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Kirubakaran R, Singh RM, Carland JE, Day RO, Stocker SL. Evaluation of Published Population Pharmacokinetic Models to Inform Tacrolimus Therapy in Adult Lung Transplant Recipients. Ther Drug Monit 2024; 46:434-445. [PMID: 38723160 DOI: 10.1097/ftd.0000000000001210] [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] [Received: 10/25/2023] [Accepted: 02/15/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND The applicability of currently available tacrolimus population pharmacokinetic models in guiding dosing for lung transplant recipients is unclear. In this study, the predictive performance of relevant tacrolimus population pharmacokinetic models was evaluated for adult lung transplant recipients. METHODS Data from 43 lung transplant recipients (1021 tacrolimus concentrations) administered an immediate-release oral formulation of tacrolimus were used to evaluate the predictive performance of 17 published population pharmacokinetic models for tacrolimus. Data were collected from immediately after transplantation up to 90 days after transplantation. Model performance was evaluated using (1) prediction-based assessments (bias and imprecision) of individual predicted tacrolimus concentrations at the fourth dosing based on 1 to 3 previous dosings and (2) simulation-based assessment (prediction-corrected visual predictive check; pcVPC). Both assessments were stratified based on concomitant azole antifungal use. Model performance was clinically acceptable if the bias was within ±20%, imprecision was ≤20%, and the 95% confidence interval of bias crossed zero. RESULTS In the presence of concomitant antifungal therapy, no model showed acceptable performance in predicting tacrolimus concentrations at the fourth dosing (n = 33), and pcVPC plots displayed poor model fit to the data set. However, this fit slightly improved in the absence of azole antifungal use, where 4 models showed acceptable performance in predicting tacrolimus concentrations at the fourth dosing (n = 33). CONCLUSIONS Although none of the evaluated models were appropriate in guiding tacrolimus dosing in lung transplant recipients receiving concomitant azole antifungal therapy, 4 of these models displayed potential applicability in guiding dosing in recipients not receiving concomitant azole antifungal therapy. However, further model refinement is required before the widespread implementation of such models in clinical practice.
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Affiliation(s)
- Ranita Kirubakaran
- School of Clinical Medicine, St. Vincent's Healthcare Clinical Campus, 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
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rani M Singh
- School of Clinical Medicine, St. Vincent's Healthcare Clinical Campus, 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
- School of Clinical Medicine, St. Vincent's Healthcare Clinical Campus, 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
| | - Richard O Day
- School of Clinical Medicine, St. Vincent's Healthcare Clinical Campus, 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
| | - Sophie L Stocker
- School of Clinical Medicine, St. Vincent's Healthcare Clinical Campus, 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, University of Sydney, Sydney, NSW, Australia
- Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW, Australia ; and
- Sydney Musculoskeletal Health, University of Sydney, Sydney, NSW, Australia
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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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Hazra S, Singh PA. Safety Aspects of Herb Interactions: Current Understanding and Future Prospects. Curr Drug Metab 2024; 25:28-53. [PMID: 38482621 DOI: 10.2174/0113892002289753240305062601] [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: 10/27/2023] [Revised: 01/11/2024] [Accepted: 02/09/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND The use of herbal medicines is on the rise throughout the world due to their perceived safety profile. However, incidences of herb-drug, herb-herb and herb-food interactions considering safety aspects have opened new arenas for discussion. OBJECTIVE The current study aims to provide comprehensive insights into the various types of herb interactions, the mechanisms involved, their assessment, and historical developments, keeping herbal safety at the central point of discussion. METHODS The authors undertook a focused/targeted literature review and collected data from various databases, including Science Direct, Wiley Online Library, Springer, PubMed, and Google Scholar. Conventional literature on herbal remedies, such as those by the WHO and other international or national organizations. RESULTS The article considered reviewing the regulations, interaction mechanisms, and detection of herb-herb, herb-drug and herb-food interactions in commonly used yet vital plants, including Glycyrrhiza glabra, Mentha piperita, Aloe barbadensis, Zingiber officinale, Gingko biloba, Withania somnifera, etc. The study found that healthcare professionals worry about patients not informing them about their herbal prescriptions (primarily used with conventional treatment), which can cause herb-drug/herb-food/herb-herb interactions. These interactions were caused by altered pharmacodynamic and pharmacokinetic processes, which might be explained using in-vivo, in-vitro, in-silico, pharmacogenomics, and pharmacogenetics. Nutrivigilance may be the greatest method to monitor herb-food interactions, but its adoption is limited worldwide. CONCLUSION This article can serve as a lead for clinicians, guiding them regarding herb-drug, herb-food, and herb-herb interactions induced by commonly consumed plant species. Patients may also be counseled to avoid conventional drugs, botanicals, and foods with a restricted therapeutic window.
