The liver is a major organ responsible for maintaining the body's homeostasis and xenobiotic metabolism. Liver transplantation is essential for the alleviation of many severe liver diseases. However, there are many patients who cannot receive liver transplants because of donor shortage. Therefore development of effective therapeutic drugs that can replace the need for liver transplantation is desired. To this end, model cells that faithfully reproduce hepatic functions are essential. It is expected that human induced pluripotent stem cell (iPS)-derived hepatocyte-like cells, which faithfully reproduce hepatic functions, would be a valuable tool for drug discovery. Hepatic differentiation from human iPS cells has been performed using growth factors, but the hepatic differentiation efficiency was quite low and liver functions of human iPS cell-derived hepatocyte-like cells were lower than those of primary human hepatocytes. Therefore we tried to improve the hepatic differentiation technology using gene transfer, genome editing, three-dimensional culture, and extracellular matrix technologies. As a result, the purity of human iPS cell-derived hepatocyte-like cells was improved into 90% or more, and the liver functions of human iPS cell-derived hepatocyte-like cells were improved to a level comparable to primary human hepatocytes. In this article, we introduce the research results we have acquired over the last decade.

Pharmacometrics is the mathematical study of pharmacokinetics, disease progression, and clinical outcomes. One objective of pharmacometrics is to facilitate rational drug treatment in patients, also termed clinical pharmacometrics. In this review, our clinical pharmacometric studies conducted over the last 10 years are discussed. Population pharmacokinetic analysis using therapeutic monitoring data for levetiracetam revealed that oral clearance allometrically scaled to both body weight and estimated glomerular filtration rate can accurately predict clinical data from patients of various ages (pediatric to elderly) with varying renal function. Dosage adjustments based on renal function in the package information are effective in controlling the trough and peak concentrations in similar ranges. In addition, a retrospective pharmacokinetic and pharmacodynamic study revealed that the efficacy of low-dose clobazam therapy was significantly influenced by CYP2C19 polymorphisms. Pharmacokinetic and pharmacodynamic models were successfully built using electronic medical information to explain retrospective international normalized ratio values of prothrombin time before and after catheter ablation in warfarin-treated patients. Simulation studies suggest that more than 20 mg of vitamin K₂ is unnecessary in the preoperative period of catheter ablation. A physiologically based pharmacokinetic model adapted to tacrolimus pharmacokinetic data in patients who underwent living-donor liver transplantation was constructed, and clarified that oral clearance of this drug was affected by CYP3A5 genotypes in both the liver and intestine to the same extent. In conclusion, pharmacometrics is a useful methodology for individualized and optimized drug therapy.

Reactive oxygen species (ROS) are highly reactive molecules generated during mitochondrial respiration and under various environmental stresses, and cause damage to DNA, proteins, and lipids, which is linked to a wide variety of pathologies. However, recent studies have revealed the physiological importance of ROS as signaling molecules, which play crucial roles in the maintenance of cellular functions and homeostasis. According to the extent and duration of ROS generation, ROS-mediated oxidation-reduction (redox) signaling (ROS signaling) is tightly regulated by various molecules and post-translational modifications (PTMs), for inducing appropriate cellular responses. Dysregulation of ROS signaling causes cellular malfunctions, which are also linked to various diseases, such as cancer, neurodegeneration and inflammatory diseases. In this review, we focus on a ROS-responsive protein kinase apoptosis signal-regulating kinase 1 (ASK1) that belongs to the mitogen-activated protein (MAP) kinase kinase kinase (MAP3K) family, and activates the c-jun N-terminal kinase (JNK) and p38 MAP kinase pathways, which consequently induces various cellular responses, including apoptosis and inflammation. Here, we introduce a novel regulatory mechanism and the pathophysiological significance of ASK1 activation. We found that an E3 ubiquitin ligase TRIM48 orchestrates fine-tuning of ROS-induced ASK1 activation mediated by multiple types of PTMs, including ubiquitination, methylation, and phosphorylation. We also found that trans-fatty acids (TFAs) enhance ROS-dependent ASK1 activation induced by extracellular ATP, a damage-associated molecular pattern (DAMP), and thereby promotes apoptosis, which possibly contributes to the pathogenesis of TFA-related diseases including atherosclerosis. Thus, this review provides recent advances in the study of ROS signaling, especially ROS-ASK1 signaling pathway.

