title: Pharmacokinetic and tolerability assessment of a pediatric oral formulation of pentoxifylline in kawasaki disease.
abstract: BACKGROUND
  In infants and children, treatment of Kawasaki disease (KD) with high-dose intravenous immunoglobulin (IVIG) and acetylsalicylic acid ([ASA] aspirin) diminishes inflammatory response and reduces the risk for coronary artery abnormalities. However, patients with high serum concentrations of tumor necrosis factor (TNF)-alpha, which is associated with vascular damage, may develop coronary artery lesions even with treatment. The hemorheologic agent pentoxifylline blocks the production of TNF-alpha and may be an appropriate adjunctive therapy to IVIG and ASA.
  
  
  OBJECTIVE
  The objective of this study was to assess the pharmacokinetic characteristics and tolerability of a new oral syrup formulation of pentoxifylline as an adjunct to IVIG and ASA in the treatment of KD in children.
  
  
  METHODS
  Hospitalized boys and girls aged 6 months to 5 years and who were diagnosed with KD within the first 10 days of illness were eligible. Patients were assigned to 1 of 4 pentoxifylline treatment groups, by dose level (dose levels 1, 2, 3, and 4: 10, 15, 20, and 25 mg/kg daily, respectively, divided into 3 doses). Six plasma samples collected at the time the first dose was administered, and 4 samples collected after administration of the last dose on study day 6, were assessed by high-performance liquid chromatography using noncompartmental and 1-compartment pharmacokinetic analyses for pentoxifylline and its active metabolite (M-1). TNF-alpha levels on days 1 and 6 were assessed using electroimmunoassay.
  
  
  RESULTS
  Fourteen boys and 10 girls were enrolled. The mean age, body weight, and illness day at study entry were 34.5 months, 13.8 kg, and 6, respectively. Pentoxifylline exhibited nonlinear kinetic characteristics, with median area under the plasma concentration-time curve from time 0 to infinity(AUC0-∞) values of 622, 3428, 8416, and 10,347 ng/mL · h for dose levels 1 to 4, respectively, on study day 1. Pentoxifylline noncompartmental oral clearance and volume of distribution were significantly lower, and dose-normalized AUC0-∞ was significantly higher, for dose level 3 than dose level 1. M-1 parameters were not significantly different between dose levels. No accumulation of pentoxifylline or M-1 was noted. Fifteen of 24 patients (63%) reported mild to moderate adverse events that may or may not have been treatment related. Frequency and severity did not differ significantly between dose levels.
  
  
  CONCLUSIONS
  In the children in this study, pentoxifylline was well tolerated at the doses studied. No notable differences in clinical outcomes were observed between dose levels, and dose levels 3 and 4 (20 and 25 mg/kg daily, respectively) resulted in similar exposure to both pentoxifylline and M-1. Future efficacy and tolerability studies should use a daily dose of 20 mg/kg of pentoxifylline in acute KD.
authors.affiliation: Department of Pediatrics, University of California at San Diego, Children's Hospital and Health Center, San Diego, California, CA.
authors.forename: Brookie M
authors.initials: BM
authors.lastname: Best
authors.affiliation: Department of Pediatrics, University of California at San Diego, Children's Hospital and Health Center, San Diego, California, CA.
authors.forename: Jane C
authors.initials: JC
authors.lastname: Burns
authors.affiliation: Departments of Pediatrics and.
authors.forename: John
authors.initials: J
authors.lastname: DeVincenzo
authors.affiliation: Departments of Pediatrics and ; Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee.
authors.forename: Stephanie J
authors.initials: SJ
authors.lastname: Phelps
authors.affiliation: Division of Pediatric Pharmacology and Critical Care, Rainbow Babies and Children's Hospital, Cleveland, Ohio, and.
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Blumer
authors.affiliation: Department of Pediatrics, Louisiana State University Medical Center, Shreveport, Louisiana, USA.
authors.forename: John T
authors.initials: JT
authors.lastname: Wilson
authors.affiliation: Department of Pediatrics, University of California at San Diego, Children's Hospital and Health Center, San Diego, California, CA.
authors.forename: Edmund V
authors.initials: EV
authors.lastname: Capparelli
authors.affiliation: Department of Pediatrics, University of California at San Diego, Children's Hospital and Health Center, San Diego, California, CA.
authors.forename: James D
authors.initials: JD
authors.lastname: Connor
keywords: Kawasaki disease; TNF-alpha; pediatrics; pentoxifylline; pharmacokinetics