<p>Antibiotic treatment causes an ecological disturbance on the human microflora. Four commensal bacteria: E. coli, enterococci, a-streptococci and coagulase-negative staphylococci, from patients with extensive, high antibiotic usage were investigated with regard to resistance pattern and mutation frequency. Among 193 investigated strains it was found that high antibiotic usage selected for resistant bacteria and enriched for bacteria with a small but significantly increased mutation frequency. </p><p>The relative biological fitness cost of resistance in <i>Staphylococcus epidermidis</i> was assessed in a human in vivo model where the indigenous flora was present. In vitro data of the bacterial growth rate correlated well to in vivo fitness assayed in the competition experiments on skin. </p><p>An in vitro kinetic model was shown to be a useful tool to establish the pharmacokinetic and pharmacodynamic (PK/PD) indices for efficacy of antibiotics. It was confirmed that the time, when the concentration exceeds the minimal inhibitory concentration (MIC), correlates with efficacy for b-lactam antibiotics. To achieve maximal killing for penicillin-resistant pneumococci, with an MIC of 2 mg/L, the peak concentration was also of importance. </p><p>Suboptimal dosing regimen facilitates selection of resistance. Penicillin-resistant pneumococci were easily selected in a mixed population with penicillin-sensitive, -intermediate and -resistant pneumococci in an in vitro kinetic model. The selection of the resistant strain was prevented when the benzylpenicillin concentration exceeded the MIC for approximately 50% of 24 h.</p>

Le tiludronate (Tildren, CEVA Santé Animale, Libourne, France) est un bisphosphonate récemment introduit sur le marché dans plusieurs pays européens pour le traitement du syndrome podotrochléaire (syndrome naviculaire) et de lostéoarthrose des articulations intertarsienne distale et tarso-métatarsienne (éparvin) chez le cheval. Il est le premier bisphosphonate disponible en médecine vétérinaire en général, et en médecine équine en particulier. La posologie de tiludronate qui a fait lobjet dun enregistrement dans différents pays dEurope est de 10 administrations quotidiennes consécutives de 0.1 mg/kg sous forme de bolus intraveineux (IV). Or, il ressort de la pratique courante que ladministration de la dose totale de 1 mg/kg en une perfusion lente unique est préférée par les utilisateurs pour des raisons pratiques et financières. Il ressort aussi de différentes études que cette forme dadministration est bien tolérée (Varela et al., 2002) et efficace dans certaines pathologies (Coudry et al., 2007). La première étude de ce travail a consisté en la comparaison pharmacologique de ces deux schémas posologiques. Il en est ressorti quils produisaient une même exposition plasmatique totale et des effets similaires sur le marqueur plasmatique de résorption osseuse carboxy-télopeptide du collagène de type I (CTX-1). Il en a été conclu que les dix administrations quotidiennes consécutives de 0.1 mg/kg pouvaient être remplacées par la perfusion IV lente unique de 1 mg/kg. Les bisphosphonates sont caractérisés par des propriétés pharmacologiques très spécifiques et inhabituelles, de par leur forte affinité pour los et leur stockage à long terme dans ce compartiment profond. De ce fait, les modèles PK-PD classiques qui mettent en relation mathématique les concentrations plasmatiques avec les effets du médicament sont inadaptés pour décrire le comportement pharmacologique des bisphosphonates, et il est suggéré que les concentrations osseuses doivent être davantage prises en compte pour le développement de tels modèles (Cremers et al., 2005). Dans le but final de développer un modèle PK-PD du tiludronate chez le cheval, une méthode de biopsie osseuse permettant la répétition de dosages de tiludronate osseux a été validée dans la seconde étude de cette thèse. Dans celle-ci, huit chevaux ont subi des biopsies osseuses bilatéralement en quatre sites (le tuber coxae, le métacarpien principal, la 13ème côte et los cuboïde) à différentes échéances sétalant de 1 jour à 1 an après 1 (n=4) ou 2 (n=4, à 4 semaines dintervalle) traitement(s) au tiludronate à raison de 1 mg/kg par voie IV. En chaque site, les biopsies osseuses ont été effectuées à la fois à laide dune fraise électrique de 5 mm de diamètre interne (Implanteo, Anthogyr) pour léchantillon test et dun ostéotome ou dune scie oscillante pour léchantillon de référence. Le tuber coxae sest avéré être le meilleur site de biopsie, à la fois accessible, facile à biopsier, et sur lequel les dosages de tiludronate ne présentaient pas de difficultés techniques et étaient fiables. Malheureusement, ces biopsies noffraient pas un matériel qualitativement et quantitativement suffisant que pour permettre des analyses histologiques et histomorphométriques. Dans une troisième étude, a donc été testée sur quatre chevaux la validité pour ce type danalyses dune autre technique de biopsies, utilisant un plus grand trocart que dans létude 2 (15 versus 5 mm de diamètre interne), et de type manuel. Les biopsies ont été réalisées sur cheval debout au niveau du tuber coxae immédiatement avant (côté gauche) et 48 h après (côté droit) ladministration dune perfusion IV lente de 1 mg/kg de tiludronate. Les biopsies ainsi réalisées ont permis deffectuer les analyses escomptées. Cependant, aucun effet précoce du traitement au tiludronate na pu être mis en évidence sur les paramètres histologiques et histomorphométriques étudiés. Aucun modèle expérimental équin relatif aux pathologies pour lesquelles le tiludronate a été enregistré nexiste. Or il est indispensable, pour mieux en cerner les propriétés pharmacologiques et les applications cliniques potentielles, de tester son efficacité en conditions standardisées. Limmobilisation dun membre sous plâtre est connue pour induire de lostéopénie de non usage chez le cheval (Buckingham et Jeffcott, 1991; van Harreveld et al., 2002). Dans la quatrième étude de ce travail, lefficacité clinique du tiludronate versus placebo a été testée dans les conditions standardisées dun modèle équin dostéopénie induite par immobilisation sous plâtre dun membre