2. David-Neto et al Ther Drug Monit Volume 34, Number 3, June 2012
(TAC), associated with MMF, leads to an increased exposure 180, and 360 days (periods) posttransplant and were admitted
to MPA particularly due to intestinal reabsorption of the on the evening before the PK study to ensure that medication
MPAG between 6 and 12 hours after the oral dose.11,12 On the was administered exactly at 8 PM on that the day. After a
other hand, this intestinal reabsorption does not occur or 12-hour overnight fast, blood was drawn at 8 AM (C0), and
occurs in much smaller amounts when Cyclosporin A the patients were given the drugs. Blood samples were then
(CyA) is used with MMF. collected at 1, 2, 3, 4, 6, 8, 10, and 12 hours postdose, and the
Also, there is no substantial information regarding patients were discharged after the last sample had been
whether the observed effect of PPIs on MPA absorption lasts drawn. Blood samples were stored in ethylenediaminetetra-
over time. For example, the absorption of MPA presents acetic acid tubes. The total MPA concentration was deter-
a time-dependent increase in exposure.13,14 It could be that mined by MPA–enzyme multiplied immunoassay technique
this increase in bioavailability over time could make the PPI (EMIT) 2000 assay, with an EMIT 2000 (Dade-Behring,
effect on MPA absorption clinically irrelevant after a certain United States). Total blood TAC levels were measured by
period of time. the Abbott IMx and CyA by TDx. The MPA-EMIT 2000
Therefore, there are many aspects of the effect of PPIs assay measures the total MPA and the acyl-metabolite
on MPA absorption that need to be addressed. AcMPA and gives results 6%–8% higher than those obtained
The aim of this study was to analyze the influence of using high-performance liquid chromatography. All PK
omeprazole on MPA-PK throughout the first year after parameters were analyzed, including area under the curve
transplantation in a large number of PK samplings performed (AUC)0–12h, maximum concentration (Cmax), trough level
in renal transplant recipients, using both CNIs along with (C0), and MPA concentrations at 1, 2, 3, 4, 6, 8, 10, and 12
MMF, in a cross-sectional retrospective analysis of MPA-PKs hours postdose (C1, C2, C3, C4, C6, C8, C10, and C12, respec-
obtained at sequential periods of time after transplantation. tively). To take into account the confounding factor of MMF
drug dose changes, MPA-PK parameters were analyzed both
unadjusted and adjusted for the respective MMF dose (milli-
METHODS AND PATIENTS grams per kilogram per dose) at each time point. The unad-
justed AUC0–12h was analyzed to verify whether or not
Study Design and Patients patients were exposed to the MPA therapeutic window during
The studies from which the data were derived were each period after transplantation.
approved by the Hospital das Clinicas of the University of
Sao Paulo School of Medicine Committee on ethics in Statistical Analyses
research (CAPPesq). Additionally, this retrospective analysis For statistical data analysis, the SPSS software package
received approval by the same committee (0564/11). was used (SPSS 16.0 for Windows; SPSS Inc, Chicago, IL).
This analysis included patients who had participated in Values of continuous variables are expressed as the mean ±
the previous studies13,15,16 from our group regarding MPA-PK SD. The chi-square test was used to test differences in rates
and had at least 1 complete 12-hour PK. To summarize the and proportions. One-way analysis of variance (ANOVA)
population of the 2 trials, male and female patients aged was used to compare differences among continuous variables
18–65 years, recipients of a non-HLA identical kidney allo- between groups. Differences were considered statistically sig-
graft who presented panel reactive antibodies ,50% were nificant at P , 0.05. Because not all the patients performed
considered to be eligible for the trials. Women should use all the PKs and due to differences in the frequency of using
effective contraception, and those of childbearing age should the 2 calcineurin inhibitors, mixed-model ANOVA using
have a negative pregnancy test before enrolment. The subjects SAS version 9 (SAS Institute Inc Cary, NC) was used to
were excluded if they received a nonrenal organ, had a history analyze the PKs considering 3 concurrent variables: PPI,
of alcohol or illicit drug abuse, and/or had liver enzymes period after transplantation, and TAC or CyA.
.2 times the upper normal limit.
