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We analysed the therapeutic outcomes of all consecutive patients with primary central nervous system lymphoma (PCNSL) registered in the prospective French database for PCNSL and treated with intensive chemotherapy (IC) followed by autologous stem cell transplantation (IC-ASCT) between 2011 and November 2019 (271 patients recruited, 266 analysed). In addition, treatment-related complications of thiotepa-based IC-ASCT were analysed from the source files of 85 patients from 3 centers. Patients had received IC-ASCT either in first-line treatment (n = 147) or at relapse (n = 119). The median age at IC-ASCT was 57 years (range: 22-74). IC consisted of thiotepa-BCNU (n = 64), thiotepa-busulfan (n = 24), BCNU-etoposide-cytarabine-melphalan (BEAM, n = 36) and thiotepa-busulfan-cyclophosphamide (n = 142). In multivariate analysis, BEAM and ASCT beyond the first relapse were adverse prognostic factors for relapse risk. The risk of treatment-related mortality was higher for ASCT performed beyond the first relapse and seemed higher for thiotepa-busulfan-cyclophosphamide. Thiotepa-BCNU tends to result in a higher relapse rate than thiotepa-busulfan-cyclophosphamide and thiotepa-busulfan. This study confirms the role of IC-ASCT in first-line treatment and at first-relapse PCNSL (5-year overall survival rates of 80 and 50%, respectively). The benefit/risk ratio of thiotepa-busulfan/thiotepa-busulfan-cyclophosphamide-ASCT could be improved by considering ASCT earlier in the course of the disease and dose adjustment of the IC.

Sickle cell disease (SCD) and transfusion-dependent β-thalassemia (TDT) are the most prevalent monogenic disorders worldwide. Trial HGB-205 ( NCT02151526 ) aimed at evaluating gene therapy by autologous CD34

BACKGROUND Busulfan (Bu) is the cornerstone of conditioning regimens prior to hematopoietic stem cell transplantation, widely used in both adults and children for the treatment of malignant and nonmalignant diseases. Despite an intravenous formulation, interindividual variability (IIV) remains high and optimal exposure difficult to achieve, especially in neonates and infants. PROCEDURE To ensure both efficacy and safety, we set up in 2005 an observational study designed for children not fully assessed during the drug registration procedure. From a large cohort of 540 patients, we developed a Bu population pharmacokinetic model based on body weight (BW) and maturation concepts to reduce IIV and optimize exposure. A new dosing nomogram was evaluated to better fit the population pharmacokinetic model. RESULTS Bu clearance IIV was significantly decreased from 61.3% (covariate-free model) to 28.6% when combining BW and maturation function. Median Bu area under the curve (AUC) was 1179 µmol/L × min compared to 1025 with the EMA dosing nomogram for children

Resume But/Objectif En raison de l’hypersecretion gastrique et/ou d’importantes pertes intestinales, certains patients necessitent un apport en ranitidine dans leur melange de nutrition parenterale (NP). L’objectif etait de reevaluer l’interet clinique de la ranitidine dans les prescriptions de NP suite a des tensions d’approvisionnement en ranitidine injectable. Patients et methodes Un suivi clinique prospectif des patients en NP a domicile (NPAD) a ete realise pendant 4 mois selon trois criteres : l’arret, la substitution ou le maintien de la ranitidine dans les prescriptions de NP. Resultats Parmi les 109 patients en NPAD, 64 (59 %) beneficiaient de ranitidine dans leur NP. L’arret definitif, tente chez 23 patients (36 %), s’est solde par deux echecs avec retour a la prescription initiale. Le relais per os a concerne 22 patients (34 %) et a conduit a quatre echecs. Pour ces 6 patients, des nausees/vomissements et des accelerations du transit intestinal ont ete observes. Ces effets secondaires ont concerne des patients atteints d’un syndrome du grele court (SGC). Enfin, chez 19 patients (30 %) atteint soit d’un SGC severe, d’une Maladie de Hirschsprung etendue ou d’une Pseudo obstruction intestinale chronique, la ranitidine a du etre maintenue. Conclusion Une reevaluation des prescriptions a ete menee en respectant les profils cliniques particuliers des patients avec l’arret d’un grand nombre de prescription de ranitidine. Cependant, la ranitidine reste indispensable chez les patients presentant de graves troubles digestifs (nausees, vomissements, pertes elevees). Neanmoins, la voie intraveineuse peut etre relayee par la voie orale quand cela est possible, associee a un suivi clinique.

The incidence of urinary tract infections caused by extended-spectrum β-lactamase (ESBL)-producing pathogens is increasing. These infections are associated with a long hospital stay in patients undergoing urological procedures. We aimed to demonstrate that significant intraprostatic diffusion of ertapenem is achieved after a single preoperative administration. A referred sample of 19 patients requiring surgery for benign prostatic hyperplasia was prospectively included. Patients received a 1 g intravenous (i.v.) dose of ertapenem 1 h (n = 10, group A) or 12 h (n = 9, group B) before blood and prostatic samples were collected. Plasma and intraprostatic concentrations of ertapenem were measured using LC-MS/MS. Intraprostatic concentrations were considered satisfactory when higher than the MIC90 value of urinary-targeted pathogens perioperatively and for 40% of the dosing interval. The Wilcoxon test and a pharmacokinetic predictive model were used. Median plasma concentrations of ertapenem were 144.3 mg/L (95% CI 126.5-157.9) in group A and 30.7 mg/L (95% CI 22.9-36.4) in group B (P

Musculoskeletal disorders (MSD) remain the most common occupational disease in the Western countries. Beside the effects on workers themselves, MSDs may lead to high costs to enterprises and the society as a whole. Among the painful or tiring positions encountered in healthcare settings, caregivers often cite the filling of portable infusion pumps (PIP). This context was conducive to achievement of the goal of the following project: the development of a motorized apparatus designed to minimize the risk of MSDs caused by repeated gestures of filling PIPs.: The development of the tool followed eleven steps including: (a) a market analysis, (b) a SWOT analysis, (c) definition of the specifications of the apparatus, and (d) a concurrent engineering methodology.: In approximately 18 months, a dynamic project group supported by a concurrent engineering methodology has designed and developed a compact and lightweight motorized apparatus able to suppress the risk of MSDs caused by manual filling of PIPs. After a mandatory step of familiarization, all involved operators have unanimously endorsed the new tool.: We believe that this new motorized apparatus may now simply and substantially alleviate occupational MSDs caused by the manually filling of PIPs. Another major benefit of this research program is the clear improvement of the intrinsically quality of therapeutic objects (TO) through the creation of a more accurate and reproducible method of PIP filling.

β-globin gene disorders are the most prevalent inherited diseases worldwide and result from abnormal β-globin synthesis or structure. Novel therapeutic approaches are being developed in an effort to move beyond palliative management. Gene therapy, by ex vivo lentiviral transfer of a therapeutic β-globin gene derivative (β(AT87Q)-globin) to hematopoietic stem cells, driven by cis-regulatory elements that confer high, erythroid-specific expression, has been evaluated in human clinical trials over the past 8 years. β(AT87Q)-globin is used both as a strong inhibitor of HbS polymerization and as a biomarker. While long-term studies are underway in multiple centers in Europe and in the United States, proof-of-principle of efficacy and safety has already been obtained in multiple patients with β-thalassemia and sickle cell disease.

International audience; BACKGROUND Donor availability and transplantation-related risks limit the broad use of allogeneic hematopoietic-cell transplantation in patients with transfusion-dependent beta-thalassemia. After previously establishing that lentiviral transfer of a marked beta-globin (beta(A-T87Q)) gene could substitute for long-term red-cell transfusions in a patient with beta-thalassemia, we wanted to evaluate the safety and efficacy of such gene therapy in patients with transfusion-dependent beta-thalassemia. METHODS In two phase 1-2 studies, we obtained mobilized autologous CD34+ cells from 22 patients (12 to 35 years of age) with transfusion-dependent beta-thalassemia and transduced the cells ex vivo with LentiGlobin BB305 vector, which encodes adult hemoglobin (HbA) with a T87Q amino acid substitution (HbA(T87Q)). The cells were then reinfused after the patients had undergone myeloablative busulfan conditioning. We subsequently monitored adverse events, vector integration, and levels of replication-competent lentivirus. Efficacy assessments included levels of total hemoglobin and HbA(T87Q), transfusion requirements, and average vector copy number. RESULTS At a median of 26 months (range, 15 to 42) after infusion of the gene-modified cells, all but 1 of the 13 patients who had a non-beta(0)/beta(0) genotype had stopped receiving red-cell transfusions; the levels of HbA(T87Q) ranged from 3.4 to 10.0 g per deciliter, and the levels of total hemoglobin ranged from 8.2 to 13.7 g per deciliter. Correction of biologic markers of dyserythropoiesis was achieved in evaluated patients with hemoglobin levels near normal ranges. In 9 patients with a beta(0)/beta(0) genotype or two copies of the IVS1-110 mutation, the median annualized transfusion volume was decreased by 73%, and red-cell transfusions were discontinued in 3 patients. Treatment-related adverse events were typical of those associated with autologous stem-cell transplantation. No clonal dominance related to vector integration was observed. CONCLUSIONS Gene therapy with autologous CD34+ cells transduced with the BB305 vector reduced or eliminated the need for long-term red-cell transfusions in 22 patients with severe beta-thalassemia without serious adverse events related to the drug product. (Funded by Bluebird Bio and others; HGB-204 and HGB-205 ClinicalTrials. gov numbers, NCT01745120 and NCT02151526.)

Pancreatic ductal adenocarcinoma (PDAC) is expected to become the second cause of cancer-related death in 2030. PDAC is the poorest prognostic tumor of the digestive tract, with 80% of patients having advanced disease at diagnosis and 5-year survival rate not exceeding 7%. Until 2010, gemcitabine was the only validated therapy for advanced PDAC with a modest improvement in median overall survival as compared to best supportive care (5-6 vs 3 months). Multiple phase II-III studies have used various combinations of gemcitabine with other cytotoxics or targeted agents, most in vain, in attempt to improve this outcome. Over the past few years, the landscape of PDAC management has undergone major and rapid changes with the approval of the FOLFIRINOX and gemcitabine plus nab-paclitaxel regimens in patients with metastatic disease. These two active combination chemotherapy options yield an improved median overall survival (11.1 vs 8.5 months, respectively) thus making longer survival a reasonably achievable goal. This breakthrough raises some new clinical questions about the management of PDAC. Moreover, better knowledge of the environmental and genetic events that underpin multistep carcinogenesis and of the microenvironment surrounding cancer cells in PDAC has open new perspectives and therapeutic opportunities. In this new dynamic context of deep transformation in basic research and clinical management aspects of the disease, we gathered updated preclinical and clinical data in a multifaceted review encompassing the lessons learned from the past, the yet unanswered questions, and the most promising research priorities to be addressed for the next 5 years.