antérieur pendant huit semaines. Seize chevaux ont ainsi été immobilisés, dont huit ont reçu un placebo, et huit ont été traités au tiludronate à raison de 1 mg/kg en perfusion IV lente deux fois à quatre semaines dintervalle, soit en début et à mi-immobilisation. Après la période dimmobilisation, les chevaux ont été progressivement remobilisés pendant 4 semaines puis ont subi un entraînement standardisé pendant 8 semaines. Le traitement au tiludronate a permis de prévenir la chute significative de densité minérale osseuse (DMO) mesurée par absorptiométrie biphotonique à rayons X (DEXA) observée à long terme au niveau du membre immobilisé des chevaux du groupe placebo. Cet effet préventif ne sest pas marqué sur le membre controlatéral. Le tiludronate a également induit chez les chevaux traités une chute rapide et significative du taux de CTX-1 sérique, contrairement aux chevaux du groupe placebo chez qui ce taux est resté élevé pendant la quasi-totalité de limmobilisation. Aucun effet du tiludronate na été constaté sur lactivité des iso-enzymes osseuses des phosphatases alcalines (bone ALP), marqueur de formation osseuse, ni sur les caractéristiques du cortex superficiel du canon du membre immobilisé évaluées par ultrasonographie quantitative (QUS). De lensemble de ces travaux, il a été conclu que (1) le CTX-1 sanguin est un marqueur de résorption osseuse sensible et adéquat pour le suivi dun traitement au tiludronate chez le cheval ; (2) le tuber coxae est un site de biopsie osseuse adéquat pour effectuer les analyses nécessaires à lélaboration dun modèle PK-PD du tiludronate chez le cheval ; (3) le tiludronate administré deux fois à quatre semaines dintervalle à la dose de 1 mg/kg IV est capable dinhiber la résorption osseuse dans un modèle dimmobilisation chez le cheval, et la DEXA est une méthode suffisamment sensible pour lobjectiver en quelques mois ; (4) de nouvelles études pharmacologiques devraient être menées afin de documenter laccumulation osseuse et les effets du tiludronate sur différents paramètres pharmacodynamiques en cas dadministrations répétées de perfusions de 1 mg/kg chez le cheval. Pour ce faire, des techniques plus sensibles de dosage du tiludronate devraient idéalement être utilisées dans un souci dexactitude des données. Dautre part, de nouvelles études cliniques defficacité sur des chevaux souffrant de pathologies osseuses devraient être menées en incluant des mesures de CTX-1 sanguin, et si possible des mesures de DMO à différents sites dintérêt.

Antibiotic treatment causes an ecological disturbance on the human microflora. Four commensal bacteria: E. coli, enterococci, a-streptococci and coagulase-negative staphylococci, from patients with extensive, high antibiotic usage were investigated with regard to resistance pattern and mutation frequency. Among 193 investigated strains it was found that high antibiotic usage selected for resistant bacteria and enriched for bacteria with a small but significantly increased mutation frequency. The relative biological fitness cost of resistance in Staphylococcus epidermidis was assessed in a human in vivo model where the indigenous flora was present. In vitro data of the bacterial growth rate correlated well to in vivo fitness assayed in the competition experiments on skin. An in vitro kinetic model was shown to be a useful tool to establish the pharmacokinetic and pharmacodynamic (PK/PD) indices for efficacy of antibiotics. It was confirmed that the time, when the concentration exceeds the minimal inhibitory concentration (MIC), correlates with efficacy for b-lactam antibiotics. To achieve maximal killing for penicillin-resistant pneumococci, with an MIC of 2 mg/L, the peak concentration was also of importance. Suboptimal dosing regimen facilitates selection of resistance. Penicillin-resistant pneumococci were easily selected in a mixed population with penicillin-sensitive, -intermediate and -resistant pneumococci in an in vitro kinetic model. The selection of the resistant strain was prevented when the benzylpenicillin concentration exceeded the MIC for approximately 50% of 24 h.

Antibiotics are among the most commonly prescribed drugs. Although the majority of these drugs were developed several decades ago, optimal dosage (dose, dosing interval and treatment duration) have still not been well defined. This thesis focuses on the development and evaluation of pharmacometric models that can be used as tools in the establishment of improved dosing strategies for novel and already clinically available antibacterial drugs. Infectious diseases are common causes of death in preterm and term newborn infants. A population pharmacokinetic (PK) model for gentamicin was developed based on data from a prospective study. Body-weight and age (gestational and post-natal age) were found to be major factors contributing to variability in gentamicin clearance and therefore important patient characteristics to consider for improved dosing regimens. A semi-mechanistic pharmacokinetic-pharmacodynamic (PKPD) model was also developed, to characterize in vitro bacterial growth and killing kinetics following exposure to six antibacterial drugs, representing a broad selection of mechanisms of action and PK as well as PD characteristics. The model performed well in describing a wide range of static and dynamic drug exposures and was easily applied to other bacterial strains and antibiotics. It is, therefore, likely to find application in early drug development programs. Dosing of antibiotics is usually based on summary endpoints such as the PK/PD indices. Predictions based on the PKPD model showed that the commonly used PK/PD indices were well identified for all investigated drugs, supporting that models based on in vitro data can be predictive of antibacterial effects observed in vivo. However, the PK/PD indices were sensitive to the study conditions and were not always consistent between patient populations. The PK/PD indices may therefore extrapolate poorly across sub-populations. A semi-mechanistic modeling approach, utilizing the type of models described here, may thus have higher predictive value in a dose optimization tailored to specific patient populations.

