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Malnoë D, Bories M, Pierre-Jean M, Marchand T, Corre PL. Inflammation Decreases Ciclosporin Metabolism in Allogeneic Hematopoietic Stem Cell Transplantation Recipients. J Clin Pharmacol 2024. [PMID: 39382849 DOI: 10.1002/jcph.6141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 09/13/2024] [Indexed: 10/10/2024]
Abstract
Graft-versus-host disease (GVHd) remains a significant challenge following allogeneic hematopoietic stem cell transplantation (HSCT). Prevention of GVHd relies mainly on the use of calcineurin inhibitors, notably ciclosporin that exhibits complex pharmacokinetics influenced by many factors including drug-drug interactions (DDIs). Due to the downregulation of drug metabolizing enzymes and transporters, it has been postulated that inflammation may be a contributing factor to the variability observed in ciclosporin pharmacokinetics. This study aimed to assess the impact of inflammation, as indicated by C-reactive protein (CRP) levels, on the metabolism of ciclosporin in adult allogeneic HSCT recipients. A retrospective observational study was conducted at Rennes University Hospital involving 71 adult HSCT patients. The relationship between the intensity of inflammation (no-to-mild, moderate, and severe), and the metabolism of ciclosporin (estimated by the concentration/dose ratio) was assessed. Severe inflammation significantly decreased the metabolism of ciclosporin, as evidenced by higher concentration/dose ratios. Thanks to the daily dose adjustment, inflammation did not influence the blood levels of ciclosporin. Interestingly, DDIs did not emerge as a significant covariate in influencing ciclosporin metabolism. This is likely because the CYP3A4 inhibitory potential of interacting drugs may be masked in HSCT patients where metabolism is already upstream downregulated by inflammation. The study highlights the intricate relationship between inflammation and ciclosporin pharmacokinetics in HSCT patients. This underscores the necessity for therapeutic monitoring and the potential adjustment of dosage strategies based on the inflammatory status. These insights could contribute to the development of more personalized, optimized, and effective management strategies for HSCT recipients.
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Affiliation(s)
- David Malnoë
- Centre Hospitalier Universitaire de Rennes, Pôle Pharmacie, Secteur Pharmacotechnie et Onco-Pharmacie, Rennes, France
- Faculté de Pharmacie, Laboratoire de Biopharmacie et Pharmacie Clinique, Université de Rennes, Rennes, France
- Inserm, EHESP, Institut de recherche en santé environnement et travail (IRSET) -UMR_S 1085, Université Rennes, Rennes, France
| | - Mathilde Bories
- CHU Rennes, INSERM, LTSI-UMR 1099,, Université de Rennes, Rennes, France
| | | | - Tony Marchand
- Service d'Hématologie Clinique, CHU de Rennes, INSERM U1236, Université de Rennes, Rennes, France
| | - Pascal Le Corre
- Centre Hospitalier Universitaire de Rennes, Pôle Pharmacie, Secteur Pharmacotechnie et Onco-Pharmacie, Rennes, France
- Faculté de Pharmacie, Laboratoire de Biopharmacie et Pharmacie Clinique, Université de Rennes, Rennes, France
- Inserm, EHESP, Institut de recherche en santé environnement et travail (IRSET) -UMR_S 1085, Université Rennes, Rennes, France
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2
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Chen J, Hu Y, Hu J, Ye Z, Lin Q, Cai JP, Hu GX, Xu RA. Effect of recombinant CYP3A4 variants and interaction on imatinib metabolism in vitro. Biomed Pharmacother 2024; 180:117511. [PMID: 39366029 DOI: 10.1016/j.biopha.2024.117511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 09/23/2024] [Accepted: 09/25/2024] [Indexed: 10/06/2024] Open
Abstract
The aim of this study was to investigate the catalytic activity of 26 Cytochrome P450 3A4 (CYP3A4) variants and drug interactions on imatinib metabolism in recombinant insect microsomes. This study was designed with an appropriate incubation system and carried out in the constant temperature water. By using ultra-performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) to measure the quantities of its metabolite N-desmethyl imatinib, to elucidate the impacts of the CYP3A4 genetic polymorphism and drug interactions on the metabolism of imatinib. Consequently, as compared to CYP3A4.1, the intrinsic clearance (CLint) values of the variations were dramatically changed, rising from 2.34 % to 120.57 %. CYP3A4.14 showed an increase in CLint in comparison to CYP3A4.1, and the remaining 24 variants demonstrated decreases in catalytic activity for the metabolism of imatinib. In addition, the metabolism of imatinib was decreased to varied degrees by ketoconazole, itraconazole, and fluconazole in CYP3A4.1 and CYP3A4.18. Moreover, most of CYP3A4 variants showed similar trend of enzyme activity under different substrates of imatinib and cabozantinib, except 6 variants (CYP3A4.3,.4,.10,.15,.29 and.31). The first study of the effects of 26 CYP3A4 variants on imatinib metabolism will contribute to the clinical evaluation of imatinib and help personalize therapy in clinical settings.
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Affiliation(s)
- Jie Chen
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yingying Hu
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jinyu Hu
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhize Ye
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Qianmeng Lin
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jian-Ping Cai
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China.
| | - Guo-Xin Hu
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China.
| | - Ren-Ai Xu
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.
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Taynton T, Allsup D, Barlow G. How can we optimize antifungal use and stewardship in the treatment of acute leukemia? Expert Rev Hematol 2024; 17:581-593. [PMID: 39037307 DOI: 10.1080/17474086.2024.2383401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 07/18/2024] [Indexed: 07/23/2024]
Abstract
INTRODUCTION The global need for antifungal stewardship is driven by spreading antimicrobial and antifungal resistance. Triazoles are the only oral and relatively well-tolerated class of antifungal medications, and usage is associated with acquired resistance and species replacement with intrinsically resistant organisms. On a per-patient basis, hematology patients are the largest inpatient consumers of antifungal drugs, but are also the most vulnerable to invasive fungal disease. AREAS COVERED In this review we discuss available and forthcoming antifungal drugs, antifungal prophylaxis and empiric antifungal therapy, and how a screening based and diagnostic-driven approach may be used to reduce antifungal consumption. Finally, we discuss components of an antifungal stewardship program, interventions that can be employed, and how impact can be measured. The search methodology consisted of searching PubMed for journal articles using the term antifungal stewardship plus program, intervention, performance measure or outcome before 1 January 2024. EXPERT OPINION Initial focus should be on implementing effective antifungal stewardship programs by developing and implementing local guidelines and using interventions, such as post-prescription review and feedback, which are known to be effective. Technologies such as microbiome analysis and machine learning may allow the development of truly individualized risk-factor-based approaches to antifungal stewardship in the future.
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Affiliation(s)
- Thomas Taynton
- Department of Infection, Hull University Teaching Hospitals NHS Trust, Hull, UK
- Centre for Biomedical Research, Hull York Medical School, Hull, UK
| | - David Allsup
- Biomedical Institute for Multimorbidity, Hull York Medical School, Hull, UK
- Queen's Centre for Oncology and Haematology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Gavin Barlow
- Department of Infection, Hull University Teaching Hospitals NHS Trust, Hull, UK
- York Biomedical Research Institute and Hull York Medical School, University of York, York, UK
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Nemoto H, Hino M, Aoki T, Yamashita Y, Okunushi T, Nagasawa K, Ishiwada N, Watanabe A, Yamazaki S, Hamada H. Effectiveness of isavuconazole in invasive cerebral aspergillosis during hematopoietic stem cell transplantation in a pediatric patient with myelodysplastic syndrome: A case report. J Infect Chemother 2024:S1341-321X(24)00202-2. [PMID: 39047812 DOI: 10.1016/j.jiac.2024.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 07/04/2024] [Accepted: 07/21/2024] [Indexed: 07/27/2024]
Abstract
Pediatric myelodysplasia syndrome is often characterized by hypoplastic bone marrow morphology and predisposition to infection. Invasive aspergillosis during hematopoietic stem cell transplantation poses a significant threat and often requires voriconazole (VRCZ) therapy. However, difficulties in achieving appropriate VRCZ blood levels due to drug interactions have prompted the exploration of alternative treatments, such as isavuconazole (ISCZ). We present the case of a 4-year-old boy with myelodysplasia syndrome who developed multiple abscesses, including a brain abscess caused by Aspergillus fumigatus, and was successfully treated with ISCZ. Despite initial treatment with liposomal amphotericin B and VRCZ, the patient's condition deteriorated. Transitioning to ISCZ treatment resulted in significant clinical improvement, resolution of the abscesses, and reduced antigen levels. Although ISCZ induced hepatic enzyme elevation, supportive care improved without discontinuation of treatment. This case highlights the potential of ISCZ in cases of pediatric invasive aspergillosis where traditional therapies fail, underscoring the need for further research and formulation development to optimize its use in this population. As more cases accumulate, ISCZ may become a promising option for treating severe invasive aspergillosis in pediatric patients undergoing hematopoietic stem cell transplantation.
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Affiliation(s)
- Hajime Nemoto
- Department of Pediatrics, Chiba University Hospital, Chiba, Japan
| | - Moeko Hino
- Department of Pediatrics, Chiba University Hospital, Chiba, Japan.
| | - Takahiro Aoki
- Department of Pediatrics, Chiba University Hospital, Chiba, Japan
| | | | - Tomoko Okunushi
- Department of Pediatrics, Chiba University Hospital, Chiba, Japan
| | - Koo Nagasawa
- Department of Pediatrics, Chiba University Hospital, Chiba, Japan
| | - Naruhiko Ishiwada
- Department of Infectious Diseases, Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Akira Watanabe
- Division of Clinical Research, Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Shingo Yamazaki
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan
| | - Hiromichi Hamada
- Department of Pediatrics, Chiba University Hospital, Chiba, Japan
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Gatti M, Campoli C, Muratore E, Belotti T, Masetti R, Lanari M, Viale P, Pea F. Impact of Inflammatory Burden on Voriconazole Exposure in Oncohematological Pediatric Patients Receiving Antifungal Prophylaxis after Allogeneic HCT. Microorganisms 2024; 12:1388. [PMID: 39065156 PMCID: PMC11278995 DOI: 10.3390/microorganisms12071388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 07/04/2024] [Accepted: 07/07/2024] [Indexed: 07/28/2024] Open
Abstract
(1) Background: The impact of inflammation on voriconazole exposure in oncohematological pediatric patients represents a debated issue. We aimed to investigate the impact of serum C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6) levels on voriconazole exposure in oncohematological pediatric patients requiring allogeneic hematopoietic stem cell transplantation (HCT). (2) Methods: Pediatric patients undergoing allogeneic HCT and receiving therapeutic drug monitoring (TDM)-guided voriconazole as primary antifungal prophylaxis between January 2021 and December 2023 were included. The ratio between concentration and dose (C/D) of voriconazole was used as a surrogate marker of total clearance. A receiving operating characteristic curve analysis was performed by using CRP, PCT, or IL-6 values as the test variable and voriconazole C/D ratio > 0.188 or >0.375 (corresponding to a trough concentration value [Cmin] of 3 mg/L normalized to the maintenance dose of 16 mg/kg/day in patients of age < 12 years and of 8 mg/kg/day in those ≥12 years, respectively) as the state variable. Area under the curve (AUC) and 95% confidence interval (CI) were calculated. (3) Results: Overall, 39 patients were included. The median (IQR) voriconazole Cmin was 1.7 (0.7-3.0) mg/L. A CRP value > 8.49 mg/dL (AUC = 0.72; 95%CI 0.68-0.76; p < 0.0001), a PCT value > 2.6 ng/mL (AUC = 0.71; 95%CI 0.63-0.77; p < 0.0001), and an IL-6 value > 27.9 pg/mL (AUC = 0.80; 95%CI 0.71-0.88; p < 0.0001) were significantly associated with voriconazole overexposure. Consistent results were found in patients aged <12 and ≥12 years. (4) Conclusions: A single specific threshold of inflammatory biomarkers may be linked to a significantly higher risk of voriconazole exposure in oncohematological pediatric patients after HCT, irrespective of age. Adopting a TDM-guided strategy could be useful for minimizing the risk of voriconazole overexposure.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (R.M.); (M.L.); (P.V.); (F.P.)
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Caterina Campoli
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Edoardo Muratore
- Pediatric Hematology and Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.M.); (T.B.)
| | - Tamara Belotti
- Pediatric Hematology and Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.M.); (T.B.)
| | - Riccardo Masetti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (R.M.); (M.L.); (P.V.); (F.P.)
- Pediatric Hematology and Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.M.); (T.B.)
| | - Marcello Lanari
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (R.M.); (M.L.); (P.V.); (F.P.)
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (R.M.); (M.L.); (P.V.); (F.P.)
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (R.M.); (M.L.); (P.V.); (F.P.)