The purpose of this study was to develop a Raman spectroscopy (RS) method as an effective tool for the non-intrusive pre-delivery analytical quality control (AQC) of two camptothecin analogs, i.e. irinotecan (IRI) and topotecan (TPT), which are prescribed and compounded at the hospital. Following a phase of analytical pre-validation, based on the actual conditions of use of the analogs, the protocol was validated and compared with the reference high-performance liquid chromatography (HPLC) method. For IRI, AQC by RS has been validated in ranges from 0.94 to 3.27 mg/ml in saline solutions and from 0.89 to 3.30 mg/ml in dextrose solutions. These ranges recover the entire therapeutic concentrations encountered in clinical practice, i.e. 1.08–2.8 mg/ml. The RS and HPLC methods were validated by calculating the accuracy profile and provided excellent results for the analytical validation key criteria. The Spearman and Kendall correlation tests (p-value

Summary Background Mucopolysaccharidosis type IIIB syndrome (also known as Sanfilippo type B syndrome) is a lysosomal storage disease resulting in progressive deterioration of cognitive acquisition after age 2–4 years. No treatment is available for the neurological manifestations of the disease. We sought to assess the safety and efficacy of a novel intracerebral gene therapy. Methods Local regulatory authorities in France allowed inclusion of up to four children in this phase 1/2 study. Treatment was 16 intraparenchymal deposits (four in the cerebellum) of a recombinant adenoassociated viral vector serotype 2/5 (rAAV2/5) encoding human α-N-acetylglucosaminidase (NAGLU) plus immunosuppressive therapy. We assessed tolerance, neurocognitive progression, brain growth, NAGLU enzymatic activity in CSF, and specific anti-NAGLU immune response for 30 months after surgery. This trial is registered with EudraCT, number 2012-000856-33, and the International Standard Clinical Trial Registry, number ISRCTN19853672. Findings Of seven eligible children, the four youngest, from France (n=2), Italy (n=1), and Greece (n=1), aged 20, 26, 30, and 53 months, were included between February, 2012, and February, 2014. 125 adverse events were recorded, of which 117 were treatment emergent and included six classified as severe, but no suspected unexpected serious adverse drug reactions were seen. Vector genomes were detected in blood for 2 days after surgery. Compared with the natural history of mucopolysaccharidosis type III syndromes, neurocognitive progression was improved in all patients, with the youngest patient having function close to that in healthy children. Decrease in developmental quotient was −11·0 points in patient one, −23·0 in patient two, −29·0 in patient three, and −17·0 in patient four, compared with −37·7 in the natural history of the disease. NAGLU activity was detected in lumbar CSF and was 15–20% of that in unaffected children. Circulating T lymphocytes that proliferated and produced tumour necrosis factor α upon ex-vivo exposure to NAGLU antigens were detectable at 1–12 months and 3–12 months, respectively, but not at 30 months in three of four patients. Interpretation Intracerebral rAVV2/5 was well tolerated and induced sustained enzyme production in the brain. The initial specific anti-NAGLU immune response that later subsided suggested acquired immunological tolerance. The best results being obtained in the youngest patient implies a potential window of opportunity. Longer follow-up is needed to further assess safety outcomes and persistence of improved cognitive development. Funding Association Francaise Contre les Myopathies, Vaincre les Maladies Lysosomales, Institut Pasteur, and UniQure.

Sickle cell disease results from a homozygous missense mutation in the ß-globin gene that causes polymerization of hemoglobin S. Gene therapy for patients with this disorder is complicated by the complex cellular abnormalities and challenges in achieving effective, persistent inhibition of polymerization of hemoglobin S. We describe our first patient treated with lentiviral vector-mediated addition of an antisickling ß-globin gene into autologous hematopoietic stem cells. Adverse events were consistent with busulfan conditioning. Fifteen months after treatment, the level of therapeutic antisickling ß-globin remained high (approximately 50% of ß-like-globin chains) without recurrence of sickle crises and with correction of the biologic hallmarks of the disease. (Funded by Bluebird Bio and others; HGB-205 ClinicalTrials.gov number, NCT02151526 .).

Until the 1990s, cytotoxic chemotherapy has been the cornerstone of medical therapy for gastrointestinal (GI) cancers. Better understanding of the molecular biology of cancer cell has led to the therapeutic revolution of targeted therapies, i.e. monoclonal antibodies or small molecule inhibitors directed against proteins that are specifically overexpressed or mutated in cancer cells. These agents being more specific to cancer cells were expected to be less toxic than cytotoxic agents. Targeted agents have provided clinical benefit in many GI cancer types. For example, antiangiogenics and anti-EGFR therapies have significantly improved survival of patients affected by metastatic colorectal cancer and have deeply changed the therapeutic strategy in this disease. However, their effects have sometimes been disappointing, due to intrinsic or acquired resistance mechanisms (e.g., RAS mutation for anti-EGFR therapies), or to an activity restricted to some tumour settings (e.g., lack of activity in other cancer types, or on the microscopic residual disease in adjuvant setting). Many studies are negative in overall population but positive in some specific patient subgroups (e.g., trastuzumab in HER2-positive gastric cancer), illustrating the importance of patient selection and early identification of predictive biomarkers of response to these therapies. We propose a comprehensive two-part review providing a panoramic approach of the successes and failures of targeted agents in GI cancers to unravel the pharmacologic opportunities and future directions for these agents in GI oncology. In this first part, we will focus on adenocarcinomas and squamous cell carcinomas, for which targeted therapies are mostly used in combination with chemotherapy.

This study compares the performance of a reference method of HPLC to Raman spectroscopy (RS) for the analytical quality control (AQC) of therapeutic objects. We assessed a model consisting of a widely used antiviral drug, i.e., ganciclovir, which was compounded in a medical device and then transferred in a vacuum glass vial prior to analyses. As the aim of the alternative RS method is to replace the destructive, time-consuming HPLC method, requiring sample preparation, it needs to be demonstrated that RS performs at least as good as the HPLC method. Therefore, the two methods were validated by calculating the accuracy profile and provided excellent results for the analytical validation key criteria, i.e., trueness, precision and accuracy, ranging from 0.8 to 10mg/mL. The Spearman and Kendall correlation tests (p-value

The purpose of the study was to perform a comparative analysis of the technical performance, respective costs and environmental effect of two invasive analytical methods (HPLC and UV/visible–FTIR) as compared to a new non-invasive analytical technique (Raman spectroscopy). Three pharmacotherapeutic models were used to compare the analytical performances of the three analytical techniques. Statistical inter-method correlation analysis was performed using non-parametric correlation rank tests. The study’s economic component combined calculations relative to the depreciation of the equipment and the estimated cost of an AQC unit of work. In any case, analytical validation parameters of the three techniques were satisfactory, and strong correlations between the two spectroscopic techniques vs. HPLC were found. In addition, Raman spectroscopy was found to be superior as compared to the other techniques for numerous key criteria including a complete safety for operators and their occupational environment, a non-invasive procedure, no need for consumables, and a low operating cost. Finally, Raman spectroscopy appears superior for technical, economic and environmental objectives, as compared with the other invasive analytical methods.

