Dosage individualization for a critical care patient treated with amikacin for suspected ventilator-associated pneumonia, using the population pharmacokinetic (ppk) model of Burdet et al. 2015, using the data from therapeutic drug monitoring (TDM).
mod_amikacin_Burdet2015 <- function() {
    ini({
      THETA_Cl=4.3
      THETA_Vc=15.9
      THETA_Vp=21.4
      THETA_Q=12.1
      ETA_Cl + ETA_Vc + ETA_Vp + ETA_Q ~
        c(0.1,
          0.01     ,   0.05 ,
          0.01     ,   0.02 ,   0.2  ,
          -0.06    ,   0.004,   0.003,    0.08)
      add_sd <- 0.2
      prop_sd <- 0.1
    })
    model({
      TVCl  = THETA_Cl*(CLCREAT4H/82)^0.7
      TVVc  = THETA_Vc*(TBW/78)^0.9*(PoverF/169)^0.4
      TVVp  = THETA_Vp
      TVQ   = THETA_Q
      Cl    = TVCl*exp(ETA_Cl)
      Vc    = TVVc*exp(ETA_Vc)
      Vp    = TVVp*exp(ETA_Vp)
      Q     = TVQ *exp(ETA_Q)
      ke    = Cl/Vc
      k12   = Q/Vc
      k21   = Q/Vp
      Cp    = centr/Vc
      d/dt(centr)  = - ke*centr - k12*centr + k21*periph
      d/dt(periph) =            + k12*centr - k21*periph
      Cp ~ add(add_sd) + prop(prop_sd) + combined1()
    })
  }After the first administration, the dosage selection can be refined
using the results of TDM. See
vignette("patient_data_input") for more details regarding
the patient record.
df_patientA <- data.frame(ID=1,TIME=c(0,1,6),
                              DV=c(NA,58,14),
                              EVID=c(1,0,0),
                              AMT=c(2000,0,0),
                              DUR=c(0.5,NA,NA),
                              CLCREAT4H=50,TBW=62,PoverF=169)
df_patientA
#>   ID TIME DV EVID  AMT DUR CLCREAT4H TBW PoverF
#> 1  1    0 NA    1 2000 0.5        50  62    169
#> 2  1    1 58    0    0  NA        50  62    169
#> 3  1    6 14    0    0  NA        50  62    169The concentration measured 30 min after a 30 min infusion do not meet the target for a peak concentration; it is < 60 mg/L.
The maximum a posteriori (MAP) individual parameters are estimated.
The individual pharmacokinetic profile can be plotted using the
rxode2 model provided by the poso_estim_map()
function.
With the MAP estimates of the individual parameters, the prediction of the time needed before reaching the target Cmin can be updated.
poso_time_cmin(dat=df_patientA,
               prior_model=mod_amikacin_Burdet2015,
               tdm = TRUE,
               target_cmin = 2.5)
#> $time
#> [1] 33.9
#> 
#> $type_of_estimate
#> [1] "point estimate"
#> 
#> $cmin_estimate
#> [1] 2.487865
#> 
#> $indiv_param
#>   THETA_Cl THETA_Vc THETA_Vp THETA_Q add_sd prop_sd    ETA_Cl    ETA_Vc
#> 3      4.3     15.9     21.4    12.1    0.2     0.1 0.4499479 0.2730561
#>      ETA_Vp    ETA_Q CLCREAT4H TBW PoverF
#> 3 0.7061648 -0.13884        50  62    169The next dose (if needed) can be administered 33.9 hours following the first infusion.
The optimal dose to achieve a peak concentration of 80 mg/l can be determined using the MAP estimates.
map_dose <- poso_dose_conc(dat=df_patientA,
                           prior_model=mod_amikacin_Burdet2015,
                           tdm=TRUE,
                           time_c = 35,               #target concentration at t = 35 h
                           time_dose = 34,            #dosing at t = 34 h
                           duration = 0.5,
                           target_conc = 80)
map_dose
#> $dose
#> [1] 2447.917
#> 
#> $type_of_estimate
#> [1] "point estimate"
#> 
#> $conc_estimate
#> [1] 80
#> 
#> $indiv_param
#>   THETA_Cl THETA_Vc THETA_Vp THETA_Q add_sd prop_sd    ETA_Cl    ETA_Vc
#> 3      4.3     15.9     21.4    12.1    0.2     0.1 0.4499608 0.2730596
#>      ETA_Vp      ETA_Q CLCREAT4H TBW PoverF
#> 3 0.7061496 -0.1388505        50  62    169The next dose should be 2450 mg.
The optimal inter-dose interval to reach a Cmin of 2.5 mg/L before each dosing can be determined using the MAP estimates.
map_interval <- poso_inter_cmin(dat=df_patientA,
                                prior_model=mod_amikacin_Burdet2015,
                                dose = map_dose$dose,
                                duration = 0.5,
                                target_cmin = 2.5)
map_interval
#> $interval
#> [1] 38.57781
#> 
#> $type_of_estimate
#> [1] "point estimate"
#> 
#> $conc_estimate
#> [1] 2.500173
#> 
#> $indiv_param
#>   THETA_Cl THETA_Vc THETA_Vp THETA_Q add_sd prop_sd   ETA_Cl    ETA_Vc
#> 1      4.3     15.9     21.4    12.1    0.2     0.1 0.449952 0.2730587
#>      ETA_Vp      ETA_Q CLCREAT4H TBW PoverF
#> 1 0.7061588 -0.1388432        50  62    169The interval between doses should not be less than 38.6 hours to allow adequate elimination of amikacin between each infusion.