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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Elfadil A, Ibrahem K. Antifungal Activity of 3-Hydrazinoquinoxaline-2-Thiol, a Novel Quinoxaline Derivative against Candida Species. MYCOBIOLOGY 2024; 52:191-200. [PMID: 38948451 PMCID: PMC11210417 DOI: 10.1080/12298093.2024.2362497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/29/2024] [Indexed: 07/02/2024]
Abstract
Candida ranks as among the most frequently encountered fungal infections that associated with high morbidity and mortality. Quinoxaline derivatives are a group of small molecules that showed a promising antimicrobial activity. This study aimed to investigate the fungicidal effects of 3-hydrazinoquinoxaline-2-thiol against Candida in comparison with Amphotericin B in vitro as a reference. Also, we aim to assess the efficacy of 3-hydrazinoquinoxaline-2-thiol in vivo using mice oral candidiasis model. Fifty-six Candida isolates were subjected to susceptibility testing by broth microdilution method for 3-hydrazinoquinoxaline-2-thiol and Amphotericin B. Therefore, Minimal inhibitory concentrations (MIC) were assessed and compared. The oral candidiasis mice model was used to evaluate the activity of 3-hydrazinoquinoxaline-2-thiol in vivo. Microbiological evaluation of progression and ELISA were used in this study. 3-hydrazinoquinoxaline-2-thiol was more effective than Amphotericin B against most clinical isolates of Candida albicans. Higher effectiveness was seen against Candida glabrata and Candida parapsilosis isolates. However, the efficiency against Candida tropicalis isolates varies. 3-hydrazinoquinoxaline-2-thiol was also effective against Pichia kudriavzevii and Clavispora lusitaniae. 3-hydrazinoquinoxaline-2-thiol showed a good efficacy in mice model against C. albicans cells ATCC 10231. 3-hydrazinoquinoxaline-2-thiol has shown promising antifungal and anti-inflammatory activity against different Candida species. More tests and experiments are needed.
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Affiliation(s)
- Abdelbagi Elfadil
- Department of Clinical Microbiology and Immunology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Karem Ibrahem
- Department of Clinical Microbiology and Immunology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Lewis R, Niazi-Ali S, McIvor A, Kanj SS, Maertens J, Bassetti M, Levine D, Groll AH, Denning DW. Triazole antifungal drug interactions-practical considerations for excellent prescribing. J Antimicrob Chemother 2024; 79:1203-1217. [PMID: 38629250 DOI: 10.1093/jac/dkae103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024] Open
Abstract
Systemic antifungal therapy is critical for reducing the mortality from many invasive and chronic fungal infections. Triazole antifungals are the most frequently prescribed antifungals but require attention to dosing and drug interactions. Nearly 600 severe drug-drug interactions and over 1100 moderate interactions requiring dose modifications are described or anticipated with systemic antifungal agents (see https://www.aspergillus.org.uk/antifungal-drug-interactions/). In this article, we address the common and less common, but serious, drug interactions observed in clinical practice with triazole antifungals, including a group of drugs that cannot be prescribed with all or most triazole antifungals (ivabradine, ranolazine, eplerenone, fentanyl, apomorphine, quetiapine, bedaquiline, rifampicin, rifabutin, sirolimus, phenytoin and carbamazepine). We highlight interactions with drugs used in children and new agents introduced for the treatment of haematological malignancies or graft versus host disease (midostaurin, ibrutinib, ruxolitinib and venetoclax). We also summarize the multiple interactions between oral and inhaled corticosteroids and triazole antifungals, and the strategies needed to optimize the therapeutic benefits of triazole antifungal therapy while minimizing potential harm to patients.
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Affiliation(s)
- Russell Lewis
- Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Saarah Niazi-Ali
- Antifungal Database Consultancy Pharmacist, Fungal Infection Trust, PO Box 482, Macclesfield, Cheshire SK10 9AR, UK
| | - Andrew McIvor
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Souha S Kanj
- Division of Infectious Diseases, Department of Internal Medicine and Center for Infectious Diseases Research, American University of Beirut Medical Center, Beirut, Lebanon
| | - Johan Maertens
- Department of Microbiology, Immunology, and Transplantation, Department of Haematology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Matteo Bassetti
- Department of Health Sciences, Infectious Diseases Clinic, University of Genoa and Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Deborah Levine
- Lung Transplant Program, Division of Pulmonary Critical Care and Allergy, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital, Albert-Schweitzer-Campus 1, Building A1, Münster, 48149, Germany
| | - David W Denning
- Manchester Fungal Infection Group, The University of Manchester and Manchester Academic Health Science Centre, Manchester, UK
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Zhang Y, Du Y, Ren S, Li Y, Zhang X, Cao X, Liu F, Zong H, Li Y. CYP3A5 Genotype-Dependent Drug-Drug Interaction Between Tacrolimus and Voriconazole in Chinese Kidney Transplant Patients. Ann Pharmacother 2024; 58:605-613. [PMID: 37702380 DOI: 10.1177/10600280231197399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND The effect of drug-drug interaction (DDI) between tacrolimus and voriconazole on the pharmacokinetics of tacrolimus in different CYP3A5 genotypes has not been reported in previous studies. OBJECTIVE The objective of this study was to investigate whether CYP3A5 genotype could influence tacrolimus-voriconazole DDI in Chinese kidney transplant patients. METHODS All kidney transplant patients were divided into combination and non-combination groups based on whether tacrolimus was combined with or without voriconazole. Each group was subdivided into CYP3A5 expresser (CYP3A5*1/*1 or CYP3A5*1/*3) and CYP3A5 nonexpresser (CYP3A5*3/*3). A retrospective analysis compared tacrolimus dose (D)-corrected trough concentrations (C0) (C0/D) between combination and non-combination groups, respectively. Tacrolimus C0/D was also compared between CYP3A5 expresser and nonexpresser in both groups. RESULTS The C0/D values of tacrolimus were significantly different between CYP3A5 expresser and nonexpresser in combination group (378.20 [219.38, 633.48] ng/mL/[mg/kg/d] vs 720.00 [595.35, 1681.50] ng/mL/[mg/kg/d], P = 0.0010). Either in CYP3A5 expresser or nonexpresser, we found a statistically significant difference in tacrolimus C0/D between combination and non-combination group (P < 0.0001). The increase in CYP3A5 nonexpresser was 1.38 times higher than that in CYP3A5 expresser (320.93% vs 232.19%). CONCLUSION AND RELEVANCE The median C0/D values were 90.38% higher in kidney transplant recipients with CYP3A5*3/*3 genotype than in those with CYP3A5*1/*1 or CYP3A5*1/*3 genotype when treated with both tacrolimus and voriconazole. A CYP3A5 genotype-dependent DDI was found between tacrolimus and voriconazole. Therefore, personalized therapy accounting for CYP3A5 genotype detection and therapeutic drug monitoring is necessary for kidney transplant patients when treating with tacrolimus and voriconazole.
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Affiliation(s)
- Yundi Zhang
- Department of Clinical Pharmacy, Shandong Provincial Qianfoshan Hospital, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yue Du
- The First Affiliated Hospital of Shandong First Medical University, Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Shuyu Ren
- Jinan Xinhang Experimental Foreign Language School, Jinan, China
| | - Yue Li
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Xiaoming Zhang
- Urinary Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Xiaohong Cao
- Urinary Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Fengxi Liu
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Huiying Zong
- Department of Clinical Pharmacy, Shandong Provincial Qianfoshan Hospital, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yan Li
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
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Zhang J, Ma D, Chen M, Hu Y, Chen X, Chen J, Huang M, Dai H. Prevalence and clinical significance of potential drug-drug interactions among lung transplant patients. Front Pharmacol 2024; 15:1308260. [PMID: 38379901 PMCID: PMC10876870 DOI: 10.3389/fphar.2024.1308260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/24/2024] [Indexed: 02/22/2024] Open
Abstract
Background: Drug-drug interactions (DDIs) are a major but preventable cause of adverse drug reactions. There is insufficient information regarding DDIs in lung transplant recipients. Objective: This study aimed to determine the prevalence of potential DDIs (pDDIs) in intensive care unit (ICU) lung transplant recipients, identify the real DDIs and the most frequently implicated medications in this vulnerable population, and determine the risk factors associated with pDDIs. Methods: This retrospective cross-sectional study included lung transplant recipients from January 2018 to December 2021. Pertinent information was retrieved from medical records. All prescribed medications were screened for pDDIs using the Lexicomp® drug interaction software. According to this interaction software, pDDIs were classified as C, D, or X (C = monitor therapy, D = consider therapy modification, X = avoid combination). The Drug Interaction Probability Scale was used to determine the causation of DDIs. All statistical analysis was performed in SPSS version 26.0. Results: 114 patients were qualified for pDDI analysis, and total pDDIs were 4051. The most common type of pDDIs was category C (3323; 82.0%), followed by D (653; 16.1%) and X (75; 1.9%). Voriconazole and posaconazole were the antifungal medicine with the most genuine DDIs. Mean tacrolimus concentration/dose (Tac C/D) before or after co-therapy was considerably lower than the Tac C/D during voriconazole or posaconazole co-therapy (p < 0.001, p = 0.027). Real DDIs caused adverse drug events (ADEs) in 20 patients. Multivariable logistic regression analyses found the number of drugs per patient (OR, 1.095; 95% CI, 1.048-1.145; p < 0.001) and the Acute Physiology and Chronic Health Evaluation II (APACHE Ⅱ) score (OR, 1.097; 95% CI, 1.021-1.179; p = 0.012) as independent risk factors predicting category X pDDIs. Conclusion: This study revealed a high incidence of both potential and real DDIs in ICU lung transplant recipients. Immunosuppressive drugs administered with azole had a high risk of causing clinically significant interactions. The number of co-administered drugs and APACHE Ⅱ score were associated with an increased risk of category × drug interactions. Close monitoring of clinical and laboratory parameters is essential for ensuring successful lung transplantation and preventing adverse drug events associated with DDIs.
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Affiliation(s)
- Jiali Zhang
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Danyi Ma
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Meng Chen
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yanting Hu
- Department of General Intensive Care Unit, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xveying Chen
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingyu Chen
- Department of Lung Transplantation, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Man Huang
- Department of General Intensive Care Unit, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haibin Dai
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Fernández-Ruiz M. Pharmacological management of invasive mold infections in solid organ transplant recipients. Expert Opin Pharmacother 2024; 25:239-254. [PMID: 38436619 DOI: 10.1080/14656566.2024.2326507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/29/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Solid organ transplant (SOT) recipients face an increased susceptibility to invasive fungal infection (IFI) due to filamentous fungi. Post-transplant invasive aspergillosis (IA) and mucormycosis are related to exceedingly high mortality rates and graft loss risk, and its management involve a unique range of clinical challenges. AREAS COVERED First, the current treatment recommendations for IA and mucormycosis among SOT recipients are critically reviewed, including the supporting evidence. Next, we discussed particular concerns in this patient population, such as drug-drug interactions (DDIs) between triazoles and post-transplant immunosuppression or treatment-related toxicity. The role for immunomodulatory and host-targeted therapies is also considered, as well as the theoretical impact of the intrinsic antifungal activity of calcineurin inhibitors. Finally, a personal opinion is made on future directions in the pharmacological approach to post-transplant IFI. EXPERT OPINION Despite relevant advances in the treatment of mold IFIs in the SOT setting, such as the incorporation of isavuconazole (with lower incidence of DDIs and better tolerability than voriconazole), there remains a large room for improvement in areas such as the position of combination therapy or the optimal strategy for the reduction of baseline immunosuppression. Importantly, future studies should define the specific contribution of newer antifungal agents and classes.
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Affiliation(s)
- Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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Kozuch JM, Burt C, Afshar K, Aslam S, Yung G, Mariski M, Golts E, Feist A. Difference in immunosuppressant dose requirement when transitioning to isavuconazole from other azoles in thoracic transplant recipients. Transpl Infect Dis 2024; 26:e14209. [PMID: 38059638 DOI: 10.1111/tid.14209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/21/2023] [Accepted: 11/21/2023] [Indexed: 12/08/2023]
Abstract
The triazole antifungal isavuconazole (ISAVU) is used for prevention and treatment of fungal infections in solid organ transplant (SOT). SOT recipients commonly need to transition from one azole to another due to breakthrough infection, toxicity, or other reasons. The purpose of our study was to evaluate the effect of ISAVU on immunosuppressant concentrations in thoracic transplant recipients when ISAVU was started de novo or transitioned from another azole. We conducted a single-center retrospective cohort study including 68 patients (51 lung, 14 heart, and 3 heart/lung transplant). Concentration to dosage ratios (C/D) of immunosuppressants were assessed at baseline, day 3, and weekly for 9 weeks. When starting ISAVU de novo, we observed a temporary doubling of tacrolimus exposure. Cyclosporine and sirolimus required dose decreases. Tacrolimus C/D increased by 110% at day 3 in patients started on ISAVU de novo then returned to baseline C/D ± 17% weeks 2-9 (n = 8). One cyclosporine patient started on ISAVU de novo had variable C/D, and C/D increased by 219% ± 72% in 2 sirolimus patients. When transitioning from other azoles, tacrolimus and cyclosporine required about twice the initial dose. After week 1, tacrolimus C/D decreased by 53% ± 6% in patients transitioned from posaconazole (n = 33), voriconazole (n = 14), or fluconazole (n = 2). Cyclosporine C/D decreased by 45% ± 16% in patients transitioning from other azoles (posaconazole [n = 2], voriconazole [n = 2], fluconazole [n = 1]). Sirolimus C/D decreased by 73% ± 13% in patients transitioned from posaconazole (n = 7). Aside from the initial loading phase, ISAVU had a lesser degree of interaction with immunosuppressants than other azoles in loading phase, ISAVU had a lesser degree of interaction with immunosuppressants than other azoles in adjustments for the 4-week period after initiating antifungal therapy with ISAVU or switching from another agent.