A search in the electronic database was performed to
find patients who were administered PPIs at each PK study. RESULTS
Only patients who used PPIs for at least 3 days before each Seventy-seven patients underwent 348 MPA-PK
PK sampling were considered as “with PPI” to ascertain sta- assessments during the analyzed period. The demographics
ble PPI levels. Assumption was made that oral drugs take at of those who performed the MPA-PK on day 7 (n = 72) under
least 4 times the half life to reach steady-state concentration in PPI or not are given in Table 1. These patients represented
plasma. The control patients were derived from the same a sample of our transplanted population, with the exception
studies but did not received PPIs during the PK study. PPI that our current practice was to use TAC with all the patients
doses refer to those used on the day of the PK study. with a few exceptions. The mean age of this study population
At each period after RTx, the patients were divided into was 41.7 ± 12.5 years, and most patients were white by origin
2 groups according to the administration of PPI: a control (69.4%). Most patients’ immunosuppression consisted of
group (without PPI) and a study group (with PPI). TAC and MMF (63.9%), and there were more organs trans-
planted from deceased donors (61.1%) than live donors.
Pharmacokinetics Omeprazole was the only PPI prescribed to this
The patients received MMF twice a day. They were population. Single doses were taken in the morning and
submitted to a 12-hour MPA-PK on visits of 7, 14, 30, 60, twice-a-day doses in the morning and at night. Table 2 shows
332 Ó 2012 Lippincott Williams Wilkins
3. Ther Drug Monit Volume 34, Number 3, June 2012 MPA Pharmacokinetics and PPIs
TAC (n = 224) and CyA (n = 124) patients, analyzed together
TABLE 1. Demographic Data of 72 Kidney Transplant
in all the periods.
Recipients With and Without PPIs Medication on Day 7 After
Transplantation By the mixed-model ANOVA, the PPI group had
a lower AUC0–12h (P = 0.0008) and lower Cmax (P =
Demographics PPI (%) No PPI (%) Total (%)
0.049), and these differences were not changed by the CNIs
Gender used either TAC or CyA and remain during the first year.
Female 23 (42.6) 10 (55.6) 33 (45.8) In the TAC group, the AUC0–12h and Cmax (adjusted by
Male 31 (57.4) 8 (44.4) 39 (54.2) dose) were 17.3% and 14.1% lower in the omeprazole group,
Age (yrs) 41.7 ± 12.5 41.8 ± 12.5 41.7 ± 12.5 respectively. There was also a lower MPA level at C10 (20%)
Race to C12 (22%) in the PPI group, the period of time when reab-
Oriental 1 (1.8) 1 (1.4) sorption of MPA from MPAG occurs. In the CyA group, the
White 36 (66.7) 14 (77.8) 50 (69.4) AUC0–12h and Cmax (adjusted by dose) were 17.9% and 22%
African Brazilian 17 (31.5) 4 (22.2) 21 (29.2) lower in the omeprazole group, respectively. Figures 2A–F
Baseline immunosuppression show the 12-hour unadjusted PKs at all visits. The AUC0–12h
Cyclosporine/MMF 22 (40.7) 4 (22.2) 26 (36.1) was lower in the PPI group compared with that in the non-PPI
TAC/MMF 32 (59.3) 14 (77.8) 46 (63.9) group at all visits. Similarly, the Cmax was lower at all the visits
Donor with the exception of days 14 and 360. By mixed-model
Deceased 34 (63.0) 10 (55.6) 44 (61.1) ANOVA, the effect of diminished exposure to MPA in the
Live 20 (37.0) 8 (44.4) 28 (38.9) PPI group remains statistically lower throughout the first year
Total 54 (100) 18 (100) 72 (100) (AUC0–12h, P = 0.005 and Cmax, P , 0.001).
No statistical differences were found. The adjusted-by-dose PK shows a 25.6% lower Cmax
(P = 0.039) and C12 (P = 0.021) on day 7 only, in the ome-
prazole group. During 14, 30, 60, and 180 days, average
the number of patients using omeprazole (CyA) and TAC and adjusted AUC0–12h was only 5.5%–10.6% lower in the ome-
their respective doses at each time point. Two patients of 30- prazole group.
day visits had been off CNIs 5 and 6 days, respectively, pre- On day 360, there was a lower MPA concentration at
vious to PK sampling, and their PK studies were excluded C8 through C12 (P = 0.018), and a 26.5% lower AUC0–12h
from this analysis at that specific period. (P = 0.04) in the PPI group.