Background LentiGlobin gene therapy contains autologous CD34+ hematopoietic stem cells (HSCs) transduced with the BB305 lentiviral vector (LVV), encoding human β-globin with a T87Q substitution. This substitution confers anti-sickling properties to the gene therapy-derived hemoglobin (HbAT87Q) and allows for its quantification in transduced HSCs. The proof of concept for LentiGlobin gene therapy in patients with transfusion-dependent β-thalassemia (TDT) and sickle cell disease (SCD) was established in the recently completed HGB-205 study (NCT02151526). Herein, we provide the safety and efficacy outcomes and long-term follow-up data for all 7 treated patients, 4 with TDT and 3 with SCD. Methods Patients 5−35 years old with TDT (≥ 100 mL/kg of packed red blood cells [pRBCs]/year) or severe SCD (e.g., ≥ 2 acute chest syndromes [ACS] or ≥ 2 vaso-occlusive crises in the preceding year or the year before regular transfusions) were enrolled. CD34+ HSCs were obtained by mobilization and apheresis in patients with TDT or by bone marrow harvest in patients with SCD. Following collection, cells were transduced with the BB305 LVV. Patients underwent busulfan myeloablative conditioning and were infused with transduced cells. Patients were monitored for engraftment, adverse events (AEs), HbAT87Q levels, and other hematologic and clinical parameters. After 2 years in HGB-205, patients transitioned into the long-term follow-up study, LTF-303 (NCT02633943). Summary statistics are shown as median (min-max). Results As of June 2019, patients with TDT (n=4) and SCD (n=3) had a median follow-up of 49.6 (40.5-60.6) and 28.5 (25.5-52.5) months, respectively. Table 1 shows patient and drug product characteristics and several key efficacy outcomes. All patients achieved HSC engraftment. LentiGlobin safety profile was consistent with busulfan myeloablative conditioning and, in case of SCD, with the underlying disease state. The most common non-hematologic Grade ≥ 3 AEs post-LentiGlobin gene therapy (≥ 2 patients) for patients with TDT were stomatitis (n=4) and increased aspartate aminotransferase (n=2), and for patients with SCD were ACS (n=2) and vaso-occlusive pain (n=2). In all 4 patients with TDT, total Hb and HbAT87Q levels remained generally stable up to 5 years post-LentiGlobin infusion. Three of 4 patients achieved transfusion independence (TI; defined as weighted average Hb ≥ 9g/dL without pRBC transfusions for ≥ 12 months), for an ongoing duration of 56.3 (38.2-57.6) months. Weighted average total Hb during TI was 11.4 (10.5-13.0) g/dL. One patient has been off transfusions for 37.5 months and had total Hb of 7.7 g/dL, which was below the ≥ 9 g/dL requirement to meet the protocol definition of TI. At last visit, HbAT87Q levels in these 4 patients ranged from 6.2-11.2 g/dL, which contributed 73.8-86.8% of the total Hb. The first patient treated with LentiGlobin for SCD experienced one vaso-occlusive pain episode, which developed at 30 months after LentiGlobin gene therapy following a case of acute gastroenteritis with fever and dehydration. The second SCD patient had 2 serious AEs (SAEs) of ACS approximately 6 and 8 months after LentiGlobin gene therapy. The patient resumed chronic pRBC transfusions and hydroxyurea treatment and subsequently experienced 2 SAEs of vaso-occlusive pain; no additional SAEs of vaso-occlusive pain or ACS were reported during the last 16 months of follow-up after LentiGlobin infusion. The third SCD patient had no episodes of vaso-occlusive pain or ACS during 25.5 months of follow-up post-LentiGlobin gene therapy as of the data cut-off. Two patients with SCD who have been off chronic pRBC transfusions, showed improvement in hemolysis markers post-LentiGlobin treatment and stabilization of HbAT87Q expression at approximately 6 months post-LentiGlobin infusion. Total Hb levels for patients with SCD at last visit were 13.0 g/dL (patient 1), 9.4 g/dL (patient 2), and 9.8 g/dL (patient 3), with corresponding HbAT87Q contributions of 47.9%, 7.9%, and 25.8%, respectively. Summary With up to 5 years of follow-up, treatment with LentiGlobin gene therapy was well tolerated and resulted in improvement in hematologic parameters and disease-related symptoms. Further results from the completed study will be presented. Disclosures Hermine: Celgene: Research Funding; Novartis: Research Funding; AB science: Consultancy, Equity Ownership, Honoraria, Research Funding. Brousse:bluebird bio, Inc: Consultancy; AddMedica: Consultancy. El Nemer:Hemanext: Other: Other. Bartolucci:Novartis: Membership on an entity's Board of Directors or advisory committees; AddMedica: Honoraria, Membership on an entity's Board of Directors or advisory committees; Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees; Agios: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees; HEMANEXT: Membership on an entity's Board of Directors or advisory committees. Asmal:bluebird bio, Inc: Employment, Equity Ownership. Whitney:bluebird bio, Inc: Employment, Equity Ownership. Gayron:bluebird bio, Inc: Employment, Equity Ownership. Huang:bluebird bio, Inc.: Employment, Equity Ownership. de Montalembert:AddMedica: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; bluebird bio, Inc: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees. Ribeil:bluebird bio, Inc: Employment, Equity Ownership. Cavazzana:SmartImmune: Other: Founder.

Resume L’allogreffe de cellules souches hematopoietiques (allo-CSH) reste le seul traitement curatif de nombreuses hemopathies malignes ainsi que de certaines pathologies benignes ou constitutionnelles. Le busulfan propose dans sa forme injectable est rapidement devenu l’un des piliers pharmacologiques du conditionnement myeloablatif ou non. C’est suite au declenchement courant 2010 d’un essai clinique multicentrique international de phase II que nous avons eprouve la robustesse et la fiabilite de notre organisation en un modele complexe de cooperation multifactorielle. Dans ce protocole de type « BuCy2 » d’une duree habituelle de quatre jours, le busulfan intraveineuse est administre a raison d’une seule dose quotidienne en lieu et place des 16 perfusions conventionnelles ; en revanche, la dose totale cible reste inchangee, aux adaptations posologiques pres. Le traitement est tres securise au moyen d’un suivi therapeutique conduit en temps reel via des mesures reiterees de concentrations plasmatiques et de calculs d’aires sous la courbe. Le processus est techniquement complexe et impose la cooperation etroite des equipes concernees. Une analyse SWOT/MOFF ( strength, weakness, opportunity and threat /menaces, opportunites, forces, faiblesses) a ete construite et a guide une demarche continue d’amelioration de la qualite du service rendu au triple profit de la chaine de soins, du patient et de l’environnement. Divers points critiques ont ete identifies, et corriges ; l’experience est fortement contributive de la securisation et de la fiabilite du circuit du medicament. La performance de l’allo-CSH s’en trouve amelioree. A un echelon superieur, il repond au cahier des charges et a la plupart des exigences d’un veritable systeme de management de la qualite.

Ifosfamide is a well known prodrug for cancer treatment with cytochrome P450 metabolism. It is associated with both antitumor activity and toxicities. Isophosphoramide mustard is the bisalkylating active metabolite, and acrolein is a urotoxic side product. Because acrolein toxicity is limited by coadministration of sodium mercaptoethanesulfonate, the incidence of urotoxicity has been lowered. Current evidence suggests that chloroacetaldehyde, a side-chain oxidation metabolite, is responsible for neurotoxicity and nephrotoxicity. The aim of our research is to prevent chloroacetaldehyde formation using new enantioselectively synthesized ifosfamide analogs, i.e., C7,C9-dimethyl-ifosfamide. We hypothesize that reduced toxicogenic catabolism may induce less toxicity without changing anticancer activity. Metabolite determinations of the dimethyl-ifosfamide analogs were performed using liquid chromatography and tandem mass spectrometry after in vitro biotransformation by drug-induced rat liver microsomes and human microsomes expressing the main CYP3A4 and minor CYP2B6 enzymes. Both human and rat microsomes incubations produced the same N-deschloroalkylated and 4-hydroxylated metabolites. A coculture assay of 9L rat glioblastoma cells and rat microsomes was performed to evaluate their cytotoxicity. Finally, a mechanistic study using (31)P NMR kinetics allowed estimating the alkylating activity of the modified mustards. The results showed that C7,C9-dimethyl-ifosfamide exhibited increased activities, although they were still metabolized through the same N-deschloroalkylation pathway. Analogs were 4 to 6 times more cytotoxic than ifosfamide on 9L cells, and the generated dimethylated mustards were 28 times faster alkylating agents than ifosfamide mustards. Among these new ifosfamide analogs, the 7S,9R-enantiomer will be assessed for further in vivo investigations for its anticancer activity and its toxicological profile.

Azathioprine is an antineoplastic antimetabolite drug currently used as an immunosuppressive agent after organ transplantation and for several dysimmunitary diseases. The usual daily dose ranges from 1 to 5 mg/kg orally. Azathioprine is marketed in France under the trade name Imurel in tablet form for oral administration that contains either 25 mg or 50 mg of the active ingredient. This Galenic formulation is not suitable for pediatric use and often requires a grinding operation or a dose fractionation to facilitate administration. In addition to a potential risk of imprecision in the administered dose, tablet grinding might unnecessarily expose nurses and families to a toxic compound. To overcome this problem, the objective of this study was to develop and evaluate the physicochemical and microbiological stabilities of azathioprine in a sugar-free, alcohol-free, and paraben-free InOrpha suspending agent. The studied samples were formulated into a 10-mg/mL suspension and stored in 24 plastic bottles of 60 mL at two different temperature conditions (between 2 degrees C to 8 degrees C and room temperature). Two series of 12 samples were tested for physicochemical stability using high-performance liquid chromatography as well as for a microbiological status for 35 days (daily opening of the bottles from day 0 of compounding) and for 56 days, upon daily flask opening (first opening at day 28 from compounding and daily opening for 28 consecutive days). The high-performance liquid chromatography method developed is linear, accurate, precise, and robust. In addition, a forced degradation study validated the selectivity and the specificity requirements of the method validated as stability indicating. At room temperature storage, high-performance liquid chromatography analysis showed that tested samples had concentrations ranging from 90% to 110% of the initial concentration throughout the course of the study. Microbiological status remained stable during the 56 days of investigation. Based on the data collected, the study led to the development of a new Galenic formulation of azathioprine that is suitable for pediatric use and can be safely stored at room temperature for 28 days (before and after opening for a maximum of 56 consecutive days).

Hydrocortisone is principally used as replacement therapy in adrenocortical deficiency states. In pediatric practice, posology ranges from 10 to 20 mg/m2 per day, divided in three doses, for the purpose of mimicking the nycthemeral cycle. Hydrocortisone is marketed in France in tablet form that contains 10 mg of the active ingredient. This galenic formulation is not suitable for pediatric use, and often requires a grinding operation or a dose fractionation to facilitate administration. To overcome this difficulty, the objective of this study was to develop and evaluate the physicochemical and microbiological stabilities of hydrocortisone in a sugar-free, alcohol-free, and paraben-free InOrpha suspending agent. The studied samples were formulated into a 2-mg/mL suspension and stored in glass bottles at two temperature conditions, between 2 degrees C to 8 degrees C and at room temperature). Two series of twelve samples were tested for physicochemical stability using high-performance liquid chromatography as well as for a microbiological status for 28 days (daily opening of the bottles from day 0 of compounding) and for 56 days (first opening at day 28 from compounding and daily opening for 28 consecutive days). The high-performance liquid chromatography method developed is linear, accurate, precise, and robust. On the other hand, a forced degradation study has demonstrated the selectivity and specificity of the method validated as stability indicating. In both storage conditions, high-performance liquid chromatography analysis showed that tested samples had concentrations ranging within 90% to 110% of the initial concentration for 28 consecutive days upon daily bottle opening and, for a maximum of 42 days with a first opening at day 28 from the compounding time. Microbiological status remained stable throughout the course of the study. Based on the data collected, the study led to the development of a new galenic formulation of hydrocortisone suitable for pediatric use which can be safely stored under refrigerated conditions or at room temperature for a maximum of 42 consecutive days.

OBJECTIVES This work includes (1) the characterization of a reproducible poly[lactide-coglycolide] (PLGA) microparticle preparation with an optimial mean diameter and size distribution and (2) the preliminary in vivo ultrasonographic investigation of PLGA microparticles. METHODS A first series of PLGA microparticle preparations (1 to 15 mum) was acoustically characterized on a hydrodynamic device to select the most appropriate for ultrasound contrast agent application. Preparations of 3-microm microparticles were selected, characterized at different doses, and then injected into 20 melanoma grafted mice for contrast-enhanced power Doppler ultrasonography evaluation. RESULTS The 3-microm microparticles (3.26-microm mean diameter with 0.41-microm standard deviation) led to in vitro enhancement of 18.3 dB at 0.62 mg/mL. In vivo experiments showed 47% enhancement of intratumoral vascularization detection after PLGA injection, significantly correlated (P < 0.0001) with preinjection intravascularization and tumoral volume. No toxicity was histologically observed. CONCLUSION The 3-microm PLGA microparticles provided significant enhancement in vitro and in vivo without any toxicity.