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Affiliation(s)
- Jade M Kozuch
- Department of Pharmacy, University of California San Diego, La Jolla, California, USA
| | - Carrie Burt
- Department of Pharmacy, Scripps Memorial Hospital, La Jolla, California, USA
| | - Kamyar Afshar
- Division of Pulmonary and Critical Care, University of California San Diego, La Jolla, California, USA
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - Gordon Yung
- Division of Pulmonary and Critical Care, University of California San Diego, La Jolla, California, USA
| | - Mark Mariski
- Department of Pharmacy, University of California San Diego, La Jolla, California, USA
| | - Eugene Golts
- Division of Cardiothoracic Surgery, University of California San Diego, La Jolla, California, USA
| | - Ashley Feist
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
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Farina F, Acerbis A, Oltolini C, Chiurlo M, Xue E, Clerici D, Marktel S, Mastaglio S, Bruno A, Piemontese S, Diral E, Orofino G, Campodonico E, Corti C, Teresa Lupo Stanghellini M, Scarpellini P, Dell’Acqua R, Castagna A, Peccatori I, Ciceri F, Greco R. Coadministration of isavuconazole and sirolimus in allogeneic hematopoietic stem cell transplant recipients. Ther Adv Infect Dis 2024; 11:20499361241252539. [PMID: 39351448 PMCID: PMC11440545 DOI: 10.1177/20499361241252539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 04/17/2024] [Indexed: 10/04/2024] Open
Abstract
Background Invasive fungal infections (IFIs) represent a major cause of morbidity among allogeneic hematopoietic stem cell transplantation (allo-HSCT). Isavuconazole (ISA) is a broad-spectrum triazole with favorable safety profile. Objectives and design Herein, we evaluate the real life coadministration of ISA and sirolimus in allo-HSCT recipients in a single-center retrospective analysis, describing clinical efficacy, safety, and therapeutic drug monitoring (TDM) of both drugs. Methods All consecutive allo-HSCT recipients who received the coadministration of ISA and sirolimus for at least 2 weeks between July 2017 and December 2022 were included in this retrospective analysis. TDM was longitudinally performed during treatment. IFIs were classified according to the revised European Organization for Research and Treatment of Cancer/Mycoses Study Group consensus criteria. Results A total of 51 recipients were included in the analysis. A total of 17 patients received ISA as continuous antifungal treatment for IFI diagnosed before transplant: one patient experienced a probable invasive pulmonary aspergillosis, and one patient switched from ISA to liposomal amphotericin B for a possible IFI. A total of 34 patients started ISA as antifungal therapy for IFI diagnosed after transplant. Sixteen of 34 were treated for a proven/probable breakthrough IFI during mold-active prophylaxis: 6/16 patients died for IFI after a median of 51 days of ISA. Eighteen of 34 started ISA as empirical therapy for a possible IFI: 15/18 patients were alive with resolution of infection after 6 weeks, 1 died for disease progression, and 2 had empirically changed antifungal therapy due to pneumonia progression. Clinical and radiological response rate was 68% after 90 days from IFI diagnosis. No toxicities related to drug-drug interaction have been registered in patients reaching concomitant therapeutic levels of ISA and sirolimus. Conclusion The coadministration of ISA and sirolimus was safe and feasible in this cohort, confirming favorable clinical efficacy in patients with multiple-drug coadministration.
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Affiliation(s)
- Francesca Farina
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, via Olgettina 60, 20132 Milano, Italy
| | - Andrea Acerbis
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Chiara Oltolini
- Clinic of Infectious Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Matteo Chiurlo
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Elisabetta Xue
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Daniela Clerici
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Sarah Marktel
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Sara Mastaglio
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Bruno
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Simona Piemontese
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Elisa Diral
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Giorgio Orofino
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Edoardo Campodonico
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Consuelo Corti
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Maria Teresa Lupo Stanghellini
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Paolo Scarpellini
- Clinic of Infectious Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Raffaele Dell’Acqua
- Clinic of Infectious Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Antonella Castagna
- University Vita-Salute San Raffaele, Milan, Italy
- Clinic of Infectious Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Iacopo Peccatori
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, via Olgettina 60, 20132 Milano, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
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13
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Han G, Xu Q, Lv Q, Li X, Shi X. Pharmacoeconomic evaluation of isavuconazole, posaconazole, and voriconazole for the treatment of invasive mold diseases in hematological patients: initial therapy prior to pathogen differential diagnosis in China. Front Public Health 2023; 11:1292162. [PMID: 38179563 PMCID: PMC10766362 DOI: 10.3389/fpubh.2023.1292162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024] Open
Abstract
Background Invasive mold diseases (IMD) is associated with high mortality and a substantial economic burden. For high-risk patients, fever drive or diagnostic drive therapy is usually initiated prior to the differential diagnosis of the pathogen. This study evaluated the cost-effectiveness of isavuconazole, posaconazole, vs. voriconazole in the treatment of IMD from the perspective of the Chinese healthcare system, informing healthcare decision-making and resource allocation. Methods A decision analytic model was constructed using TreeAge Pro 2011 software to evaluate the cost-effectiveness of the entire disease course. We assumed that the prevalence of mucormycosis in the patients entering the model was 7.8%. Efficacy, cost, adverse events, and other data included in the model were mainly derived from clinical studies, published literature, and publicly available databases. The primary outcomes of the model output were total cost, quality-adjusted life years (QALYs), life years (Lys), and incremental cost-effectiveness ratio (ICER). The willing-to-pay (WTP) threshold was defined as one to three times China's GDP per capita in 2022. One-way sensitivity analysis and probability sensitivity analysis were used to determine the robustness of the model. At the same time, the cost-effectiveness of three triazole antifungal agents under a broader range of mucormycosis prevalence, when voriconazole was covered by medical insurance reimbursement, and after the price reduction of posaconazole was discussed. Results Compared with voriconazole, isavuconazole provided an additional 0.38 Lys (9.29 vs. 8.91 LYs) and 0.31 QALYs (7.62 vs. 7.31 QALYs); ICER was $15,702.46/QALY, well-below the WTP threshold ($38,223/QALY). However, posaconazole did not provide a significant economic advantage over voriconazole (9.40 vs. 9.36 Lys; 7.71 vs. 7.68 QALYs; ICER $64,466.57/QALY). One-way sensitivity analysis found that ICER was highly sensitive to the mortality of patients with invasive aspergillus infection. In the probabilistic sensitivity analysis, when the WTP threshold was $38,223/QALY, the probability of isavuconazole being cost-effective was 72.9%. The scenario analysis results indicated that posaconazole would become cost-effective when the price was reduced by 15% or the prevalence of mucormycosis was 14%. Conclusions Isavuconazole represents a cost-effective initial option for treating IMD in high-risk hematological patients prior to the differential diagnosis of pathogens. It will also be economical when a 15% reduction in posaconazole cost is achieved.
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Affiliation(s)
- Guangxin Han
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Qing Xu
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qianzhou Lv
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoyu Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoping Shi
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
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Dresler E, Woliński P, Wróblewska A, Jasiński R. On the Question of Zwitterionic Intermediates in the [3+2] Cycloaddition Reactions between Aryl Azides and Ethyl Propiolate. Molecules 2023; 28:8152. [PMID: 38138640 PMCID: PMC10745654 DOI: 10.3390/molecules28248152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/13/2023] [Accepted: 12/16/2023] [Indexed: 12/24/2023] Open
Abstract
The molecular mechanism of the [3+2] cycloaddition reactions between aryl azides and ethyl propiolate was evaluated in the framework of the Molecular Electron Density Theory. It was found that independently of the nature of the substituent within the azide molecule, the cycloaddition process is realized via a polar but single-step mechanism. All attempts of localization as postulated earlier by Abu-Orabi and coworkers' zwitterionic intermediates were not successful. At the same time, the formation of zwitterions with an "extended" conformation is possible on parallel reaction paths. The ELF analysis shows that the studied cycloaddition reaction leading to the 1,4-triazole proceeds by a two-stage one-step mechanism. It also revealed that both zwitterions are created by the donation of the nitrogen atom's nonbonding electron densities to carbon atoms of ethyl propiolate.
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Affiliation(s)
- Ewa Dresler
- Łukasiewicz Research Network—Institute of Heavy Organic Synthesis “Blachownia”, Energetyków 9, 47-225 Kędzierzyn-Koźle, Poland;
| | - Przemysław Woliński
- Institute of Organic Chemistry and Technology, Cracow University of Technology, Warszawska 24, 31-155 Cracow, Poland;
| | - Aneta Wróblewska
- Department of Organic Chemistry, Faculty of Chemistry, University of Lódź, Tamka 12, 91-403 Łódź, Poland;
| | - Radomir Jasiński
- Institute of Organic Chemistry and Technology, Cracow University of Technology, Warszawska 24, 31-155 Cracow, Poland;
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Silva JT, Husain S, Aguado JM. Isavuconazole for Treating Invasive Mould Disease in Solid Organ Transplant Recipients. Transpl Int 2023; 36:11845. [PMID: 38161768 PMCID: PMC10754982 DOI: 10.3389/ti.2023.11845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/23/2023] [Indexed: 01/03/2024]
Abstract
Solid organ transplant (SOT) recipients have a higher risk of developing invasive mould diseases (IMD). Isavuconazole is a novel broad-spectrum azole active against Aspergillus spp. and Mucor, well tolerated, with an excellent bioavailability and predictable pharmacokinetics, that penetrates in most tissues rapidly, and has few serious adverse effects, including hepatic toxicity. Contrary to other broad-spectrum azoles, such as voriconazole and posaconazole, isavuconazole appears to show significant smaller drug-drug interactions with anticalcineurin drugs. We have performed an extensive literature review of the experience with the use of isavuconazole in SOT, which included the SOTIS and the ISASOT studies, and published case reports. More than 140 SOT recipients treated with isavuconazole for IMD were included. Most patients were lung and kidney recipients treated for an Aspergillus infection. Isavuconazole was well tolerated (less than 10% of patients required treatment discontinuation). The clinical responses appeared comparable to that found in other high-risk patient populations. Drug-drug interactions with immunosuppressive agents were manageable after the reduction of tacrolimus and the adjustment of mTOR inhibitors at the beginning of treatment. In conclusion, isavuconazole appears to be a reasonable option for the treatment of IMD in SOT. More clinical studies are warranted.
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Affiliation(s)
- Jose Tiago Silva
- Unit of Infectious Diseases, University Hospital 12 de Octubre, Instituto de Investigación del Hospital 12 de Octubre (imas12), School of Medicine, Universidad Complutense, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Shahid Husain
- Department of Transplant Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - José María Aguado
- Unit of Infectious Diseases, University Hospital 12 de Octubre, Instituto de Investigación del Hospital 12 de Octubre (imas12), School of Medicine, Universidad Complutense, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
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Wu L, Li S, Gao W, Zhu X, Luo P, Xu D, Liu D, He Y. Real-World, Multicenter Case Series of Patients Treated with Isavuconazole for Invasive Fungal Disease in China. Microorganisms 2023; 11:2229. [PMID: 37764073 PMCID: PMC10535861 DOI: 10.3390/microorganisms11092229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/25/2023] [Accepted: 08/31/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The incidence of invasive fungal disease (IFD) has increased significantly, and IFD is a major cause of mortality among those with hematological malignancies. As a novel second-generation triazole antifungal drug offering both efficacy and safety, isavuconazole (ISA) is recommended by various guidelines internationally for the first-line treatment of invasive aspergillosis (IA) and invasive mucormycosis (IM) infecting adults. Given that it was only approved in China at the end of 2021, there is currently a lack of statistical data regarding its usage in the Chinese population. The primary objective of this report is to describe early experiences with ISA for the treatment of IFD. METHODS This was a real-world, multicenter, observational case series study conducted in China. It included patients from three centers who received ISA treatment from January 2022 to April 2023. A retrospective assessment on patient characteristics, variables related to ISA administration, the treatment response of IFD to ISA, and potential adverse events attributed to ISA was conducted. RESULTS A total of 40 patients met the inclusion criteria. Among them, 12 (30%) were diagnosed with aspergillosis, 2 (5%) were diagnosed with candidiasis, 12 (30%) were diagnosed with mucormycosis, and 14 cases did not present mycological evidence. The predominant site of infection was the lungs (36), followed by the blood stream (8), sinuses (4), and respiratory tract (2). The overall response rate was 75% (30 patients), with male patients having a higher clinical response than female patients (24/24 versus 6/16, p = 0.000) and autologous stem cell transplant patients having a higher clinical response than allogeneic stem cell transplant patients (6/6 versus 4/10, p = 0.027). During the observation period, four patients experienced adverse effects associated with ISA, but none of them discontinued the treatment. CONCLUSIONS Our findings suggest that ISA, a novel first-line treatment for IA and IM, is associated with a high clinical response rate, low incidence, and a low grade of adverse effects. Given the short time that ISA has been available in China, further research is needed to identify its efficacy and safety in the real world.
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Affiliation(s)
- Lisha Wu
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (L.W.); (P.L.)
- Department of Pharmacy, Huangjiahu Hospital, Hubei University of Traditional Chinese Medicine, Wuhan 430065, China
| | - Shougang Li
- Department of Rehabilitation Medicine, General Hospital of Central Theater Command of Chinese People’s Liberation Army, Wuhan 430070, China;
| | - Weixi Gao
- Department of Pharmacy, Hubei General Hospital, Renmin Hospital of Wuhan University, Wuhan 430060, China;
| | - Xiaojian Zhu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China;
| | - Pan Luo
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (L.W.); (P.L.)
| | - Dong Xu
- Department of Infection Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China;
| | - Dong Liu
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (L.W.); (P.L.)
| | - Yan He
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (L.W.); (P.L.)
