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Direct Thrombin Inhibitors in Treatment and Prevention of Venous Thromboembolism: Dose – Concentration – Response Relationships
Uppsala University, Medicinska vetenskapsområdet, Faculty of Pharmacy, Department of Pharmaceutical Biosciences, Division of Pharmacokinetics and Drug Therapy.
2006 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

For prevention and treatment of thrombotic diseases with an anticoagulant drug it is important that an adequate dose is given to avoid occurrence or recurrence of thrombosis, without increasing the risk of bleeding and other adverse events to unacceptable levels. The aim of this thesis was to develop mathematical models that describe the dose-concentration (pharmacokinetic) and concentration-response (pharmacodynamic) relationships of direct thrombin inhibitors, in order to estimate optimal dosages for treatment and long-term secondary prevention of venous thromboembolism (VTE).

Population pharmacokinetic-pharmacodynamic models were developed, based on data from clinical investigations in healthy volunteers and patients receiving intravenous inogatran, subcutaneous melagatran and/or its oral prodrug ximelagatran. The benefit-risk profiles of different ximelagatran dosages were estimated using clinical utility functions. These functions were based on the probabilities and fatal consequences of thrombosis, bleeding and elevation of the hepatic enzyme alanine aminotransferase (ALAT).

The studies demonstrate that the pharmacokinetics of melagatran and ximelagatran were predictable and well correlated to renal function. The coagulation marker, activated partial thromboplastin time (APTT), increased non-linearly with increasing thrombin inhibitor plasma concentration. Overall, the systemic melagatran exposure (AUC) and APTT were similarly predictive of thrombosis and bleedings. The identified relationship between the risk of ALAT-elevation and melagatran AUC suggests that the incidence approaches a maximum at high exposures. The estimated clinical utility was favourable compared to placebo in the overall study population and in special subgroups of patients following fixed dosing of ximelagatran for long-term secondary prevention of VTE. Individualized dosing was predicted to add limited clinical benefit in this indication.

The models developed can be used to support the studied dosage and for selection of alternative dosing strategies that may improve the clinical outcome of ximelagatran treatment. In addition, the models may be extrapolated to aid the dose selection in clinical trials with other direct thrombin inhibitors.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis , 2006. , p. 71
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Pharmacy, ISSN 1651-6192 ; 35
Keywords [en]
Pharmaceutical biosciences, Ximelagatran, pharmacokinetic, pharmacodynamic, activated partial thromboplastin time, utility function, dosing strategy, venous thromboembolism, NONMEM
Keywords [sv]
Farmaceutisk biovetenskap
Identifiers
URN: urn:nbn:se:uu:diva-6872ISBN: 91-554-6563-3 (print)OAI: oai:DiVA.org:uu-6872DiVA, id: diva2:168336
Public defence
2006-05-24, Lecture hall B22, Biomedical Centre (BMC), Husargatan 3, Uppsala, 10:00
Opponent
Supervisors
Available from: 2006-05-02 Created: 2006-05-02Bibliographically approved
List of papers
1. Population modelling of the effect of inogatran, at thrombin inhibitor, on ex vivo coagulation time (APTT) in healthy subjects and patients with coronary artery disease
Open this publication in new window or tab >>Population modelling of the effect of inogatran, at thrombin inhibitor, on ex vivo coagulation time (APTT) in healthy subjects and patients with coronary artery disease
2001 (English)In: British Journal of Clinical Pharmacology, ISSN 0306-5251, E-ISSN 1365-2125, Vol. 51, no 1, p. 71-79Article in journal (Refereed) Published
National Category
Pharmaceutical Sciences
Identifiers
urn:nbn:se:uu:diva-94472 (URN)10.1046/j.1365-2125.2001.01326.x (DOI)
Available from: 2006-05-02 Created: 2006-05-02 Last updated: 2018-01-13Bibliographically approved
2. Utility of ecarin clotting time, an ex vivo coagulation test, for pharmacokinetic analysis of the direct thrombin inhibitor melagatran
Open this publication in new window or tab >>Utility of ecarin clotting time, an ex vivo coagulation test, for pharmacokinetic analysis of the direct thrombin inhibitor melagatran
(English)Article in journal (Refereed) Submitted
Identifiers
urn:nbn:se:uu:diva-94473 (URN)
Available from: 2006-05-02 Created: 2006-05-02 Last updated: 2011-06-21Bibliographically approved
3. Pharmacokinetics of ximelagatran and relationship to clinical response in acute vein thrombosis
Open this publication in new window or tab >>Pharmacokinetics of ximelagatran and relationship to clinical response in acute vein thrombosis
Show others...
2005 (English)In: Clinical Pharmacology and Therapeutics, ISSN 0009-9236, E-ISSN 1532-6535, Vol. 77, no 4, p. 279-290Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE:

Our objective was to characterize the pharmacokinetics of melagatran, the active form of the oral direct thrombin inhibitor ximelagatran, and the relationship between melagatran exposure and clinical outcome in patients with acute deep vein thrombosis.

METHODS:

A population pharmacokinetic analysis was performed on samples from patients with deep vein thrombosis participating in a randomized dose-finding study (THRombin Inhibitor in Venous thrombo-Embolism [THRIVE I]). Patients received fixed doses of oral ximelagatran (24, 36, 48, or 60 mg twice daily) for 12 to 16 days. Thrombus size was evaluated by venography before and after treatment. Exposure-response curves were characterized for the probability of regression, no change, and progression of the thrombus extension and of having a bleeding-related event, by use of logistic regression models.

RESULTS:

The pharmacokinetics of melagatran (1836 samples in 264 patients) was predictable, without significant time or dose dependencies. Clearance after oral administration (population mean, 27.3 L/h) was correlated with creatinine clearance (P < 10(-6)), and volume of distribution (population mean, 176 L) was correlated with body weight (P = 2 x 10(-5)). Gender, age, or smoking did not significantly influence melagatran pharmacokinetics after the influence of renal function and body weight was accounted for. Unexplained interpatient variability values in total plasma clearance and bioavailability were 19% and 21%, respectively. The median area under the plasma melagatran concentration versus time curve across all patients and dose levels was 3.22 h x micromol/L (5th-95th percentiles, 1.35-7.69). There was no significant relationship between area under the plasma concentration versus time curve and change in thrombus extension (P = .59) or bleeding-related events (P = .77), and the estimated exposure-response curves were relatively flat.

CONCLUSIONS:

The pharmacokinetics of melagatran in patients with acute deep vein thrombosis was predictable after oral ximelagatran administration. Shallow exposure-response curves for efficacy and bleeding indicate that there is no need for individualized dosing or therapeutic drug monitoring in the patient population studied.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-94474 (URN)10.1016/j.clpt.2004.11.001 (DOI)15903126 (PubMedID)
Available from: 2006-05-02 Created: 2006-05-02 Last updated: 2017-12-14Bibliographically approved
4. Ximelagatran in extended secondary prevention of venous thromboembolism: Pharmacokinetics, pharmacodynamics and relationships to clinical events
Open this publication in new window or tab >>Ximelagatran in extended secondary prevention of venous thromboembolism: Pharmacokinetics, pharmacodynamics and relationships to clinical events
Show others...
Manuscript (Other academic)
Identifiers
urn:nbn:se:uu:diva-94475 (URN)
Available from: 2006-05-02 Created: 2006-05-02 Last updated: 2011-03-01

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