Individualizing liver transplant immunosuppression using a phenotypic personalized medicine platform

Postoperative liver transplant immunosuppression was personalized using a phenotypic, disease mechanism–independent and indication-agnostic approach. Personalizing drug dosing After organ transplant, patients are on a merry-go-round of medicines and procedures to make sure that the graft is not rejected. Currently, physicians use dosing guidelines for drugs meant to suppress the immune system, but also use educated guesses in choosing dose, to account for variability in patient response to the drugs and drug-drug interactions. Now, Zarrinpar and colleagues have come up with a mathematical approach to remove the guesswork. Their approach, called parabolic personalized dosing (PPD), relies on algebraic equations to relate phenotype (in this case, trough level of an immunosuppressant, tacrolimus) to input (tacrolimus concentration). By mapping patient response over the course of treatment, the equation produces a two-dimensional (2D) parabola that indicates the next dose that the patient should receive. The parabola shifts as drugs are added or taken away, or as the patient undergoes additional clinical procedures, such as hemodialysis, which can interfere with drug distribution within the body. The PPD approach was tested in four patients and compared to the standard of care, physician guidance. The PPD patients were out of trough range less frequently and for shorter periods of time than controls, suggesting that the equation was predicting next doses accurately. Future studies will involve more patients and will expand the PPD equation to represent a 3D parabolic surface, which will factor in drug combinations. The PPD approach will have broad applicability beyond transplant medicine, because it is independent of disease mechanism or drug of choice and could thus personalize regimens for many types of patients. Posttransplant immunosuppressive drugs such as tacrolimus have narrow therapeutic ranges. Inter- and intraindividual variability in dosing requirements conventionally use physician-guided titrated drug administration, which results in frequent deviations from the target trough ranges, particularly during the critical postoperative phase. There is a clear need for personalized management of posttransplant regimens to prevent adverse events and allow the patient to be discharged sooner. We have developed the parabolic personalized dosing (PPD) platform, which is a surface represented by a second-order algebraic equation with experimentally determined coefficients of the equation being unique to each patient. PPD uses clinical data, including blood concentrations of tacrolimus—the primary phenotypic readout for immunosuppression efficacy—to calibrate these coefficients and pinpoint the optimal doses that result in the desired patient-specific response. In this pilot randomized controlled trial, we compared four transplant patients prospectively treated with tacrolimus using PPD with four control patients treated according to the standard of care (physician guidance). Using phenotype to personalize tacrolimus dosing, PPD effectively managed patients by keeping tacrolimus blood trough levels within the target ranges. In a retrospective analysis of the control patients, PPD-optimized prednisone and tacrolimus dosing improved tacrolimus trough-level management and minimized the need to recalibrate dosing after regimen changes. PPD is independent of disease mechanism and is agnostic of indication and could therefore apply beyond transplant medicine to dosing for cancer, infectious diseases, and cardiovascular medicine, where patient response is variable and requires careful adjustments through optimized inputs.