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Gatti M, Pea F. The expert clinical pharmacological advice program for tailoring on real-time antimicrobial therapies with emerging TDM candidates in special populations: how the ugly duckling turned into a swan. Expert Rev Clin Pharmacol 2023; 16:1035-1051. [PMID: 37874608 DOI: 10.1080/17512433.2023.2274984] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/20/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION The growing spread of infections caused by multidrug-resistant pathogens makes the need of tailoring antimicrobial therapies by means of a 'patient-centered' approach fundamental. In this scenario, therapeutic drug monitoring (TDM) of emerging antimicrobial candidates may be a valuable approach, but expert interpretation of TDM results should be granted for making them more clinically useful. The MD Clinical Pharmacologist may take over this task since this specialist may couple PK/PD expertise on drugs with a medical background and may provide expert interpretation of TDM results of antimicrobials for tailoring therapy on real-time in each single patient based on specific both drug/pathogen issues and patient issues. AREAS COVERED This article aims to highlight the main key-points and organizational aspects for implementing a successful TDM-based expert clinical pharmacological advice (ECPA) program for tailoring antimicrobial therapies on real-time in different hospitalized patient special populations. EXPERT OPINION TDM-based ECPA programs lead by the MD Clinical Pharmacologist may represent a way forward for maximizing clinical efficacy and for minimizing the risk of resistance developments and/or toxicity of antimicrobials. Stakeholders should be aware of the fact that this innovative approach may be cost-effective.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
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18
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Escamilla JE, January SE, Vazquez Guillamet R. Diagnosis and Treatment of Fungal Infections in Lung Transplant Recipients. Pathogens 2023; 12:pathogens12050694. [PMID: 37242364 DOI: 10.3390/pathogens12050694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/27/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023] Open
Abstract
Fungal infections are a significant source of morbidity in the lung transplant population via direct allograft damage and predisposing patients to the development of chronic lung allograft dysfunction. Prompt diagnosis and treatment are imperative to limit allograft damage. This review article discusses incidence, risk factors, and symptoms with a specific focus on diagnostic and treatment strategies in the lung transplant population for fungal infections caused by Aspergillus, Candida, Coccidioides, Histoplasma, Blastomyces, Scedosporium/Lomentospora, Fusarium, and Pneumocystis jirovecii. Evidence for the use of newer triazole and inhaled antifungals to treat isolated pulmonary fungal infections in lung transplant recipients is also discussed.
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Affiliation(s)
- Jesus E Escamilla
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO 63110, USA
| | - Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO 63110, USA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO 63110, USA
- Rodrigo Vazquez Guillamet, 4921 Parkview Place, Saint Louis, MO 63110, USA
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Li Y, Liu Y, Wen L, Chen H, Wang W, Tian M, Cheng Y, Xue H, Chen C. Clinical efficacy analysis of paxlovid in children with hematological diseases infected with the omicron SARS-CoV-2 new variant. Front Pediatr 2023; 11:1160929. [PMID: 37181421 PMCID: PMC10167044 DOI: 10.3389/fped.2023.1160929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/23/2023] [Indexed: 05/16/2023] Open
Abstract
Objective To summarize the clinical characteristics of children with hematological malignancies co-infected with novel coronavirus and explore the safety and effectiveness of Paxlovid treatment. Methods From December 10, 2022, to January 20, 2023, the clinical data of children with hematological diseases diagnosed with novel coronavirus infection in the outpatient and emergency department of the Seventh Affiliated Hospital of Sun Yat-sen University were retrospectively analyzed. Results According to whether to give paxlovid or not, it is divided into group A (paxlovid group) and group B (non-paxlovid group). The length of fever was 1-6 days in group A and 0-3 days in group B. The viral clearance time was shorter in group A than in group B. The inflammatory indexes CRP and PCT were significantly higher in group A than in group B (P < 0.05). Twenty patients were followed up for 1 month after leaving the hospital, and there were 5 cases of reappearance of fever, 1 case of increased sleep, 1 case of physical fatigue and 1 case of loss of appetite within 2 weeks. Conclusions Paxlovid has no apparent adverse reactions in children 12 years old and younger with underlying hematological diseases infected with the new coronavirus. Focusing on the interaction between paxlovid and other drugs is necessary during the treatment.
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Affiliation(s)
- Yixian Li
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Yong Liu
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Luping Wen
- Department of Pharmacy, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Hui Chen
- Research Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Wenqing Wang
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Mengyao Tian
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Yucai Cheng
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Hongman Xue
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Chun Chen
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
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Cui YF, Pan Y, Zhu MF, Jiao Z. Pharmacokinetic Evaluation of Tacrolimus in Chinese Adult Patients during the Early Stages Post-Lung Transplantation. J Pers Med 2023; 13:jpm13040656. [PMID: 37109042 PMCID: PMC10145266 DOI: 10.3390/jpm13040656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/27/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Although tacrolimus has been widely used in patients undergoing lung transplantation, few studies have reported the pharmacokinetics of tacrolimus in Chinese patients after lung transplantation. Thus, we aimed to investigate the pharmacokinetics and influential factors in this patient cohort in the early stage after lung transplantation. METHODS We enrolled 14 adult lung transplant recipients who were treated with tacrolimus and then intensively collected blood samples within a 12-h dosing interval. The pharmacokinetic parameters of tacrolimus were calculated using non-compartmental analysis, and the influence of pathophysiological characteristics and CYP3A5*3 and CYP3A4*1G genotypes on the pharmacokinetics of tacrolimus was assessed. Using linear regression analysis, we investigated the correlation between tacrolimus concentration at different sampling points and measured the area under the time-concentration curve (AUC0-12h). RESULTS Geometric mean of apparent clearance (CL/F) was 18.13 ± 1.65 L/h in non-CYP3A5*3/*3 carriers, five times higher than that in CYP3A5*3/*3 carriers (p < 0.001). Furthermore, the tacrolimus concentration 4 h after administration had the strongest correlation with AUC0-12h (R2 = 0.979). CONCLUSION The pharmacokinetics of tacrolimus varied largely between patients during the early stage post-transplantation, which could be partially explained by CYP3A5*3 genetic polymorphisms.
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Affiliation(s)
- Yi-Fan Cui
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Yan Pan
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Min-Fang Zhu
- Department of Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
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Fernández-Ruiz M, Bodro M, Gutiérrez Martín I, Rodriguez-Álvarez R, Ruiz-Ruigómez M, Sabé N, López-Viñau T, Valerio M, Illaro A, Fortún J, Salto-Alejandre S, Cordero E, Fariñas MDC, Muñoz P, Vidal E, Carratalà J, Goikoetxea J, Ramos-Martínez A, Moreno A, Aguado JM. Isavuconazole for the Treatment of Invasive Mold Disease in Solid Organ Transplant Recipients: A Multicenter Study on Efficacy and Safety in Real-life Clinical Practice. Transplantation 2023; 107:762-773. [PMID: 36367924 DOI: 10.1097/tp.0000000000004312] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Isavuconazole has theoretical advantages over other mold-active triazoles for the treatment of invasive aspergillosis and mucormycosis after solid organ transplantation (SOT). The available clinical experience, nevertheless, is scarce. METHODS We performed a retrospective study including all adult SOT recipients with proven or probable invasive mold disease (IMD) that received isavuconazole for ≥24 h as first-line or salvage therapy at 10 Spanish centers between September 2017 and November 2021. The primary efficacy outcome was clinical response (complete or partial resolution of attributable symptoms and findings) by weeks 6 and 12. Safety outcomes included the rates of treatment-emergent adverse events and premature isavuconazole discontinuation. RESULTS We included 81 SOT recipients that received isavuconazole for a median of 58.0 days because of invasive aspergillosis (n = 71) or mucormycosis (n = 10). Isavuconazole was used as first-line (72.8%) or salvage therapy due because of previous treatment-emergent toxicity (11.1%) or refractory IMD (7.4%). Combination therapy was common (37.0%), mainly with an echinocandin or liposomal amphotericin B. Clinical response by weeks 6 and 12 was achieved in 53.1% and 54.3% of patients, respectively, and was more likely when isavuconazole was administered as first-line single-agent therapy. At least 1 treatment-emergent adverse event occurred in 17.3% of patients, and 6.2% required premature discontinuation. Daily tacrolimus dose was reduced in two-thirds of patients by a median of 50.0%, although tacrolimus levels remained stable throughout the first month of therapy. CONCLUSIONS Isavuconazole is a safe therapeutic option for IMD in SOT recipients, with efficacy comparable to other patient groups.
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Affiliation(s)
- Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Marta Bodro
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Isabel Gutiérrez Martín
- Department of Internal Medicine, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
| | | | - María Ruiz-Ruigómez
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Núria Sabé
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain
- Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain
| | - Teresa López-Viñau
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Unit of Infectious Diseases, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba, Córdoba, Spain
| | - Maricela Valerio
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Aitziber Illaro
- Department of Pharmacy, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla, Santander, Spain
| | - Jesús Fortún
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad de Alcalá, Alcalá de Henares, Spain
| | - Sonsoles Salto-Alejandre
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen del Rocío, Institute of Biomedicine of Seville, Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
| | - Elisa Cordero
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen del Rocío, Institute of Biomedicine of Seville, Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
| | - María Del Carmen Fariñas
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla, Santander, Spain
- Department of Medicine, School of Medicine, Universidad de Cantabria, Santander, Spain
| | - Patricia Muñoz
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Elisa Vidal
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Unit of Infectious Diseases, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba, Córdoba, Spain
- Department of Medicine, School of Medicine, University of Córdoba, Córdoba, Spain
| | - Jordi Carratalà
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain
- Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain
| | - Josune Goikoetxea
- Unit of Infectious Diseases, Hospital Universitario de Cruces, Baracaldo, Spain
| | - Antonio Ramos-Martínez
- Unit of Infectious Diseases, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Majadahonda, Spain
- Department of Medicine, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Asunción Moreno
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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Kirubakaran R, Uster DW, Hennig S, Carland JE, Day RO, Wicha SG, Stocker SL. Adaptation of a population pharmacokinetic model to inform tacrolimus therapy in heart transplant recipients. Br J Clin Pharmacol 2023; 89:1162-1175. [PMID: 36239542 PMCID: PMC10952588 DOI: 10.1111/bcp.15566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 09/24/2022] [Accepted: 10/03/2022] [Indexed: 11/28/2022] Open
Abstract
AIM Existing tacrolimus population pharmacokinetic models are unsuitable for guiding tacrolimus dosing in heart transplant recipients. This study aimed to develop and evaluate a population pharmacokinetic model for tacrolimus in heart transplant recipients that considers the tacrolimus-azole antifungal interaction. METHODS Data from heart transplant recipients (n = 87) administered the oral immediate-release formulation of tacrolimus (Prograf®) were collected. Routine drug monitoring data, principally trough concentrations, were used for model building (n = 1099). A published tacrolimus model was used to inform the estimation of Ka , V2 /F, Q/F and V3 /F. The effect of concomitant azole antifungal use on tacrolimus CL/F was quantified. Fat-free mass was implemented as a covariate on CL/F, V2 /F, V3 /F and Q/F on an allometry scale. Subsequently, stepwise covariate modelling was performed. Significant covariates influencing tacrolimus CL/F were included in the final model. Robustness of the final model was confirmed using prediction-corrected visual predictive check (pcVPC). The final model was externally evaluated for prediction of tacrolimus concentrations of the fourth dosing occasion (n = 87) from one to three prior dosing occasions. RESULTS Concomitant azole antifungal therapy reduced tacrolimus CL/F by 80%. Haematocrit (∆OFV = -44, P < .001) was included in the final model. The pcVPC of the final model displayed good model adequacy. One recent drug concentration is sufficient for the model to guide tacrolimus dosing. CONCLUSION A population pharmacokinetic model that adequately describes tacrolimus pharmacokinetics in heart transplant recipients, considering the tacrolimus-azole antifungal interaction was developed. Prospective evaluation is required to assess its clinical utility to improve patient outcomes.
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Affiliation(s)
- Ranita Kirubakaran
- School of Clinical Medicine, Faculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt. Vincent's HospitalSydneyNew South WalesAustralia
- Department of PharmacyHospital Seberang JayaPenangMalaysia
| | - David W. Uster
- Department of Clinical Pharmacy, Institute of PharmacyUniversity of HamburgHamburgGermany
| | - Stefanie Hennig
- Certara Inc.PrincetonNew JerseyUSA
- School of Clinical Sciences, Faculty of HealthQueensland University of TechnologyBrisbaneQueenslandAustralia
| | - Jane E. Carland
- School of Clinical Medicine, Faculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt. Vincent's HospitalSydneyNew South WalesAustralia
| | - Richard O. Day
- School of Clinical Medicine, Faculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt. Vincent's HospitalSydneyNew South WalesAustralia
| | - Sebastian G. Wicha
- Department of Clinical Pharmacy, Institute of PharmacyUniversity of HamburgHamburgGermany
| | - Sophie L. Stocker
- School of Clinical Medicine, Faculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt. Vincent's HospitalSydneyNew South WalesAustralia
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
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Phaeohyphomycosis in Kidney Transplant Recipients: Highlighting the Importance of Early Recognition and Surgical Debridement. Transplant Direct 2022; 9:e1430. [PMID: 36582672 PMCID: PMC9750663 DOI: 10.1097/txd.0000000000001430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/06/2022] [Accepted: 11/08/2022] [Indexed: 12/27/2022] Open
Abstract
Fungal infections are a recognized complication of immunosuppression in solid organ transplant recipients. Phaeohyphomycoses are fungal infections caused by a diverse group of dematiaceous fungi. Methods We share the learning points from 2 Australian cases of phaeohyphomycosis secondary to Phaeacreomonium species (spp). A literature review was performed using Medline, Embase, and Google Scholar to identify this condition among kidney transplant recipients. Results With the 2 cases reported in this article, a total of 17 cases were identified in the literature. Phaeacremonium spp is ubiquitous in humid and temperate flora, including Australia. Minor trauma is likely the source of inoculation in most cases and diagnosis is often delayed. Presently, no guidelines for management exist given the rarity of this condition. Most known cases have been treated with surgical debulking combined with long-course antifungal therapy. Conclusion This paper describes 2 Australian cases of phaeohyphomycosis in kidney transplant recipients. A high index of suspicion, especially in the immunosuppressed, is essential for timely diagnosis in kidney transplant recipients. There are several diagnostic and therapeutic challenges that remain with this condition.
