strictly prohibited. If you have received this e-mail in error, please contact the sender and delete all copies.
