Inflammation and Organ Failure Severely Affect Midazolam Clearance in Critically Ill Children

Am J Respir Crit Care Med. 2016 Jul 1;194(1):58-66. doi: 10.1164/rccm.201510-2114OC.


Rationale: Various in vitro, animal, and limited human adult studies suggest a profound inhibitory effect of inflammation and disease on cytochrome P-450 3A (CYP3A)-mediated drug metabolism. Studies showing this relationship in critically ill patients are lacking, whereas clearance of many CYP3A drug substrates may be decreased, potentially leading to toxicity.

Objectives: To prospectively study the relationship between inflammation, organ failure, and midazolam clearance as a validated marker of CYP3A-mediated drug metabolism in critically ill children.

Methods: From 83 critically ill children (median age, 5.1 mo [range, 0.02-202 mo]), midazolam plasma (n = 532), cytokine (e.g., IL-6, tumor necrosis factor-α), and C-reactive protein (CRP) levels; organ dysfunction scores (Pediatric Risk of Mortality II, Pediatric Index of Mortality 2, Pediatric Logistic Organ Dysfunction); and number of failing organs were prospectively collected. A population pharmacokinetic model to study the impact of inflammation and organ failure on midazolam pharmacokinetics was developed using NONMEM 7.3.

Measurements and main results: In a two-compartmental pharmacokinetic model, body weight was the most significant covariate for clearance and volume of distribution. CRP and organ failure were significantly associated with clearance (P < 0.01), explaining both interindividual and interoccasional variability. In simulations, a CRP of 300 mg/L was associated with a 65% lower clearance compared with 10 mg/L, and three failing organs were associated with a 35% lower clearance compared with one failing organ.

Conclusions: Inflammation and organ failure strongly reduce midazolam clearance, a surrogate marker of CYP3A-mediated drug metabolism, in critically ill children. Hence, critically ill patients receiving CYP3A substrate drugs may be at risk of increased drug levels and associated toxicity.

Keywords: critical illness; inflammation; midazolam; pediatrics; pharmacokinetics.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Anesthetics, Intravenous / pharmacokinetics
  • Child
  • Child, Preschool
  • Critical Illness*
  • Female
  • Humans
  • Infant
  • Infant, Newborn
  • Inflammation / metabolism*
  • Male
  • Midazolam / pharmacokinetics*
  • Multiple Organ Failure / metabolism*
  • Prospective Studies


  • Anesthetics, Intravenous
  • Midazolam