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Ssebambulidde K, Anjum SH, Hargarten JC, Chittiboina P, Shoham S, Seyedmousavi S, Marr KA, Hammoud DA, Billioux BJ, Williamson PR. Treatment recommendations for non-HIV associated cryptococcal meningoencephalitis including management of post-infectious inflammatory response syndrome. Front Neurol 2022; 13:994396. [PMID: 36530631 PMCID: PMC9751747 DOI: 10.3389/fneur.2022.994396] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/04/2022] [Indexed: 08/29/2023] Open
Abstract
Cryptococcal meningoencephalitis (CM) continues to cause major morbidity and mortality in a range of patients such as those immunosuppressed from HIV and with biologic immunosuppressants, including treatments of autoimmunity, malignancies, and conditioning regimens for transplantation. It is currently the most common cause of non-viral meningitis in the United States. Infections in previously healthy patients also develop with autoantibodies to granulocyte-macrophage colony stimulating factor or with monogenetic defects. In all populations, mortality and significant long-term morbidity occur in 30-50% despite therapy, and immune reconstitution and post-infectious inflammatory response syndromes complicate management. To help with these difficult cases, we present here a practical tutorial of the care of a range of patients with CM in the absence of HIV/AIDS.
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Affiliation(s)
- Kenneth Ssebambulidde
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Seher H. Anjum
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Jessica C. Hargarten
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Prashant Chittiboina
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - Shmuel Shoham
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Seyedmojtaba Seyedmousavi
- Microbiology Service, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Kieren A. Marr
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Dima A. Hammoud
- Center for Infectious Disease Imaging (CIDI), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Bridgette Jeanne Billioux
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Peter R. Williamson
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
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Gatti M, Campoli C, Belotti T, Cojutti PG, Masetti R, Pession A, Viale P, Pea F. Real-World Comparison of Isavuconazole and Voriconazole in Terms of the Need for Dosage Adjustments Guided by Clinical Pharmacological Advice During Primary Prophylaxis of Invasive Fungal Infections in Pediatric Patients with Hemato-Oncological Malignancies. Ther Drug Monit 2022; 44:641-650. [PMID: 35344524 DOI: 10.1097/ftd.0000000000000980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 02/25/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Limited evidence concerning optimal azole dosing regimens currently exists for antifungal prophylaxis in hemato-oncological pediatric patients. METHODS Hemato-oncological children receiving intravenous or oral isavuconazole or voriconazole for primary antifungal prophylaxis at IRCCS Azienda Ospedaliero-Universitaria of Bologna during November 2020 to October 2021 and undergoing CPA programs based on real-time therapeutic drug monitoring (TDM) were retrospectively analyzed. CPAs for isavuconazole and voriconazole and the number of dosage adjustments were collected. Normalized trough concentrations [(C min )/dose/kg] were calculated for both drugs at each TDM assessment, and the coefficient of variation was determined. The efficacy and safety of the drugs were evaluated. RESULTS Sixteen hemato-oncological pediatric patients received azole prophylaxis (mean age and weight: 9.1 ± 4.9 years and 32.6 ± 16.0 kg; 6 isavuconazole and 10 voriconazole). Sixty and 89 CPAs were delivered as isavuconazole and voriconazole, respectively. Dosage adjustments were needed in 3.3% of cases for isavuconazole and 53.9% of cases for voriconazole ( P < 0.001). At first TDM, achievement of the desired target during standard dosing regimens was higher for isavuconazole (83.3%) than for voriconazole (10.0%; P = 0.008). Dispersion of normalized concentrations was higher for voriconazole (CV = 139.1% vs. CV = 79.4%). Elevation of ALT and aspartate aminotransferase levels between baseline and the third month was higher in patients receiving voriconazole (median, 28 vs. 90 U/L; P = 0.038, and 19 vs. 65.5 U/L; P = 0.002). CONCLUSIONS Our findings suggest that there is limited variability in isavuconazole exposure in hemato-oncological pediatric patients receiving azole prophylaxis , resulting in a low need for CPA-guided dosage adjustments.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Caterina Campoli
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; and
| | - Tamara Belotti
- Pediatric Oncology and Hematology Unit "Lalla Seràgnoli," IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pier Giorgio Cojutti
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Riccardo Masetti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Pediatric Oncology and Hematology Unit "Lalla Seràgnoli," IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Pession
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Pediatric Oncology and Hematology Unit "Lalla Seràgnoli," IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; and
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Abstract
Isavuconazole is the newest of the clinically available advanced generation triazole antifungals and is active against a variety of yeasts, molds, and dimorphic fungi. Its current FDA-approved indications include the management of invasive aspergillosis as well as mucormycosis, though the latter indication is supported by limited clinical data. Isavuconazole did not achieve noninferiority to caspofungin for the treatment of invasive candidiasis and therefore lacks an FDA-approved indication for this invasive disease. Significant advantages of isavuconazole, primarily over voriconazole but in some circumstances posaconazole as well, make it an appealing option for the management of complex patients with invasive fungal infections. These potential advantages include lack of QTc interval prolongation, more predictable pharmacokinetics, a less complicated drug interaction profile, and improved tolerability, particularly when compared to voriconazole. This review discusses these topics in addition to addressing the in vitro activity of the compound against a variety of fungi and provides insight into other distinguishing factors among isavuconazole, voriconazole, and posaconazole. The review concludes with an opinion section in which the authors provide the reader with a framework for the current role of isavuconazole in the antifungal armamentarium and where further data are required.
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Effect of posaconazole on the concentration of intravenous and oral cyclosporine in patients undergoing hematopoietic stem cell transplantation. Eur J Clin Pharmacol 2022; 78:1677-1685. [PMID: 36045212 DOI: 10.1007/s00228-022-03378-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/25/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE This study aimed to investigate the interactions between posaconazole (POS) and intravenously/orally administered cyclosporine A (CsA) in allogeneic hematopoietic stem cell transplant (HSCT) recipients. METHODS We included 118 allogeneic HSCT patients who received CsA and POS simultaneously between January 2017 and June 2020 in this study. The ratio of CsA blood concentration (ng/mL) to dosage (mg/day) (C/D) before and after POS initiation was compared. RESULTS After the initiation of POS, the level of CsA increased 1 to 2 times in 66% (78/118) of patients compared to those without POS. However, the CsA C/D ratio increased by more than threefold in 6% (7/118) of patients after POS initiation, with an increase of more than fourfold in two patients. The median C/D ratio of CsA increased from 0.89 to 1.23 (P < 0.001) and 0.78 to 1.22 (P < 0.001) after POS initiation when CsA was administered intravenously and orally, respectively. In patients who received POS at the time of transition from intravenous to oral CsA, the value increased from 1.01 to 1.38 (P = 0.001). The route of administration had no significant effect on the change in the CsA C/D ratio (P = 0.615). Additionally, we observed the time required for the C/D ratio to reach a plateau after POS initiation was similar on days 13, 8, and 15 under various scenarios. CONCLUSION POS treatment increased blood CsA levels. A large variability was found in the fold-change in the CsA C/D ratio. Therefore, CsA doses should be adjusted by closely monitoring the blood levels of CsA after POS initiation.
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Hartinger JM, Ryšánek P, Slanař O, Šíma M. Pharmacokinetic principles of dose adjustment of mTOR inhibitors in solid organ transplanted patients. J Clin Pharm Ther 2022; 47:1362-1367. [PMID: 35934622 DOI: 10.1111/jcpt.13753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 07/17/2022] [Indexed: 11/24/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES mTOR inhibitors possess narrow therapeutic range and substantial pharmacokinetic variability and the consequences from suboptimal dosing are serious. The aim of this review is to summarize the current knowledge about the factors influencing mTOR inhibitors pharmacokinetics and the possibility of using these relationships in order to improve its therapy individualization in solid organ transplanted patients. METHODS Literature search from Pubmed and Web of Science databases were performed using Boolean search operators in order to identify relevant studies. RESULTS AND DISCUSSION A total of 701 reports were identified from the initial literature search. Out of which 40 studies dealt with relationships between various factors and pharmacokinetics of mTOR inhibitors and with relevance of these associations for dosage optimization. WHAT IS NEW AND CONCLUSION The overview of the current covariates for pharmacokinetic variability of mTOR inhibitors has been provided on the level of absorption, distribution and elimination, and consequences of these relationships for dosing optimization has been summarized.
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Affiliation(s)
- Jan Miroslav Hartinger
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague 2, Czech Republic
| | - Pavel Ryšánek
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague 2, Czech Republic
| | - Ondřej Slanař
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague 2, Czech Republic
| | - Martin Šíma
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague 2, Czech Republic
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Chen X, Xiao Y, Li H, Huang Z, Gao J, Zhang X, Li Y, Van Timothee BM, Feng X. Therapeutic drug monitoring and CYP2C19 genotyping guide the application of voriconazole in children. Transl Pediatr 2022; 11:1311-1322. [PMID: 36072540 PMCID: PMC9442201 DOI: 10.21037/tp-22-156] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 07/19/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND This study used therapeutic drug monitoring (TDM) and CYP2C19 gene polymorphism analysis to explore the efficacy and safety of different doses of voriconazole (VCZ) for the clinical treatment of pediatric patients, with the aim of providing guidelines for individualized antifungal therapy in children. METHODS Our study enrolled 94 children with 253 VCZ concentrations. The genotyping of CYP2C19 was performed by polymerase chain reaction (PCR)-pyrosequencing. VCZ trough concentration (Ctrough) was detected by high-performance liquid chromatography-tandem mass spectrometry. SPSS 23.0 was used to analyze the correlations between VCZ concentration, CYP2C19 phenotype, adverse effects (AEs), and drug-drug interactions. RESULTS A total of 94 children aged between 1 and 18 years (median age 6 years) were enrolled in the study. In total, 42.6% of patients reached the therapeutic range at initial dosing, while the remaining patients reached the therapeutic range after the adjustment of the dose or dosing interval. CYP2C19 gene polymorphism was performed in 59 patients. Among these patients, 24 (40.7%) had the normal metabolizer (NM) phenotype, 26 (44.1%) had the intermediate metabolizer (IM) phenotype, and 9 (15.3%) had the poor metabolizer (PM) phenotype. No cases of the rapid metabolizer (RM) or ultrarapid metabolizer (UM) phenotypes were found. The initial VCZ Ctrough was significantly higher in patients with the PM and IM phenotypes than in those with the NM phenotype. The combination of immunosuppressive drugs (ISDs) did not affect VCZ Ctrough. The incidence of AEs was 25.5%, and liver function damage (46.2%) and gastrointestinal reactions (19.2%) were the most common. CONCLUSIONS Our study showed significant individual differences of VCZ metabolism in children. Combining TDM with CYP2C19 gene polymorphism has important guiding significance for individualized antifungal therapy in pediatric patients.
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Affiliation(s)
- Xiaomin Chen
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuhua Xiao
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Huiping Li
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhi Huang
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jingyu Gao
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xinyao Zhang
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yirong Li
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | | | - Xiaoqin Feng
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Study on In Vitro Metabolism and In Vivo Pharmacokinetics of Beauvericin. Toxins (Basel) 2022; 14:toxins14070477. [PMID: 35878215 PMCID: PMC9320654 DOI: 10.3390/toxins14070477] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/04/2022] [Accepted: 07/08/2022] [Indexed: 01/25/2023] Open
Abstract
Beauvericin (BEA) is a well-known mycotoxin produced by many fungi, including Beaveria bassiana. The purpose of this study was to evaluate the in vitro distribution and metabolism characteristics as well as the in vivo pharmacokinetic (PK) profile of BEA. The in vitro metabolism studies of BEA were performed using rat, dog, mouse, monkey and human liver microsomes, cryopreserved hepatocytes and plasma under conditions of linear kinetics to estimate the respective elimination rates. Additionally, LC-UV-MSn (n = 1~2) was used to identify metabolites in human, rat, mouse, dog and monkey liver microsomes. Furthermore, cytochrome P450 (CYP) reaction phenotyping was carried out. Finally, the absolute bioavailability of BEA was evaluated by intravenous and oral administration in rats. BEA was metabolically stable in the liver microsomes and hepatocytes of humans and rats; however, it was a strong inhibitor of midazolam 1′-hydroxylase (CYP3A4) and mephenytoin 4′-hydroxylase (CYP2C19) activities in human liver microsomes. The protein binding fraction values of BEA were >90% and the half-life (T1/2) values of BEA were approximately 5 h in the plasma of the five species. The absolute bioavailability was calculated to be 29.5%. Altogether, these data indicate that BEA has great potential for further development as a drug candidate. Metabolic studies of different species can provide important reference values for further safety evaluation.
