Problems of emerging antibiotic resistance are becoming a serious threat worldwide, and at the same time, the interest to develop new antimicrobials has declined. There is consequently a need for efficient methods to develop new treatments that minimize the risk of resistance development and that are effective on infections caused by resistant strains. Based on in silico mathematical models, describing the time course of exposure (Pharmacokinetics, PK) and effect (Pharmacodynamics, PD) of a drug, information can be collected and the outcome of various exposures may be predicted. A general model structure, that characterizes the most important features of the system, has advantages as it can be used for different situations. The aim of this thesis was to develop Pharmacokinetic-Pharmacodynamic (PKPD) models describing the bacterial growth and killing after mono- and combination exposures to antibiotics and to explore the predictive ability of PKPD-models across preclinical experimental systems. Models were evaluated on data from other experimental settings, including prediction into animals. A PKPD model characterizing the growth and killing for a range of E. coli bacteria strains, with different MICs, as well as emergence of resistance, was developed.  The PKPD model was able to predict results from different experimental conditions including high start inoculum experiments, a range of laboratory and clinical strains as well as experiments where wild-type and mutant bacteria are competing at different drug concentrations. A PKPD model, developed based on in vitro data, was also illustrated to have the capability to replicate the data from an in vivo study. This thesis illustrates the potential of PKPD models to characterize in vitro data and their usage for predictions of different types of experiments. The thesis supports the use of PKPD models to facilitate development of new drugs and to improve the use of existing antibiotics.

Pharmacometrics is a quantitative science that is rapidly changing the landscape of drug development, and particularly so for the pediatric population. The motivation behind the research underlying this dissertation is to contribute towards the improvement of pediatric drug development by the astute application of pharmacometric methods. Two distinct research areas have been focused upon: 1- improving pediatric pharmacokinetic (PK) trial design and 2- improving pediatric dosing of warfarin by using a genetics-based dosing regimen. The first project examined in detail the feasibility of and simulation-based methodology for implementing a recent regulatory PK quality standard. The focus was on designing pediatric PK trials that employ sparse sampling and population analysis methods, using a simulation-estimation platform. The research provided clarity on the impact of various trial design elements, such as PK sampling, adult data inclusion, PK variability and analysis method on sample size adequacy to honor the standard. The PK quality standard was found to be practically feasible in terms of sample size adequacy. Informative sampling schedule for a given number of PK samples per subject is assumed during trial design. Recommendations are made to: 1- use prior adult or pediatric data for trial design and analysis, wherever possible and 2 - use one-stage population analysis methods and biologically feasible covariate models for designing pediatric PK studies. The second project involved derivation of the first ever pediatric warfarin dosing regimen, including starting dose and titration scheme, based on pharmacogenetics (Cyp2c9 *1/*2/*3 and VKORc1 -1629 G>A polymorphisms). While extensive research and several dosing models for warfarin use in adults exist, there is paucity of data in pediatrics. A validated adult warfarin population PKPD model was bridged using physiological principles and limited pediatric data to arrive at a pediatric PKPD model and dosing regimen. Pediatric data (n=26) from an observational study conducted at the Children’s Hospital Los Angeles (CHLA) was used to qualify the pediatric model. A 2-step pediatric starting dose based on body weight (<20 kg and ≥20 kg) for each of 18 (6 Cyp2c9 x 3 VKORC1) genotype categories is proposed. The titration scheme involves percentage changes relative to previous dose, based on latest patient INR. The dosing regimen targets a major (≥ 60%) proportion of INRs within therapeutic range of 2.0-3.0, by the second week into warfarin therapy. Simulataneously, bleeding and thromboembolic risks are minimized via minimal proportions (≤ 10% and ≤ 20%) of INRs > 3.5 and INRs < 2.0, respectively. In simulations, the proposed dosing regimen performed better on target INR outcomes than the standard-of-care dosing used in the CHLA patients. Given the challeneges in and low likelihood of conducting pediatric warfarin clinical studies, the proposed dosing regimen is believed to be an important advance in pediatric warfarin therapy. Prospective warfarin studies in pediatrics using the proposed dosing regimen are recommended to refine and validate the suggested dosing strategy.

