Critical illness is a major determinant of midazolam clearance in children aged 1 month to 17 years

Ibrahim Ince, Saskia N. De Wildt, Mariska Y.M. Peeters, Daryl J. Murry, Dick Tibboel, Meindert Danhof, Catherijne A.J. Knibbe

Research output: Contribution to journalArticlepeer-review

31 Scopus citations


BACKGROUND: In children, a large variability in pharmacokinetics of midazolam, a cytochrome P450 3A4/5 (CYP3A4/5) enzyme substrate, has been described, which cannot be explained by age-related changes alone. In this study, these age-related changes are studied in relation to other covariates to explain the variability in the pharmacokinetics of midazolam in children. METHODS: Population pharmacokinetic modeling was performed using a joint dataset of 3 studies conducted previously: study 1: pediatric intensive care patients requiring sedation in the intensive care unit; study 2: pediatric oncology patients undergoing an invasive procedure; study 3: otherwise healthy infants admitted for postoperative monitoring after elective major craniofacial surgery. Midazolam, 1-hydroxymidazolam, and 1-hydroxymidazolam glucuronide concentrations were considered to determine the pharmacokinetics of midazolam and metabolites using NONMEM 6.2. SimCYP pediatric simulator was used for simulation. RESULTS: Fifty-four children aged between 1 month and 17 years who received intravenous midazolam (bolus and/or continuous infusion) for sedation were included in this study. A reduction of 93% for CYP3A4/5 (midazolam to 1-hydroxymidazolam) and 86% for uridine diphosphate glucuronosyltransferase (1-hydroxymidazolam to 1-hydroxymidazolam glucuronide) mediated clearance was found in pediatric intensive care patients compared with the other 2 patient groups. We did not find a significant influence of age or bodyweight on CYP3A4/5-mediated total clearance. For uridine diphosphate glucuronosyltransferaseg-mediated clearance, bodyweight explained 41.5% of the variability. CONCLUSIONS: From infancy to adolescence, critical illness seems to be a major determinant of midazolam clearance, which may result from reduced CYP3A4/5 activity due to inflammation. This may have important implications for dosing of midazolam and other CYP3A drug substrates in critically ill children.

Original languageEnglish (US)
Pages (from-to)381-389
Number of pages9
JournalTherapeutic Drug Monitoring
Issue number4
StatePublished - Aug 2012
Externally publishedYes


  • CYP3A4
  • critical illness
  • midazolam
  • pediatrics
  • population pharmacokinetics
  • therapeutic drug monitoring

ASJC Scopus subject areas

  • Pharmacology
  • Pharmacology (medical)

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