Title:
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Safe and effective use of medicine in children : adherence and population pharmacokinetic approaches
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Safe and effective use of medicines is an important issue especially in children with chronic illness who
are less resilient to adverse events and in whom disease progression may not be addressed if appropriate
medication is not taken. The research programme presented in this thesis focused on the use of dried
blood spot (DBS) sampling in the assessment of adherence and population pharmacokinetics (PK) of
medicines in children. The first aspect of the research focused on the use of azathioprine/6-
mercaptopurine (AZA/6-MP) for the treatment of children with Inflammatory Bowel disease (IBD).
Portraying IBD and its treatments by the newspaper media in the UK and USA, as·a source of
information and advice to the public, was investigated. Research demonstrated that information about
IBD and its treatment was not frequently mentioned and reporting was generally of low quality. The
media may impact public beliefs and concerns about medications and in turn influence how they use
medicines themselves and give them to their children.
Assay methods for the quantification of AZA/6-MP metabolites (as an adherence measure} in packed
RBCs and plasma (using HPLC) and in dried blood spots (using LC/MS/MS) were developed and
validated. The Bland-Altman test indicated equivalence in determined concentrations of AZA/6-MP
metabolites in packed red blood cells and DBS samples. These assays were applied successfully, as part
of a multi-method approach, to assess adherence to AZA/6-MP in a pilot study in children with IBD,
including home DBS samples collected by children or their parents. The overall adherence rate using
this method, coupled with other objective and subjective measures, was determined to be 71 %. The
return rate of home DBS was reasonably high (81 .0%), however, more training on the proper use of the
calibrated capillary used to collect home samples is required to help ensure good quality samples. Child
concerns about medicines and the presence of side-effects, were found to significantly decrease the
probability of the patient being adherent.
The second major piece of clinical research presented in this thesis involved the development of a
pharmacokinetic model for ketamine when used for procedural sedation and anaesthesia in neonatal
intensive care patients. An LC-MS/MS method was developed, validated and applied effectively to the
quantification of ketamine and norketamine enantiomers in dried blood spot samples collected from
neonates recruited into the clinical trial. Utilising the data generated from the work, pharmacokinetic
parameters were estimated for this patient group using population pharmacokinetic modelling. A lower
volume of distribution and a shorter half-life for both ketamine enantiomers, compared to published
data for older children and adults, were found. Weight was found to be the only covariate with a
significant influence on the PK parameters. With further refinement, the final pharmacokinetic models
can be utilised when designing ketamine dosage regimen in neonates.
The research presented in this thesis clearly demonstrated the utility of the novel DBS approach which
has extended the scope for conducting adherence and population pharmacokinetic studies in children.
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