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Affiliation(s)
- Subhajit Hazra
- University Institute of Pharma Sciences (UIPS), Chandigarh University, Mohali-140413, Punjab, India
| | - Preet Amol Singh
- University Institute of Pharma Sciences (UIPS), Chandigarh University, Mohali-140413, Punjab, India
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4
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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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Antypenko L, Meyer F, Sadyk Z, Shabelnyk K, Kovalenko S, Steffens KG, Garbe LA. Combined Application of Tacrolimus with Cyproconazole, Hymexazol and Novel {2-(3-R-1 H-1,2,4-triazol-5-yl)phenyl}amines as Antifungals: In Vitro Growth Inhibition and In Silico Molecular Docking Analysis to Fungal Chitin Deacetylase. J Fungi (Basel) 2023; 9:79. [PMID: 36675900 PMCID: PMC9866229 DOI: 10.3390/jof9010079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/01/2023] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
Agents with antifungal activity play a vital role as therapeutics in health care, as do fungicides in agriculture. Effectiveness, toxicological profile, and eco-friendliness are among the properties used to select suitable substances. Furthermore, a steady supply of new agents with different modes of action is required to counter the well-known potential of human and phyto-pathogenic fungi to develop resistance against established antifungals. Here, we use an in vitro growth assay to investigate the activity of the calcineurin inhibitor tacrolimus in combination with the commercial fungicides cyproconazole and hymexazol, as well as with two earlier reported novel {2-(3-R-1H-1,2,4-triazol-5-yl)phenyl}amines, against the fungi Aspergillus niger, Colletotrichum higginsianum, Fusarium oxysporum and the oomycete Phytophthora infestans, which are notoriously harmful in agriculture. When tacrolimus was added in a concentration range from 0.25 to 25 mg/L to the tested antifungals (at a fixed concentration of 25 or 50 mg/L), the inhibitory activities were distinctly enhanced. Molecular docking calculations revealed triazole derivative 5, (2-(3-adamantan-1-yl)-1H-1,2,4-triazol-5-yl)-4-chloroaniline), as a potent inhibitor of chitin deacetylases (CDA) of Aspergillus nidulans and A. niger (AnCDA and AngCDA, respectively), which was stronger than the previously reported polyoxorin D, J075-4187, and chitotriose. The results are discussed in the context of potential synergism and molecular mode of action.
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Affiliation(s)
- Lyudmyla Antypenko
- Faculty of Agriculture and Food Science, Neubrandenburg University of Applied Sciences, Brodaer Str. 2, 17033 Neubrandenburg, Germany
| | - Fatuma Meyer
- Faculty of Agriculture and Food Science, Neubrandenburg University of Applied Sciences, Brodaer Str. 2, 17033 Neubrandenburg, Germany
| | - Zhanar Sadyk
- Faculty of Agriculture and Food Science, Neubrandenburg University of Applied Sciences, Brodaer Str. 2, 17033 Neubrandenburg, Germany
- Faculty of Applied Natural Sciences, TH Köln-University of Applied Sciences, Campusplatz 1, 51379 Leverkusen, Germany
| | - Konstyantyn Shabelnyk
- Pharmaceutical Chemistry, Organic and Bioorganic Chemistry Department, Zaporizhzhia State Medical University, Mayakovs’ky Ave. 26, 69035 Zaporizhzhia, Ukraine
| | - Sergiy Kovalenko
- Pharmaceutical Chemistry, Organic and Bioorganic Chemistry Department, Zaporizhzhia State Medical University, Mayakovs’ky Ave. 26, 69035 Zaporizhzhia, Ukraine
| | - Karl Gustav Steffens
- Faculty of Agriculture and Food Science, Neubrandenburg University of Applied Sciences, Brodaer Str. 2, 17033 Neubrandenburg, Germany
| | - Leif-Alexander Garbe
- Faculty of Agriculture and Food Science, Neubrandenburg University of Applied Sciences, Brodaer Str. 2, 17033 Neubrandenburg, Germany
- ZELT–Center for Nutrition and Food Technology, Seestrasse 7A, 17033 Neubrandenburg, Germany
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Enger K, Tonnar X, Kotter E, Bertz H. Sequential low-dose CT thorax scans to determine invasive pulmonary fungal infection incidence after allogeneic hematopoietic cell transplantation. Ann Hematol 2023; 102:413-420. [PMID: 36460795 PMCID: PMC9889523 DOI: 10.1007/s00277-022-05062-9] [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: 02/01/2022] [Accepted: 11/18/2022] [Indexed: 12/05/2022]
Abstract
Invasive fungal disease (IFD) during neutropenia goes along with a high mortality for patients after allogeneic hematopoietic cell transplantation (alloHCT). Low-dose computed tomography (CT) thorax shows good sensitivity for the diagnosis of IFD with low radiation exposure. The aim of our study was to evaluate sequential CT thorax scans at two time points as a new reliable method to detect IFD during neutropenia after alloHCT. We performed a retrospective single-center observational study in 265/354 screened patients admitted for alloHCT from June 2015 to August 2019. All were examined by a low-dose CT thorax scan at admission (CT t0) and after stable neutrophil recovery (CT t1) to determine the incidences of IFD. Furthermore, antifungal prophylaxis medications were recorded and cohorts were analyzed for statistical differences in IFD incidence using the sequential CT scans. In addition, IFD cases were classified according to EORTC 2008. At CT t0 in 9.6% of the patients, an IFD was detected and antifungal therapy initiated. The cumulative incidence of IFD in CT t1 in our department was 14%. The use of Aspergillus-effective prophylaxis through voriconazole or posaconazole decreased CT thorax t1 suggesting IFD is statistically significant compared to prophylaxis with fluconazole (5.6% asp-azol group vs 16.3% fluconazole group, p = 0.048). In 86%, CT t1 was negative for IFD. Low-dose sequential CT thorax scans are a valuable tool to detect pulmonary IFDs and guide antifungal prophylaxis and therapies. Furthermore, a negative CT t1 scan shows a benefit by allowing discontinuation of antifungal medication sparing patients from drug interactions and side effects.