A specific and sensitive quantitative assay has been developed using high performance liquid chromatography–electrospray ionization mass spectrometry (HPLC–ESI-MS) for the simultaneous quantitation of the antitumor drug ifosfamide (IFM) and its two metabolites, N2-deschloroethylifosfamide (N2-DCE-IFM) and N3-deschloroethylifosfamide (N3-DCE-IFM) in microsomal medium. The analytes and the internal standard (cyclophosphamide) were isolated by ethylacetate extraction from rat liver microsomes. They were analysed on a Nucleosil® C18 HD column (125 mm × 4 mm, 5 μm) using a step gradient with the mobile phase (2 mM ammonium formate and methanol). The HPLC–ESI-MS method used selected ion monitoring of ions m/z 199.1 Th and m/z 261.1 Th and was validated in the concentrations ranges of 100–5000 ng/mL for IFM and 50–2500 ng/mL for its N-deschloroethylated metabolites (DCE-IFM) with good accuracy and precision (CV less than 15%). The low limits of quantitation (LLOQ) were found at 50 ng/mL for N-deschloroethylated metabolites and at 100 ng/mL for the parent drug (IFM). The method was applied for the determination of ifosfamide and its N-deschloroethylated metabolites in rat microsomal incubations.

Morphine and meperidine in Patient-Controlled Analgesic devices are commonly used to treat chronic pain patients. These devices deliver a programmed amount of drug and allow self-administration by the patient depending on the pain. In our department of pharmacy, 300 devices were manufactured in 2003. The aim of this study was to assess their shelf-life. The devices were filled aseptically and without preservatives with 1 and 40 mg/ml morphine solution and 5 and 20 mg/ml meperidine and stored over 30 days at room temperature and protected from light. Culture assay of the solutions showed that they remained sterile for 30 days. No turbidity of any solutions from samples collected twice a week was noticed. pH and osmolarity remained constant. Drug concentrations were determined using stability indicating HPLC method, as we showed that degradation products can be separated from the drugs. Little loss of meperidine occurred within 21 days (

The use of midostaurin, a multikinase inhibitor, has been associated with a response in 60% of patients with systemic mastocytosis, including mast-cell leukemia; the median overall survival was 28 months. A second, smaller trial in France showed a 71% response rate.

International audience; This study compares the performance of a reference method of HPLC to Raman spectroscopy (RS) for the analytical quality control (AQC) of complex therapeutic objects. We assessed a model consisting of a widely used anticancer drug, i.e., 5-fluorouracil, which was compounded in a complex medical device, i.e., an elastomeric portable infusion pump. In view of the main objective, the two methods provided excellent results for the analytical validation key criteria, i.e., trueness, precision and accuracy, ranging from 7.5 to 50mg/mL and in either isotonic sodium or 5% dextrose. The Spearman and Kendall correlation tests (p-value

As part of the development of a quality assurance program (QAP), a high performance thin layer chromatography (HPTLC) analysis unit was installed in the pharmacy department at Gustave-Roussy. The HPTLC-CAMAG consists of: 1) an HPTLC-Vario development chamber for optimization of the mobile phases; 2) TLC Sampler III automated sample applicators; 3) solid teflon migration chambers, i.e., horizontal tanks that enable separation to be carried out either in sandwich or in saturation mode; 4) a TLC Scanner 3 densitometer controlled by CATS 4 software; and 5) a Pentium MMX 233 MHz personal computer with an external backup unit. HPTLC quantitative and qualitative analysis has now reached a remarkably high level of development and performance. The samples (aqueous or non-aqueous solutions) that are to be processed are automatically applied by spraying (50-300 nl) in calibrated bands of a few mm (with up to 64 3-mm bands per 10 x 20 cm plate) on high-performance stationary phases and of wide technological diversity. The chromatogram is obtained in 10 min, and run over a migration pathway of 5-6 cm. The plates are read by absorption-reflection or fluorescence-reflection at an ad hoc wavelength (190-800 nm), then the peak areas which have been scanned are calculated by the trapezoid method. The calibration curves are generated by Michaelis-Menten non-linear regression, and validated by internal quality control. The analytical yield is high, i.e., up to 50 assays and 250 determinations per day. HPTLC analysis covers a wide functional range, and can be used in the following ways: 1) as a teaching tool for separative analysis and GLP; 2) it is an invaluable method for the optimization of mobile phases and for the determination of absorption spectra and absorption maxima, with a view to developing HPLC methods in complex matrices; 3) it provides major support for post-production quality control of prescribed hospital preparations of all types, e.g., those connected with parenteral nutrition, chemotherapy, synthetic narcotic analgesia; and it can also be used for dry dosage analysis; 4) it is useful in pharmaceutical assessment, e.g., in studies on the physico-chemical characteristics of various substances, such as their identity, purity, concentration, stability and compatibility, particularly with regard to generic products; 5) it can contribute to monitoring the safety of medical apparatus and equipment via the analysis of container-content interactions; 6) it provides a qualification system for personnel and procedures for within- and between-center validation of GMP. Setting up such an HPTLC quality control unit requires a basic investment of about 0.9 MF or 70,000 US dollars for a cost of no more than 10 F or 1.5 US dollars (including tax) per routine assay. After 18 months in operation and 16,500 assays, the HPTLC analysis unit has become one of the mainstays of the Gustave-Roussy QAP.

Resume Le departement de pharmacie clinique (DPC) de l'Institut Gustave-Roussy a developpe un progiciel de tracabilite integree au dossier patient. SIMBAD-TRACE® comporte : 1) un dictionnaire des produits industriels ; 2) un ecran d'acces specifique et un sous-deroulant a six domaines ; 3) une fenetre de selection pour la categorie objet ; 4) un ecran de saisie des lots de produits industriels ; 5) une composante historisation pour la fenetre de saisies-dispensations-retours ; 6) une composante dispensations-retours ; 7) un listing des dossiers de tracabilite non clotures ; 8) un ecran partage consultable en temps reel (les donnees ne peuvent etre modifiees par le consultant) et, 9) un ecran des vigilances destine a la realisation d'enquetes descendantes. L'unite fonctionnelle Tracabilite et Dispositifs Medicaux pilote les circuits de tracabilite des Medicaments Derives du Sang (MDS), de plus de 400 Dispositifs Medicaux Steriles (DMS) et, d'une facon generale, de tous les biens pharmaceutiques soumis a unimperatif de tracabilite. Le progiciel SIMBAD-TRACE® a ete developpe in situ et ouvert a la consultation en mars 1999. Il permet l'acces aux donnees de tracabilite pharmaceutique au moyen de 500 terminaux reunes en reseau. Les references tracees correspondent a pres de 10 000 mouvements par an. En terme de performance, le produit repond a trois objectifs complementaires : 1) le releve des scores de tracabilite qui traduisent la capacite du DPC et de l'etablissement a repondre au quotidien, et avec pertinence, a une exigence reglementaire complexe ; 2) la contribution de l'outil a la maitrise de la depense en matiere d'allocation de biens rares ; 3) la contribution du progiciel a la realisation d'enquetes de materiovigilance notamment descendantes. SIMBAD-TRACE® est un des piliers de notre Systeme d'Assurance Qualite (SAQ).

As with vancomycin, treatment with teicoplanin requires monitoring and dosage adjustment. As is often the case in dose adjustment, the decision is essentially based on measurements of trough concentrations ( C min ),i.e. 10–12 μg/ml in the case of teicoplanin. It appeared essential to validate the polarization immunoassay technique (FPIA) vs HPLC for low values as well as higher values. We compared an HPLC assay method with FPIA for the measurement of teicoplanin in the serum of 25 ICU patients (i.e. 211 samples). Equation C1 of the global correlation for HPLC vs. FPIA was: FPIA = 3.4398 + 0.8050HPLC ( R = 0.9716). The Student test revealed a significant difference between the two techniques. The real difference between the two techniques was assessed by means of an accuracy test: the FPIA method appears to be inaccurate over the concentration range analyzed in the study. Further, we verified whether the FPIA technique remained constantly inaccurate over C 1. A partial correlation C 2 corresponding to concentrations μ g/ml ( n = 112) was constructed. Application of the accuracy test led to the same conclusion as for C1: over this range of concentrations, the FPIA method remained inaccurate. The FPIA:HPLC concentration ratio, (1.09 ± 0.29 (0.49−2.15)) , indicates that the assays performed by FPIA tended to be overestimated. HPLC method remains the analytical reference and should be preferred to FPIA for the assay of TCN for pharmacokinetic or pharmacological research. For treatment monitoring, FPIA represents a simple method and also an alternative solution when HPLC is not available. Correlation observed with the reference chromatographic technique remains acceptable for concentrations of the order of 12 μg/ml and over while, for low concentrations, the FPIA method appears inaccurate.

We developed and validated quantitative bioanalytical liquid chromatography–tandem mass spectrometry assay for the protein kinase inhibitor, midostaurin. Plasma samples were pre-treated using a protein precipitation with methanol containing midostaurin-d5 as an internal standard. After centrifugation, 5 μL of the supernatant was injected into the chromatographic system. The system consisted of a 3.5 μm particle bonded octadecyl silica column, with gradient elution using a mixture of 0.1% (v/v) formic acid in acetonitrile and 10 mM ammonium formate in water with 0.1% formic acid. The analyte was quantified using the selected reaction-monitoring mode of a triple quadrupole mass spectrometer equipped with a heated electrospray interface. The assay was validated in a 75–2500 ng/mL calibration range. For quality control, within-day and between-day precisions were 1.2–2.8%, and 1.2–6.9%, respectively. The β-expectation tolerance limit (accuracy) met the limits of acceptance ±15% (±20% for the LLQ). The drug was sufficiently stable under all relevant analytical conditions. The assay has successfully been used to assess drug levels for therapeutic drug monitoring in patients presenting advanced systemic mastocytosis and treated with the promising midostaurin.