Ιστορικά, τα ευρήματα των C.B. Huggins (Huggins and Hodges, 1941; Huggins, 1963) και A.V. Schally (Schally et al., 1984) αποτέλεσαν την απαρχή μιας ερευνητικής πορείας με αφετηρία το πεδίο της νευροενδοκρινολογίας και προορισμό εκείνα της γυναικολογίας και της ογκολογίας. Η γνώση αναφορικά με τη φυσιολογία της ενδογενούς ορμόνης (LHRH) και το ρόλο της στην παθοβιοχημεία των ασθενειών (ενδοκρινικών διαταραχών και ορμονο – εξαρτώμενων καρκίνων) και υπό το πρίσμα της πρωτεύουσας ή υποστηρικτικής θεραπευτικής προσέγγισης, κατέστησε τον ιατρικό ευνουχισμό μέσω της δράσης στον υποδοχέα της LHRH – Ι στρατηγική επιλογής για την καταπολέμηση των ενδοκρινικών διαταραχών και των ορμονο – εξαρτώμενων καρκίνων (καρκίνος του μαστού, καρκίνος των ωοθηκών, καρκίνος του ενδομητρίου, καρκίνος του προστάτη). Μια πληθώρα αναλόγων της LHRH έδωσε και δίνει το παρόν σε προκλινικό και κλινικό επίπεδο, με τη συστηματική έρευνα, σύνθεση και ανάπτυξη να αποδίδουν μόρια – αγωνιστές ή – ανταγωνιστές του υποδοχέα της LHRH – Ι, πεπτιδικής (γραμμική ή κυκλική δομή, stapled peptides) ή μη φύσης ως μοναδιαίες οντότητες ή σε σύζευξη με ένα ευρύ φάσμα κυτταροτοξικών μορίων (Αnderes et al., 2003; Keramida et al., 2006; Persson et al., 2009; Kritzer, 2010; Mezo and Manea, 2010). Η παρούσα διδακτορική διατριβή αποσκοπεί στην in vitro και in vivo αξιολόγηση και φαρμακοκινητική μελέτη καινοτόμων αναλόγων της LHRH – κυκλικής και γραμμικής δομής – στη βάση του ορθολογικού μοριακού σχεδιασμού και αποσκοπώντας σε εναλλακτικές προσεγγίσεις για την καταπολέμηση του καρκίνου του προστάτη (και έτερων ενδοκρινικών διαταραχών), συγκριτικά με το leuprolide (εμπορικά διαθέσιμος αγωνιστής του υποδοχέα της LHRH – Ι). Η παρούσα διδακτορική διατριβή θέτει ως υπόθεση εργασίας πως καινοτόμα ανάλογα της LHRH των ήδη υπάρχοντων στην κλινική με βελτιωμένο φαρμακοκινητικό προφίλ δύναται να αποτελέσουν τη βάση βέλτιστων εναλλακτικών θεραπευτικών προσεγγίσεων με ενισχυμένη αποτελεσματικότητα και μειωμένη τοξικότητα, δρώντας in situ ή/ και προσφέροντας νέες δυνατότητες χορήγησης, εστιάζοντας στην οδό ή/ και τη μείωση της συχνότητας αυτής. Η εν λόγω ερευνητική προσέγγιση εστιάζει στον καρκίνο του προστάτη, μια νόσο που χρήζει εναλλακτικής θεραπευτικής στρατηγικής, δεδομένης της χαμηλής αποτελεσματικότητας αυτής (η νόσος προοδευτικά γίνεται ανεξάρτητη των ορμονών και συνεπώς, μεταστατική), αλλά και της χαμηλής ποιότητας ζωής των ασθενών στη βάση του «συμβιβασμού» με τις οδούς χορήγησης που εφαρμόζονται σήμερα στην κλινική (depot formulations). Επιπρόσθετα και κατά την εκπόνηση της εν λόγω ερευνητικής προσέγγισης αναπτύχθηκαν, επικυρώθηκαν και βελτιστοποιήθηκαν καινοτόμες μεθοδολογίες υγρής χρωματογραφίας – φασματομετρίας μάζας (LC – MS/ MS) σε βιολογικά υγρά – ηπατικά μικροσώματα (μύα, επίμυα, ανθρώπου), νεφρικές μεμβράνες μύα, πλάσμα και όρχεις μύα – και έτερα υποστρώματα (κυτταρικά εκχυλίσματα, υδάτινο περιβάλλον ιχθύων Danio rerio), οι οποίες, εν συνεχεία, συζεύχθηκαν με in vitro ή/ και in vivo βιοδοκιμασίες. Τα πειραματικά ευρήματα συγκρίθηκαν με εκείνα των εμπορικά διαθέσιμων αναλόγων της LHRH, με αγωνιστική (leuprolide) ή ανταγωνιστική δράση (antide, cetrorelix). Πιο αναλυτικά και λαμβάνοντας υπόψην το «νοσηρό» φαρμακοκινητικό προφίλ των αναλόγων της LHRH που χρησιμοποιούνται σήμερα στην κλινική, διερευνήθηκε η in vitro (ηπατικά μικροσώματα μύα, επίμυα και ανθρώπου – νεφρικές μεμβράνες μύα) και in vivo (πλάσμα μύα) πεπτιδική σταθερότητα των υπό μελέτη αναλόγων, συγκριτικά με την LHRH και εμπορικά διαθέσιμα ανάλογα αυτής (antide, leuprolide). Τα ευρήματα επέτρεψαν την αξιολόγηση και ταξινόμηση των αναλόγων του ενδιαφέροντος βάσει πεπτιδικής σταθερότητας (δοκιμασία σάρωσης). Ταυτόχρονα, προσδιορίστηκε το μεταβολικό τους προφίλ, αποκαλύπτοντας τους ευάλωτους πεπτιδικούς δεσμούς, καθώς και τις εμπλεκόμενες ενδοπεπτιδάσες (NEP – EC 3.4.24.11, ACE – EC 3.4.15.1). Τα ευρήματα επιβεβαιώθηκαν περαιτέρω με τη χρήση ειδικών ενζυμικών αναστολέων (ενδεικτικά: DL – Thiorphan). Ο νεφρός βρέθηκε να είναι το πρωτεύον μεταβολικό όργανο. Η ανίχνευση και η ημι – ποσοτικοποίηση των μεταβολικών προϊόντων οδήγησε στον προσδιορισμό σχέσεων δομής – δραστικότητας, αποτελώντας τη βάση του ορθολογικού σχεδιασμού καινοτόμων μορίων. Οι απορρέουσες σχέσεις δομής –δραστικότητας υποστηρίζουν πως (i) η μεθυλίωση της υδροξυλομάδας της Tyr5, (ii) η αντικατάσταση της Pro9 από Aze και (iii) η κυκλοποίηση ενισχύουν την πεπτιδική σταθερότητα των αναλόγων του ενδιαφέροντος. Στα πλαίσια μελετών φαρμακοδυναμικής, αναπτύχθηκε καινοτόμος μεθοδολογία LC – MS/ MS για τον ταυτόχρονο ποσοτικό προσδιορισμό της τεστοστερόνης και των υπό μελέτη αναλόγων σε πλάσμα (0, 05 – 100 ng/mL) και όρχεις μύα (2, 0 – 2000 ng/g). Η τεστοστερόνη θεσπίστηκε βιοδείκτης αποτελεσματικότητας (efficacy) και τοξικότητας (toxicity) στη βάση του καίριου ρόλου που