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Affiliation(s)
- K. Enger
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Freiburg University Medical Center, Freiburg, Germany
| | - X. Tonnar
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Freiburg University Medical Center, Freiburg, Germany
| | - E. Kotter
- Department of Diagnostic and Interventional Radiology, Freiburg University Medical Center, Freiburg, Germany
| | - H. Bertz
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Freiburg University Medical Center, Freiburg, Germany
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7
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Katada Y, Nakagawa S, Itohara K, Suzuki T, Kato R, Endo H, Sugimoto M, Yonezawa A, Nakagawa T, Ohsumi A, Nakajima D, Date H, Terada T. Association between time in therapeutic range of tacrolimus blood concentration and acute rejection within the first three months after lung transplantation. J Pharm Health Care Sci 2022; 8:25. [PMID: 36180948 PMCID: PMC9526258 DOI: 10.1186/s40780-022-00256-9] [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: 07/05/2022] [Accepted: 08/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tacrolimus is a key drug in immunosuppressive therapy following lung transplantation. The blood tacrolimus levels are likely to fluctuate in the early postoperative period, and failure to maintain the tacrolimus trough level in target ranges is a risk factor for rejection. However, there is little information about the relationship between the time in therapeutic range (TTR) of the tacrolimus trough level (tacrolimus TTR) and clinical outcomes. This study aimed to evaluate the association between tacrolimus TTR and acute rejection (AR) within the first three months after lung transplantation. METHODS This was a retrospective study of patients who underwent lung transplantation at a single center. The target tacrolimus trough levels were 10-15 ng/mL, and tacrolimus TTR was calculated using the Rosendaal method. The cut-off value of the tacrolimus TTR was estimated by receiver operating characteristic analysis based on AR. RESULTS The study included 90 patients. AR was observed in 26 patients. In this study, ''early-AR'' was defined as any AR within 2 weeks post-transplant (n = 22) and ''late-AR'' was defined as any AR after 1-month post-transplant (n = 4). For early AR, the relationship between tacrolimus TTR and the onset of AR was examined. There were no differences in the tacrolimus TTR between the early-AR group and non-AR group (35.7 ± 22.4 vs 31.5 ± 19.9%, P = 0.416). For late-AR, the relationship with tacrolimus TTR was examined every 10 d. The tacrolimus TTR during postoperative days (POD) 21-30 and POD 31-onset was significantly lower in the late-AR group than the no-AR group (50.0 ± 7.1 vs. 71.8 ± 18.0% and 37.0 ± 26.6 vs. 68.9 ± 31.5%, P < 0.05, respectively). The cutoff value of the tacrolimus TTR during POD 21-30 was estimated as 55.0%. CONCLUSIONS Our findings suggest that a lower tacrolimus TTR is a predictor of late AR. A tacrolimus TTR of 55% or higher is necessary to reduce the risk of AR during this period after lung transplantation.
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Affiliation(s)
- Yoshiki Katada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Shunsaku Nakagawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Kotaro Itohara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Takuya Suzuki
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Ryota Kato
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Hiroki Endo
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Mitsuhiro Sugimoto
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Takayuki Nakagawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Akihiro Ohsumi
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Daisuke Nakajima
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Tomohiro Terada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan.
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8
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Nwabufo CK. Relevance of ABC Transporters in Drug Development. Curr Drug Metab 2022; 23:434-446. [PMID: 35726814 DOI: 10.2174/1389200223666220621113524] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/04/2022] [Accepted: 05/06/2022] [Indexed: 11/22/2022]
Abstract
ATP-binding cassette (ABC) transporters play a critical role in protecting vital organs such as the brain and placenta against xenobiotics, as well as in modulating the pharmacological and toxicological profile of several drug candidates by restricting their penetration through cellular and tissue barriers. This review paper provides a description of the structure and function of ABC transporters as well as the role of P-glycoprotein, multidrug resistance-associated protein 2 and breast cancer resistance protein in the disposition of drugs. Furthermore, a review of the in vitro and in vivo techniques for evaluating the interaction between drugs and ABC transporters are provided.
