Everolimus in pulmonary transplantation: pharmacokinetics and exposure-response relationships.
BACKGROUND
In this study we evaluated exposure, safety and efficacy data from an international trial of everolimus. We sought to identify a tolerated and efficacious range for blood levels of this agent in maintenance lung transplant recipients.


METHODS
In a randomized, double-blind, multicenter trial, 213 maintenance lung transplant recipients received either everolimus 1.5 mg twice daily (n = 101) or azathioprine 1 to 3 mg/kg/day (n = 112) with cyclosporine and corticosteroids. At 15 visits over the first 2 years of the trial, we obtained 826 everolimus trough (C0) blood samples. We used median-effect analysis to assess relationships between everolimus C0 vs efficacy and safety responses.


RESULTS
Everolimus administration began at 1.5 mg twice daily and was progressively lowered over the first 2 months to an average of 1.2 +/- 0.4 mg twice daily, which was maintained thereafter. This dose yielded median C0 levels of 6.6 ng/ml (10th to 90th percentiles: 2.8 to 11.8 ng/ml). Over this range of everolimus C0, freedom from a decline in pulmonary function with bronchiolitis obliterans syndrome and freedom from biopsy-proven acute rejection were both > or = 88%. The incidence of increased cholesterol (> 6.5 mmol/liter), increased triglycerides (> 2.9 mmol/liter) and transiently decreased platelet count (< 100 x 10(9)/liter) rose significantly with increasing C0. Infections and drug-related adverse events were not significantly related to exposure.


CONCLUSIONS
A tolerated and efficacious concentration range for everolimus in maintenance lung transplantation appears to be 3 to 12 ng/ml when used in conjunction with cyclosporine and corticosteroids. This range should be prospectively assessed with possible refinement as more clinical experience is gained.
Novartis Pharmaceuticals, Basel, Switzerland. john.kovarik@novartis.com
John M
JM
Kovarik
Gregory I
GI
Snell
Vincent
V
Valentine
Robert
R
Aris
Charles K N
CK
Chan
Heinz
H
Schmidli
Ulrich
U
Pirron
D000328:Adult; D019540:Area Under Curve; D001379:Azathioprine / Q000627:therapeutic use; D016572:Cyclosporine / Q000627:therapeutic use; D004305:Dose-Response Relationship, Drug; D004311:Double-Blind Method; D016903:Drug Monitoring; D004359:Drug Therapy, Combination; D000068338:Everolimus; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D007166:Immunosuppressive Agents / Q000493:pharmacokinetics* / Q000627:therapeutic use; D016040:Lung Transplantation / Q000276:immunology*; D008297:Male; D008875:Middle Aged; D020123:Sirolimus / Q000031:analogs & derivatives* / Q000493:pharmacokinetics / Q000627:therapeutic use; D016896:Treatment Outcome
D005938:Glucocorticoids; D007166:Immunosuppressive Agents; D016572:Cyclosporine; D000068338:Everolimus; D001379:Azathioprine; D020123:Sirolimus