διαδραματίζει το εν λόγω στεροειδές στη φυσιολογία του άξονα υποθάλαμος – υπόφυση – γονάδες και την παθοβιοχημεία των ενδοκρινικών διαταραχών και του ορμονο – εξαρτώμενου καρκίνου του προστάτη. Η φαρμακολογική απόκριση (απελευθέρωση τεστοστερόνης) βρέθηκε πως είναι ειδική και λαμβάνει χώρα μέσω του υποδοχέα της LHRH – Ι. Πιο σημαντικά, επετεύχθη ιατρικός ευνουχισμός, βάσει ιστοπαθολογικών ευρημάτων και προσδιορισμού της τεστοστερόνης (πλάσμα και όρχεις μύα), κατόπιν επαναλαμβανόμενης ενδοπεριτοναϊκής χορήγησης του επιλεγμένου καινοτόμου γραμμικού αναλόγου της LHRH, linearGnRH1. Το ίδιο ανάλογο βρέθηκε να έχει κυτταροστατική δράση σε πειράματα κυτταρικού πολλαπλασιασμού (κύτταρα LNCaP και PC3). Παράλληλα και υπό το πρίσμα του ρόλου της LHRH στην παθοβιοχημεία έτερων ορμονο – εξαρτώμενων καρκίνων (καρκίνος του μαστού, καρκίνος των ωοθηκών, καρκίνος του ενδομητρίου), αναπτύχθηκε, επικυρώθηκε και βελτιστοποιήθηκε καινοτόμος μεθοδολογία LC – MS/ MS για τον ποσοτικό προσδιορισμό της 17β – οιστραδιόλης σε βιολογικά υγρά. Τέλος, αναπτύχθηκε καινοτόμος μεθοδολογία LC – MS/MS για τον ποσοτικό προσδιορισμό πεπτιδίων του ενδιαφέροντος στο υδάτινο περιβάλλον των ιχθύων του είδους Danio rerio. Το καινοτόμο γραμμικό ανάλογο της LHRH, linearGnRH1, δεδομένου του φαρμακοκινητικού/ φαρμακοδυναμικού του προφίλ, δρα υποστηρικτικά ως προς την υπόθεση της παρούσας διδακτορικής διατριβής, σύμφωνα με την οποία καινοτόμα ανάλογα των ήδη υπάρχοντων στην κλινική με βελτιωμένο φαρμακοκινητικό προφίλ δύναται να αποτελέσουν τη βάση βέλτιστων εναλλακτικών θεραπευτικών προσεγγίσεων με ενισχυμένη αποτελεσματικότητα και μειωμένη τοξικότητα, δρώντας in situ ή/ και προσφέροντας νέες δυνατότητες χορήγησης, εστιάζοντας στην οδό ή/ και τη μείωση της συχνότητας αυτής. Το linearGnRH1 δύναται να αποτελέσει τη βάση για τον ορθολογικό σχεδιασμό μορίων (stapled peptides, μιμητές), αποσκοπώντας σε εναλλακτικές θεραπευτικές στρατηγικές για την καταπολέμηση του ορμονο – εξαρτώμενου καρκίνου ή/ και των ενδοκρινικών διαταραχών. Πέραν του linearGnRH1, ας σημειωθεί πως κατά την εκπόνηση της παρούσας διδακτορικής διατριβής συγκεκριμένα καινοτόμα κυκλικά ανάλογα της LHRH (cyclicGnRH1, cyclicGnRH2, cyclicGnRHDL1, cyclicGnRHDL2) εμφάνισαν ένα διακριτό φαρμακοκινητικό προφίλ. Το φαρμακοδυναμικό προφίλ των εν λόγω κυκλικών πεπτιδίων απαιτείται να διερευνηθεί περαιτέρω με την εφαρμογή των καινοτόμων μεθοδολογιών LC – MS/MS που αναπτύχθηκαν, επικυρώθηκαν και βελτιστοποιήθηκαν κατά την εκπόνηση της παρούσας διδακτορικής διατριβής. Συνολικά, η καινοτομία της εν λόγω ερευνητικής προσέγγισης έγκειται (i) στην ανάπτυξη, επικύρωση και βελτιστοποίηση ενός πλήθους μεθοδολογιών LC – MS/MS σε σύζευξη με in vitro και in vivo βιοδοκιμασίες, οι οποίες και αποτελούν ένα διακριτό αναλυτικό εργαλείο και (ii) στο προκλινικό φαρμακολογικό μοντέλο που αναπτύχθηκε με την επιλογή του μύα ως ζωικό πρότυπο. Κοινή συνισταμένη, η εν τω βάθει αξιολόγηση της φαρμακοκινητικής/ φαρμακοδυναμικής των πεπτιδίων του ενδιαφέροντος με το ερευνητικό βλέμμα στα πεπτιδικά φάρμακα.. stapled peptides.. μιμητές.. / The highly influential findings of C. B. Huggins (Huggins, 1963) and A. V. Schally (Schally et al., 1984) brought a new era in the research fields of neuroendocrinology, gynecology and oncology. The knowledge acquired regarding the physiology of LHRH and its role in the pathobiochemistry of the disease resulted in the consideration of medical castration via the LHRH receptor as a well established strategy for the treatment of endocrine disorders (e.g. precocious puberty) and hormone – dependent cancers (breast cancer, endometrial cancer, prostate cancer). Numerous LHRH analogues have been synthesized and evaluated both in the clinic and preclinical level. Overall, systematic work has resulted in the synthesis of LHRH receptor agonists and antagonists, either peptides (linear, cyclic, stapled peptides) or small organic molecules as entities or combined with various cytotoxic molecules (Αnderes et al., 2003; Keramida et al., 2006; Persson et al., 2009; Kritzer, 2010; Mezo and Manea, 2010). Although extensive research has been carried out in the field of hormonal therapy, poor pharmacokinetic properties still characterize LHRH peptide analogues. Poor stability of LHRH analogues compromises efficacy, while the need for their subcutaneous administration (depot formulations) aggravates the quality of life for cancer patients. Nowadays, LHRH analogues in the clinic most likely achieve the desired pharmacologic effects by action primarily on the pituitary and to a much lesser extent by direct antiproliferative effects on tumor cells. Herein, we hypothesize that stable analogues of such super – agonists would be advantageous, either by allowing a reduction in dosing frequency or by allowing the use of analogues that act