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Affiliation(s)
- Chukwunonso K Nwabufo
- Drug Discovery and Development Research Group, College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada.,Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
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9
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Weis TM, Gutierrez J, Kabel CC, King AC, Daley RJ, Stump SE. Real-world management of targeted therapies in chronic lymphocytic leukemia. J Oncol Pharm Pract 2022; 28:1411-1433. [PMID: 35350909 DOI: 10.1177/10781552221090869] [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: 01/14/2023]
Abstract
The advent of novel targeted therapies, including B-cell receptor (BCR) pathway and B-cell lymphoma 2 (BCL2) inhibitors, has substantially changed the treatment paradigm for chronic lymphocytic leukemia (CLL). Although targeted therapies have improved outcomes compared to traditional chemoimmunotherapy in the front-line and relapsed or refractory settings, they are associated with resistance mutations and suboptimal outcomes in certain high-risk patients. Additionally, targeted therapies are associated with drug interactions and unique adverse effect profiles which can be challenging for patients and clinicians to manage. Ongoing studies continue to address questions regarding optimal sequencing of therapies, the role of treatment combinations, and the efficacy of next-generation novel agents. This review provides a comprehensive overview regarding the clinical management of targeted therapies for CLL and applies current literature to clinical practice.
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Affiliation(s)
- Taylor M Weis
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Jillian Gutierrez
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Charlene C Kabel
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Amber C King
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Ryan J Daley
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Sarah E Stump
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
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10
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Uchida M, Hanada N, Yamazaki S, Takatsuka H, Imai C, Utsumi A, Shiko Y, Kawasaki Y, Suzuki T, Ishii I. Analysis of the variable factors affecting changes in the blood concentration of cyclosporine before and after transfusion of red blood cell concentrate. J Pharm Health Care Sci 2022; 8:4. [PMID: 35101135 PMCID: PMC8805225 DOI: 10.1186/s40780-021-00235-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/02/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The blood concentration of cyclosporine (CyA) is frequently elevated following the transfusion of red blood cell concentrate (RCC) to patients after allogeneic hematopoietic stem cell transplantation (HSCT). The aim of this retrospective study was to identify the variable factors affecting changes in the blood concentration of CyA before and after transfusion of RCC.
Methods
We enrolled 105 patients (age, 5–66 years) who received both CyA and transfusion after HSCT. The ratio of the measurement after transfusion to the measurement before transfusion was calculated for the hematocrit and blood concentration/dose ratio of CyA (termed the HCT ratio and the CyA ratio, respectively).
Results
The blood concentration/dose ratio of CyA was increased after transfusion compared with before transfusion (P < 0.001). The HCT ratio was significantly correlated with the CyA ratio (P = 0.23, P < 0.001). The HCT ratio, concomitant medication that could elevate CyA concentration after RCC transfusion, and difference in the alkaline phosphatase level between before and after transfusion (ΔALP) were explanatory variables associated with the variation in the CyA ratio. There was no correlation between the CyA concentration after transfusion and the change in the estimated glomerular filtration rate.
Conclusions
A change in the blood concentration/dose ratio of CyA was found to be associated with a change in the HCT, concomitant medication that could elevate CyA concentration after RCC transfusion, and ALP levels. If the HCT level rises significantly after RCC transfusion, clinicians and pharmacists should pay attention to changes in the blood CyA concentration.
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11
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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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12
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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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13
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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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14
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Chen X, Zhang RL, Zhai WH, Ma QL, Pang AM, Yang DL, He Y, Wei JL, Jiang EL, Feng SZ, Han MZ. [The effect of CYP3A5 gene polymorphism on tacrolimus concentration and adverse events in patients undergoing allogeneic hematopoietic stem cell transplantation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:828-833. [PMID: 34788922 PMCID: PMC8607024 DOI: 10.3760/cma.j.issn.0253-2727.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Indexed: 11/30/2022]
Abstract
Objective: To investigates the relationship between CYP3A5 gene polymorphism, tacrolimus concentration, and acute graft versus host disease (GVHD) in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) . Methods: A retrospective analysis of the clinical data of 35 Chinese adult patients who received allo-HSCT from July 2019 to February 2020 was conducted. Also, bone marrow samples were collected before transplantation for CYP3A5 genotyping, and intravenous infusion of tacrolimus and a short course of methotrexate (MTX) ± mycophenolate were used to prevent GVHD. The initial concentration was monitored on the second or third day of tacrolimus administration, followed by 2-3 times a week. The drug dose was adjusted according to the target blood concentration (10-15 ng/ml) . Results: In 16 allo-HSCT patients with CYP3A5 *3/*3 gene, the initial concentration of tacrolimus (9.82 ng/ml vs 8.53 ng/ml) , the initial concentration/dose (C/D) ratio (5.72 ng·ml(-1)·mg(-1) vs 4.26 ng·ml(-1)·mg(-1)) , and the median C/D ratio in the first two weeks after HSCT (5.29 ng·ml(-1)·mg(-1) vs 4.61 ng·ml(-1)·mg(-1), 5.65 ng·ml(-1)·mg(-1) vs 4.56 ng·ml(-1)·mg(-1)) were significantly higher than in 19 patients with at least one CYP3A5 * 1 allele (P=0.028, 0.001, 0.037, 0.045) . The incidence of Ⅲ-Ⅳ aGVHD in patients with CYP3A5*1 alleles was higher than in patients with CYP3A5*3/*3 gene[ (26.3±10.1) %vs (6.2±6.1) %, P=0.187]. Conclusion: CYP3A5 genotype-directed administration may help achieve the target blood concentration of tacrolimus after HSCT more quickly, reduce the incidence of severe aGVHD, and improve the efficacy of transplantation.