Direct functionalization of the C-H bond is a highly attractive method because it does not require any pre-functionalized starting materials. Therefore this method can be adopted to attain the atom- and step-economic synthesis of organic compounds. We recently developed novel C-H functionalization reactions using two strategies. The first strategy is transition-metal catalyzed C-H functionalization, which comprises the copper-catalyzed oxidative C(sp³)-H functionalization of 2-alkyl-N-arylbenzamides for the synthesis of N-aryl-isoindolinones. This method can be applied to various substituted substrates and the synthesis of bioactive compounds, indoprofen and DWP205190. It provides an efficient approach toward the construction of isoindolinone skeletons. The second strategy is an in situ generated base-mediated C-H functionalization comprising the deprotonative silylation of C(sp)-H and C(sp²)-H bonds by the base generated in situ from trifluoromethyltrimethylsilane (CF₃SiMe₃) and its activator. In the C(sp)-H silylation of terminal alkynes, 1,3-dimethyl-3,4,5,6-tetrahydro-2(1H)-pyrimidinone (DMPU) acts as both a solvent and activator; therefore no additional activator is required. Moreover, the preferential deprotonation of terminal alkynes using this system proceeds faster than the trifluoromethylation of ketones and esters.

To administer optimal and safe pharmacotherapy, development of stratified and personalized therapy is imperative. Pharmacogenomics (PGx) is useful in elucidating factors causing individual differences in drug efficacy and the emergence of adverse effects. It also helps design accurate drug administration methods by evaluating the effects of patient-related factors, such as genetic factors, that influence pharmacokinetics (PK) and pharmacodynamics (PD). In addition, selection of appropriate therapeutic agents requires the implementation of precision medicine allowing accurate disease diagnosis. To establish precision medicine, it is necessary to uncover the association of pathophysiological factors, which are represented as endotype or genotype, with the pathology of several phenotypes. This review describes two aspects related to realization of individualized medicine, namely the effectiveness of PK/PD/PGx studies and the stratification of pathological conditions. First, we conducted a PK/PD/PGx study with the aim to individualize warfarin treatment. In this study, we elucidated the effect of CYP4F2 polymorphisms associated with vitamin K metabolism by measuring the blood concentrations of warfarin and vitamin K. Then, to develop precision medicine for asthma and chronic obstructive pulmonary disease (COPD), we analyzed not only clinical symptoms but also pathological biomarkers and genes associated with inflammation. The findings may contribute toward better understanding of the pathological conditions of asthma, COPD, and asthma-COPD overlap.

The first total synthesis of avenaol was achieved using a new robust strategy involving all-cis-substituted cyclopropane formation via an alkylidene cyclopropane. The keys to success for the total synthesis were (i) Rh-catalyzed intramolecular cyclopropanation of an allene; (ii) Ir-catalyzed stereoselective double-bond isomerization to form an all-cis cyclopropane; and (iii) differentiation of two hydroxymethyl groups via regioselective cyclization and oxidation of tetrahydropyran based on the reactivity of cyclopropyl group. This strategy effectively avoids cyclopropane ring opening and undesired formation of a cage structure. Additionally, the proposed structure of avenaol, especially unique all-cis-substituted cyclopropane was confirmed correct by this total synthesis.

Dispensing clinical preparations requires the professional ability of pharmacists as specialists who understand the physicochemical properties of drugs. Clinical preparations contribute to the support of drug therapy and to commercialization by pharmaceutical companies. The Japanese Society of Hospital Pharmacists published the Guidelines on Hospital Preparations and Use in 2012. Those guidelines were designed to improve the safety and utility of hospital preparations, indicate the standard procedures for treatment in hospitals, and show how to ensure the quality of hospital preparations. The expiration dates for clinical preparations should be determined, although this is not done for most because of the numerous hospitals and differences in their approaches to quality control. Furthermore, the acquisition of informed consent for the use of clinical preparations is inadequate. After the guidelines were released, some problems have occurred, such as the underfilling of prescriptions for progesterone vaginal suppositories and overdoses of selenium injections. It therefore appears necessary to consider the development of a new procedural manual on clinical preparations. In this symposium, I discuss relief or safety measures for clinical preparations.