directly on the tumor, with possible additive effects and subsequent enhancements in efficacy. In this context, the pharmacokinetic/ pharmacodynamic profiles of novel LHRH analogues were determined both in vitro and in vivo. Similarly, commercially available LHRH analogues (leuprolide, antide, cetrorelix) served as positive controls. Novel LC – MS/MS based approaches (LC – MS/ MS methodologies coupled to in vitro and in vivo bioassays) were developed, validated and optimized for the evaluation of the peptide analogues in question (linear or cyclic) in various biological fluids and matrices; (i) mouse, rat and human liver microsomes, (ii) mouse kidney membrane preparations, (iii) mouse plasma and tissue (testis), (iv) egg – water (Danio rerio embryos environment). Furthermore, a novel LC – MS/MS based approach was developed, validated and optimized for the simultaneous quantification of testosterone and peptides in question, upon the intraperitoneal administration of peptide analogues in mice. Testosterone served as an efficacy and toxicity biomarker. Peptide metabolism was thoroughly studied by an LC – MS/MS based approach coupled to an in vitro bioassay (mouse kidney membrane preparations), allowing (i) structural elucidation and semi – quantitation of metabolites (and peptides) as a function of time, (ii) determination of the susceptible to proteolysis peptide – bonds, (iii) structure – activity relationships (SARs) and (iv) peptide ranking (screening assay). Taking into account the role of LHRH in gynecology and hormone – dependent cancers of breast, endometrium and ovary, an LC – MS/MS based approach was developed for the quantification of 17β – oestradiol (efficacy and toxicity biomarker) in mouse plasma upon the intraperitoneal administration of peptide analogues in mice. A novel LC – MS/MS based approach was also developed for the quantification of peptides of interest in the aquatic environment of Danio rerio. Employing the aforementioned analytical tools, peptide stability against proteolysis was evaluated both in vitro (mouse kidney membrane preparations) and in vivo (mouse plasma). LHRH and commercially available analogues served as positive controls. The SARs derived suggested that enhanced stability was achieved by (i) methylation on the hydroxyl group of Tyr5, (ii) replacement of Pro9 by Aze and (iii) cyclisation. Hence, new promising chemical entities could be synthesized and developed on the basis of rational drug design. Metabolic profiles were also determined revealing the susceptible to proteolysis peptide bonds. Susceptible peptide bonds and endopeptidases involved were further confirmed in the presence of specific endopeptidase inhibitors. A facile preclinical mouse model was developed in the context of our objectives. Intraperitoneal administration was selected, since (i) it is a mix – mode type of administration with elements of rapid absorption and (ii) oral administration was not practical due to the low bioavailability of the peptides that were tested. The LC – MS/MS based quantification of the selected bioactive peptides and their corresponding metabolites as well as the selective monitoring of biomarkers (e.g. testosterone) in response to drug dose, in plasma and testes, combined with the appropriate preclinical mouse model, represents a distinctive approach. The mouse model described in this paper is particularly valuable, since (i) the human LHRH receptor is homologous to the mouse receptor (Millar, 2004), (ii) information on in vitro and in vivo stability can be obtained with a relatively small amount of peptide (1 – 2 mg), (iii) information on the LHRH receptor agonism (receptor specific in vivo modulation) can be obtained by using testosterone as a marker, (iv) it allows the determination of the dosing regimen required for efficacy based on action on the pituitary, (v) it can become the basis of follow up experiments on genetically modified mouse animal models or other tumour xenografted mouse models (Sharpless and Depinho, 2006; Morgan et al., 2008). The robust sensitive methodology that was developed for the quantification of testosterone in mouse plasma (0.05 – 100 ng/mL) or determination of testosterone in testes (2 – 2000 ng/g) provides an excellent handle on compound efficacy assessment. Testosterone as an efficacy and toxicity biomarker was found to be specific upon peptide binding to the LHRH receptor. Medical castration was achieved upon the repeated dosing of a selected novel linear analogue (linearGnRH1). Measurements in plasma were further supported by statistical significant testosterone values in testis and histopathological findings (atrophy). Moreover the testis weights of the treated animals were significantly lower in comparison to the control group (atrophy induced by dosing), thus