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Affiliation(s)
- X Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - R L Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - W H Zhai
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - Q L Ma
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - A M Pang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - D L Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - Y He
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - J L Wei
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - E L Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - S Z Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - M Z Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
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15
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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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16
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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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17
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Huang F, Zhou C, Zhang XY, Shen MY, Zhang H, Wang Y, Sun L. Impact of CYP2C19 genotype on voriconazole exposure and effect of voriconazole on the activity of CYP3A in patients with haematological malignancies. Xenobiotica 2021; 51:1199-1206. [PMID: 34402388 DOI: 10.1080/00498254.2021.1969481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Voriconazole (VRC) is a first-line drug for the treatment of invasive fungal infections (IFIs) and an inhibitor of CYP3A activity. The aims of this study are to investigate the influence of related factors on the plasma concentration of voriconazole and the effect of voriconazole on the activity of CYP3A in patients with haematological malignancies.A total of 89 patients received an initial dose of 6 mg/kg followed by 4 mg/kg every 12 h were included in the study. Blood samples were collected before and 2 h after administration for subsequent testing and for the extraction of DNA samples. Voriconazole and voriconazole N-oxide in the plasma were detected by LC-MS/MS. The effect of voriconazole on CYP3A activity was evaluated by the ratio of the endogenous biomarkers 6β-hydroxycortisol and cortisol.During the study period, the overall incidence of adverse reactions was 33.6% (with no deaths). The metabolite type of CYP2C19 and combined use of CYP2C19 enzyme inhibitors both had a significant impact on voriconazole exposure. Voriconazole has a long-lasting and potent inhibitory effect on CYP3A activity. The exposure of CYP3A substrate in combination with metabolic enzyme inhibitors voriconazole could increase. Therefore, the combination uses with voriconazole need to be considered carefully and assessed adequately.
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Affiliation(s)
- Fengru Huang
- Research Division of Clinical Pharmacology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, China
| | - Chen Zhou
- Research Division of Clinical Pharmacology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, China
| | - Xiao-Yan Zhang
- Department of Hematology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, China
| | - Miss Ye Shen
- Research Division of Clinical Pharmacology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, China
| | - Hongwen Zhang
- Research Division of Clinical Pharmacology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, China
| | - Yongqing Wang
- Research Division of Clinical Pharmacology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, China
| | - Luning Sun
- Research Division of Clinical Pharmacology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, China
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18
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Takeshima H, Yoshikawa N, Akizuki K, Hidaka T, Shimoda K, Ikeda R. Ursodeoxycholic acid markedly promotes the absorption of microemulsion-formulated cyclosporine A: A case report. J Clin Pharm Ther 2021; 47:260-262. [PMID: 34288009 DOI: 10.1111/jcpt.13496] [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: 03/24/2021] [Revised: 06/28/2021] [Accepted: 07/13/2021] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Cyclosporine A (CyA) causes intrahepatic biliary stasis via inhibition of bile acid excretion through the bile salt export pump. We report a case of a patient in whom ursodeoxycholic acid (UDCA) markedly promoted the absorption of microemulsion-formulated CyA. CASE SUMMARY The patient was a 22-year-old Japanese man diagnosed with stage 3 aplastic anaemia. He was treated with CyA, and 2 h post-dose (C2) was increased by UDCA. WHAT IS NEW AND CONCLUSION A remarkable interaction was observed between CyA and UDCA. This is a valuable finding for improving the treatment strategies for haematological disorders.
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Affiliation(s)
- Hidemi Takeshima
- Department of Pharmacy, University of Miyazaki Hospital, Miyazaki, Japan
| | - Naoki Yoshikawa
- Department of Pharmacy, University of Miyazaki Hospital, Miyazaki, Japan
| | - Keiichi Akizuki
- Department of Gastroenterology and Hematology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Tomonori Hidaka
- Department of Gastroenterology and Hematology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Kazuya Shimoda
- Department of Gastroenterology and Hematology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Ryuji Ikeda
- Department of Pharmacy, University of Miyazaki Hospital, Miyazaki, Japan
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19
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Jahan D, Peile E, Sheikh MA, Islam S, Parasnath S, Sharma P, Iskandar K, Dhingra S, Charan J, Hardcastle TC, Samad N, Chowdhury TS, Dutta S, Haque M. Is it time to reconsider prophylactic antimicrobial use for hematopoietic stem cell transplantation? a narrative review of antimicrobials in stem cell transplantation. Expert Rev Anti Infect Ther 2021; 19:1259-1280. [PMID: 33711240 DOI: 10.1080/14787210.2021.1902304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Hematopoietic Stem Cell Transplantation (HSCT) is a life-saving procedure for multiple types of hematological cancer, autoimmune diseases, and genetic-linked metabolic diseases in humans. Recipients of HSCT transplant are at high risk of microbial infections that significantly correlate with the presence of graft-versus-host disease (GVHD) and the degree of immunosuppression. Infection in HSCT patients is a leading cause of life-threatening complications and mortality. AREAS COVERED This review covers issues pertinent to infection in the HSCT patient, including bacterial and viral infection; strategies to reduce GVHD; infection patterns; resistance and treatment options; adverse drug reactions to antimicrobials, problems of antimicrobial resistance; perturbation of the microbiome; the role of prebiotics, probiotics, and antimicrobial peptides. We highlight potential strategies to minimize the use of antimicrobials. EXPERT OPINION Measures to control infection and its transmission remain significant HSCT management policy and planning issues. Transplant centers need to consider carefully prophylactic use of antimicrobials for neutropenic patients. The judicious use of appropriate antimicrobials remains a crucial part of the treatment protocol. However, antimicrobials' adverse effects cause microbiome diversity and dysbiosis and have been shown to increase morbidity and mortality.