<p>Pharmacometrics uses models based on pharmacology, physiology and disease for quantitative analysis of interactions between drugs and patients. The availability of software implementing modern statistical methods is important for efficient model building and evaluation throughout pharmacometric data analyses.</p><p>The aim of this thesis was to facilitate the practical use of available and new statistical methods in the area of pharmacometric data analysis. This involved the development of suitable software tools that allows for efficient use of these methods, characterisation of basic properties and demonstration of their usefulness when applied to real world data. The thesis describes the implementation of a set of statistical methods (the bootstrap, jackknife, case-deletion diagnostics, log-likelihood profiling and stepwise covariate model building), made available as tools through the software Perl-speaks-NONMEM (PsN). The appropriateness of the methods and the consistency of the software tools were evaluated using a large selection of clinical and nonclinical data. Criteria based on clinical relevance were found to be useful components in automated stepwise covariate model building. Their ability to restrict the number of included parameter-covariate relationships while maintaining the predictive performance of the model was demonstrated using the antiarrythmic drug dofetilide. Log-likelihood profiling was shown to be equivalent to the bootstrap for calculating confidence intervals for fixed-effects parameters if an appropriate estimation method is used. The condition number of the covariance matrix for the parameter estimates was shown to be a good indicator of how well resampling methods behave when applied to pharmacometric data analyses using NONMEM. The software developed in this thesis equips modellers with an enhanced set of tools for efficient pharmacometric data analysis. </p>

Pharmacometrics uses models based on pharmacology, physiology and disease for quantitative analysis of interactions between drugs and patients. The availability of software implementing modern statistical methods is important for efficient model building and evaluation throughout pharmacometric data analyses. The aim of this thesis was to facilitate the practical use of available and new statistical methods in the area of pharmacometric data analysis. This involved the development of suitable software tools that allows for efficient use of these methods, characterisation of basic properties and demonstration of their usefulness when applied to real world data. The thesis describes the implementation of a set of statistical methods (the bootstrap, jackknife, case-deletion diagnostics, log-likelihood profiling and stepwise covariate model building), made available as tools through the software Perl-speaks-NONMEM (PsN). The appropriateness of the methods and the consistency of the software tools were evaluated using a large selection of clinical and nonclinical data. Criteria based on clinical relevance were found to be useful components in automated stepwise covariate model building. Their ability to restrict the number of included parameter-covariate relationships while maintaining the predictive performance of the model was demonstrated using the antiarrythmic drug dofetilide. Log-likelihood profiling was shown to be equivalent to the bootstrap for calculating confidence intervals for fixed-effects parameters if an appropriate estimation method is used. The condition number of the covariance matrix for the parameter estimates was shown to be a good indicator of how well resampling methods behave when applied to pharmacometric data analyses using NONMEM. The software developed in this thesis equips modellers with an enhanced set of tools for efficient pharmacometric data analysis.

As multidrug resistance in Gram-negative bacilli increases, the old antibiotic colistin has rapidly gained attention as one of few last line treatment options in the form of colistin methanesulfonate (CMS), which is hydrolyzed to colistin both in vitro and in vivo. There is a dearth of knowledge on fundamental aspects of colistin, including pharmacokinetics and optimal dosing regimens. The aim of this thesis was to improve the basis for optimal colistin therapy. To be able to study colistin, an LC-MS/MS assay method was developed which is sensitive, specific and useful in both in vivo and in vitro studies. Using this method we detected a significant loss of colistin during standard laboratory procedures. This loss was characterized and quantified, the hypothesis being that the loss is mainly caused by adsorption to labware. The pharmacokinetics of colistin was studied in two populations of critically ill patients, one with normal renal function and one with renal replacement therapy. Plasma concentrations were assayed with the method above, and population modeling was employed to describe the data. The results include a previously unseen, long elimination half-life of colistin. The data from the population on renal replacement therapy was described without modeling, and showed that both CMS and colistin are cleared by hemodiafiltration. Combination therapy is an approach that is often used when treating patients infected with multidrug-resistant pathogens. The thesis discusses how the joint effect of antibiotics can be measured using colistin and meropenem as a model, and proposes a method for testing antibiotic combinations. Furthermore, a PKPD model was adapted to describe the pharmacodynamics of the combination. In conclusion, a specific and sensitive method for analysis of colistin was developed and the adsorption of colistin to materials was described. The assay method has been well accepted internationally. The pharmacokinetics of colistin and CMS was described in two important patient populations, partly with surprising results that have influenced dosages of colistin worldwide. The pharmacodynamics of combination therapy was investigated and quantified, and the methods applied could be further developed into clinically useful tools for selection of antibiotic combinations.