making the differences in testosterone testis concentration between control and peptide treated animals even more pronounced. Although the binding affinity of linearGnRH1 on the LHRH receptor was not as high as the binding affinity of leuprolide (~ 15 nM versus <1 nM), the in vivo efficacy between the two analogues was similar (at the tested dose), suggesting that the enhanced stability or bioavailability of linearGnRH1, compensates for binding affinity differences. LinearGnRH1 was also found to be anti – proliferative upon dosing in LNCaP cells (as potent as the superagonist leuprolide). It is possible that linearGnRH1 can play a significant role for the treatment of hormone – dependent cancers, by acting not only at the pituitary level (thus, suppressing the pituitary – testicular axis), but also by exerting an antitumor activity directly on cancer cells, as has been previously shown for other LHRH agonists (Maudsley et al., 2004; Marelli et al., 2006). Except for linearGnRH1, selected cyclic analogues (cyclicGnRH1, cyclicGnRH2, cyclicGnRHDL1, cyclicGnRHDL2) exhibited a distinct pharmacokinetic profile. Their pharmacodynamic profiles should be evaluated further employing the novel LC – MS/MS based approaches developed and validated in this study. Overall, the novelty of the approach described herein consists of (i) the LC – MS/MS methodologies coupled with in vitro and in vivo bioassays developed, validated and employed that provide a distinct analytical tool and (ii) the facile preclinical pharmacological mouse model developed and employed. The approach aims to the pharmacokinetic/pharmacodynamic evaluation of the peptides of interest towards a new generation of peptide drugs.. stapled peptides.. mimetics. Considering the pharmacokinetic/ pharmacodynamic profiles of linearGnRH1, findings on this novel analogue satisfy our hypothesis according to which stable analogues of the LHRH super – agonists used in the clinic would be advantageous, either by allowing a reduction in dosing frequency or by allowing the use of analogues that act directly on the tumor, with possible additive effects and subsequent enhancements in efficacy. LinearGnRH1 can serve as the platform for the rational drug design of new chemical entities (stapled peptides, mimetics) for the treatment of hormone – dependent cancers and/ or endocrine disorders.

This study aimed to investigate the pharmacology of selected pyrrolobenzodiazepine (PBD) compounds shown to have cytotoxic activity with predicted DNA sequence selectivity. Research focused upon the PBD dimer, SJG-136, selected for clinical trials, and the novel PBD monomer compounds D709119, MMY-SJG and SJG-303. SJG-136, a novel sequence-selective DNA minor groove cross-linking agent, was shown to have potent tumour cell type selective cytotoxicity in in vitro assays. Pharmacokinetic studies in mice via both the i.p. and i.v. route (dosed at the maximum tolerated dose (MTD)) showed that SJG-136 reaches concentrations in plasma well in excess of the in vitro IC50 values for 1 h exposure, and was detected in tumour and brain samples also above the in vitro IC50 values. Furthermore, SJG-136 showed linear pharmacokinetics over a 3-fold drug dose range. Metabolism studies showed SJG-136 is readily metabolised in vitro by hepatic microsomes, predominantly to a monodemethylated metabolite; this metabolite could be detected in vivo. Analytical method development work was also conducted for the imminent Phase I clinical trial of SJG-136 resulting in a sensitive and selective bio-analytical detection protocol. Comet analysis showed that SJG-136 dosed at the MTD and ⅓MTD causes significant interstrand DNA cross-linking in lymphocytes in vivo. In vitro studies demonstrated that SJG-136 localises within the cell nucleus, and acts to disrupt cell division via a G2/M block in the cell cycle at realistic concentrations and exposure times that are achievable in vivo. In vivo pharmacokinetic studies of D709119 showed the compound is easily detectable in mouse plasma following i.p. dosing at the MTD, but could not be detected in either tumour or brain samples. In vitro cytotoxicity studies revealed D709119 to have potent activity across a selection of tumour cell lines. SJG-136, D709119, MMY-SJG, SJG-303 and DC-81 demonstrated a non-enzyme-catalysed reactivity with the biologically relevant thiol, reduced glutathione (GSH). Studies demonstrated that reactivity of the PBD compounds toward GSH was dependent on GSH concentrations. At levels of GSH found in plasma, the PBD compounds showed considerably lower reactivity with GSH than at intracellular GSH levels. SJG-136 and D709119 also showed favourable pharmacokinetic profiles in mice, and warrant further study for anti-tumour activity in vivo and progression to use in patients.