Aphthous stomatitis is induced by chemotherapy and radiotherapy. It has been reported that 100% of patients administered high-dose chemotherapy and 80% of patients receiving radiotherapy develop stomatitis. The most serious cases are accompanied by pain and bleeding of the ulcers, which cause significant suffering and reduce patients' quality of life. Rebamipide (RB) was developed in Japan as a treatment for gastric ulcer. In this study, we prepared and evaluated a mouthwash for stomatitis taking into consideration the solubilization of RB. RB nanoparticles were prepared by the wet-milling technique using various forms of hydroxypropyl cellulose (HPC-L, -SL, and -SSL) and sodium lauryl sulfate (SLS). RB nanoparticles sized between 126.6 and 286.8 nm were obtained under various conditions. From the results of zeta potential measurement and evaluation of their dispersibility, it appeared that the prepared nanosuspensions were stable. Furthermore, adhesion of the nanoparticles to the mucous membrane in the oral cavity was evaluated using quartz crystal microbalance with dissipation monitoring (QCM-D) technology. From the changes in the thickness of the gold sensor observed in QCM-D measurement, it was suggested that HPC-SSL molecules interact with mucin mounted on the gold sensor. It appears feasible to utilize RB nanoparticles dispersed in HPC-SSL solution in mouthwash to prevent stomatitis.

In this symposium, we present a novel breathable protective ointment (BPO) formulation developed at the University of Shizuoka for the prevention of moisture-associated skin damage (MASD) intended for use in healthcare settings. MASD occurs when moisture is in constant contact with the skin for prolonged periods of time, causing degradation of the skin barrier. Exposure to physical or chemical stimuli in addition to moisture may lead to different types of moisture-associated dermatitis such as incontinence-associated or periwound dermatitis. Another type of moisture-associated dermatitis, diaper dermatitis, is treated with protective ointments such as white petrolatum and zinc ointment. These ointments protect the skin from irritants but also block insensible dermal perspiration, which promotes further skin maceration. Therefore, we have developed a BPO formulation from white petrolatum and calcium carbonate, which serve as a protectant and pore-forming agent, respectively. In vitro water-proof tests confirmed the skin-protective properties of the BPO, and moisture-permeation tests indicated its breathability. Moreover, the BPO protected the skin from irritants without the loss of skin hydration in rats. Our next step involves the trial of BPO in infants with diaper dermatitis. In the future, this BPO could be used as an ointment base for active pharmaceutical ingredients used to prevent MASD.

In the healthcare setting, the handling of clinical preparations is essential for the development of tailor-made pharmaceutical agents. However, during the design and development of new clinical formulations, pharmacists may encounter various questions and problems related to handling the formulations, such as a lack of knowledge of and experience in prescription design. In addition, if pharmacists require assistance to solve problems, it is rare to find a person with sufficient knowledge of and experience with the formulation in their facilities, and there are few connections among facilities; therefore, in practice, no consultants are available for advice. Universities may play an important role in solving this problem. We believe that it would be beneficial for both clinical practitioners and universities to develop a plan-do-check-action (PDCA) cycle that brings needs, problems, and questions from clinical sites to universities where research is conducted and the results are fed back to the clinics. This complements one of the major missions of universities as research institutes, which is to compile evidence. For new drug candidates that require a high degree of support from universities, the demonstration of sufficient safety information to warrant clinical trials and subsequent drug development will increase pharmacists' awareness of drugs and lead to uptake of formulations. This paper introduces the case for clinical formulation design in universities as part of the C (check) element of the PDCA cycle and how this corresponds to the needs of the pharmaceutical industry.

