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Resume L’objectif de ce travail est d’evaluer une methode de criblage toxicologique en chromatographie gazeuse couplee a la spectrometrie de masse (CG-SM) dans le plasma et dans l’urine, en utilisant le logiciel de retraitement MassHunter Unkown Analysis (MHUA). Les resultats sont compares a ceux obtenus en CG-SM avec le logiciel AMDIS et en chromatographie liquide couplee a la spectrometrie de masse en tandem (CL-SM/SM). Les analyses sont effectuees avec un appareil de CG Agilent 7890A et un analyseur Agilent 5975 C en SM. Les resultats sont retraites grâce aux logiciels AMDIS et MHUA v10.1 avec 3 bibliotheques : SWGDRUG version 3.7 (3346 spectres) NIST 17 (2017) (220 460 spectres) et une bibliotheque maison (140 spectres). La preparation des echantillons suit celle decrite par Maurer et al. [1] . L’evaluation des performances de la methode est en premier lieu realisee par l’analyse d’echantillons de plasma surcharge avec 122 molecules. Dans un second temps est realisee l’analyse d’echantillons de plasma et d’urine de patients pour lesquels une recherche de toxiques a ete adressee a notre laboratoire. Dans les echantillons de plasma surcharge, 25 molecules sont identifiees grâce au logiciel AMDIS et 46 grâce au logiciel MHUA (a des concentrations principalement comprises entre 25 et 500 ng/mL). Dans les 52 echantillons de patients, 47 molecules sont identifiees en CG-SM grâce au logiciel MHUA, 30 avec le logiciel AMDIS et 59 en CL-SM/SM. Dix-neuf molecules sont identifiees en CG-SM et dosees en CL-SM/SM a des concentrations relativement basses (codeine (

CPX-351 is a liposome encapsulating cytarabine and daunorubicin for treating Acute Myeloid Leukemia (AML) patients. To what extent differences in cytidine deaminase (CDA) activity, the enzyme that catabolizes free cytarabine in the liver, can affect the pharmacokinetics of liposomal cytarabine as well, is unknown. We have studied the pharmacokinetics (PK) of released, liposomal and total cytarabine using a population-modeling approach in 9 adult AML patients treated with liposomal CPX-351. Exposure levels and PK parameters were compared with respect to the patient's CDA status (i.e., Poor Metabolizer (PM) vs. Extensive Metabolizer (EM)). Overall response rate was 75%, and 56% of patients had non-hematological severe toxicities, including one lethal toxicity. All patients had febrile neutropenia. A large (>60%) inter-individual variability was observed on pharmacokinetics parameters and subsequent drug levels. A trend towards severe toxicities was observed in patients with higher exposure of cytarabine. Results showed that liposomal CPX-351 led to sustained exposure with reduced clearance (Cl = 0.16 L/h) and prolonged half-life (T1/2 = 28 h). Liposomal nanoparticles were observed transiently in bone marrow with cytarabine levels 2.3-time higher than in plasma. Seven out of 9 patients were PM with a strong impact on the PK parameters, i.e., PM patients showing higher cytarabine levels as compared with EM patients (AUC: 5536 vs. 1784 ng/mL.h), sustained plasma exposure (T1/2: 33.9 vs. 13.7 h), and reduced clearance (Cl: 0.12 vs. 0.29 L/h). This proof-of-concept study suggests that CDA status has a major impact on cytarabine PK and possibly safety in AML patients even when administered as a liposome.

In the last two years, the number of shops selling CBD-rich THC-deprived cannabis flowers (CrTd) has increased considerably in France as in many European countries. The objective of this study was to determine the actual composition of the samples sold in these stores, and to discuss regulatory consequences that may affect users. Samples were provided from shops in the region Provence-Alpes Cote d'Azur (PACA), in France. Pictures of the samples were taken before they were weighed then crushed. Twenty milligrams were diluted in 10 mL heptane ethyl acetate (7:1; v:v) for analysis by liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS). The method was validated according to SWGTOX guidelines for the quantification of cannabidiol (CBD), delta-9-tetrahydrocannabinol (THC) and cannabinol (CBN). Thirty-nine samples obtained between November 2021 and January 2022 in the PACA region were analyzed in this study. Mean content was 0.32% (0.03%-0.77%; STDV=0.17%; n=39) for THC, 2.23% (0.01%-5.97%; STDV=1.29%; n=39) for CBD and 0.01% (0.004%-0.025%; STDV=0.01%; n=19) for CBN. THC content over the threshold defined by the European legislation (0.3%) was found in 18 of the 39 samples analyzed together with a CBD content1% in 9 samples (23%). None of the products analyzed had health risk messages on the packaging. The consumption of these products may lead to the presence of THC in biological fluids which can be detected by screening. Users may then find themselves in breach of the law particularly when driving. Consumers should therefore be informed both about the actual composition of these products and about the legal and health risks they run.

The aim of this study was to develop and to validate a toxicological untargeted screening relying on LC-HRMS in meconium including the detection of the four main classes of drugs of abuse (DoA; amphetamines, cannabinoids, opioids and cocaine). The method was then applied to 29 real samples. Analyses were performed with a liquid chromatography system coupled to a benchtop Orbitrap operating in a data-dependent analysis. The sample amount was 300 mg of meconium extracted twice by solid phase extraction following two distinct procedures. Raw data were processed using the Compound Discoverer 3.2 software (Thermo). The method was evaluated and validated on 15 compounds (6-MAM, morphine, buprenorphine, norbuprenorphine, methadone, EDDP, amphetamine, MDA, MDMA, methamphetamine, cocaine, benzoylecgonine, THC, 11-OH-THC, THC-COOH). Limits of detection were between 0.5 and 5 pg/mg and limits of identification between 5 and 50 pg/mg. Mean matrix effect was between −79 and −19% (n = 6) and mean overall recovery between 18 and 73% (n = 6) at 100 pg/mg. The application allows the detection of 88 substances, including 47 pharmaceuticals and 15 pharmaceutical metabolites, cocaine and its metabolites, THC and its metabolites, and natural (morphine, codeine) and synthetic (methadone, buprenorphine, tramadol, norfentanyl) opioids. This method is now used routinely for toxicological screening in high-risk pregnancies

International audience; Different target exposures with sunitinib have been proposed in metastatic renal cell carcinoma (mRCC) patients, such as trough concentrations or AUCs. However, most of the time, rather than therapeutic drug monitoring (TDM), clinical evidence is preferred to tailor dosing, i.e., by reducing the dose when treatment-related toxicities show, or increasing dosing if no signs of efficacy are observed. Here, we compared such empirical dose adjustment of sunitinib in mRCC patients, with the parallel dosing proposals of a PK/PD model with TDM support. In 31 evaluable patients treated with sunitinib, 53.8% had an empirical change in dosing after treatment started (i.e., 46.2% decrease in dosing, 7.6% increase in dosing). Clinical benefit was observed in 54.1% patients, including 8.3% with complete response. Overall, 58.1% of patients experienced treatment discontinuation eventually, either because of toxicities or progressive disease. When choosing 50–100 ng/mL trough concentrations as a target exposure (i.e., sunitinib + active metabolite N-desethyl sunitinib), 45% patients were adequately exposed. When considering 1200–2150 ng/mL.h as a target AUC (i.e., sunitinib + active metabolite N-desethyl sunitinib), only 26% patients were in the desired therapeutic window. TDM with retrospective PK/PD modeling would have suggested decreasing sunitinib dosing in a much larger number of patients as compared with empirical dose adjustment. Indeed, when using target trough concentrations, the model proposed reducing dosing for 61% patients, and up to 84% patients based upon target AUC. Conversely, the model proposed increasing dosing in 9.7% of patients when using target trough concentrations and in 6.5% patients when using target AUC. Overall, TDM with adaptive dosing would have led to tailoring sunitinib dosing in a larger number of patients (i.e., 53.8% vs. 71–91%, depending on the chosen metrics for target exposure) than a clinical-based decision. Interestingly, sunitinib dosing was empirically reduced in 41% patients who displayed early-onset severe toxicities, whereas model-based recommendations would have immediately proposed to reduce dosing in more than 80% of those patients. This observation suggests that early treatment-related toxicities could have been partly avoided using prospective PK/PD modeling with adaptive dosing. Conversely, the possible impact of model-based adapted dosing on efficacy could not be fully evaluated because no clear relationship was found between baseline exposure levels and sunitinib efficacy measured at 3 months.