We have recently studied the relative affinity of fusidate (F) for various categories of albumin solutions in vitro, including plasma samples collected from hypoalbuminemic patients in surgical ICU. A metabolic model has been proposed in order to evaluate the theoretical consequences of the albumin status of a patient on F kinetics. On the other hand, it has been suggested by Peter et al. (1993) that pharmacokinetic changes observed for FA in patients with cholestasis are related to an alteration of the metabolism of the free fraction of fusidate (fuF), i.e. a marked increase, linked with the hypoalbuminemic status of the subjects. In order to verify in part our hypothesis and the one suggested by Peter et al. (1993), we studied the behaviour of the unbound fraction of F administered in the cholestatic individuals previously studied. Data obtained in vitro were compared to those determined after pharmacokinetic analysis in patients with cholestasis: (1) there was a significant increase in C max and C min of total and unbound F between the first and 10th infusion; (2) AUCs of fuF did not differ between groups of subjects; it could be considered that, at equal dose, behavior of fuF is not dependent upon the type of disease; (3) hypoalbuminemia cannot alone explain the marked increase in fuF seen in patients. We feel that results obtained in vivo are the product of hypoalbuminemia and of a picture of liver failure. Cholestasis in itself does not appear to play a preponderant role. In total, comparison of data obtained in this study shows the limitations of certain in vitro models.

Purpose: Activating KRAS mutations are frequent (>90%) in pancreatic ductal adenocarcinoma (PDAC) and drive downstream deregulation of both MAPK and PI3K-mTOR pathways. MEK inhibitors (MEKi) are under clinical evaluation in PDAC, in combination with other agents including PI3K-mTOR inhibitors. While RAS and BRAF mutations, EMT, PI3K-mTOR activation, and pERK inhibition have been suggested as predictive markers for MEKi efficacy, they are not validated in PDAC. We aimed to explore the cellular and molecular effects of MEKi GSK1120212 (GSK212) alone or in combination with PI3K-mTOR inhibitors, in PDAC cell lines and on an innovative ex vivo system. Methods: GSK212 is an allosteric non-ATP competitive MEKi, everolimus (Ev) a mTORC1 inhibitor, and BKM120 a pan-class PI3K inhibitor. Effects on proliferation were evaluated by MTT assay. Combinations were analyzed by the Chou-Talalay method. Protein expression was assessed by Western blot. Ex vivo drug assays were performed at different drug concentrations on cultures of fresh tumor tissue slices prepared from patient surgical specimens. Apoptosis and proliferation were assessed by cleaved caspase 3 (Cas-3) and MIB-1 (Ki67) immunostainings, respectively; MEKi sensitivity was defined as cleaved Cas-3 expression in 30% or more of cancer cells. Correlations between protein expressions were explored using linear regression and Pearson’s R2 calculation. Samples will be classified into PDAC subtypes according to Collisson’s, Moffit’s and Bailey’s transcriptomic signatures using non-negative matrix factorization and correlation methods. Results: MIAPaCa-2 and PANC-1 are two mesenchymal KRAS mutated/BRAF wild-type PDAC cell lines with very different response to GSK212, MIAPaCa-2 being sensitive (72h-IC50=0.009µM) and PANC-1 resistant (72h-IC50=33µM). MIAPaCa-2 was more sensitive than PANC-1 to Ev (IC50=23.3µM vs 47.0µM) and BKM120 (IC50=4.19µM vs 31.6µM). Combination of GSK212 and Ev or BKM120 for 72h resulted in synergistic effects (CI0.50 discriminated between sensitive and resistant tumors. There was no correlation with RAS/RAF mutation status. Predictive value of transcriptomic signatures for MEKi response will be presented. Conclusion: Response to combined MEK/mTOR pathway inhibition was not correlated with known biomarkers of response to MEKi. Besides the therapeutic potential of MEK/mTOR pathway inhibition in PDAC, this work provides the first evidence of feasibility of pharmacodynamic biomarker monitoring on fresh PDAC tissue slices. Citation Format: Cindy Neuzillet, Annemilaï Tijeras-Raballand, Anguraj Sadanandam, Pierre Bourgoin, Philippe Bourget, Pawan Poudel, Maria Serova, Armand De Gramont, Philippe Ruszniewski, Valérie Paradis, Eric Raymond, Jérôme Cros, Pascal Hammel.{Authors}. Effects of MEK inhibition alone or in combination with PI3K-mTOR pathway inhibitors in pancreatic ductal adenocarcinoma in vitro and on an innovative ex vivo fresh tumor tissue culture model. [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Advances in Science and Clinical Care; 2016 May 12-15; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2016;76(24 Suppl):Abstract nr B57.

Introduction: β-globin gene transfer into hematopoietic stem cells (HSCs) has the potential to reduce or eliminate the symptoms of severe sickle cell disease (SCD) and reduce or eliminate transfusion requirements in transfusion-dependent β-thalassemia (TDT). LentiGlobin Drug Product (DP) contains autologous CD34+ cells transduced with the BB305 lentiviral vector, which encodes a human β-globin gene containing a single point mutation (AT87Q) designed to confer anti-sickling properties similar to those observed with γ-globin. We previously reported proof of concept for LentiGlobin DP treatment in severe SCD and early data from 4 treated patients with TDT. We now report 18 months of follow-up for the patient with SCD and between 9 and 30 months of follow-up for the 4 patients with TDT. Patients (5-35 years of age) with severe SCD (e.g. ≥2 acute chest syndrome episodes or ≥2 vaso-occlusive crises [VOC] in preceding year/in year prior to regular transfusions) or TDT (≥100mL/kg of packed red blood cells [RBCs] per year) were enrolled. Following mobilization and apheresis (for TDT) or bone marrow harvest (for SCD), autologous CD34+ cells were transduced with the BB305 lentiviral vector. Patients underwent myeloablative conditioning with busulfan prior to infusion of the transduced cells. After infusion, patients were monitored for hematologic engraftment, vector copy number (VCN), and HbAT87Q expression. Disease-specific assessments included transfusion requirements for TDT, or VOCs and hospitalizations for SCD. Safety assessments included adverse events (AEs) and integration site analysis. Results: As of July 2016, 1 patient with severe SCD (male; 13 years old) and 4 patients with TDT (2 male, 2 female; 16-19 years old) have received LentiGlobin DP in Study HGB-205. The median LentiGlobin DP cell dose was 8.9 (range 5.6-13.6) x 106 CD34+ cells/kg with a DP VCN of 1.2 (range: 0.8-2.0) vector copies/diploid genome. Median post-infusion follow-up as of July 6, 2016 is 20.8 months (range 9.5-31.3). All subjects successfully engrafted after receiving LentiGlobin DP, with a median time to neutrophil engraftment of 17 days (range 14-38 days). VCN in peripheral blood has remained generally consistent from Month 3 in all patients with a range of 0.2 to 3.4 at last measurement. The toxicity profile observed from start of conditioning to latest follow-up remains consistent with myeloablative conditioning with single-agent busulfan, with no DP-related ≥Grade 3 AEs or serious AEs and no evidence of clonal dominance reported to date. Three patients with TDT have β0/βE genotypes and 1 is homozygous for the severe β+ mutation IVS1 nt 110 G>A. The 2 patients who have completed the 2-year primary follow-up period (both β0/βE) have not required RBC transfusions for 31 and 28 months, with total Hb of 10.9 and 13.5 g/dL, and HbAT87Q expression of 7.7 and 10.1 g/dL, respectively, at most recent study visit. Iron chelation has been discontinued and phlebotomy initiated for 1 of the patients. The remaining patient with β0/βE genotype has 9 months of follow-up and has not required transfusions since 4 days post-LentiGlobin DP infusion, achieving a total Hb of 11.3 g/dL at last study visit. The patient with the severe IVS1 genotype has 12 months of follow-up and has been free of transfusions for 9 months, with a total Hb of 8.3 g/dL at last study visit. The patient with severe SCD, who prior to study enrollment received regular RBC transfusions, has experienced no clinical symptoms or complications of SCD in the 18 months since treatment, despite discontinuing transfusions 3 months after LentiGlobin DP infusion. Total Hb in this patient was 12.5 g/dL, with 6.6 g/dL HbAT87Q (53%) and 5.7 g/dL HbS (45%) at last study visit. Compared with values at screening, unconjugated bilirubin had dropped 78% (50 to 11 μmol/L), lactate dehydrogenase had dropped 54% (626 to 287 U/L), and reticulocyte count had dropped 45% (238x109/L to 132x109/L) by Month 18. Conclusions: Data from this ongoing Phase 1/2 clinical study suggest that treatment with LentiGlobin DP can result in sustained production of therapeutic HbAT87Q, which ameliorates the clinical and biochemical effects of severe SCD and TDT, with an acceptable safety profile. Gene therapy presents a potentially promising therapy for patients with severe hemoglobinopathies. Further follow-up and additional data from patients are needed to confirm the encouraging results seen to date in this study. Disclosures Ribeil: Bluebirdbio: Consultancy; Addmedica: Research Funding. Payen:bluebird bio: Patents & Royalties. Hermine:Alexion: Research Funding; Celgene: Research Funding; Novartis: Research Funding; AB science: Consultancy, Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties, Research Funding, Speakers Bureau. Asmal:bluebird bio: Employment, Equity Ownership. Joseney-Antoine:bluebird bio: Employment, Equity Ownership. De Montalembert:Addmedica: Research Funding; Novartis: Research Funding, Speakers Bureau. Leboulch:bluebird bio, Inc: Consultancy, Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties, Research Funding.