Objectives Main objectives of this doctoral thesis were to review available information on pharmacological properties of benzodiazepines and their age-related changes; to evaluate the prevalence of benzodiazepine use in older patients residing in long term care facilities; to investigate the association between use of benzodiazepines and occurrence of falls in acutely hospitalized older patients; and to describe utilization of benzodiazepines in the Czech Republic. Methods A narrative review of literature focused on pharmacokinetics, pharmacodynamics, adverse effects and association of benzodiazepines with falls in older population was conducted. The evaluation of benzodiazepine use in long term care facilities was analysed in a retrospective cross-sectional study using data from the EC 7th Framework Program SHELTER project (Service and Health in the Elderly in Long Term Care). A prospective cohort study data of acutely hospitalized patients in Australia were used to evaluate association between benzodiazepines and falls. To describe utilization of benzodiazepines in the Czech Republic, data from the State Institute for Drug Control and from databases of General Health Insurance Fund were used. This dissertation thesis is a summary of published articles from above stated works and analyses. Results...

O carvedilol é um fármaco utilizado na terapêutica da hipertensão e da insuficiência cardíaca congestiva. É disponível para uso clínico como racemato e seus enantiômeros apresentam atividade semelhante sobre os receptores 1-adrenérgicos, sendo que o enantiômero S-(-) é mais ativo como antagonista dos receptores adrenérgicos. O presente estudo visa investigar a influência do Diabetes mellitus (DM) tipo 2 e da insuficiência renal crônica (IRC) em pacientes em diálise peritoneal ambulatorial contínua (DPAC) na farmacocinética enantiosseletiva e na farmacodinâmica do carvedilol em pacientes hipertensos. Os pacientes hipertensos investigados divididos nos grupos controle (n=8), DM tipo 2 (n=8) e IRC em DPAC (n=6) receberam dose única p.o. de 25 mg de carvedilol racêmico. Os enantiômeros do carvedilol e metabólitos 4-hidroxifenil e O-desmetilcarvedilol foram analisados no sistema LC-MS/MS empregando coluna quiral e fase móvel constituída por mistura de metanol: ácido acético: dietilamina. O método foi linear no intervalo de concentrações de 0,1-100 ng de cada enantiômero do carvedilol/mL de líquido de diálise, 0,2-200 ng de cada enantiômero do carvedilol/mL de plasma, 2,5-2500 ng de cada enantiômero do carvedilol, 4-hidroxifenil e O-desmetilcarvedilol/mL de urina. Os parâmetros farmacocinéticos foram calculados empregando o programa WinNonlin. O teste de Wilcoxon foi usado para avaliar as razões enantioméricas dentro dos grupos e o teste de Mann-Whitney foi utilizado para avaliar as diferença dos parâmetros farmacocinéticos entre os grupos. Na investigação do fenótipo oxidativo tipo metoprolol todos os pacientes incluídos no estudo foram fenotipados como metabolizadores extensivos. Os pacientes investigados com DM tipo 2 comparados com o grupo controle não apresentaram alterações na farmacocinética e farmacodinâmica (PK-PD) do carvedilol. Os pacientes com IRC em DPAC apresentaram valores de clearance (CL/F) dos enantiômeros R-(+) - e S-(-)-carvedilol de 25,17 e 27,89 L/h, respectivamente, sendo significativamente inferiores aos obtidos para os pacientes do grupo controle (76,76 e 142,0 L/h). As razões de AUCR/S foram de 2,27 para os pacientes do grupo controle e de 0,97 para os pacientes com IRC em DPAC. Os pacientes com IRC em DPAC não mostraram enantiosseletividade na farmacocinética do carvedilol em razão do acúmulo plasmático preferencial do enantiômero com atividade -bloqueadora S-(-)-carvedilol. / Carvedilol is used for the treatment of hypertension and congestive heart failure. The drug is available for clinical use as the racemate and its enantiomers exert similar activity on 1-adrenergic receptors, whereas the S-(-) enantiomer is more active as a -adrenergic receptor antagonist. The aim of the present study was to investigate the influence of type 2 Diabetes mellitus (DM) and chronic renal failure (CRF) on patients receiving continuous ambulatory peritoneal dialysis (CAPD) on the enantioselective pharmacokinetics and pharmacodynamics of carvedilol in hypertensive patients. The hypertensive patients were divided into a control (n=8), type 2 DM (n=8) and CRF on CAPD (n=6) group and received a single oral dose of 25 mg racemic carvedilol. The enantiomers of carvedilol and of the metabolites 4-hydroxyphenyl and O-desmethylcarvedilol were analyzed by LC-MS/MS using a chiral column and a mobile phase consisting of a mixture of methanol:acetic acid-diethylamine. The method was linear within the following concentration ranges: 0.1-100 ng of each carvedilol enantiomer/mL dialysis fluid, 0.2-200 ng of each carvedilol enantiomer/mL plasma, and 2.5-2500 ng of each enantiomer of carvedilol, 4-hydroxyphenyl carvedilol and O-desmethyl carvedilol/mL urine. The pharmacokinetic parameters were calculated using the WinNonlin program. Enantiomer ratios within groups were evaluated by the Wilcoxon test and the Mann-Whitney test was used to determine differences in the pharmacokinetic parameters between groups. Determination of the metoprolol type oxidation phenotype showed that all patients included in the study were extensive metabolizers. Patients with type 2 DM presented no changes in the pharmacokinetics or pharmacodynamics of carvedilol when compared to the control group. Clearance (CL/F) of the R-(+)- and S-(-)-carvedilol enantiomers was significantly lower in patients with CRF on CAPD (25.17 and 27.89 L/h, respectively) compared to the control group (76.76 and 142.0 L/h). The AUCR/S ratios were 2.27 for control patients and 0.97 for patients with CRF on CAPD. Patients with CRF on CAPD showed no enantioselectivity in the pharmacokinetics of carvedilol due to the preferential plasma accumulation of the enantiomer with -blocker activity, S-(-)-carvedilol.