Anne Rodallec,1 Guillaume Sicard,1 Sarah Giacometti,1 Manon Carré,1 Bertrand Pourroy,2 Fanny Bouquet,3 Ariel Savina,3 Bruno Lacarelle,1 Joseph Ciccolini,1 Raphaelle Fanciullino1 1SMARTc Unit, Laboratory of Pharmacokinetics and Toxicology UFR Pharmacy, Center for Research on Cancer of Marseille, Inserm UMR1068, CNRS UMR7258, Aix Marseille University, Marseille, France; 2Pharmacy Department, APHM La Conception, Marseille, France; 3Roche Institute, Boulogne Billancourt, France Purpose: Nanoparticles are of rising interest in cancer research, but in vitro canonical cell monolayer models are not suitable to evaluate their efficacy when prototyping candidates. Here, we developed three-dimensional (3D) spheroid models to test the efficacy of trastuzumab-docetaxel immunoliposomes in breast cancer prior to further testing them in vivo. Materials and methods: Immunoliposomes were synthesized using the standard thin film method and maleimide linker. Two human breast cancer cell lines varying in Her2 expression were tested: Her2+ cells derived from metastatic site: mammary breast MDA-MB-453 and triple-negative MDA-MB-231 cells. 3D spheroids were developed and tested with fluorescence detection to evaluate viability. In vivo efficacy and biodistribution studies were performed on xenograft bearing nude mice using fluorescent and bioluminescent imaging. Results: In vitro, antiproliferative efficacy was dependent upon cell type, size of the spheroids, and treatment scheduling, resulting in subsequent changes between tested conditions and invivo results. Immunoliposomes performed better than free docetaxel + free trastuzumab and ado-trastuzumab emtansine (T-DM1). On MDA-MB-453 and MDA-MB-231 cell growth was reduced by 76% and 25%, when compared to free docetaxel + free trastuzumab and by 85% and 70% when compared to T-DM1, respectively. In vivo studies showed tumor accumulation ranging from 3% up to 15% of the total administered dose in MDA-MB-453 and MDA-MB-231 bearing mice. When compared to free docetaxel + free trastuzumab, tumor growth was reduced by 89% (MDA-MB-453) and 25% (MDA-MB-231) and reduced by 66% (MDA-MB-453) and 29% (MDA-MB-231) when compared to T-DM1, an observation in line with data collected from 3D spheroids experiments. Conclusion: We demonstrated the predictivity of 3D in vitro models when developing and testing nanoparticles in experimental oncology. In vitro and in vivo data showed efficient drug delivery with higher efficacy and prolonged survival with immunoliposomes when compared to current anti-Her2 breast cancer strategies. Keywords: docetaxel, trastuzumab, breast cancer, immunoliposome, spheroids, distribution, tumor xenograftErratumfor this paper has been published

Resume Les intoxications au laurier rose (Nerium oleander) sont peu frequentes mais sont graves. La plante contient un heteroside cardiotonique, l’oleandrine, pouvant conduire au deces par arret cardiaque. Les auteurs presentent le cas d’une patiente âgee de 86 ans ayant tente de mettre fin a ses jours en ingerant une infusion de feuilles de laurier rose. Devant l’apparition de troubles de la conduction cardiaque, d’une hyperkaliemie et d’un dosage positif de la digoxine effectue en immunoanalyse (0,7 ng/mL) la patiente a rapidement recu un traitement par anticorps anti-digitaliques en deux administrations (40 mg puis 80 mg) suivi d’une evolution clinique favorable en reanimation.

Background Community pharmacists are among the frontline health professionals who manage patients with an opioid-related disorder (ORD). Pharmacists frequently have a negative attitude toward these patients, which could have a negative impact on their management. However, education on ORD may improve the attitude of future healthcare professionals. This cross-sectional study aimed to assess French pharmacy students’ perceptions of ORD. Methods This online survey was performed by emails sent to French pharmacy schools (between January 14, 2019 and May 31, 2019). The primary outcome was the perception (visual analogic scale) of ORD as a disease, the roles of community pharmacies (delivery of opioid agonist therapy—OAT and harm reduction kits), and the efficacy of OAT. The secondary outcomes assessed professional experience, university experience of and education on ORD, and the individual characteristics of students. Results Among the 1,994 students included, 76.3% perceived ORD as a disease and felt that it was normal for pharmacists to deliver OAT (78.9%) and harm reduction kits (74.6%). However, only 46.9% perceived OAT as being effective. Multivariable analyses showed that females had a more positive perception in recognizing ORD as a disease. The progression through university years increased the positive perception of ORD as a disease and the delivery of OAT and harm reduction kits by pharmacists. Education on substance-related disorders had no impact on any scores. Students who had already delivered OAT had a negative perception of their efficacy. The students who had already performed pharmacy jobs or traineeships had a negative perception of harm reduction kit delivery. Conclusion Education on substance-related disorders had no impact on students’ perceptions. It seemed that the maturity acquired through university years had a stronger impact on the students’ perceptions of ORD. Efforts must be made to improve our teaching methods and reinforce the confidence of students in the roles of community pharmacists.

International audience; Therapeutic drug monitoring of hydroxychloroquine (HCQ) has been recommended to optimize the treatment of patients with COVID-19. The authors describe an ultrahigh-performance liquid chromatography tandem spectrometry method developed in a context of emergency, to analyze HCQ in both human plasma and blood samples. After adding the labeled internal standard and simple protein precipitation, plasma samples were analyzed using a C18 column. Blood samples required evaporation before analysis. The total chromatographic run time was 4 minutes (including 1.5 minutes of column equilibration). The assay was linear over the calibration range (r2 > 0.99) and up to 1.50 mcg/mL for the plasma samples (5.00 mcg/mL for the blood matrix). The limit of quantification was 0.0150 mcg/mL for plasma samples (0.05 mcg/mL blood matrix) with accuracy and precision ranging from 91.1% to 112% and from 0.750% to 11.1%, respectively. Intraday and interday precision and accuracy values were within 15.0%. No significant matrix effect was observed in the plasma or blood samples. This method was successfully applied to patients treated for COVID-19 infection. A simple and rapid ultrahigh-performance liquid chromatography tandem spectrometry method adapted to HCQ therapeutic drug monitoring in the context of SARS-CoV-2 infection was successfully developed and validated.

International audience; A 53-year-old woman with papillary thyroid cancer treated with 800 mg sorafenib therapy rapidly experienced grade 3 toxicities. Dosing was reduced in a step-wise manner with several treatment discontinuations down to 200 mg every 2 days but severe toxicities continued. Plasma drug monitoring showed high exposure, even at low dose. Dosing was then further reduced at 200 mg every 3 days and tolerance was finally acceptable (i.e., grade 1 toxicity) with stable disease upon RECIST imaging. Pharmacogenetic investigations showed polymorphisms affecting both UGT1A9 ( UGT1A9-rs3832043) and nuclear receptor PXR ( NR1I2-rs3814055 , NR1I2-rs2472677 and NR1I2-rs10934498), possibly resulting in downregulation of liver metabolizing enzymes of sorafenib (i.e., CYP and UGT). Patient's clearance (0.48 l/h) estimated by Bayesian approach was consistently lower than usually described. This is the first time that, in addition to mutations affecting UGT1A9, genetic polymorphisms of NR1I2 have possibly been associated with both plasma overexposure and severe toxicities upon sorafenib intake.