Prazosin (PRZ) in conventional tablet form (P-CT) has the disadvantages of a relatively short terminal half-life, a slight solubility in water and the well-recognized adverse effect of symptomatic orthostatic hypotension. The pharmacokinetic study of a new rate-controlled formulation of prazosin (Prazosin-Gastrointestinal System: P-GS) was performed in 9 pregnant women during the third trimester of pregnancy. Patients had persistent elevation of blood pressure. The subjects gave their informed consent for oral administration of 1 daily dose of 5 mg P-GS at 8 a.m. A first analysis period on day 1 enabled definition of the initial pharmacokinetic behavior of the drug, while the aim of a second was to evaluate its fate at plateau. The clinical course of both mother and fetus was subsequently monitored. This was an open, non-randomized study, each patient serving as her own control. For 3 patients, we aimed to determine the possible transplacental passage of PRZ at delivery. PRZ levels were measured by HPLC and data were analysed by noncompartmental linear pharmacokinetic methods. The data show: (i) P-GS was well tolerated by all patients and there were no significant changes in fetal heart rate during the study. (ii) A significant decrease in diastolic blood pressure was observed after the 36th hour following the first dose of P-GS while a reduction in systolic blood pressure was observed on day 4. (iii) An approximated relative bioavailability (f'P-GS) of 36.5% was calculated. P-GS appears to have a lower bioavailability than P-CT in women of similar gestational age. (iv) Both Cmax and AUC0-->infinity are significantly increased at plateau. Further, terminal half-life is increased with regard to the value determined with P-CT. No accumulation of PRZ was noted at steady-state. (v) P-GS is an example of an oral zero-order absorption product that offers one approach to control and improve the outcome of hypertensive therapy during pregnancy. This treatment could represent an alternative to methyldopa as a first treatment of pregnancy-associated hypertension. (vi) There is a slight transplacental passage of the drug (of the order of 10-20%).

Fusidic acid (FA: Fucidine® Leo Laboratories) is a type I drug: acid, ionized at plasma pH, with a high intrinsic affinity for albumin. In the case of this kind of product, the possibility exists of the saturation of protein binding and of drug interactions. The relative affinity of fusidate (F) for different solutions of albumin was compared in vitro, i.e., purified industrial albumin, fresh frozen plasma, and plasma from surgical intensive care unit (ICU) patients. The theoretical consequences of the albumin status of a patient on FA kinetics were envisaged in the form of a model. The three stock solutions were diluted such that solution S1 yielded concentrations of 38, 29 and 19 g/l of albumin, and S2 provided concentrations of 44, 32 and 20 g/l of albumin. The concentration of solution S3 was initially 24 g/l (severe hypoalbuminemia). The seven solutions were spiked with known quantities of FA (10, 50, 100 and 150 mg/l) in which total F (tF) and free F (fuF) were assayed by HPLC. The per cent binding of F to albumin was determined, as was the number of binding sites (n) and its saturable or non-saturable character as a function of the medium (Scatchard plots). The conclusions drawn were: (1) the number of F binding sites on albumin is between two and three and the per cent binding of F is in the range of 91.5–98.7%; (2) Fucidine® belongs to the group of drugs sensitive to the albumin status of the media in which it is added; (3) the often severe hypoalbuminemia of ICU patients may lead to a considerable increase in the active fraction fuF; the most seriously affected patients should be more exposed to variations in the tF/fuF ratio; (4) the clinical status of the patients (kidney failure, malnutrition hypoalbuminemia, etc.) should be taken into account when determining the dosage schedules of parenterally administered FA. In summary, after repeated administration, the significant increase in fuF should induce the following: an increase in Vd, an increase then a decrease in Cl, a decrease then an increase in the AUC. The hypothesis according to which Fucidine® would be more effective in the hypoalbuminemic patient remains to be confirmed in selected patients with coupled measurements of tF anf fuF.

Pregnancy is a specific dynamic state, and the potential usefulness of caring for a disorder in the fetus or the mother is now well established. Previously, pregnant women have been excluded from clinical trials, therefore only a few studies concerning evaluation of the pregestational metabolism or transplacental transfer (TPT) of drugs exist. Questions regarding the TPT of drugs are extensive and complex. For example, does TPT occur at a given gestational age, in the context of a particular type of pathology or when a drug is administered by a certain dosage regimen? If this is the case, what is the rapidity of penetration of the products of conception by the drug (bearing in mind its physicochemical characteristics)? Need harmful adverse effects on the child be feared? Is such penetration desirable, of no consequence, or dangerous? Does the possibility exist of accumulation in the placenta, fetal tissue or amniotic fluid? Should such findings modify the therapeutic regimens of drugs given to expectant mothers? Exchange mechanisms are complicated and models developed in vitro only partially reflect the actual equilibria that exist between mother and fetus. These include: (i) the perfused cotyledon model, which while simple, elegant and inexpensive, offers only a localised, restricted and fixed view of pregnancy; (ii) isolated anatomical fractions that are informative, but which straddle the border between physiology and pharmacology; and (iii) the necessary study, using microsomes, of placental metabolic capacity (enzyme cartography). In vivo study of TPT is based upon various multicompartmental pharmacokinetic models, some of which have been relatively validated in animals. The simplest indicator for the in vivo evaluation of TPT of a drug in the human species is determination of a feto-maternal blood concentration ratio (usually performed at the time of placental separation). However, the usefulness and limitations of this parameter are controversial, and it would seem preferable to associate it with a pharmacokinetic profile of variations in blood concentrations established in the mother. Furthermore, any extrapolation of a single result to fetal and adjacent tissues must be done with the greatest caution. Although, no drug should be used in pregnancy unless there is a clear therapeutic indication, study of the TPT of therapeutically useful agents is essential to the understanding of their metabolism and is a prerequisite to the safe use of medications during pregnancy.

Allogeneic hematopoietic stem-cell transplant (allo-SCT) remains the only cure for many hematological malignancies and some benign and congenital diseases. Busulfan, proposed in its injectable form, has quickly become a mainstay of pharmacological and myeloablative (or non-myeloablative) conditioning. This is following the outbreak in 2010 of a multicenter international clinical phase II trial, we tested the robustness and reliability of our organization in a complex model of organization and multifactorial partnership. In this type "BuCy2" protocol based on a classical treatment duration of 4 consecutive days, the administration of IV busulfan is given in one single daily infusion instead of the conventional 16 infusions, while keeping the same total dose. Under these conditions, the treatment is totally secured using a therapeutic drug monitoring of busulfan, applied in real-time. The process is technically complex and requires the very close cooperation of the teams involved. A strength, weakness, opportunity and threat (SWOT) analysis has been constructed; it fully supports continuous quality improvement to the triple benefit of the nursing chain, the patients and their environment. Several critical points were identified and corrected. The experiment strongly contributes to the safety and security of the medication circuit at the hospital and, improves the performance of allo-SCT. It also contributes to the protection of all actors in the health field and their working environment via a well-functioning quality management system.

Objective To determine the optimal dose and route of methotrexate (MTX) in the treatment of ectopic pregnancy (EP). Design Prospective randomized study. Setting Department of Obstetrics and Gynecology (A. Beclere Public Hospital, Clamart, France, Paris-Sud University). Patients and Methods Forty-eight patients with unruptured EP clearly visualized by ultrasound were randomly allocated into four groups of treatment (12 patients in each group): group 1,1mg/kg injected locally in the ectopic gestational sac and 1mg/kg by IM administration 48hours later; group 2, 1mg/kg locally; group 3, 0.5mg/kg locally; group 4, 1mg/kg by IM administration. Inclusion criteria used a pretherapeutic score ≤12. Blood samples were collected at time 0.25, 0.5, 1, 2, 6, 12, 24, 36, and 48hours after MTX administration. Pharmacokinetics of MTX plasma levels were measured by fluorescence polarization immunoassay. Kinetic parameters were compared by Wilcoxon test and Mann-Whitney test. Plasma hCG concentrations were assessed on days 2, 5, and 10 and then weekly until they returned to undetectable levels. Results Success rate was 12 of 12, 11 of 12, 10 of 12, and 10 of 12 in groups 1, 2, 3, and 4, respectively. Six patients in group 3 required an additional MTX IM injection because of an inadequate decrease of hCG plasma levels. Five patients underwent surgery for abdominal pain or inadequate decrease of hCG. Area under the curve decreased more rapidly after injection in the gestational sac alone than after IM injection and was similar in groups 1 and 2 after local injection and lower in group 3. Terminal half-life and mean residence time remained similar in the four groups. Systemic side effects of MTX therapy occurred in three cases in groups 1 and 4. The regression curve of hCG plasma levels appeared similar in the four groups with a decrease to pretreatment values between days 6 and 8 after an initial rise after MTX was given. Conclusion Area under the curve found after injection in the ectopic sac may be related to a decrease in bioavailability of MTX that links to trophoblastic cells. Patients in group 3 were clearly undertreated by 0.5mg/kg MTX and required additional therapy. Residual values of MTX plasma levels were always below the limit of detection of our assay and confirmed that citrovarum factor rescue is unnecessary. Injection of 1mg/kg of MTX in the ectopic sac appears as effective as systemic (IM) injection with less side effects for the patients.

Gérard Guiffant1, Jean-Jacques Durussel1, Patrice Flaud1, Jean-Pierre Vigier1, Christian Dupont2, Philippe Bourget3, Jacques Merckx11University Paris Diderot, Paris, France; 2University Teaching Hospital Cochin, Paris, France; 3University Teaching Hospital Necker-Enfants Malades, Paris, FranceAbstract: The use of elastomeric diffusers (EDs) has grown together with the expansion of home care. In these devices, the fill volume of the drug reservoir and the flow rate are preset and cannot be modified. The elastomer, which makes up the reservoir walls, is what makes the infusate flow due to the pressure it exerts. The purpose of this work was to quantify, under standardized experimental conditions and following recommended conditions of use, the mechanical performances of the 2 commonly used elastomers (silicone and polyisoprene) and their impact on infusion flow rate consistency. Results show that they exhibit different mechanical performances which leads to concerns regarding the use of these devices for some intravenous (IV) therapies.Keywords: elastomeric diffusers, perfusion, drug administration rate, infusion flow, infusion devices

Orthostatic hypotension is frequently observed in the elderly population and has been previously identified as a significant risk factor for increased mortality. The link between this condition and increased mortality could be due to an abnormal circadian pattern of blood pressure. The absence of a physiological nocturnal decrease in blood pressure is termed the non-dipping pattern. This abnormality is relatively frequent in elderly people suffering from orthostatic hypotension, but its prevalence in the diabetic geriatric population is unknown. The purpose of this study is to compare blood pressure profiles on ambulatory blood pressure monitoring (ABPM) in a sample of elderly diabetic subjects suffering from orthostatic hypotension with those without postural hypotension. One hundred and ninety-eight patients were recruited by mail. The presence or absence of orthostatic hypotension was determined. They all subsequently underwent ABPM. One hundred and thirty-one of our subjects (68%) suffered from orthostatic hypotension; of these, 76% had a non-dipping pattern on ABPM, compared with 74% of the subjects not suffering from orthostatic hypotension (P = NS). This study thus demonstrates the high prevalence of orthostatic hypotension in an elderly diabetic population. On the other hand, we could not demonstrate a correlation between the non-dipping pattern and the presence of orthostatic hypotension. This is in contrast with previous work done in a non-diabetic elderly population. Further studies are needed to determine the effect of diabetes on blood pressure.