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Affiliation(s)
- Dilshad Jahan
- Department of Hematology, Asgar Ali Hospital, 111/1/A Distillery Road, Gandaria Beside Dhupkhola, Dhaka 1204, Bangladesh
| | - Ed Peile
- Department of Medical Education, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Salequl Islam
- Department of Microbiology, Jahangirnagar University, Savar, Dhaka-1342, Bangladesh
| | - Sharlene Parasnath
- Department of Clinical Hematology, Inkosi Albert Luthuli Central Hospital, 800 Vusi Mzimela Road, Cato Manor, Durban, South Africa
| | - Paras Sharma
- Department of Pharmacognosy, BVM College of Pharmacy, Gwalior, India
| | - Katia Iskandar
- Lebanese University, School of Pharmacy, Beirut, Lebanon.,INSPECT-LB: Institute National de Sante Publique, Epidemiologie Clinique et Toxicologie, Beirut, Lebanon.,Universite Paul Sabatier UT3, INSERM, UMR1027, Toulouse, France
| | - Sameer Dhingra
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), Hajipur, Bihar, India
| | - Jaykaran Charan
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Timothy Craig Hardcastle
- Trauma Service, Inkosi Albert Luthuli Central Hospital, Mayville, South Africa.,Department of Surgery, Nelson R Mandela School of Clinical Medicine, UKZN, South Africa
| | - Nandeeta Samad
- Department of Public Health, North South University, Bangladesh
| | | | - Siddhartha Dutta
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Mainul Haque
- The Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kem Perdana Sungai Besi, Kuala Lumpur, Malaysia
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Reis J, Coelho A, Lopes V, Gandara J, Cunha Velho G, Selores M. Painless rash in a transplant patient. Transpl Infect Dis 2021; 23:e13613. [PMID: 33835649 DOI: 10.1111/tid.13613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 03/17/2021] [Accepted: 03/21/2021] [Indexed: 11/26/2022]
Abstract
Dermatophytes are common keratinophilic fungi responsible for superficial skin infections. Deep dermatophytosis is a rare form of invasive skin infection described in immunocompromised patients. We report the case of a 65-year-old man with a history of an orthotopic liver transplant for hepatocarcinoma 6 months earlier, who presented with small painless erythematous papules in lower limbs, some of which were umbilicated. Skin biopsy showed an intense non-necrotizing granulomatous reaction in the dermis around fungal structures. Trichophyton rubrum was identified as the causal agent through culture and internal transcribed spacer sequencing.
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Affiliation(s)
- Joel Reis
- Dermatology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - André Coelho
- Pathology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Virgínia Lopes
- Microbiology Laboratory, Pathology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Judit Gandara
- Liver and Pancreatic Transplant Unit, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Glória Cunha Velho
- Dermatology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Manuela Selores
- Dermatology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
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21
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Johnston JP, Cohen EA, Casal GH, Asch WS, Reardon DP. Impact of Low-Dose Fluconazole on Tacrolimus Dosing in Renal Transplant. J Pharm Pract 2021; 35:701-706. [PMID: 33759619 DOI: 10.1177/08971900211000702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The interaction between azole antifungal therapy and immunosuppressant tacrolimus (TAC) is a barrier to use. OBJECTIVE This study quantified the drug interaction between low-dose fluconazole (LDF) and TAC to determine the appropriate TAC dose adjustment when used concurrently in renal transplant recipients. METHODS We conducted a single-center retrospective chart review of renal transplant patients >18 years who received LDF or nystatin (NYS), and TAC. The primary outcome was the difference in tacrolimus total daily dose (TAC TDD) for LDF versus NYS groups. Secondary outcomes included days with supratherapeutic, therapeutic and subtherapeutic tacrolimus levels, time to therapeutic level, incidence of adverse drug reactions and graft rejection. RESULTS We evaluated 94 patients and included 81. Low-dose fluconazole received a greater TAC TDD prior to post-operative day (POD) 10 (10.5 ± 4.7 mg vs. 7.1 ± 4.5 mg, p < 0.001), but a decreased TAC TDD POD 10 - 30 (8.6 ± 2.2 mg vs. 9.8 ± 0.8 mg, p < 0.001) and following LDF discontinuation (6.9 ± 0.1 mg vs. 9.0 ± 0.4 mg, p < 0.001). Low-dose fluconazole had more patient-days with supratherapeutic (17.9 ± 7.0 vs. 13.9 ± 8.5; p = 0.02) but fewer with subtherapeutic (6.7 ± 5.7 vs. 12.9 ± 7.2; p < 0.01) TAC levels. There was no difference in patient-days with therapeutic TAC levels (15.9 ± 5.8 vs. 14.4 ± 6.6, p = 0.28), meanwhile LDF required less patient-days to therapeutic TAC level (7.1 ± 2.7 vs. 11.5 ± 7.7; p < 0.01). There was no difference in adverse drug reactions between groups and no incidence of graft rejection. CONCLUSION A 20% reduction in TAC TDD is warranted in renal transplant patients when used concomitantly with LDF to achieve therapeutic levels.