Table 3 shows the number of patients within the defined
Pharmacokinetic Studies therapeutic window for MPA (AUC $ 30 ng$h/mL). By
The 348 PK sampling periods were grouped according univariate Cox analysis, the use of PPI was associated with
to the following visits: day 7 (n = 72), 14 (n = 63), 30 (n = a 25% less chance of being adequately exposed to MPA
66), 60 (n = 56), 180 (n = 61), and 360 (n = 30) after trans- (hazard ratio: 0.75; 0.58–0.99, P = 0.04) when all PK curves
plantation. They were also divided according to the CNI used were analyzed together.
(either TAC or CyA). Figures 1A and B show the effect of Figure 3 shows the mean (±SD) of the unadjusted 12-
PPI for all PK curves, adjusted for dose, performed in the hour AUC at all time points for the patients treated with and
TABLE 2. Number of Patients Using Omeprazole, CyA, TAC, and MMF and Their Respective Doses at Each Time-Point
Days Omeprazole CyA CyA TAC TAC MMF
Posttransplant Group N (mg/d) N (mg$kg21$d21) N (mg$kg21$d21) MMF (mg/d) (mg$kg21$d21)
7 With PPI 54 31.8 ± 12.0 22 11.3 ± 5.1 32 0.25 ± 0.08 1791.6 ± 282.1 28.8 ± 7.5
Without 18 4 9.8 ± 1.4 14 0.24 ± 0.07 1694.4 ± 250.8 30.7 ± 7.4
PPI
14 With PPI 47 29.8 ± 10.1 17 9.4 ± 1.8 30 0.24 ± 0.08 1734.0 ± 373.7 28.0 ± 8.8
Without 16 5 9.6 ± 1.6 11 0.27 ± 0.10 1718.7 ± 256.1 30.7 ± 7.1
PPI
30 With PPI 51 29.0 ± 12.2 20 7.5 ± 2.6 29 0.20 ± 0.06 1686.2 ± 360.0 27.0 ± 8.3
Without 15 5 8.7 ± 2.9 10 0.24 ± 0.08 1700.0 ± 316.2 30.6 ± 7.8
PPI
60 With PPI 39 27.1 ± 12.5 14 6.1 ± 2.4 25 0.17 ± 0.08 1692.3 ± 336.7 27.6 ± 7.4
Without 17 6 5.9 ± 1.7 11 0.16 ± 0.10 1676.4 ± 303.1 29.5 ± 8.9
PPI
180 With PPI 35 28.0 ± 13.0 11 4.7 ± 2.5 24 0.10 ± 0.04 1685.7 ± 322.8 26.7 ± 7.7
Without 26 10 4.3 ± 1.2 16 0.11 ± 0.04 1692.3 ± 285.5 28.5 ± 8.2
PPI
360 With PPI 11 29.0 ± 10.4 4 3.6 ± 0.5 7 0.07 ± 0.02 1863.6 ± 393.1 29.5 ± 8.3
Without 19 4 3.5 ± 1.0 15 0.08 ± 0.04 1736.8 ± 256.5 30.0 ± 8.7
PPI
Ó 2012 Lippincott Williams Wilkins 333
4. David-Neto et al Ther Drug Monit Volume 34, Number 3, June 2012
discussion because of the lack of assays to measure MPA in
most centers and inconclusive data on whether or not MPA
monitoring help prevent rejection and side effects.2,17 Until
MPA monitoring is regularly performed in clinical practice,
all possible influences on the MPA-PK should be analyzed
both in adults14 and children.18
PPIs are often prescribed to renal transplant recipients
to prevent peptic ulcers, as they can increase the gastric pH
to .4.8 The solubility of MMF in buffer is approximately
4 mg/L at pH 4 but only 0.24 mg/L at pH 5.2.19 Therefore,
the increase in gastric pH could lead to reduced MMF solu-
bility, which could subsequently lead to less MPA absorption.
