Population pharmacokinetics and pharmacodynamics of Propofol in morbidly obese patients
Jeroen Diepstraten (1), Simone van Kralingen (2), Mariska Y.M. Peeters (1), Eric P.A. van Dongen (2), Bert van Ramshorst (3), Vera H.M. Deneer (1), Meindert Danhof (4) and Catherijne A.J. Knibbe(1,4)
(1) Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands; (2) Department of Anaesthesiology and Intensive Care, St. Antonius Hospital, Nieuwegein, The Netherlands; (3) Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands; (4) Division of Pharmacology, Leiden/ Amsterdam Center for Drug Research, Leiden University, Leiden, The Netherlands
Objectives: The number of morbidly obese patients (Body Mass Index (BMI) > 40 kg.m-2) undergoing (weight-reducing) surgery increases. However, the dose of anesthetics is unknown because of the lack of evidence of the exact pharmacokinetics and -dynamics. We therefore developed a population PK-PD model of propofol used for anaesthesia in morbidly obese patients, thereby studying the influence of covariates.
Methods: In morbidly obese patients induction and maintenance of anesthesia was performed using propofol with use of the Bispectral index (BIS). Population PK-PD modelling was performed using NONMEM VI. A step-wise covariate analysis was performed for TBW, LBW, IBW, BMI, age, sex, creatinine, bilirubin, PEEP and remifentanil. The analysis was repeated with inclusion of non-obese patients [1, 2].
Results: In twenty morbidly obese patients (TBW 98-167 kg, BMI 38-60 kg.m-2) 517 propofol samples were collected. In the three-compartment model, TBW was the only significant covariate (p< 0.001). Its influence was best characterised using an allometric equation with an estimated exponential scaling factor of 0.72. In the final model, Cl was (2.29*(TBW/70)** 0.75)) and no other covariates proved to be significant for any of the parameters. When the non-obese data sets were added, similar pharmacokinetic parameters were obtained, including the estimated allometric function for clearance. Depth of sedation using the BIS could be described by an indirect sigmoid Emax model. Based on preliminary results, we anticipate that EC50 is higher compared to non obese patients (analysis still in progress).
Conclusions: In morbidly obese patients, propofol clearance is significantly affected by TBW in a 0.75 allometric function. The model can be used for extrapolation to patients outside the study population.
References:
[1] Knibbe C.A., Eur J Clin Pharmacol 2000; 56: 89-95
[2] Knibbe C.A., Br J Clin Pharmacol 1999; 47: 653-660