Nanoparticles have been used for decades in breast cancer. More recently, anti-human epidermal receptor 2 (Her2) immunoliposomes are of rising interest. However, recent studies have questioned the actual relevance of using anti-Her2 antibodies to improve liposome distribution and efficacy. Using standard thin-film method and maleimide linker, we have synthesized a 140-nm docetaxel-trastuzumab immunoliposome. This nanoparticle was then tested on a canonical Her2-overexpressing breast cancer model (i.e., SKBR3), using 3D spheroids and xenografted mice. Its efficacy was compared with free docetaxel + trastuzumab, liposomal docetaxel + free trastuzumab and to reference antibody-drug conjugate trastuzumab-emtansine (T-DM1). Immunoliposomes resulted in better efficacy as compared with all other treatments, both in vitro and in vivo. To explain such an improvement, immunoliposome biodistribution was investigated using live imaging in xenografted mice. Surprisingly, no difference in tumor uptake was found between anti-Her2 immunoliposomes and standard docetaxel liposomes (i.e., 1.9 ± 1.2 vs. 1.7 ± 0.5% at the end of treatment and 1.4 ± 0.6 vs. 1.6 ± 0.4% at the end of the study, respectively, P > 0.05). We hypothesized that passive targeting (i.e., enhanced permeation and retention effect) contributed more to tumor distribution than active targeting and that the observed differences in efficacy could come from a better internalization of immunoliposomes into Her2+ cells as compared with standard liposomes, and not from a higher specificity towards tumor tissue.

Background In spite of recurrent and dramatic outbreaks, there are no therapeutics approved against Ebola virus disease. Favipiravir, a RNA polymerase inhibitor active against several RNA viruses, recently demonstrated significant but not complete protection in a non-human primate model of Ebola virus disease. In this study, we assessed the benefit of the combination of favipiravir and ribavirin, another broad spectrum antiviral agent, in the same model. Methods 15 female cynomolgus macaques were challenged intramuscularly with 1,000 FFU of Ebola virus Gabon 2001 strain and followed for 21 days. All animals received favipiravir 180 mg/kg twice a day (BID), either as monotherapy (n = 5) or in combination with ribavirin (n = 10). Ribavirin was given either at the dose 10 mg/kg BID (n = 5) or 5 mg/kg BID (n = 5). Favipiravir and ribavirin were initiated two and one days before viral challenge respectively and treatment were continued for 14 days. Treatment effects on viral and hematological markers were assessed using a mathematical model. Survival rate of 0% and 20% were obtained in macaques receiving favipiravir plus ribavirin 10 and 5 mg/kg BID, respectively, compared to 40% in the favipiravir monotherapy group (P = 0.061 when comparing monotherapy and bitherapy, log rank). Viral dynamic modeling analysis did not identify an association between plasma concentrations of ribavirin and viral load levels. Using a model of erythropoiesis, plasma concentrations of ribavirin were strongly associated with a hemoglobin drop (p = 0.0015). Conclusion Ribavirin plus favipiravir did not extend survival rates and did not lower viral replication rate compared to favipiravir monotherapy in this animal model. Patients receiving this combination in other indications, such as Lassa fever, should be closely monitored to prevent potential toxicity associated with anemia.

Background Trastuzumab plus docetaxel is a mainstay to treat HER2-positive breast cancers. However, developing nanoparticles could help to improve the efficacy/toxicity balance of this doublet by improving drug trafficking and delivery to tumors. This project aimed to develop an immunoliposome in breast cancer, combining docetaxel encapsulated in a stealth liposome engrafted with trastuzumab, and comparing its performances on human breast cancer cell lines with standard combination of docetaxel plus trastuzumab. Methods Several strategies to engraft trastuzumab to pegylated liposomes were tested. Immunoliposomes made of natural (antibody nanoconjugate-1 [ANC-1]) and synthetic lipids (ANC-2) were synthesized using standard thin film method and compared in size, morphology, docetaxel encapsulation, trastuzumab engraftment rates and stability. Antiproliferative activity was tested on human breast cancer models ranging from almost negative (MDA-MB-231), positive (MDA-MB-453) to overexpressing (SKBR3) HER2. Finally, cell uptake of ANC-1 was studied by electronic microscopy. Results ANC-1 showed a greater docetaxel encapsulation rate (73%±6% vs 53%±4%) and longer stability (up to 1 week) as compared with ANC-2. Both ANC presented particle size ≤150 nm and showed similar or higher in vitro antiproliferative activities than standard treatment, ANC-1 performing better than ANC-2. The IC50s for docetaxel combined to free trastuzumab were 8.7±4, 2±0.7 and 6±2 nM with MDA-MB-231, MDA-MB-453 and SKBR3, respectively. The IC50s for ANC-1 were 2.5±1, 1.8±0.6 and 3.4±0.8 nM and for ANC-2 were 1.8±0.3 nM, 2.8±0.8 nM and 6.8±1.8 nM with MDA-MB-231, MDA-MB-453 and SKBR3, respectively. Cellular uptake appeared to depend on HER2 expression, the higher the expression, the higher the uptake. Conclusion In vitro results suggest that higher antiproliferative efficacy and efficient drug delivery can be achieved in breast cancer models using nanoparticles., Video abstract

Objectif Presenter le cas d’une investigation toxicologique a la suite d’une intoxication avec un liquide d’origine inconnu chez un jeune enfant. Description Un enfant âge de 26 mois, de sexe masculin, est surpris par ses parents buvant un liquide incolore issu d’une fiole non identifiee de 20 mL trouvee dans le jardin public ou il jouait. Un quart d’heure apres, il presente un comportement inhabituel qualifie de « pseudo-ebrieux ». Ses parents le presentent au service d’accueil d’urgence du centre hospitalier le plus proche. L’enfant est hypotonique, confus et en mydriase bilaterale reactive. Le reste de l’examen clinique et l’electrocardiogramme realises sont sans particularites. L’enfant est hospitalise pour surveillance au sein d’un service de pediatrie. Les cliniciens notent une amelioration de la reactivite aux stimuli dans les heures qui suivent l’admission mais un etat d’agitation persistant, l’enfant semble decrire une diplopie et est exagerement souriant. Au bout de 24 heures, devant un etat de conscience et un comportement consideres comme normaux, l’enfant retourne a domicile. Les analyses toxicologiques realisees sur place sont negatives, un echantillon de plasma preleve lors de l’admission ainsi que la fiole et son contenu sont adresses a notre laboratoire pour identification de la substance inconnue. Methode Un criblage est realise en chromatographie liquide couplee a la spectrometrie de masse haute resolution (CL-SMHR) (appareil de chromatographie Vanquish Thermo, spectrometre de masse Exploris 120 Thermo). Le plasma et le contenu de la fiole dilue 10 fois dans du methanol, sont traites par precipitation dans de l’acetonitrile apres ajout d’un etalon interne et de sels QuEChERS. L’acquisition des donnees est realisee grâce au logiciel Xcalibur (Thermo). Puis elles sont traitees avec le logiciel Compound Discoverer 3,2 (Thermo). La detection et l’identification des composes sont realisees par un criblage non cible, la masse exacte de l’ion parent et les spectres MS2 sont compares a la base de donnees mzCloud™ (19 004 composes le 29/04/21), avec un seuil d’identification a 60 %. Resultats Dans les 2 echantillons le diethyllysergamide (LSD) est mis en evidence. Les parents sont contactes et rapportent spontanement des hallucinations visuelles et des pertes de l’equilibre qui se sont amendes 4 jours apres l’intoxication, l’enfant reste neanmoins « capricieux » et craintif dans l’obscurite, comportements qu’il n’avait jamais presentes auparavant. Discussion Le LSD est un derive semi-synthetique de l’ergot du seigle, synthetise pour la premiere fois en 1938 [1] . Les cas d’intoxication au LSD sont rares en pediatrie, une vingtaine de cas a ete decrit dans la litterature. Ils se sont principalement deroules dans les annees 1970, le plus souvent l’ingestion est accidentelle et l’issue favorable apres la prise en charge symptomatique recommandee [2] , [3] . Le tableau clinique le plus souvent decrit est identique a celui de l’enfant et comprend mydriase, hallucinations visuelles et sensorielles, comportement anormal avec ataxie et manque de reactivite aux stimuli [2] . Dans les annees 1970 quelques cas de recurrence symptomatique ont ete decrits [4] , le jeune patient beneficiera d’un suivi programme. Le criblage non cible en CL-SMHR permet d’identifier des xenobiotiques rares et non retrouves par les analyses toxicologiques immunologiques ou enzymatiques et les criblages realises en routine. Conclusion L’intoxication au LSD est rare chez l’enfant, le plus souvent d’issue favorable. La realisation d’un criblage toxicologique non cible realise en CL-SMHR a permis d’identifier le LSD dans le plasma et le contenu de la fiole.