With societies aging all around the world, the global burden of degenerative diseases is expected to increase exponentially. From the perspective drug development, degenerative diseases represent an especially challenging class. Clinical trials, in this context often termed disease progression studies, are long, costly, require many individuals, and have low success rates. Therefore, it is crucial to use informative study designs and to analyze efficiently the obtained trial data. The development of novel approaches intended towards facilitating both the design and the analysis of disease progression studies was the aim of this thesis. This aim was pursued in three stages (i) the characterization and extension of pharmacometric software, (ii) the development of new methodology around statistical power, and (iii) the demonstration of application benefits. The optimal design software PopED was extended to simplify the application of optimal design methodology when planning a disease progression study. The performance of non-linear mixed effect estimation algorithms for trial data analysis was evaluated in terms of bias, precision, robustness with respect to initial estimates, and runtime. A novel statistic allowing for explicit optimization of study design for statistical power was derived and found to perform superior to existing methods. Monte-Carlo power studies were accelerated through application of parametric power estimation, delivering full power versus sample size curves from a few hundred Monte-Carlo samples. Optimal design and an explicit optimization for statistical power were applied to the planning of a study in Alzheimer's disease, resulting in a 30% smaller study size when targeting 80% power. The analysis of ADAS-cog score data was improved through application of item response theory, yielding a more exact description of the assessment score, an increased statistical power and an enhanced insight in the assessment properties. In conclusion, this thesis presents novel pharmacometric methods that can help addressing the challenges of designing and planning disease progression studies.

The cost of releasing a new drug on the market has increased rapidly in the last decade. The reasons for this increase vary with the drug, but the need to make correct decisions earlier in the drug development process and to maximize the information gained throughout the process is evident. Optimal experimental design (OD) describes the procedure of maximizing relevant information in drug development and drug treatment processes. While various optimization criteria can be considered in OD, the most common is to optimize the unknown model parameters for an upcoming study. To date, OD has mainly been used to optimize the independent variables, e.g. sample times, but it can be used for any design variable in a study. This thesis addresses the OD of multiple continuous or discrete design variables for nonlinear mixed effects models. The methodology for optimizing and the optimization of different types of models with either continuous or discrete data are presented and the benefits of OD for such models are shown. A software tool for optimizing these models in parallel is developed and three OD examples are demonstrated: 1) optimization of an intravenous glucose tolerance test resulting in a reduction in the number of samples by a third, 2) optimization of drug compound screening experiments resulting in the estimation of nonlinear kinetics and 3) an individual dose-finding study for the treatment of children with ciclosporin before kidney transplantation resulting in a reduction in the number of blood samples to ~27% of the original number and an 83% reduction in the study duration. This thesis uses examples and methodology to show that studies in drug development and drug treatment can be optimized using nonlinear mixed effects OD. This provides a tool than can lower the cost and increase the overall efficiency of drug development and drug treatment.