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Diagnosis and Management of Acquired Aplastic Anemia: Consensus Statement of Indian Academy of Pediatrics. Indian Pediatr 2022. [DOI: 10.1007/s13312-022-2538-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Phoompoung P, Herrera S, Pérez Cortés Villalobos A, Foroutan F, Orchanian-Cheff A, Husain S. Risk factors of invasive fungal infections in liver transplant recipients: A systematic review and meta-analysis. Am J Transplant 2022; 22:1213-1229. [PMID: 34953174 DOI: 10.1111/ajt.16935] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 01/25/2023]
Abstract
Invasive fungal infections (IFIs) remain one of the most common infectious complications after organ transplantation, and liver transplant recipients (LTRs) have the highest mortality rate. However, risk factors associated with IFIs have only been evaluated in small single-center studies. We performed a meta-analysis by conducting a comprehensive search using Ovid MEDLINE, Ovid Embase, Cochrane database of systematic reviews, and Cochrane central register of controlled trials. All case-control and cohort studies evaluating risk factors for IFIs in adult LTRs were screened. Utilizing a random-effects model, a multivariate analysis was completed, and 28 studies were eligible for meta-analysis. Rates of IFIs ranged from 1.4% to 32.7%. Previous antibiotic use (OR 9.3; 95% CI 3.2-27.0) and bacterial infection (OR 4.3; 95% CI 2.1-8.6) were risk factors of invasive candidiasis. Yet for invasive aspergillosis, posttransplant renal replacement therapy (OR 9.2; 95% CI 4.2-20.4), reoperation (OR 8.0; 95% CI 2.9-21.7), and cytomegalovirus infection (OR 6.2; 95% CI 2.0-19.3) were risk factors. The top independent risk factors for IFIs during studies from 2010 to 2019 were previous fungal colonization (OR 9.19; 95% CI 4.92-17.16), reoperation (OR 5.45; 95% CI 2.93-10.15), and previous bacterial infections (OR 3.81; 95% CI 2.13-6.83). These risk factors may be targeted by antifungal prophylaxis in LTRs.
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Affiliation(s)
- Pakpoom Phoompoung
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada.,Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sabina Herrera
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Farid Foroutan
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Shahid Husain
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
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Safety and Effectiveness of Isavuconazole Treatment for Fungal Infections in Solid Organ Transplant Recipients (ISASOT Study). Microbiol Spectr 2022; 10:e0178421. [PMID: 35171022 PMCID: PMC8849063 DOI: 10.1128/spectrum.01784-21] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Isavuconazole (ISA) is an alternative treatment for Aspergillus spp. and other fungal infections, but evidence regarding its use in solid organ transplant recipients (SOTR) is scarce. All SOTR who received ISA for treatment of a fungal infection (FI) at our center from December 2017 to January 2021 were included. The duration of the treatment depended on the type of infection. All patients were followed up to 3 months after treatment. Fifty-three SOTR were included, and the majority (44, 83%) were lung transplant recipients. The most frequently treated FI was tracheobronchitis (25, 46.3%). Aspergillus spp. (43, 81.1%); specially A. flavus (16, 37.2%) and A. fumigatus (12, 27.9%), was the most frequent etiology. Other filamentous fungi including one mucormycosis, and four yeast infections were treated. The median duration of treatment was 81 days (IQR 15-197). Mild gamma-glutamyltransferase elevation was the most frequent adverse event (34%). ISA was prematurely discontinued in six patients (11.3%) due to mild hepatotoxicity (2), fatigue (2), gastrointestinal intolerance (1) and myopathy (1). The mean tacrolimus dose decrease was 30% after starting ISA. Seven patients received ISA with mTOR inhibitors with good tolerability. Two patients developed breakthrough FI (3.8%). Among patients who completed the treatment, 27 (50.9%) showed clinical cure and 15 (34.1%) presented fungal persistence. Three patients (6%) died while on ISA due to FI. ISA was well tolerated and appeared to be an effective treatment for FI in SOTR. IMPORTANCE We describe 53 solid organ transplant recipients treated with isavuconazole for fungal infections. Because its use in clinical practice, there is scarce data of its use in solid organ transplant recipients, where interactions with calcineurin inhibitors and mTOR and adverse drug events have limited the use of other triazoles. To the best of our knowledge, this is the first article describing the safety regarding adverse events and drug interactions of isavuconazole for the treatment of fungal infections in a cohort of solid organ transplant recipients. Also, although this is a noncomparative study, we report some real world effectivity data of these patients, including treatment of non-Aspergillus fungal infections.
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Nakashima T, Inamoto Y, Aoki J, Ito A, Tanaka T, Kim SW, Hashimoto H, Fukuda T, Furukawa T. Differences in kinetics of tacrolimus concentration after letermovir discontinuation by type of concomitant azole antifungal. Int J Hematol 2022; 115:158-162. [PMID: 35088349 DOI: 10.1007/s12185-021-03277-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 11/24/2022]
Abstract
Letermovir is commonly used for CMV prophylaxis after allogeneic hematopoietic cell transplantation (HCT). Pharmacokinetic studies have shown an increase in tacrolimus exposure among healthy volunteers who took letermovir. However, studies in HCT recipients are needed because these patients are typically using concomitant antifungals with different degrees of CYP3A4 inhibition that may further interact with tacrolimus pharmacokinetics. In this study, we retrospectively evaluated the kinetics of tacrolimus concentration after letermovir discontinuation by type of concomitant azole antifungal in 57 HCT recipients. The median fold change in tacrolimus concentration-to-dose (C/D) ratio after discontinuing letermovir was 0.64 (range 0.43-0.99) with fluconazole and 1.10 (range 0.59-1.73) with voriconazole (p < 0.001). The tacrolimus C/D ratio decreased ≥ 30% after discontinuing letermovir (p < 0.001) in 66% of patients on fluconazole and 9% on voriconazole. Among patients whose tacrolimus C/D ratio decreased ≥ 30%, three (9%) patients in the fluconazole group and one (4%) in the voriconazole group experienced worsening of GVHD. Careful monitoring of tacrolimus concentration is important after letermovir discontinuation to avoid worsening of GVHD due to decreased tacrolimus concentration.
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Affiliation(s)
| | - Yoshihiro Inamoto
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
| | - Jun Aoki
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Ayumu Ito
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Takashi Tanaka
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Sung-Won Kim
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | | | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Tetsuya Furukawa
- Department of Pharmacy, National Cancer Center Hospital, Tokyo, Japan
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Zhang Y, Zhang X, Zou Y, Sun Y, Li X. Population pharmacokinetics of sirolimus in Chinese adult liver transplant recipients: a retrospective study. Xenobiotica 2022; 51:1408-1415. [PMID: 34983304 DOI: 10.1080/00498254.2022.2025628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Considering the significant interindividual variability and a narrow therapeutic index, we aimed to determine the population pharmacokinetics (PPK) of sirolimus and identify the factors in Chinese adult liver transplant recipients.Data were retrospectively extracted from adult liver transplant recipients receiving sirolimus in our hospital. The trough blood concentration data, obtained from traditional therapeutic drug monitoring-based dose adjustments, were used to develop a population pharmacokinetic model by non-linear mixed-effects modelling (NONMEM). The effect of demographic features, biological characteristics and concomitant medications was measured. The final model was verified by visual prediction check (VPC), bootstrap, and simulation.One hundred and sixteen blood concentrations from 63 patients were analysed. The PPK of sirolimus could be described by a one-compartment model with first-order absorption. Covariate analysis indicated that voriconazole co-therapy significantly decreased the oral clearance (CL) of sirolimus. The results of VPC and Bootstrap demonstrated that the final pharmacokinetic model adequately predicted observed concentrations. The simulation results showed that the dosage regimen of sirolimus should be reduced to 0.25 ∼ 0.45 mg/day for adult liver transplant recipients co-administered with voriconazole. The present study developed and validated a sirolimus PPK model for Chinese adult liver transplant recipients, and voriconazole co-therapy was found to be a significant covariate in the model. These results provide important information for clinicians to optimise the treatment regimens of sirolimus in Chinese adult liver transplant recipients.
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Affiliation(s)
- Yang Zhang
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery Systems, State Key Laboratory of Natural and Biomimetic Drugs, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Xuanling Zhang
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yue Zou
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yiqi Sun
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xingang Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Douglas AP, Smibert OC, Bajel A, Halliday CL, Lavee O, McMullan B, Yong MK, Hal SJ, Chen SC. Consensus guidelines for the diagnosis and management of invasive aspergillosis, 2021. Intern Med J 2021; 51 Suppl 7:143-176. [DOI: 10.1111/imj.15591] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Abby P. Douglas
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne Victoria Australia
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Infectious Diseases Austin Health Melbourne Victoria Australia
| | - Olivia. C. Smibert
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne Victoria Australia
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Infectious Diseases Austin Health Melbourne Victoria Australia
| | - Ashish Bajel
- Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne Victoria Australia
- Department of Clinical Haematology Peter MacCallum Cancer Centre and The Royal Melbourne Hospital Melbourne Victoria Australia
| | - Catriona L. Halliday
- Centre for Infectious Diseases and Microbiology Laboratory Services Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital Sydney New South Wales Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity The University of Sydney Sydney New South Wales Australia
| | - Orly Lavee
- Department of Haematology St Vincent's Hospital Sydney New South Wales Australia
| | - Brendan McMullan
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Immunology and Infectious Diseases Sydney Children's Hospital Sydney New South Wales Australia
- School of Women's and Children's Health University of New South Wales Sydney New South Wales Australia
| | - Michelle K. Yong
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne Victoria Australia
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Victorian Infectious Diseases Service Royal Melbourne Hospital Melbourne Victoria Australia
| | - Sebastiaan J. Hal
- Sydney Medical School University of Sydney Sydney New South Wales Australia
- Department of Microbiology and Infectious Diseases Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - Sharon C.‐A. Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital Sydney New South Wales Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity The University of Sydney Sydney New South Wales Australia
- Sydney Medical School University of Sydney Sydney New South Wales Australia
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Discovery of Octahydroisoindolone as a Scaffold for the Selective Inhibition of Chitinase B1 from Aspergillus fumigatus: In Silico Drug Design Studies. Molecules 2021; 26:molecules26247606. [PMID: 34946697 PMCID: PMC8705689 DOI: 10.3390/molecules26247606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/08/2021] [Accepted: 12/13/2021] [Indexed: 11/21/2022] Open
Abstract
Chitinases represent an alternative therapeutic target for opportunistic invasive mycosis since they are necessary for fungal cell wall remodeling. This study presents the design of new chitinase inhibitors from a known hydrolysis intermediate. Firstly, a bioinformatic analysis of Aspergillus fumigatus chitinase B1 (AfChiB1) and chitotriosidase (CHIT1) by length and conservation was done to obtain consensus sequences, and molecular homology models of fungi and human chitinases were built to determine their structural differences. We explored the octahydroisoindolone scaffold as a potential new antifungal series by means of its structural and electronic features. Therefore, we evaluated several synthesis-safe octahydroisoindolone derivatives by molecular docking and evaluated their AfChiB1 interaction profile. Additionally, compounds with the best interaction profile (1–5) were docked within the CHIT1 catalytic site to evaluate their selectivity over AfChiB1. Furthermore, we considered the interaction energy (MolDock score) and a lipophilic parameter (aLogP) for the selection of the best candidates. Based on these descriptors, we constructed a mathematical model for the IC50 prediction of our candidates (60–200 μM), using experimental known inhibitors of AfChiB1. As a final step, ADME characteristics were obtained for all the candidates, showing that 5 is our best designed hit, which possesses the best pharmacodynamic and pharmacokinetic character.
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Gago‐Sánchez AI, Font P, Cárdenas M, Aumente MD, Del Prado JR, Calleja MÁ. Real clinical impact of drug-drug interactions of immunosuppressants in transplant patients. Pharmacol Res Perspect 2021; 9:e00892. [PMID: 34755493 PMCID: PMC8578873 DOI: 10.1002/prp2.892] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/23/2021] [Indexed: 11/27/2022] Open
Abstract
The main objective was to determine the prevalence of real drug-drug interactions (DDIs) of immunosuppressants in transplant patients. We conducted a prospective, observational 1-year study at a tertiary hospital, including all transplanted patients. We evaluated data from monitoring blood concentrations of immunosuppressive drugs and adverse drug events (ADEs) caused by DDIs. The DDIs were classified as C, D, or X according to their Lexi-Interact rating (C = monitor therapy, D = consider therapy modification, X = avoid combination). The clinical importance of real DDIs was expressed in terms of patient outcomes. The causality of DDIs was determined using Drug Interaction Probability Scale. The data were analyzed using Statistical Package for Social Sciences v. 25.0. A total of 309 transplant patients were included. Their mean age was 52.0 ± 14.7 years (18-79) and 69.9% were male. The prevalence of real DDIs was 21.7%. Immunosuppressive drugs administered with antifungal azoles and tacrolimus (TAC) with nifedipine have a great clinical impact. Real DDIs caused ADEs in 22 patients. The most common clinical outcome was nephrotoxicity (1.6%; n = 5), followed by hypertension (1.3%; n = 4). Suggestions for avoiding category D and X DDIs included: changing the immunosuppressant dosage, using paracetamol instead of non-steroidal anti-inflammatory drugs, and interrupting atorvastatin. The number of drugs prescribed and having been prescribed TAC was associated with an increased risk of real DDIs. There are many potential DDIs described in the literature but only a small percentage proved to be real DDIs, based on the patients´ outcomes.