Objectifs Les principales atteintes consecutives a l’usage de cocaine touchent le systeme cardio-vasculaire, nerveux et psychique [1] . Les atteintes hepatiques sont rares, les auteurs presentent ici le cas d’une intoxication aigue a la cocaine suivie d’une insuffisance hepatique aigue ayant conduit au deces. Cas Mme M. 21 ans connue pour des antecedents de schizophrenie et d’addiction au cannabis fait une crise convulsive generalisee compliquee d’une chute. A l’arrivee du SMUR, la patiente presente un score de Glasgow a 5, une mydriase bilaterale, une tachycardie a 120 bpm avec une pression arterielle systolique a 120 mmHg. L’evolution est marquee par un premier arret cardio-respiratoire (ACR) en rythme non choquable recupere apres une intubation orotracheale et l’administration de 1 mg d’adrenaline puis un deuxieme ACR ayant necessite 3 × 1 mg d’adrenaline et un relais par 1 mg/h d’adrenaline. A l’arrivee en reanimation la patiente se stabilise rapidement sur le plan hemodynamique avec un sevrage initial rapide des amines en quelques heures. Son bilan biologique comporte : TP = 53 %, facteur V = 27 %, ASAT = 359 UI/L, ALAT = 397 UI/L, LDH = 930 UI/L. Dans les heures qui suivent, la fonction hepatique se degrade malgre la mise en place d’un traitement par N-acetyl-cysteine. Le bilan biologique realise 28 h apres son hospitalisation presente les resultats suivants : TP = 10 %, facteur V = 3 %, ASAT = 2028 UI/L, ALAT = 812 UI/L, LDH > 2500 UI/L et des hypoglycemies associees. La patiente decedera 41 h apres son admission par defaillance multiviscerale. Methode L’echantillon de plasma a ete analyse en chromatographie liquide couplee a la spectrometrie de masse haute resolution (Exploris 120, Thermo, Les Ulis, France). Le criblage toxicologique et la quantification ont ete realises avec la meme methode. Les analyses toxicologiques ont ete realisees sur un echantillon de sang preleve 5 h apres l’hospitalisation de la patiente. Resultats et discussion Les analyses retrouvent la presence de cocaine = 339 ng/mL, benzoylecgonine = 11440 ng/mL, ecgonine methylester = 3210 ng/mL, anhydroecgonine methylester (AEME ; non quantifiee, NQ), cocaethylene (NQ), levamisole (NQ). La concentration plasmatique de cocaine retrouvee 5 h apres l’hospitalisation est compatible avec une overdose. L’AEME est un biomarqueur de l’exposition a la cocaine fumee (cocaine basee ou crack). Les concentrations mesurees sont compatibles avec la survenue d’un arret cardiaque et d’une atteinte hepatique en l’absence d’autre etiologie. Les lesions hepatiques consecutives a une intoxication a la cocaine apparaissent dans les heures ou les jours qui suivent l’overdose [2] . Cette atteinte correspond a une necrose hepatique aigue. Le mecanisme lesionnel chez l’homme est peu clair, celui-ci semble impliquer une anoxie tissulaire par vasospasme ainsi que le role toxique de certains metabolites de la cocaine. Conclusion Les atteintes hepatiques liees a la cocaine sont rares mais graves, celles-ci pouvant conduire au deces. Il n’existe pas de traitement specifique a ce jour.

We evaluate the impact of ledipasvir on both tenofovir plasma trough concentration and estimated glomerular renal function in human immunodeficiency virus-hepatitis C virus coinfected patients receiving a tenofovir-based antiretroviral regimen and treated with ledipasvir/sofosbuvir. Twenty-six patients [81% male, median age: 51 years; hepatitis C virus genotype 1(75%)/4(15%)] were included. Tenofovir trough concentration (interquartile range) increased from 78 ng ml-1 (53-110) at baseline to 141 ng ml-1 (72-176) at 1 month (P = 0.003). No significant difference on estimated glomerular renal function using both Cockroft-Gault and Modification of Diet in Renal Disease formulae, respectively, [median (interquartile range)] was observed between baseline [101.3 ml min-1 (91.1-114.1); 95.6 ml min-1 (86.5-111.2)], 1 month [102.4 ml min-1 (89.8-112.9), P = 0.26; 92.5 ml min-1 (88.1-114.3), P = 0.27], end-of-treatment [96.5 ml min-1 (82.4-115.4), P = 0.39; 95.4 ml min-1 (84.2-105.4), P = 0.16] and 12 weeks after the end of treatment [100.5 ml min-1 (83.3-111.9), P = 0.24; 93.4 ml min-1 (82.2-103.5), P = 0.16]. Three patients progressed from chronic kidney disease stage 1 to stage 2 at 12 weeks post-treatment. A significant increase in tenofovir exposure through P-glycoprotein inhibition by ledipasvir was confirmed without significant impact on glomerular renal function in our population with normal renal function or mild renal impairment.

Objectifs Bien que l’usage recreatif du cannabis en France soit illegal, la population francaise (18–75 ans) est au premier rang europeen en termes d’experimentation (45 %), et la region Provence-Alpes-Cote d’Azur est de loin la premiere du classement national (54 %). Cette banalisation de l’usage du cannabis expose les enfants a un risque plus important d’exposition accidentelle, pouvant conduire a une intoxication aigue. Nous presentons les resultats d’une etude observationnelle realisee sur une annee concernant les intoxications aigues par le cannabis chez les enfants de moins de 4 ans dans l’agglomeration de Marseille. Methode Les patients ont ete inclus du 1er fevrier 2019 au 31 janvier 2020. Tous les enfants ayant un âge compris entre un mois et 4 ans, admis dans les services d’urgences avec un depistage urinaire de cannabis positif ont ete inclus. Les donnees cliniques ont ete recueillies dans les dossiers medicaux d’hospitalisation. Le depistage urinaire a ete realise par methode automatisee en immuno-analyse, les echantillons positifs ont ensuite ete confirmes par une quantification du 11-nor-9-carboxy-THC (THC-COOH) dans l’urine et du δ-9-tetrahydrocannabinol (THC), du THC-COOH et du 11-hydroxy-delta-9-THC (11-OH-THC) dans le sang. Les echantillons ont ete traites par extraction sur phase solide suivie d’une analyse par chromatographie liquide couplee a la spectrometrie de masse en tandem (Xevo TQ-XS, Waters, USA). La methode utilisee a prealablement ete validee selon les recommandations de l’EMA dans le plasma et l’urine sur une gamme allant de 0,5 a 100 ng/mL. Resultats Durant la periode de l’etude, 270 echantillons d’urine ont ete depistes pour le cannabis, 27 ont ete retrouves positifs (10 %). L’âge median etait de 14 mois (10–41 mois). Les concentrations medianes de THC, 11-OH-THC et THC-COOH dans le plasma (n = 23) etaient de 22 ng/mL (2,9–93 ng/mL), 18 ng/mL (2,6–65 ng/mL) et 207 ng/mL (29 a 914 ng/mL), respectivement. Les niveaux medians de THC-COOH dans l’urine (n = 21) etaient de 131 ng/mL (7,2–655 ng/mL). Les symptomes cliniques les plus courants etaient la somnolence (n = 17), l’hypotonie (n = 8) et la tachycardie (n = 4). Cinq enfants ont presente un coma, tous les enfants ayant une concentration plasmatiques de THC superieure a 60 ng/mL etaient dans le coma (n = 3), suggerant un lien entre les concentrations plasmatiques de THC et la gravite de l’intoxication. Conclusion Le centre antipoison de Marseille a signale 93 cas d’intoxication accidentelle par le cannabis entre 1993 et 2007 chez des personnes de moins de 18 ans, soit en moyenne 7 cas par an [1] . Cela met en evidence une augmentation marquee des cas d’intoxication par le cannabis chez les enfants, et en particulier une augmentation des intoxications severes. Ces observations peuvent etre expliquees par une augmentation de la teneur en THC dans la resine et les sommites fleuries de cannabis au cours des 15 dernieres annees associee a une banalisation de la consommation de cannabis dans la population generale.