This effect was first described by Miura et al.3
Other studies confirmed these findings by reporting
a lower MPA maximal concentration and exposure in patients
using PPIs. Kofler et al4 studied MPA-PK using a 2-hour
AUC in 33 heart transplant patients, including 21 patients
prescribed 40 mg of pantoprazole daily and 12 control sub-
jects, 2 years posttransplant. They also performed a complete
12-hour AUC in a subgroup of patients (6 in the control group
and 15 in the PPI group) and found a lower MPA AUC0–12h,
AUC0–12h, AUC0–12h adjusted for dose and Cmax.
The same authors repeated this observation in 22 heart
transplant patients (transplanted for a mean of 2.5 years) who
were given pantoprazole and then again underwent 4-point
PK studies 1 month later without the PPI. They found a lower
Cmax (1.9-fold lower) and AUC (34% lower) with concomi-
tant use of PPI.9
Transplanted patients are usually placed under either
CyA or TAC treatment along with MMF, and exposure to
MPA in patients using TAC is higher than in patients using
CyA due to the enteric reabsorption of MPA from the MPAG
excreted in the biliary tract.11,12 In our study, we have con-
firmed that the PPI effect occurs when MMF is used with both
CNIs (Figs. 1A, B). However, in our study, the patients with
TAC showed that the PPI effect also occurred at the time of
MPA reabsorption (6–12 hours), leading to a lower trough
FIGURE 1. A, MPA-PK for all the curves, adjusted for dose, concentration and consequently a lower AUC0–12h.
performed in the patients using TAC. B, MPA-PK for all curves, MPA reabsorption is derived from the gut-transformed
adjusted for dose, performed in the patients using CyA. By MPAG. In the patients using PPI, there is a lower biliary
mixed-model ANOVA, AUC0–12h and Cmax were statistically MPAG excretion due to a lower MPA plasma concentration.5
lower in the PPI group (P = 0.008 and P = 0.049, respectively),
for both TAC and cyclosporine curves and does not change
As with many other immunosuppressants, MPA
according to CNI used (P = NS). presents a time-dependent increase in bioavailability.13,14 This
increase could make the PPI effect less important after a cer-
tain time after transplantation, which is exactly what we have
without PPI. The therapeutic window (30–60 ng$h/mL) is found. Although the exposure to MPA was lower in the
designated by dotted lines. As indicated, the mean AUC patients using PPI throughout the entire time period, the dif-
was lower in the PPI group. However, there was a steady ference was not clinically significant. The mean AUC0–12h
increase in MPA exposure over time in both groups indepen- was in the lower limit of the therapeutic window on day 7
dently of PPI, reflecting that the time-dependent increase in in patients using PPI but quickly increased on day 14 and
MPA exposure was maintained even in the presence of PPI. thereafter, such that most patients were within the therapeutic
On day 7, the mean exposure to MPA in patients with PPI window after day 7. This information is essential because
was at the lower limit of the therapeutic window. there is a decreased incidence of acute rejection when the
patients are adequately exposed to MPA during the first
week.2,14
DISCUSSION Our study has some limitations. We only measured the
MMF is the most used antiproliferative immunosup- MPA concentration at 1-hour intervals, which may have
pressant in renal transplantation and regularly administered at caused us to lose the true Cmax in the PK curves. This may
fixed doses. The need for MPA monitoring is still a matter of be the reason why we did not find a highly statistically
334 Ó 2012 Lippincott Williams Wilkins
5. Ther Drug Monit Volume 34, Number 3, June 2012 MPA Pharmacokinetics and PPIs
FIGURE 2. A–F, MPA-PK in the patients with and without PPI on days 7, 14, 30, 60, 180, and 360 after transplantation.
significant Cmax values at different periods in our analysis, as seems that it is the AUC that matters for a clinical point of
reported by others. However, by mixed-model ANOVA with view and not Cmax.
all curves, Cmax was statistically lower in the PPI group. Additionally, we have only performed PK during day
Nevertheless, MPA activity is related to exposure,20 and it time after the morning dose of MMF. Half of our patients were
Ó 2012 Lippincott Williams Wilkins 335
6. David-Neto et al Ther Drug Monit Volume 34, Number 3, June 2012
MMF dose should be increased in patients with PPI; however,
TABLE 3. Number of Patients Above or Below the Minimum
after this period, the time-dependent increase in the MPA
Therapeutic 12-hour Area Under the Curve (AUC0–12h)
$30 ng$mL/h absorption causes the PPI effect to be clinically irrelevant.
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