Despite the growing promise of pharmaceutical research, inferior experimentation or interpretation of data can inhibit breakthrough molecules from finding their way out of research institutions and reaching patients. This thesis provides evidence that better characterization of pre-clinical and clinical data can be accomplished using non-linear mixed effect modeling (NLMEM) and more effective experiments can be conducted using optimal design (OD).  To demonstrate applicability of NLMEM and OD in pre-clinical applications, in vitro ligand binding studies were examined. NLMEMs were used to evaluate precision and accuracy of ligand binding parameter estimation from different ligand binding experiments using sequential (NLR) and simultaneous non-linear regression (SNLR). SNLR provided superior resolution of parameter estimation in both precision and accuracy compared to NLR.  OD of these ligand binding experiments for one and two binding site systems including commonly encountered experimental errors was performed.  OD was employed using D- and ED-optimality.  OD demonstrated that reducing the number of samples, measurement times, and separate ligand concentrations provides robust parameter estimation and more efficient and cost effective experimentation. To demonstrate applicability of NLMEM and OD in clinical applications, a phase advanced sleep study formed the basis of this investigation. A mixed-effect Markov-chain model based on transition probabilities as multinomial logistic functions using polysomnography data in phase advanced subjects was developed and compared the sleep architecture between this population and insomniac patients. The NLMEM was sufficiently robust for describing the data characteristics in phase advanced subjects, and in contrast to aggregated clinical endpoints, which provide an overall assessment of sleep behavior over the night, described the dynamic behavior of the sleep process. OD of a dichotomous, non-homogeneous, Markov-chain phase advanced sleep NLMEM was performed using D-optimality by computing the Fisher Information Matrix for each Markov component.  The D-optimal designs improved the precision of parameter estimates leading to more efficient designs by optimizing the doses and the number of subjects in each dose group.  This thesis provides examples how studies in drug development can be optimized using NLMEM and OD. This provides a tool than can lower the cost and increase the overall efficiency of drug development. / <p>My name should be listed as "Charles Steven Ernest II" on cover.</p>

Population PK models aim to describe the change in drug concentration over time for a specific population. The populations in population PK modelling often refer to subjects in a clinical trial of a potential drug candidate. Population PK models are frequently described by non-linear mixed effect (NLME) models, that including both random and fixed effect components. The fixed effect components 𝜽 (THETA) portray typical parameter values in the population while the random effects components 𝜼 (ETA) allow for the incorporation of inter-individual variability (IIV) on the typical population value. The IIVs are therefore an important element of NLME models, but the estimation of the IIVs can be time consuming and become a limiting factor for more complex models. Linear approximation of the IIV’s has been suggested as a way to reduce the estimation time whilst maintaining robustness. The aim of this project was to evaluate and compare the estimation time and robustness of the IIVs for the linear approximation of parameter estimation errors in NLME models compared to those estimated in non-linear models. Population PK NLME models were developed for two datasets of phenobarbital and moxonidine. The datasets contained different levels of complexity such as number of subjects, datapoints and route of administration. The models were developed within R-studio using the assembler and Pharmpy packages and evaluated in NONMEM 7.5. Based on the objective function values (OFVs), obtained in the model building processes, selected models were linearised using Pearl speaks NONMEM (PsN). The estimated 𝜀′𝑠 and run-time of the linearised models were compared to their non-linearized counterparts. For all the models a reduction in run-time could be observed but with a slight variation in the estimations between the linearised and non-linearised models. The biggest run time reduction was seen in the oral transit compartment models for moxonidine with a 3100-fold reduction in estimation time. The estimation time reduction displayed could more quickly provide valuable information regarding the chosen error models of more complex models and while parameters estimated may not be identical to the non-linearised models, they should be sufficient during the model building phase.

Information retrieval within a company can be referred to as enterprise search. With the use of enterprise search, employees can find the information they need in company internal data. If a business can take advantage of the knowledge within the organization, it can save time and effort, and be a source for innovation and development within the company.  In this project, two open source search engines, Recoll and Apache Solr, are selected, set up, and evaluated based on requirements and needs at the pharmacometric consulting company Pharmetheus AB. A requirement analysis is performed to collect system requirements at the company. Through a literature survey, two candidate search engines are selected. Lastly, a Proof of Concept is performed to demonstrate the feasibility of the search engines at the company. The search tools are evaluated on criteria including indexing performance, search functionality and configurability. This thesis presents assessment questions to be used when evaluating a search tool. It is shown that the indexing time for both Recoll and Apache Solr appears to scale linearly for less than one hundred thousand pdf documents. The benefit of an index is demonstrated when search times for both search engines greatly outperforms the Linux command-line tools grep and find. It is also explained how the strict folder structure and naming conventions at the company can be used in Recoll to only index specific documents and sub-parts of a file share. Furthermore, I demonstrate how the Recoll web GUI can be modified to include functionality for filtering on document type.  The results show that Recoll meets most of the company’s system requirements and for that reason it could serve as an enterprise search engine at the company. However, the search engine lacks support for authentication, something that has to be further investigated and implemented before the system can be put into production.