Hospital-prepared drugs, as one form of off-label use, are prepared by pharmacists in individual Japanese hospitals. More than 20 originally hospital-prepared drugs have become commercially available in Japan, although the number reaching the commercialization stage has decreased recently. In this study, we show our recent approach to developing hospital preparations into commercially available drugs. Our first endpoint was to start phase 2 clinical trials of hospital-prepared drugs. The second endpoint was to determine whether the drugs could continue to phase 3 trials. We have developed an evidence database on 107 hospital-prepared drugs by performing a literature survey on each drug for references to the words “stability”, “efficacy”, and “safety”. If evidence is lacking, in vitro study results are compiled in the database, which will be needed when initiating clinical trials. So far, a phase 2 clinical trial of one hospital-prepared drug has been completed, and we have started stability testing of some drugs for which evidence of stability is lacking. This paper presents our recent approach to developing hospital preparations into commercially available drugs.

Population pharmacokinetics (PPK) is a useful approach to the evaluation of drug pharmacokinetics in patients and is a widely used method for the evaluation of pharmacokinetics in clinical trials. PPK uses a statistical model to calculate population parameters, their variance, and covariates from sparse and unbalanced data in a large target population. Population parameters can subsequently be used to establish individual prescribing regimens for specific patients. Post-marketing clinical studies using PPK analysis have been reported by medical and academic institutions in order to complement the poor pharmacokinetics information, thus increasing the available pharmacokinetics information. However, because, in many cases, PPK information is not indicated in the package insert (PI), pharmacokinetics information such as pharmacokinetics parameters and associated variable factors is insufficient. We investigated what kind of new information was obtained in the post-marketing clinical studies using PPK analysis and whether these PPK results were described in Japan PI and/or interview form (IF). We showed that many post-marketing clinical studies were conducted as a single-center and observational study in order to supplement deficient pharmacokinetics data. Also, most PPK results obtained from post-marketing studies were not included in Japan PI and/or IF presumably due to lack of quality of PPK models. If sufficient post-marketing clinical studies using high-quality PPK models are performed, PPK models based on patients with diverse backgrounds, which take inter-individual variability into consideration, can be constructed and PPK information can contribute to the proper use of drugs and the promotion of individualized treatment strategies.

Herbal medicines, acupuncture and moxibustion are often used for unidentified complaints. It is well known that catecholamine secreted by the sympatho-adrenal medullary system primarily functions to increase cardiac output and raise glucose levels in the blood during acute stress. In the present study, the effects of yokukansankachimpihange (YKSKCH, a Kampo medicine) on urinary catecholamine in mice that were repeatedly stressed by restraining were examined. Restraint stress (240 min/d×3 d×3 cycles, daytime: 12:00-16:00) induced a marked increase in noradrenaline (NA) and adrenaline (A) levels in the urine. Oral administration of YKSKCH (750 mg/kg of body weight) significantly inhibited the increase in urinary NA and A levels in mice after repeated restraint stress. In addition, the NA/dopamine (physical stress) and A/dopamine (mental stress) ratios were lower in the 750 mg/kg YKSKCH-treated group than in the control group. The tail suspension test was also performed and locomotor activity was investigated. Oral administration of YKSKCH at 750 mg/kg significantly reduced the immobility time, which was longer in mice after repeated restraint stress. Furthermore, oral administration of YKSKCH at 750 mg/kg increased locomotor activity, which was lower in mice after repeated restraint stress. These results suggest that YKSKCH has positive effects on mental and physical stress after repeated restraint stress, without reducing locomotor activity.

Compared to oral medication, the base plays a large role in the external preparation for skin, and dermatologists select the dosage form based on understanding of the effect of the base as well as according to skin symptoms and conditions, application site, age, season, etc. Further, in treatment with external preparations, it is important for patients to understand the application method and continue to apply an adequate amount to achieve the treatment goal. However, there is little evidence regarding the relationship between base properties or usability and the application amount. In this study, we investigated the usability and application amount of three bases with different properties (ointment base, cream base, and lotion base) in 62 adult subjects and exploratively examined the effect of the different base properties on the application amount. The results of this clinical study showed that the usability and preference for the base used for external preparations varies, and poor usability and low preference may lead to a reduction in the application amount. Even with good usability and high preference, there were many cases in which an adequate amount was not applied due to lack of specific instructions on external use. When selecting or changing the base in an external therapy, it is important for not only dermatologists but also pharmacists providing instructions on external use to be aware of the importance of the base and actively instruct patients to apply an adequate amount of the preparation.