The introduction of artemisinin-based combination therapy (ACT) substantially reduced malaria-related mortality and morbidity during the past decade. Despite the widespread use of ACT, there is still a considerable knowledge gap with regards to safety, efficacy and pharmacokinetic properties of these drugs, particularly in vulnerable populations like children and pregnant women. In addition, there is growing evidence of widespread artemisinin-resistance across the Greater Mekong Subregion. Expedited delivery of novel antimalarial drugs with different mechanisms of action to the clinical setting is still far off; therefore, it is crucial to improve the use of existing antimalarial drugs for optimal outcome in order to prolong their therapeutic life span. This thesis focuses on utilizing pharmacometric tools to support this effort for malaria prevention and treatment. An extensive simulation framework was used to explore alternative malaria chemopreventive dosing regimens of a commonly used ACT, dihydroartemisinin-piperaquine. Different monthly and weekly dosing regimens were evaluated and this allowed an understanding of the interplay between adherence, loading dose and malaria incidence. A weekly dosing regimen substantially improved the prevention effect and was less impacted by poor adherence. This is also expected to reduce selection pressure for development of resistance to piperaquine. Population pharmacokinetics-pharmacodynamic models were developed for artesunate and the active metabolite dihydroartemisinin, effect on parasite clearance, in patients with artemisinin-resistant and -sensitive malaria infections in Southeast Asia. The modeling identified an association between parasite density and drug bioavailability. It predicted the presence of high levels of artemisinin resistant infection among patients in Cambodia and its spread into Myanmar. A nomogram to identify patients with artemisinin resistant infections was developed. Furthermore, the model was used to demonstrate the need for extended treatment duration to treat patients with artemisinin resistant infections. A population pharmacokinetic model developed from data on pregnant women in East Africa allowed further understanding of artemether-lumefantrine exposure in pregnant populations. It also suggested that the lumefantrine exposure in this population is not compromised. In summary, the results presented in this thesis demonstrate the value of pharmacometric approaches for improving antimalarial drug treatment and prevention. This ultimately contributes to overcoming the prevailing challenges to malaria control.

Les effets des catécholamines en réanimation sont peu prédictibles. La variabilité interindividuelle des observations est d’origine multifactorielle dont des facteurs pharmacocinétiques et pharmacodynamiques, dépendant de caractéristiques constitutionnelles et acquises de chaque individu. Les posologies de l’adrénaline et de la noradrénaline chez l’enfant sont extrapolées des données adultes. Pourtant l’âge est une source de grande variabilité liée au développement. Un modèle pharmaco- statistique de l’adrénaline et de la noradrénaline a été établi chez l’enfant en insuffisance circulatoire aigüe. Il a permis d’identifier des facteurs de variabilité entre les individus ainsi que de proposer des schémas de prescription des deux molécules en fonction de l’effet souhaité et des caractéristiques de l’enfant. La pharmacocinétique de l’adrénaline chez 39 enfants en prévention du syndrome de bas débit cardiaque postopératoire suivait un modèle monocompartimental. La clairance augmentait avec le poids selon le principe de l’allométrie. Les augmentations résultantes de la fréquence cardiaque et de la pression artérielle moyenne suivaient un modèle d’effet direct Emax. Elles étaient influencées par l’âge et la gravité des patients. Les augmentations de glycémie et lactatémie suivaient un modèle d’effet indirect. Pour la noradrénaline, chez 38 enfants atteints d’hypotension artérielle systémique, la pharmacocinétique était mono-compartimentale. La clairance était influencée par le poids (allométrie). L’augmentation induite de la pression artérielle moyenne suivait un modèle direct Emax. Elle était fonction de l’âge et de la gravité des patients. Les posologies de l’adrénaline et de la noradrénaline chez l’enfant devraient tenir compte du poids, de l’âge et de la gravité du patient : plus jeune est l’enfant et plus grave est son état, plus la posologie doit être élevée pour satisfaire les objectifs hémodynamiques. / The effects of catecholamines are difficult to predict. The between-subject variability observed in clinical setting is multifactorial including constitutional and acquired characteristics of each individual. Epinephrine and norepinephrine dosages are usually extrapolated from adult data. Yet, age is a source of high variability due to development- related phenomena. A population model of epinephrine or norepinephrine was developed in haemodynamically critically ill children. This allowed to identify between-subject variability factors as well as to propose individualized dosage regimens of these two catecholamines according to the desired effect and child characteristics. Epinephrine pharmacokinetics in 39 children at high risk of postoperative low cardiac output syndrome followed a one-compartment model. Clearance increased with bodyweight according to the allometric rule. The resulting increases in heart rate and mean arterial pressure followed a direct Emax model. These were related to age and illness severity. A turn-over model described the increases in blood glucose and lactate. Norepinephrine pharmacokinetics in 38 hypotensive critically ill children followed a one compartment model. Clearance increased with bodyweight (allometry). The resulting increase in mean arterial pressure followed a direct Emax model. This was a function of age and illness severity. The dosage of epinephrine and norepinephrine in children should take into account the bodyweight, age and illness severity of the patient: the younger the child and the more serious the condition, the higher the dosage in order to meet the haemodynamic goals.