Objectifs L’objectif de ce travail a ete de developper une methode de criblage toxicologique en chromatographie gazeuse couplee a spectrometrie de masse (CG-SM), methode de reference dans le domaine de la toxicologie hospitaliere [1] en utilisant le logiciel de retraitement MassHunter Unkown Analysis (MHUA), applicable en routine pour des echantillons de plasma et d’urine et de l’evaluer. Methode La preparation des echantillons suit celle decrite par Grapp et al. [2] . La prise d’essai est de 1 mL de matrice a laquelle est ajoute 50 μL d’etalon interne (prazepam 1 mg/L). L’extraction liquide-liquide est double a pH neutre et pH alcalin. La phase organique des 2 extractions est melangee et evaporee sous azote a 50 °C. Le residu sec est repris avec 100 μL d’acetate d’ethyle et 2 μL sont injectes dans le systeme CG-SM. Les analyses sont effectuees avec un appareil CG Agilent 7890A et un appareil SM Agilent 5975 C. Les injections sont realisees en mode splitless. Les analytes sont separes sur une colonne HP-5MS 30 m × 0,25 mm ; 0,25 μm (Agilent Technologies). Le gaz vecteur utilise est l’helium a un debit de 1 mL/min. Un gradient de temperature est utilise, il demarre a 100 °C pendant 2 min, puis augmente de 15 °C/min jusqu’a 325 °C, la duree totale est de 23 min. La source d’ionisation fonctionne par impact electronique a une energie constante de 70 eV. Les ions sont analyses en mode full scan entre 44 et 600 m/z. Les resultats ont ete retraites grâce aux logiciel AMDIS et MHUA v10.1 avec 3 bibliotheques : SWGDRUG (3346 spectres) NIST (220 460 spectres) et une bibliotheque maison (> 120 spectres). Les 58 echantillons de notre etude (12 urines et 46 plasmas) ont ete adresses par les hopitaux de l’agglomeration marseillaise au laboratoire de Pharmacocinetique et de Toxicologie de la Timone pour recherche de toxiques. Ils ont ete analyses en immunoanalyse et par CL-SM/SM sur une chaine Alliance couplee a un Quattro 1er (Waters, Etats-Unis). En cas de depistage positif pour les stupefiants, ou de demande specifique, une quantification est realisee en CL-SM/SM sur une chaine Acquity XEVO TQXS (Waters, Etats-Unis). Enfin, les echantillons sont analyses en CG-MS avec la methode developpee. Les resultats obtenus avec ces differentes methodes sont ensuite compares. Resultats Sur 58 echantillons, 65 molecules ont ete identifiees en CG-SM grâce au logiciel MH UA, 36 avec le logiciel AMDIS et 59 en CL-SM/SM. Dix-neuf molecules ont ete identifiees en CG-SM et dosees en CL-SM/SM a des concentrations relativement basses, notamment la codeine ( Conclusion Ce travail a permis de developper et d’optimiser une methode de criblage CG-SM et d’evaluer le logiciel MHUA. En comparaison avec les autres approches evaluees, le criblage CG-SM a permis d’identifier un nombre plus important de molecules, bien que certaines ne soient pas identifiees ou presentent des limites de detection plus elevees. La methode developpee est donc complementaire de la CL-SM/SM et de l’immunoanalyse et adaptee aux criblages toxicologiques realises dans le cadre hospitalier.

International audience; France is the country with the highest prevalence of cannabis use in Europe, despite the fact that cannabis has not been legalized. This prevalence is still increasing along with THC content in cannabis products. In the meantime, unintentional cannabis poisoning by ingestion in toddlers is constantly rising. The aim of this study was to document children's cannabis poisoning biologically and clinically. Plasma and urine samples were extracted by solid phase extraction and analyzed by liquid chromatography coupled to tandem mass spectrometry. Children under 4 years old admitted in pediatric emergency departments for cannabis intoxication between February 1st 2019 and January 31st 2020 were included in this study. Twenty-six children were included (14 female and 12 male), the mean age was 17 months (10-41 months). THC, 11-OH-THC and THC-COOH plasma concentrations ranged from 2.9 to 93 ng/mL, 2.6-65 ng/mL and 29-914 ng/mL, respectively. The most frequent symptoms were drowsiness and hypotonia. Six critical cases were observed: 5 coma and 1 respiratory depression. All children having THC plasma concentrations over 60 ng/mL were in coma. Cannabis poisoning in toddlers become more frequent, 9 cases/year were reported in Marseille in 2007 and 26 cases/year in this study. There is a rising in severe clinical cases, particularly coma. These observations could be explained by an increase in THC content in cannabis products, and a trivialization of cannabis consumption. The unintentional ingestion of cannabis by children is a serious public health concern, and cannabis legalization could worsen this problem.

Gemcitabine remains a pillar in pancreatic cancer treatment. However, toxicities are frequently observed. Dose adjustment based on therapeutic drug monitoring might help decrease the occurrence of toxicities. In this context, this work aims at describing the pharmacokinetics (PK) of gemcitabine and its metabolite dFdU in pancreatic cancer patients and at identifying the main sources of their PK variability using a population PK approach, despite a sparse sampled-population and heterogeneous administration and sampling protocols.Data from 38 patients were included in the analysis. The 3 optimal sampling times were determined using KineticPro and the population PK analysis was performed on Monolix. Available patient characteristics, including cytidine deaminase (CDA) status, were tested as covariates. Correlation between PK parameters and occurrence of severe hematological toxicities was also investigated.A two-compartment model best fitted the gemcitabine and dFdU PK data (volume of distribution and clearance for gemcitabine: V1 = 45 L and CL1 = 4.03 L/min; for dFdU: V2 = 36 L and CL2 = 0.226 L/min). Renal function was found to influence gemcitabine clearance, and body surface area to impact the volume of distribution of dFdU. However, neither CDA status nor the occurrence of toxicities was correlated to PK parameters.Despite sparse sampling and heterogeneous administration and sampling protocols, population and individual PK parameters of gemcitabine and dFdU were successfully estimated using Monolix population PK software. The estimated parameters were consistent with previously published results. Surprisingly, CDA activity did not influence gemcitabine PK, which was explained by the absence of CDA-deficient patients enrolled in the study. This work suggests that even sparse data are valuable to estimate population and individual PK parameters in patients, which will be usable to individualize the dose for an optimized benefit to risk ratio.