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Affiliation(s)
- Ana Isabel Gago‐Sánchez
- Pharmacy DepartmentHospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/University of CórdobaCórdobaSpain
| | - Pilar Font
- Rheumatology DepartmentHospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/University of CórdobaCórdobaSpain
| | - Manuel Cárdenas
- Pharmacy DepartmentHospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/University of CórdobaCórdobaSpain
| | - María Dolores Aumente
- Pharmacy DepartmentHospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/University of CórdobaCórdobaSpain
| | - José Ramón Del Prado
- Pharmacy DepartmentHospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/University of CórdobaCórdobaSpain
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Kirubakaran R, Stocker SL, Carlos L, Day RO, Carland JE. Tacrolimus Therapy in Adult Heart Transplant Recipients: Evaluation of a Bayesian Forecasting Software. Ther Drug Monit 2021; 43:736-746. [PMID: 34126624 DOI: 10.1097/ftd.0000000000000909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Therapeutic drug monitoring is recommended to guide tacrolimus dosing because of its narrow therapeutic window and considerable pharmacokinetic variability. This study assessed tacrolimus dosing and monitoring practices in heart transplant recipients and evaluated the predictive performance of a Bayesian forecasting software using a renal transplant-derived tacrolimus model to predict tacrolimus concentrations. METHODS A retrospective audit of heart transplant recipients (n = 87) treated with tacrolimus was performed. Relevant data were collected from the time of transplant to discharge. The concordance of tacrolimus dosing and monitoring according to hospital guidelines was assessed. The observed and software-predicted tacrolimus concentrations (n = 931) were compared for the first 3 weeks of oral immediate-release tacrolimus (Prograf) therapy, and the predictive performance (bias and imprecision) of the software was evaluated. RESULTS The majority (96%) of initial oral tacrolimus doses were guideline concordant. Most initial intravenous doses (93%) were lower than the guideline recommendations. Overall, 36% of initial tacrolimus doses were administered to transplant recipients with an estimated glomerular filtration rate of <60 mL/min/1.73 m despite recommendations to delay the commencement of therapy. Of the tacrolimus concentrations collected during oral therapy (n = 1498), 25% were trough concentrations obtained at steady-state. The software displayed acceptable predictions of tacrolimus concentration from day 12 (bias: -6%; 95%confidence interval, -11.8 to 2.5; imprecision: 16%; 95% confidence interval, 8.7-24.3) of therapy. CONCLUSIONS Tacrolimus dosing and monitoring were discordant with the guidelines. The Bayesian forecasting software was suitable for guiding tacrolimus dosing after 11 days of therapy in heart transplant recipients. Understanding the factors contributing to the variability in tacrolimus pharmacokinetics immediately after transplant may help improve software predictions.
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Affiliation(s)
- Ranita Kirubakaran
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
- Department of Pharmacy, Ministry of Health, Putrajaya, Malaysia
| | - Sophie L Stocker
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney
- Garvan Institute of Medical Research
| | | | - Richard O Day
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Jane E Carland
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
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41
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Ling J, Yang XP, Dong LL, Jiang Y, Zou SL, Hu N, Chen R. Population pharmacokinetics of ciclosporin in allogeneic hematopoietic stem cell transplant recipients: C-reactive protein as a novel covariate for clearance. J Clin Pharm Ther 2021; 47:483-492. [PMID: 34779003 DOI: 10.1111/jcpt.13569] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/26/2021] [Accepted: 11/01/2021] [Indexed: 12/01/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Ciclosporin (CsA), a potent immunosuppressive agent used to prevent graft-versus-host disease in allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients, is characterized by large inter-individual variability and a narrow therapeutic range. The aim of this study was to develop a population pharmacokinetic model for CsA in Chinese allo-HSCT recipients and to identify covariates influencing CsA pharmacokinetics. METHODS A total of 758 retrospective drug monitoring data points were collected after intravenous infusion or oral administration of CsA from 59 patients. Population pharmacokinetic analysis was performed using nonlinear mixed effects modelling expressed by differential equations. Monte Carlo simulation was applied to optimize dosage regimens. The final model was validated using bootstrap and normalized prediction distribution errors. RESULTS AND DISCUSSION The results showed that the daily CsA dose, haematocrit, total bile acid, C-reactive protein (CRP) and co-administration of triazole antifungal agent were identified as significant covariates for clearance (CL) of CsA. The typical value of CL was 19.8 L/h with an inter-individual variability of 13.1%. The volume of distribution was 1340 L. Bioavailability was 67.2% with an inter-individual variability of 8.5%. Dosing simulation based on the developed model indicated that patients with high CRP concentration required a higher daily dose to attain the therapeutic trough concentration. The influence of CRP ultimately on the therapy outcome of CsA is not clear, which needs further study. WHAT IS NEW AND CONCLUSION CRP concentration was identified as a novel marker associated with CsA pharmacokinetics, which should be considered when determining the appropriate dosage of CsA in allo-HSCT recipients.
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Affiliation(s)
- Jing Ling
- Department of Pharmacy, the First People's Hospital of Changzhou/the Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Xu-Ping Yang
- Department of Pharmacy, the First People's Hospital of Changzhou/the Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Lu-Lu Dong
- Department of Pharmacy, the First People's Hospital of Changzhou/the Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Yan Jiang
- Department of Pharmacy, the First People's Hospital of Changzhou/the Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Su-Lan Zou
- Department of Pharmacy, the First People's Hospital of Changzhou/the Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Nan Hu
- Department of Pharmacy, the First People's Hospital of Changzhou/the Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Rong Chen
- Department of Pharmacy, the First People's Hospital of Changzhou/the Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
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Management of Pulmonary Mucormycosis After Orthotopic Heart Transplant: A Case Series. Transplant Proc 2021; 53:3051-3055. [PMID: 34772489 DOI: 10.1016/j.transproceed.2021.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/30/2021] [Indexed: 11/22/2022]
Abstract
Invasive pulmonary mucormycosis is a potentially fatal infection that can occur in immunosuppressed patients such as those who have undergone orthotopic heart transplant (OHT). High-dose intravenous antifungal agents, including amphotericin B, are generally accepted as the first-line medical treatment, with prompt surgical resection of lesions if feasible. The body of evidence guiding treatment decisions, however, is sparse, particularly regarding adjustment of immunosuppression during acute infection and long-term recovery. We present 2 cases of patients with pulmonary mucormycosis occurring within the first 6 months after OHT, both of whom successfully recovered after appropriate medical and surgical treatment, and we highlight differences in immunosuppression management strategies for this life-threatening condition.
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43
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Zhang C, Gao L, Ren Y, Gu H, Zhang Y, Lu L. The CCAAT-binding complex mediates azole susceptibility of Aspergillus fumigatus by suppressing SrbA expression and cleavage. Microbiologyopen 2021; 10:e1249. [PMID: 34964293 PMCID: PMC8608569 DOI: 10.1002/mbo3.1249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 10/20/2021] [Accepted: 10/20/2021] [Indexed: 11/10/2022] Open
Abstract
In fungal pathogens, the transcription factor SrbA (a sterol regulatory element-binding protein, SREBP) and CBC (CCAAT binding complex) have been reported to regulate azole resistance by competitively binding the TR34 region (34 mer) in the promoter of the drug target gene, erg11A. However, current knowledge about how the SrbA and CBC coordinately mediate erg11A expression remains limited. In this study, we uncovered a novel relationship between HapB (a subunit of CBC) and SrbA in which deletion of hapB significantly prolongs the nuclear retention of SrbA by increasing its expression and cleavage under azole treatment conditions, thereby enhancing Erg11A expression for drug resistance. Furthermore, we verified that loss of HapB significantly induces the expression of the rhomboid protease RbdB, Dsc ubiquitin E3 ligase complex, and signal peptide peptidase SppA, which are required for the cleavage of SrbA, suggesting that HapB acts as a repressor for these genes which contribute to the activation of SrbA by proteolytic cleavage. Together, our study reveals that CBC functions not only to compete with SrbA for binding to erg11A promoter region but also to affect SrbA expression, cleavage, and translocation to nuclei for the function, which ultimately regulate Erg11A expression and azole resistance.
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Affiliation(s)
- Chi Zhang
- Jiangsu Key Laboratory for Microbes and Functional GenomicsJiangsu Engineering and Technology Research Center for MicrobiologyCollege of Life SciencesNanjing Normal UniversityNanjingChina
| | - Lu Gao
- Jiangsu Key Laboratory for Microbes and Functional GenomicsJiangsu Engineering and Technology Research Center for MicrobiologyCollege of Life SciencesNanjing Normal UniversityNanjingChina
| | - Yiran Ren
- Jiangsu Key Laboratory for Microbes and Functional GenomicsJiangsu Engineering and Technology Research Center for MicrobiologyCollege of Life SciencesNanjing Normal UniversityNanjingChina
| | - Huiyu Gu
- Jiangsu Key Laboratory for Microbes and Functional GenomicsJiangsu Engineering and Technology Research Center for MicrobiologyCollege of Life SciencesNanjing Normal UniversityNanjingChina
| | - Yuanwei Zhang
- Jiangsu Key Laboratory for Microbes and Functional GenomicsJiangsu Engineering and Technology Research Center for MicrobiologyCollege of Life SciencesNanjing Normal UniversityNanjingChina
| | - Ling Lu
- Jiangsu Key Laboratory for Microbes and Functional GenomicsJiangsu Engineering and Technology Research Center for MicrobiologyCollege of Life SciencesNanjing Normal UniversityNanjingChina
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Gatti M, Cojutti PG, Campoli C, Caramelli F, Corvaglia LT, Lanari M, Pession A, Ramirez S, Viale P, Pea F. A Proof of Concept of the Role of TDM-Based Clinical Pharmacological Advices in Optimizing Antimicrobial Therapy on Real-Time in Different Paediatric Settings. Front Pharmacol 2021; 12:755075. [PMID: 34646143 PMCID: PMC8502823 DOI: 10.3389/fphar.2021.755075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 09/13/2021] [Indexed: 01/14/2023] Open
Abstract
Introduction: Antimicrobial treatment is quite common among hospitalized children. The dynamic age-associated physiological variations coupled with the pathophysiological alterations caused by underlying illness and potential drug-drug interactions makes the implementation of appropriate antimicrobial dosing extremely challenging among paediatrics. Therapeutic drug monitoring (TDM) may represent a valuable tool for assisting clinicians in optimizing antimicrobial exposure. Clinical pharmacological advice (CPA) is an approach based on the correct interpretation of the TDM result by the MD Clinical Pharmacologist in relation to specific underlying conditions, namely the antimicrobial susceptibility of the clinical isolate, the site of infection, the pathophysiological characteristics of the patient and/or the drug-drug interactions of cotreatments. The aim of this study was to assess the role of TDM-based CPAs in providing useful recommendations for the real-time personalization of antimicrobial dosing regimens in various paediatric settings. Materials and methods: Paediatric patients who were admitted to different settings of the IRCCS Azienda Ospedaliero-Universitaria of Bologna, Italy (paediatric intensive care unit [ICU], paediatric onco-haematology, neonatology, and emergency paediatric ward), between January 2021 and June 2021 and who received TDM-based CPAs on real-time for personalization of antimicrobial therapy were retrospectively assessed. Demographic and clinical features, CPAs delivered in relation to different settings and antimicrobials, and type of dosing adjustments were extracted. Two indicators of performance were identified. The number of dosing adjustments provided over the total number of delivered CPAs. The turnaround time (TAT) of CPAs according to a predefined scale (optimal, <12 h; quasi-optimal, between 12-24 h; acceptable, between 24-48 h; suboptimal, >48 h). Results: Overall, 247 CPAs were delivered to 53 paediatric patients (mean 4.7 ± 3.7 CPAs/patient). Most were delivered to onco-haematological patients (39.6%) and to ICU patients (35.8%), and concerned mainly isavuconazole (19.0%) and voriconazole (17.8%). Overall, CPAs suggested dosing adjustments in 37.7% of cases (24.3% increases and 13.4% decreases). Median TAT was 7.5 h (IQR 6.1-8.8 h). Overall, CPAs TAT was optimal in 91.5% of cases, and suboptimal in only 0.8% of cases. Discussion: Our study provides a proof of concept of the helpful role that TDM-based real-time CPAs may have in optimizing antimicrobial exposure in different challenging paediatric scenarios.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.,SSD Clinical Pharmacology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pier Giorgio Cojutti
- SSD Clinical Pharmacology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Caterina Campoli
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Fabio Caramelli
- Pediatric Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luigi Tommaso Corvaglia
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.,Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marcello Lanari
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.,Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Pession
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.,Pediatric Oncology & Hematology Unit 'Lalla Seràgnoli', IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.,Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.,SSD Clinical Pharmacology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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45
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Phoompoung P, Villalobos APC, Jain S, Foroutan F, Orchanian-Cheff A, Husain S. Risk factors of invasive fungal infections in lung transplant recipients: A systematic review and meta-analysis. J Heart Lung Transplant 2021; 41:255-262. [PMID: 34872817 DOI: 10.1016/j.healun.2021.09.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/02/2021] [Accepted: 09/27/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Invasive fungal infection (IFI) remains a common complication after lung transplantation, causing significant morbidity and mortality. We have attempted to quantify systematically risk factors of IFI in lung transplant recipients. METHODS Studies were retrieved from Ovid MEDLINE, Ovid Embase, Cochrane database of systematic reviews and Cochrane central register of controlled trials. All case-control and cohort studies evaluating the risk factors of IFI in adult lung transplant recipients were screened. Two researchers reviewed and assessed all studies independently. We pooled the estimated effect of each factor associated with IFI by using a random effect model. RESULTS Eight studies were included in the systematic review and 5 studies were eligible for the meta-analysis. Rates of IFI range from 8% to 33% in lung transplant recipients. Independent risk factors for invasive aspergillosis (IA) in lung transplantation include previous fungal colonization (odds ratio [OR] 2.44; 95% confidence interval [CI] 0.08-0.47), cytomegalovirus infection (OR 1.96; 95% CI 1.08-3.56), and single lung transplantation (OR 1.77; 95% CI 1.08-2.91). Pre-emptive antifungal therapy is a protective factor for IA in lung transplant (OR 0.2; 95% CI 0.08-0.47). CONCLUSION Cytomegalovirus infection, previous fungal colonization and single lung transplantation independently increase the risk of IA in lung transplant recipients. Pre-emptive antifungal therapy is a protective factor for IA in the lung transplant population.