The dosage of cisplatin is adjusted according to creatinine clearance (Ccr) estimated by the Cockcroft-Gault formula, which is commonly used as a marker for renal function. It is known that different serum creatinine (Scr) levels are reported depending on the analytical methods utilized such as the Scr level by the enzyme method being lower than that by the Jaffe method. Although the enzyme method is used in Japan, most drug dosages, including cisplatin, are adjusted according to the estimated Ccr using the Jaffe method-based Scr level. The purpose of this study was to investigate whether assessment of renal function with or without Scr adjustment affects cisplatin-based chemotherapy in cervical cancer patients. The patients were divided into two groups, normal (Ccr≥60 mL/min with adjusted Scr) and false normal (Ccr<60 mL/min with adjusted Scr, but Ccr≥60 mL/min with non-adjusted Scr). The false normal group had significantly higher rates of cisplatin dose reduction after the second course than the normal group (p<0.05). Leukocytopenia and Grade 2 or higher neutropenia were significantly more common in the false normal group than in the normal group (p<0.05). These results suggest that evaluation of renal function using the adjusted Scr is important for the accurate dosage of cisplatin and that it helps to improve the patient's quality of life. Further investigations may provide useful information for accurate and safe cisplatin-based chemotherapy for cancer patients.

Cancer patients use health foods (HFs) as complementary and alternative medicine, although the details of their adverse events (AEs) are unclear. We searched three databases [PubMed, “Igaku Chuo Zasshi”, and Information System on Safety and Effectiveness for Health Foods website (https://hfnet.nibiohn.go.jp/)] for case reports on AEs related to HF intake in cancer patients published before October 2018. Of the matched reports, 76 studies and 92 patients (31 in Japan, 61 overseas) that met the selection criteria were included in this review. Thus, the severity of AEs and outcomes were not related to either the concomitant use of HF with cancer chemotherapy or cancer stages of patients. AEs caused by HF intake itself accounted for 87%, while drug-HF interaction accounted for 11%. According to the Common Terminology Criteria for Adverse Events (CTCAE) classification, 70% of patients whose grades were identified had severe cases (grades 3 to 5). In Japanese patients, hepatic and respiratory disorders accounted for 52% of the severe cases. Cases were predominantly developed as a result of an allergic mechanism, and mushroom products were mostly used. Overseas, serious cases were induced by products that were already indicated for safety problems. Moreover, notable AEs were recognized, such as hypercalcemia, which were caused by intake of HF containing calcium, vitamin D, and shark cartilage, and bacterial infection caused by probiotic products. Analyzing the details of AEs related to HF intake can help health professionals and cancer patients prevent health hazards.

Patients with cognitive dysfunction caused by dysmnesia face difficulties in memorizing and learning general concepts; therefore, they encounter trouble in taking medications. Recently, a prescription notebook has been shown to be useful for patients receiving pharmacotherapy; however, it is not yet clear whether a common prescription notebook is useful for patients with a memory disorder. In our study, using a questionnaire for 61 patients, we first determined the benefits of and improvement in the drug administration guidance provided by a pharmacist to patients with a memory disorder compared with those undergoing medical examination by a doctor. Although 35-74% of patients could not communicate with a pharmacist or doctor, most found it easier to communicate with a pharmacist than with a doctor. Moreover, we investigated whether a common prescription notebook and our designed notebook, called the personal notebook, were useful to patients with a memory disorder. Although 89% of patients with a memory disorder use a common prescription notebook, 41% of them answered that they found it difficult to use. On the other hand, 66% of the patients with a memory disorder answered that they wished to use the personal notebook. Remarkably, all patients within 5 years of onset of a memory disorder wished to use this notebook. These findings indicate that it is useful for patients within 5 years of onset of a memory disorder to use the personal notebook. We propose a method to improve the use of a prescription notebook for patients with a memory disorder through this survey.