// Fabrice Barlesi 1, 2 , Diane-Charlotte Imbs 2 , Pascale Tomasini 1 , Laurent Greillier 1 , Melissa Galloux 1 , Albane Testot-Ferry 1 , Melanie Garcia 3 , Xavier Elharrar 1 , Annick Pelletier 1 , Nicolas Andre 2, 4 , Celine Mascaux 1 , Bruno Lacarelle 2, 3 , Raouf El Cheikh 2 , Raphael Serre 2 , Joseph Ciccolini 2, 3 and Dominique Barbolosi 2 1 Aix Marseille University, APHM, Marseille Early Phases Cancer Trials Center CLIP, Marseille, France 2 Aix Marseille University, SMARTc Unit, INSERM U911, Marseille, France 3 Aix Marseille University, APHM, Department of Pharmacology, Marseille, France 4 Aix Marseille University, APHM, Department of Pediatric Hematology and Oncology, Marseille, France Correspondence to: Fabrice Barlesi, email: fabrice.barlesi@ap-hm.fr Keywords: lung cancer, mesothelioma, mathematical modeling, vinorelbine, metronomic Received: March 24, 2017 Accepted: April 19, 2017 Published: May 02, 2017 ABSTRACT Introduction: Using mathematical modelling allows to select a treatment’s regimen across infinite possibilities. Here, we report the phase I assessment of a new schedule for metronomic vinorelbine in treating refractory advanced NSCLC and mesothelioma patients. Results: Overall, 13 patients were screened and 12 were treated (50% male, median age: 68yrs), including 9 NSCLC patients. All patients received at least one week (3 doses) of treatment. At data cut-off, the median length of treatment was 6.5 weeks (1–32+). All the patients presented with at least one adverse event (AE) and six patients with a severe AE (SAE). One partial response and 5 stable diseases were observed. The median OS was 6.4 months (95% CI, 4.8 to 12 months). The median and mean vinorelbine’s AUC were 122 ng/ml*h and 159 ng/ml*h, respectively, with the higher plasmatic vinorelbine exposure associated with the best ORR (difference of AUC comparison between responders and non-responders, p-value 0.017). Materials and Methods: The mathematical modelling determined the administration of vinorelbine, 60 mg on Day 1, 30 mg on Day 2 and 60 mg on Day 4 weekly until progression, as the best schedule. Advanced NSCLC or mesothelioma patients progressing after standard treatment were eligible for the trial. NCT02555007. Conclusions: Responses with acceptable safety profile were observed in heavily pretreated NSCLC and mesothelioma patients using oral vinorelbine at this metronomic dosage based on a mathematic modeling. This study demonstrates the feasibility of this new type of approach, as mathematical modeling may help to rationally decide the better regimen to be clinically tested across infinite possibilities.

Dihydropryimidine dehydrogenase (DPD) deficiency is a pharmacogenetic syndrome associated with severe or lethal toxicities with oral capecitabine. Usually, patients with history of 5-FU-based therapy with no signs for life-threatening toxicities are considered as not DPD-deficient individuals who can be safely treated next with capecitabine if required. Here we describe the case of a woman originally treated with standard FEC100 protocol for metastatic breast cancer with little severe toxicities but grade-3 mucosities that were quickly resolved by symptomatic treatment. When switched to capecitabine + vinorelbine combo, extremely severe toxicities with fatal outcome were unexpectedly observed. Pharmacogenetic investigations were performed on cytidine deaminase and DPYD, and showed that this patient was heterozygous for the 2846A>T mutation on the DPYD gene. DPD phenotyping (i.e., uracil plasma levels >250 ng/ml, dihydrouracil/uracil ratio 2 5-FU) and capecitabine (i.e., 2250 mg daily) could explain why initial 5-FU-based protocol did not lead to life-threatening toxicities, whereas capecitabine rapidly triggered toxic death. Overall, this case report suggests that any toxicity, even when not life threatening, should be considered as a warning signal for possible underlying profound DPD deficiency syndrome, especially with low-dose protocols.

International audience; Purine analogs like aracytine (AraC) are a mainstay for treating acute myeloid leukemia (AML). There are marked differences in drug dosing and scheduling depending on the protocols when treating AML patients with AraC. Large inter-patient pharmacokinetics variability has been reported, and genetic polymorphisms affecting cytidine deaminase (CDA), the liver enzyme responsible for the conversion of Ara-C to inactive uracil arabinoside (AraU) could be a culprit for either life-threatening toxicities or poor efficacy related to substantial changes in plasma exposure levels among patients. The quantitative determination of Ara-C in plasma is challenging due the required sensitivity because of the short half-life of this drug (i.e.

Background Rilpivirine is widely prescribed in people living with HIV. Although trough plasma concentrations have been associated with virological response, the drug pharmacodynamics remain incompletely characterized. Objectives To develop the first pharmacodynamic model of rilpivirine in order to establish the rilpivirine concentration–response relationship for future treatment optimization. Methods A retrospective observational study was conducted in patients receiving the once-daily rilpivirine/tenofovir disoproxil fumarate/emtricitabine regimen. Individual rilpivirine trough plasma concentrations over time were predicted using a previous pharmacokinetic model. An established susceptible, infected, recovered model was used to describe HIV dynamics without assuming disease steady-state. Population analysis was performed with MONOLIX 2018 software. Simulations of the viral load evolution as a function of time and rilpivirine trough plasma concentration were performed. Results Overall, 60 naive and 39 pre-treated patients were included with a follow-up ranging from 2 to 37 months. The final model adequately described the data and the pharmacodynamic parameters were estimated with a good precision. The population typical value of rilpivirine EC50 was estimated at 65 ng/mL. A higher infection rate constant of CD4 cells for HIV-1 was obtained in pre-treated patients. Consequently, the time to obtain virological suppression was longer in pre-treated than in naive patients. Conclusions The concentration–response relationship of rilpivirine was satisfactorily described for the first time using an original population pharmacodynamic model. Simulations performed using the final model showed that the currently used 50 ng/mL rilpivirine trough plasma concentration efficacy target might need revision upwards, particularly in pre-treated patients.

Aims The purpose of this study was to assess the antiviral activity of the rilpivirine/emtricitabine/tenofovir disoproxil fumarate combination and to describe the pharmacokinetics of rilpivirine and its association with resistance in clinical routine. Methods A retrospective multicentre cohort study was performed in both naive and pretreated HIV patients receiving the once-daily rilpivirine/emtricitabine/tenofovir disoproxil fumarate regimen. Immuno-virologic and resistance data, and rilpivirine plasma trough concentrations were collected over the follow-up. Statistical analyses were performed to evaluate the relationship between rilpivirine pharmacokinetics and virological response. Receiver operating characteristic (ROC) curve analysis was performed to determine the best target rilpivirine trough concentration. Results Overall, 379 patients were included. After a median follow-up of 28 months, 26% of patients discontinued mainly due to toxicity and the virological success rate was 65.7%. Virological failure occurred in 5% of patients. A significant proportion of patients with HIV-RNA > 40 copies/mL displayed rilpivirine plasma trough concentrations below the currently used 50 ng/mL efficacy threshold at both M6 (28%) and M12 (31%), in agreement with a significant lower median rilpivirine plasma trough concentration compared with patients virologically suppressed. Half of the patients with virologic failure who acquired rilpivirine resistance mutations had at least one suboptimal rilpivirine trough concentration. The optimal target for rilpivirine trough concentration was 70 ng/mL (sensitivity 75.4%; specificity 61.5%). Conclusions This study shows the impact of rilpivirine plasma trough concentration on both virological response and the emergence of rilpivirine mutations. Moreover, our results suggest that a higher target of rilpivirine trough concentration could be proposed in clinical practice.