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Affiliation(s)
- Jackie P Johnston
- Department of Pharmacy Practice and Administration, 15484Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | - Elizabeth A Cohen
- Department of Transplant Surgery, 25047Yale-New Haven Hospital, New Haven, CT, USA
| | - Gianna H Casal
- Department of Pharmacy, 25047Yale New Haven Hospital, New Haven, CT, USA
| | - William S Asch
- Yale-New Haven Transplant Center, 25047Yale-New Haven Hospital, New Haven, CT, USA
| | - David P Reardon
- Pharmacy Networks, Vizient Pharmacy Member Services, 26560Vizient Inc, Irving, TX, USA
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22
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Whitmore TJ, Yaw M, Lavender M, Musk M, Boan P, Wrobel J. A novel highly bio-available itraconazole formulation (SUBA®-Itraconazole) for anti-fungal prophylaxis in lung transplant recipients. Transpl Infect Dis 2021; 23:e13587. [PMID: 33590676 DOI: 10.1111/tid.13587] [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: 11/11/2020] [Revised: 01/28/2021] [Accepted: 02/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antifungal prophylaxis remains a mainstay of lung transplantation, given invasive fungal infection is a common and serious complication after lung transplantation. Choice of systemic agent to prevent invasive fungal infection varies between centers and funding of agents remains challenging. Our center has recently changed from posaconazole to a highly bioavailable formulation of itraconazole (SUBA®-itraconazole) at substantially reduced cost, but safety and toxicity require further assessment. A retrospective study of lung transplant patients receiving systemic antifungal prophylaxis from December 2016 through December 2019 following change from posaconazole to itraconazole as standard practice. 150 patients with lung transplants were managed in this time period, with 88 (59%) receiving at least 1 mold-active triazole during the study period. 48 (58%) of these patients received SUBA®-itraconazole; 68 (82%) received posaconazole and 10 (12%) received voriconazole. The average cost per patient during the study period was significantly lower on SUBA®-itraconazole (mean $1548/patient/6 month course) than posaconazole (mean $16 921.35/patient/6 month course). Target trough concentrations for prophylaxis of itraconazole > 0.5 mg/L and posaconazole > 0.7 mg/L were achieved on empiric dosing in 49% and 68% respectively. Overall trough itraconazole (0.50 vs 1.12 mg/L, P < .001) and posaconazole (1.37 vs 2.10 mg/L P < .001) concentrations were significantly lower in patients with cystic fibrosis. Calcineurin inhibitor dose changes on introduction or cessation were similar for SUBA®-itraconazole and posaconazole. Breakthrough invasive fungal infection and toxicity were rare. SUBA®-itraconazole is well-tolerated, associated with rare breakthrough invasive fungal infection, and lower cost. Prospective studies following general introduction are required to determine long-term safety, tolerability, and efficacy.
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Affiliation(s)
- Timothy James Whitmore
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, WA, Australia.,Department of Microbiology, PathWest Laboratory Medicine WA, Perth, WA, Australia.,Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Meow Yaw
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Melanie Lavender
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Michael Musk
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Peter Boan
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, WA, Australia.,Department of Microbiology, PathWest Laboratory Medicine WA, Perth, WA, Australia
| | - Jeremy Wrobel
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia.,School of Medicine, University of Notre Dame Australia, Fremantle, WA, Australia
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23
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Bhagat V, Pandit RA, Ambapurkar S, Sengar M, Kulkarni AP. Drug Interactions between Antimicrobial and Immunosuppressive Agents in Solid Organ Transplant Recipients. Indian J Crit Care Med 2021; 25:67-76. [PMID: 33603305 PMCID: PMC7874296 DOI: 10.5005/jp-journals-10071-23439] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The number of allogeneic solid organ and bone marrow transplants is increasing all over the world. To prevent transplant rejection and treat acute rejection of transplant, immunosuppressant drugs are used. The outcomes of solid organ transplants have dramatically improved over last 30 years, due to availability of multiple immunosuppressive agents, with varied mechanisms of action. The use of intense immunosuppression makes the individual having undergone solid organ transplant at the risk of several serious infections, which may prove fatal. To prevent and treat these infections (when they occur), patients are often given antimicrobial prophylaxis and therapy. The use of antimicrobials can interfere with the metabolism of the immunosuppressants, and may put the patient at risk of developing severe adverse effects due to unwanted increase or decrease in the serum levels of immunosuppressive agents. Knowledge of these interactions is essential for successful management of solid organ transplant patients. We therefore decided to review the literature and present the interactions that commonly occur between these two life-saving groups of drugs. How to cite this article: Bhagat V, Pandit RA, Ambapurkar S, Sengar M, Kulkarni AP. Drug Interactions between Antimicrobial and Immunosuppressive Agents in Solid Organ Transplant Recipients. Indian J Crit Care Med 2021;25(1):67–76.