Objective: The opportunity to apply a sampling plan was evaluated. Costs were computed by a microcosting study. Setting: In 2003, a sampling plan was defined to reduce the number of chemotherapy quality controls while preserving the same level of quality. Recent qualitative and quantitative changes led us to define a second sampling plan supplemented by an economic evaluation to determine the cost and cost-savings of quality control. Methods: The study considers preparation produced during four semesters classified into three groups. The first one includes drugs produced below 200 batches a semester. Group 2, those for which the lot of preparation lots would have been rejected twice among these four semesters. Group 3, those would have been accepted (≥3 ‘acceptable lot’). A single sampling plan by attributes was applied to this group with an acceptance quality level of 1.65% and a lot tolerance percent defective below 5%. A micro-costing study was conducted on quality control, from the sampling to the validation of the results. Results: Among 39 cytotoxic drugs, 11 were sampled which enabled to avoid a mean of 17,512 control assays per year. Each batch of the 28 non-sampled drugs was however analyzed. Costs were estimated at 2.98€ and 5.25€ for control assays depending of the analytical method. The savings from the application of the sampling plans was 153,207€ in 6 years. Conclusion: The sampling plan allowed maintaining constancy in number of controls and the level of quality with significant costsavings, despite a substantial increase in drugs to assay and in the number of preparations produced.

The most common adverse outcome associated with vaginal delivery is endometritis. It plays a significant role in postpartum morbidity and mortality. There is considerable evidence to support the idea that a single dose of antibiotic after vaginal delivery might decrease the incidence of postpartum endometritis. In this study the evaluation of the efficacy of antibiotic prophylaxis was based upon comparison of a group of patients given a single dose of Amox-CA (Augmentin®) with a group of patients without treatment. The study was performed in the Department of Obstetrics and Gynecology of the A. Beclere Public Hospital, Clamart, France (Paris-Sud University). The patients who were the subject of the study had delivered vaginally during the period of 1 year, and were free of any clinical diagnosis of chorioamnionitis or other extragenital infection, had a maternal temperature of less than 38°C during labor and 1 h after delivery, and had no history of allergy to penicillins or cephalosporins. After application of exclusion criteria, 1373 patients were randomized and 1291 included 610 in Group I given Amox-CA and 681 in Group II without any antibiotic. A single dose of 1.2 g of Amox-CA was given by intravenous injection, 1 h after delivery, in Group I. Patients of Group II received no injection. Postpartum status was evaluated before the patient left hospital and 2 weeks later. The two groups were similar in terms of demographic and clinical parameters. Four patients developed endometritis in Group I ( 4 610 , 0.66%). Sixteen patients in Group II developed endometritis ( 16 680 , 2.38%) (P = 0.013; 95% confidence interval (CI), 0.36–3.08%). The conclusion is that a single dose of Amox-CA was effective and safe in the prevention of postpartum endometritis. The cost of prophylaxis is 70% lower than the cost of infection, according to the number of patients and the severity of endometritis. These data suggest that a single dose of antibiotic prophylaxis after vaginal delivery would result in a decreased endometritis rate, with substantial economic saving.

This study was designed to investigate the use of oral mifepristone (RU 486) for the induction of natural expulsion of concepti in women with spontaneously interrupted pregnancy in the first trimester. It consisted of a double-blind placebo-controlled study of mifepristone (600 mg) against placebo. A total of 46 women consulting for interrupted pregnancy were diagnosed at ultrasound with no clinical sign of miscarriage. Measurements were made of the occurrence of natural expulsion, the frequency of complete expulsion, the need for subsequent surgical evacuation, analgesia and the need for transfusion. Natural expulsion occurred within 5 days in 82% of patients receiving mifepristone treatment versus 8% of placebo-treated patients (P0.001). All patients experienced bleeding after RU 486 and two needed emergency aspiration for haemorrhagic expulsion. The treatment failed in four patients, who underwent evacuation under local anaesthesia. In the control group, 19 patients underwent evacuation under local (n = 10) or general (n = 9) anaesthesia. It was concluded that a standard oral pilot dose of 600 mg of mifepristone induces natural expulsion in 82% of women with non-developing first trimester intrauterine pregnancies.At the Hopital A. Beclere in Clamart, France, physicians randomly allocated 46 women with a non-developing, intrauterine pregnancy to either a group receiving a single dose of RU-486 (3 tablets = 600 mg) or a group receiving three tablets of a placebo so they could determine whether RU-486 without an associated prostaglandin could facilitate natural expulsion of the embryo in non-developing first trimester pregnancies with no clinical sign of spontaneous abortion. At the end of five days, natural expulsion was much higher in the RU-486 group than the placebo group (82% vs. 8%; p 0.001). The five-day course for spontaneous expulsion was acceptable for patients and physicians. All RU-486 patients experienced bleeding, compared to only 24% of placebo patients (p 0.01). Two RU-486 patients experienced frank hemorrhage on days two and three of treatment and required emergency aspiration. The 10% hemorrhaging rate equals that of the observed rate of natural expulsion, suggesting that hemorrhaging was likely due to natural expulsion rather than RU-486. RU-486 failed to induce natural expulsion in four women (18%) who then underwent evacuation under local anesthesia. These women had higher initial progesterone and human chorionic gonadotropin (HCG) levels and shorter amenorrhea (50-70 days) than those who did not experience treatment failure, suggesting a recent ending of trophoblastic activity. Dilation and aspiration were performed on 19 controls under local (10) or general (9) anesthesia. Between day one and day five, the total reduction in progesterone levels and in HCG levels was much greater in the RU-486 group than controls. These findings indicate that a single 600 mg dose of RU-486 is a sound way of managing non-developing pregnancies diagnosed during the first trimester.

Resume La pharmacocinetique du diazepam, benzodiazepine liposoluble a demi-vie longue, liee a plus de 98 % aux proteines plasmatiques, a ete etudiee apres administration d'une dose unique de 0,2 mg/kg chez 6 patients hospitalises en unite de soins intensifs et presentant une albuminemie inferieure a 25 g/l. L'etude a ete realisee dans sa phase initiale puis apres restauration albuminique, chaque sujet etant pris comme son propre temoin. Le diazepam a ete dose par chromatographie liquide-gaz. L'analyse statistique a utilise un test non parametrique T de Wilcoxon. Il existe, apres reequilibration albuminique, une diminution significative de la clairance d'elimination du diazepam ce qui conduit a une augmentation significative de l'aire sous la courbe des concentrations plasmatiques. Le volume apparent de distribution est significativement augmente en periode hypoalbuminique. La demi-vie terminale d'elimination du diazepam reste inchangee en raison d'une variation proportionnelle et dans le meme sens de son volume de distribution et de sa clairance. Ces perturbations sont attribuees a une augmentation de la fraction libre du diazepam en periode initiale hypoalbuminique. En dehors de toute insuffisance hepatique ou renale, ces resultats suggerent l'interet d'une surveillance therapeutique combinee a des bilans proteiques reiteres pour cette categorie de patients exposes a un risque d'hypersedation par remanence systemique.

Context The use of patient-controlled analgesia (PCA) allows patients to be managed at home and may increase the quality of life of patients with regard to drug administration. To ensure that intact drug is delivered to the patient in this setting, it is important to study its microbiological and physicochemical stability. Although these factors have been widely studied for many parenteral opioids, very few authors have investigated oxycodone stability associated with long-duration infusion in cancer patients. Objectives The aim of this study was to assess the microbiological and physicochemical stability of oxycodone hydrochloride solution in PCA devices and thereby to determine the feasibility of extending the expiration dates after mixing. Methods Sixteen CADD® reservoirs and 32 Rythmic® reservoirs were filled aseptically with pure (10mg/mL) and diluted (1mg/mL) oxycodone solution. Three different vehicles (0.9% sodium chloride, water for injection, and 5% dextrose) were used for dilution. Among the PCA systems stored over 28 days at room temperature, 16 Rythmic® reservoirs were protected from light. Microbiological stability was assessed by performing sterility tests. The physicochemical study was performed by determining aspect, pH, osmolality evolution, and weight. Drug concentrations were determined using the stability-indicating high performance liquid chromatography combined to ultraviolet detection technique. Results There was no significant change in pH, weight, and osmolality values of any solutions. No precipitation or change in color was observed in any of the sample solutions. There was no significant loss of oxycodone, and no trace of degradation products was detected. Conclusion This study indicates that pure and diluted oxycodone solutions in the PCA systems are stable for 28 days at room temperature when prepared aseptically.