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Affiliation(s)
- Pakpoom Phoompoung
- Ajmera Transplant Center, University Health Network, Toronto, Canada; Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Farid Foroutan
- Ajmera Transplant Center, University Health Network, Toronto, Canada
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Canada
| | - Shahid Husain
- Ajmera Transplant Center, University Health Network, Toronto, Canada.
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46
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Kirubakaran R, Hennig S, Maslen B, Day RO, Carland JE, Stocker SL. Evaluation of published population pharmacokinetic models to inform tacrolimus dosing in adult heart transplant recipients. Br J Clin Pharmacol 2021; 88:1751-1772. [PMID: 34558092 DOI: 10.1111/bcp.15091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/26/2021] [Accepted: 09/13/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND AIM Identification of the most appropriate population pharmacokinetic model-based Bayesian estimation is required prior to its implementation in routine clinical practice to inform tacrolimus dosing decisions. This study aimed to determine the predictive performances of relevant population pharmacokinetic models of tacrolimus developed from various solid organ transplant recipient populations in adult heart transplant recipients, stratified based on concomitant azole antifungal use. Concomitant azole antifungal therapy alters tacrolimus pharmacokinetics substantially, necessitating dose adjustments. METHODS Population pharmacokinetic models of tacrolimus were selected (n = 17) for evaluation from a recent systematic review. The models were transcribed and implemented in NONMEM version 7.4.3. Data from 85 heart transplant recipients (2387 tacrolimus concentrations) administered the oral immediate-release formulation of tacrolimus (Prograf) were obtained up to 391 days post-transplant. The performance of each model was evaluated using: (i) prediction-based assessment (bias and imprecision) of the individual predicted tacrolimus concentration of the fourth dosing occasion (MAXEVAL = 0, FOCE-I) from 1-3 prior dosing occasions; and (ii) simulation-based assessment (prediction-corrected visual predictive check). Both assessments were stratified based on concomitant azole antifungal use. RESULTS Regardless of the number of prior dosing occasions (1-3) and concomitant azole antifungal use, all models demonstrated unacceptable individual predicted tacrolimus concentration of the fourth dosing occasion (n = 152). The prediction-corrected visual predictive check graphics indicated that these models inadequately predicted observed tacrolimus concentrations. CONCLUSION All models evaluated were unable to adequately describe tacrolimus pharmacokinetics in adult heart transplant recipients included in this study. Further work is required to describe tacrolimus pharmacokinetics for our heart transplant recipient cohort.
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Affiliation(s)
- Ranita Kirubakaran
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.,Ministry of Health, Putrajaya, Malaysia
| | - Stefanie Hennig
- Certara Inc., Princeton, NJ, USA.,School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Ben Maslen
- Mark Wainwright Analytical Centre, University of New South Wales, Sydney, NSW, Australia
| | - Richard O Day
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.,Garvan Institute of Medical Research, Sydney, NSW, Australia
| | - Jane E Carland
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.,School of Medical Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Sophie L Stocker
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.,Garvan Institute of Medical Research, Sydney, NSW, Australia.,School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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47
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Population Pharmacokinetic Models of Tacrolimus in Adult Transplant Recipients: A Systematic Review. Clin Pharmacokinet 2021; 59:1357-1392. [PMID: 32783100 DOI: 10.1007/s40262-020-00922-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Numerous population pharmacokinetic (PK) models of tacrolimus in adult transplant recipients have been published to characterize tacrolimus PK and facilitate dose individualization. This study aimed to (1) investigate clinical determinants influencing tacrolimus PK, and (2) identify areas requiring additional research to facilitate the use of population PK models to guide tacrolimus dosing decisions. METHODS The MEDLINE and EMBASE databases, as well as the reference lists of all articles, were searched to identify population PK models of tacrolimus developed from adult transplant recipients published from the inception of the databases to 29 February 2020. RESULTS Of the 69 studies identified, 55% were developed from kidney transplant recipients and 30% from liver transplant recipients. Most studies (91%) investigated the oral immediate-release formulation of tacrolimus. Few studies (17%) explained the effect of drug-drug interactions on tacrolimus PK. Only 35% of the studies performed an external evaluation to assess the generalizability of the models. Studies related variability in tacrolimus whole blood clearance among transplant recipients to either cytochrome P450 (CYP) 3A5 genotype (41%), days post-transplant (30%), or hematocrit (29%). Variability in the central volume of distribution was mainly explained by body weight (20% of studies). CONCLUSION The effect of clinically significant drug-drug interactions and different formulations and brands of tacrolimus should be considered for any future tacrolimus population PK model development. Further work is required to assess the generalizability of existing models and identify key factors that influence both initial and maintenance doses of tacrolimus, particularly in heart and lung transplant recipients.
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48
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Arastehfar A, Carvalho A, Houbraken J, Lombardi L, Garcia-Rubio R, Jenks J, Rivero-Menendez O, Aljohani R, Jacobsen I, Berman J, Osherov N, Hedayati M, Ilkit M, Armstrong-James D, Gabaldón T, Meletiadis J, Kostrzewa M, Pan W, Lass-Flörl C, Perlin D, Hoenigl M. Aspergillus fumigatus and aspergillosis: From basics to clinics. Stud Mycol 2021; 100:100115. [PMID: 34035866 PMCID: PMC8131930 DOI: 10.1016/j.simyco.2021.100115] [Citation(s) in RCA: 114] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The airborne fungus Aspergillus fumigatus poses a serious health threat to humans by causing numerous invasive infections and a notable mortality in humans, especially in immunocompromised patients. Mould-active azoles are the frontline therapeutics employed to treat aspergillosis. The global emergence of azole-resistant A. fumigatus isolates in clinic and environment, however, notoriously limits the therapeutic options of mould-active antifungals and potentially can be attributed to a mortality rate reaching up to 100 %. Although specific mutations in CYP 51A are the main cause of azole resistance, there is a new wave of azole-resistant isolates with wild-type CYP 51A genotype challenging the efficacy of the current diagnostic tools. Therefore, applications of whole-genome sequencing are increasingly gaining popularity to overcome such challenges. Prominent echinocandin tolerance, as well as liver and kidney toxicity posed by amphotericin B, necessitate a continuous quest for novel antifungal drugs to combat emerging azole-resistant A. fumigatus isolates. Animal models and the tools used for genetic engineering require further refinement to facilitate a better understanding about the resistance mechanisms, virulence, and immune reactions orchestrated against A. fumigatus. This review paper comprehensively discusses the current clinical challenges caused by A. fumigatus and provides insights on how to address them.
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Affiliation(s)
- A. Arastehfar
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, 07110, USA
| | - A. Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - J. Houbraken
- Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands
| | - L. Lombardi
- UCD Conway Institute and School of Medicine, University College Dublin, Dublin 4, Ireland
| | - R. Garcia-Rubio
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, 07110, USA
| | - J.D. Jenks
- Department of Medicine, University of California San Diego, San Diego, CA, 92103, USA
- Clinical and Translational Fungal-Working Group, University of California San Diego, La Jolla, CA, 92093, USA
| | - O. Rivero-Menendez
- Medical Mycology Reference Laboratory, National Center for Microbiology, Instituto de Salud Carlos III, Madrid, 28222, Spain
| | - R. Aljohani
- Department of Infectious Diseases, Imperial College London, London, UK
| | - I.D. Jacobsen
- Department of Microbial Pathogenicity Mechanisms, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Jena, Germany
- Institute for Microbiology, Friedrich Schiller University, Jena, Germany
| | - J. Berman
- Research Group Microbial Immunology, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Jena, Germany
| | - N. Osherov
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine Ramat-Aviv, Tel-Aviv, 69978, Israel
| | - M.T. Hedayati
- Invasive Fungi Research Center/Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - M. Ilkit
- Division of Mycology, Department of Microbiology, Faculty of Medicine, Çukurova University, 01330, Adana, Turkey
| | | | - T. Gabaldón
- Life Sciences Programme, Supercomputing Center (BSC-CNS), Jordi Girona, Barcelona, 08034, Spain
- Mechanisms of Disease Programme, Institute for Research in Biomedicine (IRB), Barcelona, Spain
- ICREA, Pg. Lluís Companys 23, Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Pg. Lluís Companys 23, 08010, Barcelona, Spain
| | - J. Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - W. Pan
- Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China
| | - C. Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - D.S. Perlin
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, 07110, USA
| | - M. Hoenigl
- Department of Medicine, University of California San Diego, San Diego, CA, 92103, USA
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036, Graz, Austria
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, San Diego, CA 92093, USA
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Tragiannidis A, Gkampeta A, Vousvouki M, Vasileiou E, Groll AH. Antifungal agents and the kidney: pharmacokinetics, clinical nephrotoxicity, and interactions. Expert Opin Drug Saf 2021; 20:1061-1074. [PMID: 33896310 DOI: 10.1080/14740338.2021.1922667] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Invasive fungal infections continue to be important causes of morbidity and mortality in severely ill and immunocompromised patient populations. The past three decades have seen a considerable expansion in antifungal drug research, resulting in the clinical development of different classes of antifungal agents with different pharmacologic properties. Among drug-specific characteristics of antifungal agents, renal disposition and nephrotoxicity are important clinical considerations as many patients requiring antifungal therapy have compromised organ functions or are receiving other potentially nephrotoxic medications. AREAS COVERED The present article reviews incidence, severity and mechanisms of nephrotoxicity associated with antifungal agents used for prevention and treatment of invasive fungal diseases by discussing distribution, metabolism, elimination and drug-related adverse events in the context of safety data from phase II and III clinical studies. EXPERT OPINION Based on the available data amphotericin B deoxycholate has the highest relative potential for nephrotoxicity, followed by the lipid formulations of amphotericin B, and, to a much lesser extent and by indirect mechanisms, the antifungal triazoles.
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Affiliation(s)
- Athanasios Tragiannidis
- Childhood & Adolescent Hematology Oncology Unit, 2nd Pediatric Department, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA Hospital, Greece
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany
| | - Anastasia Gkampeta
- Childhood & Adolescent Hematology Oncology Unit, 2nd Pediatric Department, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA Hospital, Greece
| | - Maria Vousvouki
- Childhood & Adolescent Hematology Oncology Unit, 2nd Pediatric Department, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA Hospital, Greece
| | - Eleni Vasileiou
- Childhood & Adolescent Hematology Oncology Unit, 2nd Pediatric Department, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA Hospital, Greece
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany
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Al-Kofahi M, Oetting WS, Schladt DP, Remmel RP, Guan W, Wu B, Dorr CR, Mannon RB, Matas AJ, Israni AK, Jacobson PA. Precision Dosing for Tacrolimus Using Genotypes and Clinical Factors in Kidney Transplant Recipients of European Ancestry. J Clin Pharmacol 2021; 61:1035-1044. [PMID: 33512723 PMCID: PMC11240873 DOI: 10.1002/jcph.1823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/26/2021] [Indexed: 12/14/2022]
Abstract
Genetic variation in the CYP3A4 and CYP3A5 (CYP3A4/5) genes, which encode the key enzymes in tacrolimus metabolism, is associated with tacrolimus clearance and dose requirements. Tacrolimus has a narrow therapeutic index with high intra- and intersubject variability, in part because of genetic variation. High tacrolimus clearance and low trough concentration are associated with a greater risk for rejection, whereas high troughs are associated with calcineurin-induced toxicity. The objective of this study was to develop a model of tacrolimus clearance with a dosing equation accounting for genotypes and clinical factors in adult kidney transplant recipients of European ancestry that could preemptively guide dosing. Recipients receiving immediate-release tacrolimus for maintenance immunosuppression from 2 multicenter studies were included. Participants in the GEN03 study were used for tacrolimus model development (n = 608 recipients) and was validated by prediction performance in the DeKAF Genomics study (n = 1361 recipients). Nonlinear mixed-effects modeling was used to develop the apparent oral tacrolimus clearance (CL/F) model. CYP3A4/5 genotypes and clinical covariates were tested for their influence on CL/F. The predictive performance of the model was determined by assessing the bias (median prediction error [ME] and median percentage error [MPE]) and the precision (root median squared error [RMSE]) of the model. CYP3A5*3, CYP3A4*22, corticosteroids, calcium channel blocker and antiviral drug use, age, and diabetes significantly contributed to the interindividual variability of oral tacrolimus apparent clearance. The bias (ME, MPE) and precision (RMSE) of the final model was good, 0.49 ng/mL, 6.5%, and 3.09 ng/mL, respectively. Prospective testing of this equation is warranted.
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Affiliation(s)
- Mahmoud Al-Kofahi
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - William S Oetting
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - David P Schladt
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
| | - Rory P Remmel
- Department of Medicinal Chemistry, University of Minnesota, Minneapolis, Minnesota, USA
| | - Weihua Guan
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Baolin Wu
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Casey R Dorr
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Roslyn B Mannon
- Division of Nephrology, University of Nebraska, Omaha, Nebraska, USA
| | - Arthur J Matas
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ajay K Israni
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
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