Purpose Nanoparticles are of rising interest in cancer research, but in vitro canonical cell monolayer models are not suitable to evaluate their efficacy when prototyping candidates. Here, we developed three-dimensional (3D) spheroid models to test the efficacy of trastuzumab-docetaxel immunoliposomes in breast cancer prior to further testing them in vivo. Materials and methods Immunoliposomes were synthesized using the standard thin film method and maleimide linker. Two human breast cancer cell lines varying in Her2 expression were tested: Her2+ cells derived from metastatic site: mammary breast MDA-MB-453 and triple-negative MDA-MB-231 cells. 3D spheroids were developed and tested with fluorescence detection to evaluate viability. In vivo efficacy and biodistribution studies were performed on xenograft bearing nude mice using fluorescent and bioluminescent imaging. Results In vitro, antiproliferative efficacy was dependent upon cell type, size of the spheroids, and treatment scheduling, resulting in subsequent changes between tested conditions and in vivo results. Immunoliposomes performed better than free docetaxel + free trastuzumab and ado-trastuzumab emtansine (T-DM1). On MDA-MB-453 and MDA-MB-231 cell growth was reduced by 76% and 25%, when compared to free docetaxel + free trastuzumab and by 85% and 70% when compared to T-DM1, respectively. In vivo studies showed tumor accumulation ranging from 3% up to 15% of the total administered dose in MDA-MB-453 and MDA-MB-231 bearing mice. When compared to free docetaxel + free trastuzumab, tumor growth was reduced by 89% (MDA-MB-453) and 25% (MDA-MB-231) and reduced by 66% (MDA-MB-453) and 29% (MDA-MB-231) when compared to T-DM1, an observation in line with data collected from 3D spheroids experiments. Conclusion We demonstrated the predictivity of 3D in vitro models when developing and testing nanoparticles in experimental oncology. In vitro and in vivo data showed efficient drug delivery with higher efficacy and prolonged survival with immunoliposomes when compared to current anti-Her2 breast cancer strategies.

International audience; Immune checkpoint inhibitors have considerably changed the landscape of oncology. However apart from world-acclaimed success stories limited to melanoma and lung cancer, many solid tumors failed to respond to immune checkpoint inhibitors due to limited immunogenicity, unfavorable tumor micro-environments (TME), lack of infiltrating T lymphocytes or increases in Tregs. Areas covered: Combinatorial strategies are foreseen as the future of immunotherapy and using cytotoxics or modulating agents is expected to boost the efficacy of immune checkpoint inhibitors. In this respect, nanoparticles displaying unique pharmacokinetic features such as tumor targeting properties, optimal payload delivery and long-lasting interferences with TME, are promising candidates for such combinations. This review covers the basis, expectancies, limits and pitfalls of future combination between nanoparticles and immune check point inhibitors. Expert opinion: Nanoparticles allow optimal delivery of variety of payloads in tumors while sparing healthy tissue, thus triggering immunogenic cell death. Depleting tumor stroma could further help immune cells and monoclonal antibodies to better circulate in the TME, plus immune-modulating properties of the charged cytotoxics. Finally, nanoparticles themselves present immunogenicity and antigenicity likely to boost immune response at the tumor level.

Aims 5-FU is the backbone of most regimens in digestive oncology. Administration of standard 5-FU leads to 15–30% of severe side effects, and lethal toxicities are regularly reported with fluoropyrimidine drugs. Dihydropyrimidine dehydrogenase (DPD) deficiency is a pharmacogenetic syndrome responsible for most cases of life-threatening toxicities upon 5-FU intake, and pre-treatment checking for DPD status should help to reduce both incidence and severity of side effects through adaptive dosing strategies. Methods We have used a simple method for rapidly establishing the DPD phenotype of patients with cancer and used it prospectively in 59 routine patients treated with 5-FU-based therapy for digestive cancers. No patient with total DPD deficiency was found but 23% of patients exhibited poor metabolizer phenotype, and one patient was phenotyped as profoundly deficient. Consequently, 5-FU doses in poor metabolizer patients were cut by an average 35% as compared with non deficient patients (2390 ± 1225 mg vs. 3653 ± 1371 mg, P

e19517 Background: Vyxeos is a liposomal formulation of daunorubicin and cytarabine recently approved for treating adults with newly-diagnosed sAML subtypes therapy-related (t-AML) or AML with myelodysplasia-related changes (AML-MRC). The objective of this pilot study was to evaluate the influence of cytidine deaminase, the enzyme responsible for cytarabine detoxification step in the liver, on drug exposition and clinical outcome. Methods: In this proof-of-concept study, 9 adult patients were treated with Vyxeos. CDA status (i.e., determination of Poor Metabolizer or Extensive Metabolizer phenotypes) was evaluated before treatment by measuring residual CDA activity in serum. Pharmacokinetic sampling was performed 90min before infusion stops, then from T4H to T168H after the end of the infusion. Total cytarabine, encapsulated cytarabine and released cytarabine were discriminated and assayed using a validated LC-MS/MS method. Results: Nine Vyxeos patients (3M, 6F, 66 ±13 years) were included in this pilot study. Aplasia duration was significantly longer in AML-MRC patients than in AML-t (38 ±5.5 days VS. 28 ±3 days, respectively (p < 0.05)). All AML-t had complete response after induction phase (VS. 60% in AML-MRC, p > 0.05). Similar cytarabine exposure was measured in both population. Surprisingly, 8 out of 9 patients (i.e., 88%) were identified as CDA PM (CDA < 2UI/mg). Marked differences in pharmacokinetics were observed between PM and EM patients. Total, encapsulated and released cytarabine AUC’s were 2.77, 1.42, and1.46 mg/ml*h in PM patients. In EM patient, total, encapsulated and released cytarabine AUC’s were 0.97, 0.76 and 0.17 mg/ml*h. When available, microscopy analysis confirmed the presence of liposomes in patients bone marrow. Conclusions: Differences in clinical outcome between AML-t and AML-MRC patient are not supported by differences in exposure levels upon Vyxeos administration. Surprisingly, we found that CDA status has a strong impact on cytarabine pharmacokinetics since PM patients treated with Vyxeos present a +185% increase in cytarabine levels as compared with EM patient. This suggests that upfront CDA testing could help to predict clinical outcome.

International audience; Developing nanoparticles to improve the specificity of anticancer agents towards tumor tissues and to better control drug delivery is a rising strategy in oncology. An increasing number of forms (e.g., conjugated nanoparticles, liposomes, immunoliposomes…) are now made available on the shelves and numerous other scaffolds (e.g., dendrimeres, nanospheres, squalenes…) are currently at various stages of development. However, the attrition rate when developing nanoparticles is particularly high and several promising forms showing excellent behavior and efficacy in preclinical studies failed to succeed in subsequent first-in-man studies or later in phase-II trials. The issue of pharmacokinetic variability is a major, yet largely underestimated issue with nanoparticles. A wide variety of causes (e.g; tumor type and disease staging, comorbidities, patient’s immune system) can explain this variability, which can in return impact negatively on pharmacodynamic endpoints such as lack of efficacy or severe toxicities. This review aims at covering the main causes for erratic pharmacokinetics observed with most nanoparticles. Should the main causes of such variability be identified, specific studies in non-clinical or clinical development stages could be undertaken using dedicated models (i.e., mechanistic or semi-mechanistic mathematical models such as PBPK approaches) to better describe nanoparticles pharmacokinetics and decipher PK/PD relationships. In addition, identifying relevant biomarkers or parameters likely to impact on nanoparticles pharmacokinetics would allow either modifying their characteristics to reduce the influence of the expected variability during development phases, or developing biomarker-based adaptive dosing strategies to maintain an optimal efficacy/toxicity balance. Overall, we call of developing comprehensive distribution studies and state-of-the-art modeling support to help better picture and anticipate nanoparticles pharmacokinetics.