Background: In patients with hemoglobinopathies, hematopoietic stem cell (HSC) gene therapy has the potential to induce production of functional β-globin in the red blood cell lineage with the aim of reducing or eliminating the symptoms of disease. Previous results from 1 subject with severe sickle cell disease (SCD; 6 months follow-up) and 2 subjects with β0/βE-thalassemia major (up to 15 months follow-up) treated in clinical study HGB-205 suggested that transplantation with autologous CD34+ cells transduced with the LentiGlobin BB305 lentiviral vector containing an engineered βA-T87Q-globin gene (LentiGlobin BB305 Drug Product) resulted in near-normal levels of total hemoglobin (Hb) and rapid clinical improvement. Here we provide data on a new subject enrolled and additional follow-up data on the 3 subjects previously presented in Study HGB-205. Subjects and Methods: Subjects with severe SCD underwent HSC collection via bone marrow harvest, while subjects with β-thalassemia major underwent HSC collection via peripheral blood apheresis following mobilization. CD34+ cells were selected and transduced with LentiGlobin BB305 lentiviral vector to produce the drug product. Subjects underwent myeloablation with intravenous busulfan, followed by infusion of drug product. Subjects were monitored for hematological engraftment, vector copy number, βA-T87Q-globin expression, adverse events and transfusion requirements. Integration site analysis (ISA) and replication-competent lentivirus (RCL) assays were performed. Prophylactic RBC transfusions were continued in subjects with SCD who were on chronic transfusion pre-transplant to maintain HbS Results: As of 31 July 2015, 1 subject with severe SCD (Subject 1204, βS/βS with multiple vaso-occlusive crises, silent infarct, acute chest syndrome, and on prophylactic transfusions) and 3 subjects withβ-thalassemia major (Subjects 1201, 1202 and 1203) have been infused with the LentiGlobin BB305 Drug Product. The outcome of these subjects to date is shown in Table 1. No subject has experienced a drug product-related adverse event, and ISA analyses demonstrate highly polyclonal reconstitution without clonal dominance. The subject with severe SCD is producing approximately 51.5% of anti-sickling hemoglobin (48% HbAT87Q, 1.8% HbF, 1.7% HbA2) at 9 months post-infusion. This subject has not had a post-infusion hospitalization for a SCD-related event despite stopping chronic transfusions at Day +88. Both subjects with β0/βE-thalassemia major have remained transfusion-free for at least 15 months post-infusion, with a consistent expression of βA-T87Q-globin; the subject with β0/β0-thalassemia major has only had 1 month follow-up post-drug product infusion to date. Conclusion: The subject with severe SCD is producing approximately 51.5% anti-sickling globins with HbS of 48.5% and remains free of SCD-related events despite stopping chronic transfusion therapy. Two subjects with β0/βE-thalassemia major remain transfusion-free for at least 15 months post infusion of LentiGlobin BB305 Drug Product. Gene therapy using autologous HSC transduced with LentiGlobin BB305 lentiviral vector is a promising approach for the treatment of patients with hemoglobinopathies. Table 1. Demographics and Transplantation Outcomes Subject Age (years)/ Sex (M/F) Genotype BB305 Drug Product Day of Neutrophil Engraftment Drug Product- related Adverse Events Day of Last pRBC Transfusion Last Study Visit (Months) Hb at Last Visit (g/dL) VCNa CD34+ cell dose (x106 per kg) Subject with severe sickle cell disease HbAT87Q/HbF/ HbS/Total Hb 1204 13/ M βS/βS 1.2 / 1.0 5.6 Day +37 None Day +88 9M 5.5/0.2/5.5/11.4 Subjects with β-thalassemia major Hb AT87Q/ Total Hb 1201 18/ F β0/βE 1.5 8.9 Day +13 None Day +10 18M 7.8/10.7 1202 16/ M β0/βE 2.1 13.6 Day +15 None Day +12 15M 9.7/12.8 1203 19/ M β0/β0 0.8 8.8 Day +28 None Day +15 1M Pending/9.2 As of 31 July 2015 aVCN, vector copy number; F=female; M= Male for gender, and months for day of last follow-up Disclosures Payen: bluebrid bio: Consultancy. Beuzard:bluebird bio Inc: Consultancy, Equity Ownership. von Kalle:bluebird bio, Inc.: Consultancy. Sandler:bluebird bio, Inc.: Employment, Equity Ownership. Soni:bluebird bio, Inc.: Employment, Equity Ownership. De Montalembert:Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Leboulch:bluebird bio: Consultancy, Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties, Research Funding.

Introduction: Busulfan (Bu) is recognized worldwide as the cornerstone for HSCT conditioning regimens (CR). It has a narrow therapeutic window (TW), and graft rejection or toxicity are related to Bu exposure. In very young children, Bu exhibits large pharmacokinetic (PK) variability, and its metabolic clearance is non-linearly related to body weight (BW). In this setting, Bu dosage is stratified according to BW and commonly monitored once after the 1st of 16 total 2-hr infusions and finally, 96-hr exposure to this major alkylating agent. Given the narrow TW of Bu in relation to clinical outcomes and to better understand its PK/PD relationship, it is important to attempt to optimize both the duration and the intensity of exposure to Bu in children undergoing HSCT, whatever their BW and pathologies. Study objective: To optimize Bu duration/intensity exposure in children undergoing HSCT, we studied the possible contribution of double TDM of IV Bu dosing in children receiving Bu-based CR for HSCT, by comparing the expected targeted values of exposure after performing 1 PK (1st dose, PK1) and finally 2 PK (1st dose, PK1, and 9th dose, PK2). Patients and methods: In this single-centre* prospective observational study (05/2012-07/2015), the PK of Bu was performed using the NONMEM® software; a one-compartment PK model suitably fitted the concentrations vs. time data. The PK of Bu was assessed on 6 plasma samples (3 samples/PK) using a validated LC-MS/MS method, with area under the concentration-time curve (AUC) calculation from the 1st and 9th doses. AUC calculated after the 1st dose and extrapolated to the 16th one were compared intraindividually by the non-parametric Wilcoxon signed-rank test to the sum of AUC1-6 with TDM1 applied from the 7th dose with or without TDM2 applied from the 13th or 14th dose; p≤0.025 was considered statistically significant. 63 patients (Pts) undergoing HSCT were included with median follow up of 14 months [1-39]. Median age was 17 months [1-193] and BW 11 kg [3-59]. Most Pts had non-malignant diseases, received allogenic HSCT and Bu-based CR in combination with Flu (morphometric, disease and CR details will be provided). *one of the 14 French Pediatric BMT units, involved in the therapeutic monitoring of IV Bu dosing in children undergoing HSCT. Results: 63 Pts (37 males (59%) and 26 females (41%)) were included. According to the EBMT-ESID recommendations, a median Bu posology of 1 mg/kg 4x/day for 4 days [0.6-1.3 mg/kg] was given. We demonstrate that: (a) estimated total AUC obtained from 2 PK differ significantly from those calculated after none (p=8.6455 E-7) or PK1 alone (p=7.2157 E-8), (b) double TDM allows achieving no difference between the expected AUC [20,706-23,180 mmol/min] desired by the medical staff in view of diseases vs. estimated AUC (p=0.5285). In 2/63 (3.2%) Pts, PK analysis did not lead to change Bu dosage. In 11/63 (18%) and 15/63(24%) Pts, dosage was modified after PK1 (TDM1 Group) or PK2 alone, respectively. In 35/63 (56%) Pts, changes were required twice, after the 2 PK (Double-TDM Group). The mean total dose of Bu were as follows: (a) a theoretical value of 220.80 mg (20.11 mg/kg) would have been given through 16 consecutive infusions without any TDM, (b) 199.35 mg (18.08 mg/kg) were administered in the TDM1 Group (16 doses), (c) 246.00 mg (19.46 mg/kg) were administered in the Double-TDM Group, avoiding the infusion of 24.00 mg of Bu vs. PK1 alone in these Pts. In 16/63 (25%) Pts, a decision of discontinuation of Bu exposure was taken. Indeed, the value that was desired by the medical staff was achieved after 13 (6 Pts) or 14 (10 Pts) doses; the mean total amounts of Bu were 273.22 mg (14.96 mg/kg) and 225.88 mg (16.16 mg/kg), respectively, vs. 336.27 mg (18.45 mg/kg) and 262.56 mg (18.60 mg/kg) theoretically after TDM1 alone. Conclusion: In this large paediatric cohort, the double TDM of Bu is a relevant and feasible option to better control Bu exposure and to potentially minimize the risk of overexposure. Correlations with toxicities (VOD, aGVH), CR, OS are under analysis. Based on these data, the double-TDM procedure is routinely applied in our centre. Disclosures Petain: Laboratoires Pierre Fabre: Employment. Nguyen:Laboratoires Pierre Fabre: Employment.

Objectifs L’incidence des infections urinaires a germes producteurs de betalactamase a spectre etendu (BLSE) est en augmentation. Elles sont associees a une hospitalisation prolongee pour les patients (Pts) necessitant des interventions chirurgicales urologiques. L’objectif de cette etude etait de demontrer qu’une diffusion intra-prostatique significative d’ertapeneme etait obtenue apres une seule administration intraveineuse (IV) avant chirurgie prostatique. Methodes Vingt Pts avec indication de chirurgie pour hyperplasie benigne de prostate etaient inclus prospectivement et divises en 2 groupes ; 19 Pts etaient analyses. Les Pts recevaient une dose d’1 gramme IV d’ertapeneme 1 heure ( n = 10, groupe A) ou 12 heures ( n = 9, groupe B) avant prelevements sanguins et prostatiques (copeaux de resection) ( Fig. 1 ). Les concentrations plasmatiques et intra-prostatiques d’ertapeneme etaient mesurees par chromatographie en phase liquide couplee a la spectrometrie de masse tandem (LC-MS/MS). Les concentrations intra-prostatiques etaient considerees comme satisfaisantes si elles etaient superieures aux concentrations minimales inhibitrices90 (CMI90) des pathogenes cibles urinaires. Un test de Wilcoxon et un modele predictif pharmacocinetique etaient utilises. Resultats Les concentrations plasmatiques medianes d’ertapeneme etaient de 144,3 mg/L (IC95 % ; 126,5–157,9) dans le groupe A et de 30,7 mg/L (IC95 % ; 22,9–36,4) dans le groupe B ( p p P. vulgaris ) et 1 mg/L (contre Enterobacter spp) ( Fig. 2 ). Le rapport concentration plasmatique sur concentration intra-prostatique n’etait pas significativement different entre les groupes ( p = 0,97), en faveur d’une diffusion intra-prostatique similaire independamment de l’intervalle de temps entre administration et chirurgie. Les analyses pharmacocinetiques retrouvaient une demi-vie de 4,8 h pour l’ertapeneme comparable a la litterature. Conclusion Une seule dose d’ertapeneme administree en preoperatoire 1 heure avant l’intervention en IV permet d’obtenir des concentrations plasmatiques et intra-prostatiques satisfaisantes. Ces resultats suggerent qu’il pourrait s’agit d’une strategie prophylactique interessante pour les Pts porteurs de BLSE necessitant des interventions sur les voies urinaires. Ces resultats necessitent d’etre confirmes dans de futurs essais prospectifs.