Concentration Monitoring In Whole Blood, Clinical Application And Safety Evaluation Of Sirolimus In Allo-HSCT Patients

Objective:The present study was designed to establish and validate the methodology of sirolimus(SRL)determination in whole blood,and to evaluate its effects on precaution of allogenic haemopoietic stem cell transplant(allo-HSCT)and treatment of acute graft versus host disease(aGVHD),the incidence of adverse events,as well as the relationship between SRL blood concentration and adverse events incidence.Methods:A novel,reversed-phase high-performance liquid chromatography(HPLC) method was described for the analysis of SRL in whole blood with solid-phase extraction.The method of case control study was used.The patients who experienced HSCT were enrolled in this trial.Of them,the patients who treated with SRL were assigned as experimental group,and those who treated with CSA or FK506 were assigned as control groups.During the trial,the patients' medications were tracked, and their physiological index,SRL trough concentration,adverse events(AEs)and therapeutic outcome were measurement and recording.Results:The method has a well linear relationship over a range of 2.5～60ng/ml.The lower limit of quantification (LOQ)was 2ng/ml.Total 76 patients were included in the trial.26 of them were in SRL group,25 patients in CSA group,and 25 patients in FK506 group.Of those who experienced ClassⅠ～ⅡaGVHD,15 patients adopted the schedule of SRL plus methylprednisolone(MP),and achieved 100%effictive rate;13 patients adopted the schedule of CSA plus MP,and achieved 84.6%effictive rate;13 patients adopted the schedule of FK506 plus MP,and achieved 92.3%effictive rate.There is no significant difference among the three groups(P＞0.05).Among those who experienced ClassⅢ～ⅣaGVHD:There are three patients in SRL with 1 effective,1 improvement and 1 deterioration.Four patients in CSA group were ineffective.By comparison,there is a significant difference(P＜0.05).There are three patients in FK506 group with 1 effective,1 improvement and 1 deterioration.Of the eight patients shifted from CSA or FK506 to SRL due to the renal impairment,7 patients achieved renal function restoration.One patient was discontinuation due to the myelosuppression of SRL.As to routine blood parameters,among three groups, there are no significant difference in decrease of hemoglobin(Hb)and white blood cell(WBC),but significant difference in decrease of platelet(PLT).The incidence of blood presure(BP)raising is most frequent in CSA group,whereas the incidence of blood glucose increase is most frequent in FK506 group.The incidence of renal impairment are comparable between CSA group and FK506 group,both are significant higher than SRL group.Interestingly,blood fat increase and acne incidence rate in SRL group are higher than those in other two groups.There is comparable incidence rate in disturbance of blood coagulation among three groups. The increase of BP,blood glucose,and abnormality of blood fat showed significant difference among three groups.Through SRL trough concentration monitoring in patients' whole blood and adverse drug reactions(ADR),the patients who experienced decrease of PLT(9.32±6.95ng/ml,n=33),by comparison with those who has no decrease of PLT(6.89±3.61 ng/ml,n=17),show significant difference in whole blood trough concentration of SRL(P=0.015).There is no relationship between liver function impairment or Hb/WBC decrease and whole blood trough concentration of SRL were observed.Conclusion:The method was rapid,sensitive,accurate, specific,and precise.The assay did not show interference peaks from whole blood with SRL,and available to be used for the determination of human whole blood SRL. The results show that SRL could be indicated to prevention aGVHD of renal impairment patients with conclusive efficacy.The therapeutic effect of SRL for ClassⅠ～ⅡaGVHD is comparable with CSA and FK506.When used for ClassⅢ～Ⅳprevention of aGVHD patients,the efficacy of SRL is superior than CSA group,but comparable with FK506 group.The major ADR of SRL are hemogram decrease, blood fat increase,and liver function impairment.There is significant difference in SRL blood concentration between and within individuals;furthermore,the PLT decrease has close correlation to SRL trough concentration,which give the evidence that appropriate dose adjustment are necessary in clinical practice to improve the safety of SRL.