Background Upfront screening for dihydropyrimidine dehydrogenase (DPD) deficiency in patients scheduled for 5-FU should help reduce the risk of toxicities by preventive adaptive dosing. Our group has developed a simple functional testing categorizing patients upon their DPD status, i.e. extensive metabolizer (EM) or poor metabolizer (PM) patients, using UH2/U ratio measurement in plasma as a surrogate for DPD activity. 5-FU dosing can then be tailored according to DPD deficiency status. Objectives We present here an observational study of this strategy implemented in routine clinical practice when treating head-and-neck cancer patients. Results A total of 218 evaluable adult patients were treated with a 5-FU-regimen, with DPD-based adaptive dosing. Among them, 20 (9%) were identified as PM and received subsequently a 20-50% reduced dosing of 5-FU as compared with EM patients (2102 ±254 mg VS. 2577 ±353mg, p

Driving experiments in real conditions are considered as a 'gold standard' to evaluate the effects of drugs on driving performance. Several constraints are difficult to manage in these conditions, so driving simulation appears as the best alternative. A preliminary comparison is crucial before being able to use driving simulation as a valid evaluation method. The aim of this study was to design a driving simulation method for assessing drug effects on driving. We used cannabis (THC) as a positive control and assessed whether THC affects driving performance in simulation conditions and whether these effects are consistent with performance in real driving conditions. A double-blind, placebo-controlled, two successive two-way crossover design was performed using cigarettes containing 20 mg of THC. Healthy occasional users of THC, aged 25-35 years, who had a consistent driving experience were included. The first two sessions were realized in simulation conditions, and the last two sessions were in real driving conditions. Driving performance was estimated through inappropriate line crossings (ILC) and the standard deviation of the vehicle's lateral position. Participants felt significantly drowsier and more tired after THC, whatever the driving condition. Driving stability was significantly impaired after THC, both in simulated and real driving conditions. We also found that ILC were significantly more numerous in driving simulation conditions, as compared to real driving. In conclusion, the driving simulator was proven to be more sensitive for demonstrating THC-induced effects on driving performances. Driving simulation appears to be a good qualitative predictor of driving safety after drug intake.

// Nicolas Macagno 1, 2, * , Frederic Fina 1, 3, * , Nicolas Penel 4 , Corinne Bouvier 1, 2 , Isabelle Nanni 5 , Florence Duffaud 6, 7 , Raquel Rouah 5 , Bruno Lacarelle 8 , L'houcine Ouafik 5 , Sylvie Bonvalot 9 and Sebastien Salas 6, 7 1 Department of Pathology, Assistance Publique Hopitaux de Marseille Timone Hospital, Marseille, France 2 Aix-Marseille University, Medical Faculty, CRO2, UMR 911 (Equipe IV), Marseille, France 3 ID-Solutions, Grabels, France 4 Department of General Oncology, Oscar Lambret Center, Lille, France 5 Department of Molecular Oncology, Assistance Publique Hopitaux de Marseille, Marseille, France 6 Department of Oncology, Assistance Publique Hopitaux de Marseille Timone Hospital, Marseille, France 7 Aix-Marseille University, Medical Faculty, Marseille, France 8 Department of Medical Biology, Assistance Publique Hopitaux de Marseille Timone Hospital, Marseille, France 9 Department of Surgery, Institut Curie, PSL Univeristy, Paris, France * These authors contributed equally to this work Correspondence to: Sebastien Salas, email: sebastien.salas@ap-hm.fr Keywords: ddPCR; cfDNA; CTNNB1; desmoid; prognosis Received: October 27, 2017 Accepted: February 25, 2018 Published: April 06, 2018 ABSTRACT Since desmoid tumors (DT) exhibit an unpredictable clinical course, with stabilization and/or spontaneous regression, an initial “wait-and-see” policy is the new standard of care–thus, the actual challenge is to identify early factors of progression. We present a method of detection of CTNNB1 mutations using a targeted digital droplet PCR (ddPCR) on cell-free DNA (cfDNA) extracted from blood samples of 31 DT patients. Furthermore, we analyzed the correlation between DT evolution and plasmatic concentration of total and mutated cfDNA at the time of diagnosis. Circulating copies of CTNNB1 mutants (ctDNA) were detected in the plasma of 6 patients (33%) but their concentration was not correlated with evolution of the tumor. Concentration of total cfDNA was higher in the plasma of patients with progressive desmoids ( p = 0,0009). Using a threshold 1375, it was possible to predict desmoid evolution for 65% of patients by measuring the quantity of circulating DNA in their plasma as early as the time of diagnosis. Albeit showing that the detection of CTNNB1 mutants is possible in the plasma of patients harboring a desmoid tumor, the results of this preliminary study raise the hypothesis that most of the circulating DNA detected in their plasma is derived from non-neoplastic cells, most likely normal neighboring tissues being actively invaded. Our results open the perspective of using cfDNA as a biomarker to predict prognosis at the time of diagnosis and assess tumor dynamics to optimize the treatment strategy.

Introduction: The Pharmacokinetics/pharmacodynamics (PK/PD) relationships with cytotoxics are usually based on a steepening concentration-effect relationship; the greater the drug amount, the greater the effect. The Maximum Tolerated Dose paradigm, finding the balance between efficacy, while keeping toxicities at their manageable level, has been the rule of thumb for the last 50-years. Developing nanodrugs is an appealing strategy to help broaden this therapeutic window. The fact that efficacy and toxicity with cytotoxics are intricately linked is primarily due to the complete lack of specificity toward the tumor tissue during their distribution phase. Because nanoparticles are expected to better target tumor tissue while sparing healthy cells, accumulating large amounts of cytotoxics in tumors could be achieved in a safer way. Areas covered: This review aims at presenting how nanodrugs present unique features leading to reconsidering PK/PD relationships of anticancer agents. Expert commentary: The constant interplay between carrier PK, interactions with cancer cells, payload release, payload PK, target expression and target engagement, makes picturing the exact PK/PD relationships of nanodrugs particularly challenging. However, those improved PK/PD relationships now make the once contradictory higher efficacy and lower toxicities requirement an achievable goal in cancer patients.

There is a rising evidence that the proverbial statement "No pain, No gain" first coined at the light of pioneering clinical experiences with canonical chemotherapy still holds true in the era of modern treatments of cancer. This close relationship between the occurrence of specific drug-related toxicity and treatment outcome has been confirmed since then with a large variety of treatments, ranging from cytotoxics, hormonotherapy, targeted therapy and much interestingly even with the latest immune checkpoint inhibitors. In the current context of precision medicine, and along with the constant quest for identifying predictive biomarkers, close monitoring of treatment-related toxicities could therefore be convenient to help predicting therapeutic response, but presents several caveats. The purpose of this review is to briefly describe these relationships across the different treatments, to comment on possible underlying mechanisms and to comment on possible strategies aiming at exploiting this relationship while keeping the maximal safety ensured in patients with cancer. In particular, this review will investigate on how drug exposure along with germinal and somatic genetic issues does impact on the "No Pain, No Gain" aphorism, and why the temptation to use treatment-related toxicities as a cheap and convenient way to predict clinical outcome or to adapt dosing should be resisted. We do advocate instead for developing comprehensive genomic support along with extensive biomathematical modeling to better customize dosing and shift towards a new "No Pain, Maximal Gain" paradigm.

Rilpivirine, prescribed for the treatment of HIV infection, presents an important inter-individual pharmacokinetic variability. We aimed to determine population pharmacokinetic parameters of rilpivirine in adult HIV-infected patients and quantify their inter-individual variability. We conducted a multicenter, retrospective, and observational study in patients treated with the once-daily rilpivirine/tenofovir disoproxil fumarate/emtricitabine regimen. As part of routine therapeutic drug monitoring, rilpivirine concentrations were measured by UPLC-MS/MS. Population pharmacokinetic analysis was performed using NONMEM software. Once the compartmental and random effects models were selected, covariates were tested to explain the inter-individual variability in pharmacokinetic parameters. The final model qualification was performed by both statistical and graphical methods. We included 379 patients, resulting in the analysis of 779 rilpivirine plasma concentrations. Of the observed trough individual plasma concentrations, 24.4% were below the 50 ng/ml minimal effective concentration. A one-compartment model with first-order absorption best described the data. The estimated fixed effect for plasma apparent clearance and distribution volume were 9 L/h and 321 L, respectively, resulting in a half-life of 25.2 h. The common inter-individual variability for both parameters was 34.1% at both the first and the second occasions. The inter-individual variability of clearance was 30.3%. Our results showed a terminal half-life lower than reported and a high proportion of patients with suboptimal rilpivirine concentrations, which highlights the interest of using therapeutic drug monitoring in clinical practice. The population analysis performed with data from “real-life” conditions resulted in reliable post hoc estimates of pharmacokinetic parameters, suitable for individualization of dosing regimen.

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