Monitoring Of Cyclosporine A And Voriconazole In Patients With Allogeneic Hematopoietic Stem Cell Transplantation

Objective1.Retrospective study the case documents of patients with allogeneic hematopoietic stem cell transplantation?Allo-HSCT?.Analyze the correlation between blood concentration of cyclosporine A and postoperative time,sex,age,clinical efficacy and safety.2.To establish an LC-MS/MS method to simultaneously measure the blood concentrations of CsA and voriconazole.Methods1.The case documents of 101 patients adminstrated with CsA after Allo-HSCT from June 2012 to June 2018 were collected.The relationships between the blood concentration of CsA and postoperative time,sex,age,efficacy and safety were retrospectively analyzed with SPSS20.0.2.The plasma was pre-treated by liquid-liquid extraction and separated with Agilent C₁₈?4.6 mm×75 mm,3.5?m?maintained at 50?.Mobile phase consisted of methanol-water?85:15?,and 0.5 mL·min^-1 equidegree elution was used with a run time of 10 mins.Mass spectrometry was used for multi-reaction monitoring,and the quantitative ion pairs were CsA:m/z 1224.8?1112.7,ascomycin?IS₁?:m/z 814.5?604.1,VRZ:m/z 350.2?281.1,FLU?IS₂?:m/z 307.0?238.The LC-MS/MS assay,EMIT assay and FPIA assay were used to determine the CsA blood concentration of 30 samples.The correlation between these results was analysed with SPSS20.0.3.In a self-contrast study,Allo-HSCT patients from January 2019 to December 2019were enrolled according to the inclusion and exclusion criteria.These patients were treated with CsA and VRZ successively and the blood concentration of CsA and VRZ before and after 5⁷ days of VRZ administration were determinted with LC-MS/MS.The correlation between the concentration of VRZ and concentration/dose?C/D?ratio of CsA was analyzed with SPSS20.0.Results1.The case documents of 101 Allo-HSCT patients were collected.Among them,64were male and 37 were female.The CsA blood concentration was determined in 696cases/time,and 299 cases/time were distributed in the range of 150⁴00 ng·mL^-1,accounting for 42.96%;Among the 101 patients,74 patients had an average blood concentration within the range of 150⁴00 ng·mL^-1,accounting for 73.27%.The postoperative time,sex and age exhibited effects on the blood concentrations of CsA.When the blood concentration of CsA was<200 ng·mL^-1,the incidence of aGVHD was 62.50%;and when it was>200 ng·mL^-1,the incidence of aGVHD was 37.70%.When the blood concentration of CsA was>400ng·mL^-1,the incidence of DIKI was 70.00%and the incidence of DILI was 60.00%.2.The established LC-MS/MS method for simultaneous determination of CsA and VRZ blood concentration met the determination requirements in linear range and quantitative limit.The recoveries were between 80%and 120%,and the inter-day and intra-day precision were less than 15%.The CsA blood concentrations in 30 patients were determined by three methods,and the results were as follows:LC-MS/MS method:103.49±47.24ng·mL^-1;EMIT method:132.04±59.73ng·mL^-1;FPIA method:148.94±72.48ng·mL^-1.The paired t test showed the values of LC-MS/MS were siginificantly lower than EMIT and FPIA?P<0.05?.Pearson correlation analysis showed that there was a significant correlation between the results of LC-MS/MS method,EMIT method and FPIA method?r=0.908,0.923?.The Bland-Altman diagram showed smaller deviation and better consistency between the results of LC-MS/MS and EMIT method.3.A total of 15 patients were enrolled in the self-contrast study.After 5⁷ days of VRZ administration,the median C/D ratio of CsA was 123.50?45.88,178.24?(ng·mL^-1)/?mg/kg?,which was significantly higher than that before VRZ administration:64.14?25.35,112.36?(ng·mL^-1)/?mg/kg?.The results for paired design non-parametric test?Wilcoxon signed rank test?was P<0.001.The median for blood concentration of VRZ was 1.74?0.48,3.70??g·mL^-1.The median increase in the C/D ratio was 82.16%?8.00%,190.00%?.Spearman analysis showed that there was no significant correlation between them??=-0.273,P=0.32?.Conclusions1.There were significant differences in sensitivity and tolerance to CsA among different individuals.In the long course of treatment,the CsA blood concentration was affected by many factors such as postoperative time,sex,age and so on.The dose of CsA was not completely positively correlated with its blood concentration.When the CsA blood concentration was<200 ng·mL^-1,the incidence of aGVHD was high;When the blood concentration of CsA was>400 ng·mL^-1,the incidence of hepatic and renal adverse reactions increased.The safe and effective range of CsAblood concentration was suggested as 200⁴00ng·mL^-1.2.The LC-MS/MS assay was established in this experiment and can be used to simultaneously determine CsA and VRZ blood concentrations.This method exhibited good reproducibility,low detection limit,strong specificity,fast,sensitive,and accurate.There was a good linear relationship between the results of LC-MS/MS and traditional immunoassay method?EMIT and FPIA?.Nevertheless,the results of immunoassay method?EMIT and FPIA?were significantly higher than that of LC-MS/MS method.Further statistical analysis showed that the results of LC-MS/MS and EMIT methods were more consistent and interchangeable.3.There was obvious drug-drug interaction?DDI?between CsA and VRZ.VRZ increased CsA blood concentration significantly,but there was no significant correlation between VRZ blood concentration and the degree of this increase.It indicates there was an individual difference in the degree of DDI between VRZ and CsA..Considering the effectiveness and safety of drugs,it is particularly suggested the LC-MS/MS method should be used to monitor the blood concentration of CsA and VRZ in Allo-HSCT patients.