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Affiliation(s)
- Vikas Bhagat
- Department of Critical Care Medicine, Aster Hospital, Dubai, UAE
| | | | | | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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24
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Vincristine-Induced Peripheral Neuropathy in Pediatric Oncology: A Randomized Controlled Trial Comparing Push Injections with One-Hour Infusions (The VINCA Trial). Cancers (Basel) 2020; 12:cancers12123745. [PMID: 33322788 PMCID: PMC7764775 DOI: 10.3390/cancers12123745] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/29/2020] [Accepted: 12/08/2020] [Indexed: 01/19/2023] Open
Abstract
Vincristine (VCR) is a frequently used chemotherapeutic agent. However, it can lead to VCR-induced peripheral neuropathy (VIPN). In this study we investigated if one-hour infusions of VCR instead of push-injections reduces VIPN in pediatric oncology patients. We conducted a multicenter randomized controlled trial in which participants received all VCR administrations through push injections or one-hour infusions. VIPN was measured at baseline and 1-5 times during treatment using Common Terminology Criteria of Adverse Events (CTCAE) and pediatric-modified Total Neuropathy Score. Moreover, data on co-medication, such as azole antifungals, were collected. Overall, results showed no effect of administration duration on total CTCAE score or ped-mTNS score. However, total CTCAE score was significantly lower in patients receiving one-hour infusions concurrently treated with azole antifungal therapy (β = -1.58; p = 0.04). In conclusion, generally VCR administration through one-hour infusions does not lead to less VIPN compared to VCR push injections in pediatric oncology patients. However, one-hour infusions lead to less severe VIPN compared to push-injections when azole therapy is administered concurrently with VCR. These results indicate that in children treated with VCR and requiring concurrent azole therapy, one-hour infusions might be beneficial over push injections, although larger trials are needed to confirm this association.
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25
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Cairoli R, Ferrara F, Girmenia C, Luppi M, Pea F, Specchia G, Venditti A. Management of patients with acute myeloid leukemia undergoing therapy with midostaurin: a focus on antifungal prophylaxis. Hematol Oncol 2020. [DOI: 10.1002/hon.2788] [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]
Affiliation(s)
- Roberto Cairoli
- Department of Hematology Niguarda Cancer Center ASST Grande Ospedale Metropolitano Niguarda Milan Italy
| | | | - Corrado Girmenia
- Department of Hematology, Oncology and Dermatology Azienda Policlinico Umberto I Sapienza University Rome Italy
| | - Mario Luppi
- Department of Medical and Surgical Sciences Section of Hematology Azienda Ospedaliero‐Universitaria Policlinico University of Modena and Reggio Emilia Modena Italy
| | - Federico Pea
- Department of Medicine University of Udine Udine Italy
- Institute of Clinical Pharmacology Santa Maria della Misericordia University Hospital of Udine ASUIUD Udine Italy
| | - Giorgina Specchia
- Department of Emergency and Organ Transplantation Hematology Section University of Bari Bari Italy
| | - Adriano Venditti
- Department of Biomedicine and Prevention Fondazione Policlinico Tor Vergata University of Rome “Tor Vergata” Rome Italy
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26
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Michallet M, Sobh M, Deray G, Gangneux JP, Pigneux A, Larrey D, Ribaud P, Mira JP, Nivoix Y, Yakoub-Agha I, Timsit JF, Alfandari S, Herbrecht R. Antifungal Stewardship in Hematology: Reflection of a Multidisciplinary Group of Experts. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 21:35-45. [PMID: 32958431 DOI: 10.1016/j.clml.2020.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/06/2020] [Accepted: 08/10/2020] [Indexed: 02/07/2023]
Abstract
We have presented a practical guide developed by a working group of experts in infectious diseases and hematology to summarize the different recommendations issued by the different international groups on antifungal agents used for hematology patients. In addition, a working group of experts in the domains of nephrology, hepatology, and drug interactions have reported their different recommendations when administering antifungal agents, including dose adjustments, monitoring, and management of their side effects. This guide will enable prescribers to have a document available that will allow for better and optimal use of antifungal agents for hematology patients with consideration of the toxicity and interactions adjusted to each indication.
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Affiliation(s)
- Mauricette Michallet
- Hematology Department, Centre de lutte contre le cancer Léon Bérard, Lyon, France.
| | - Mohamad Sobh
- Hematology Department, Centre de lutte contre le cancer Léon Bérard, Lyon, France
| | - Gilbert Deray
- Nephrology Department, Pitié-Salpêtrière University Hospital, Paris, France
| | | | - Arnaud Pigneux
- Department of Hematology and Cellular Therapy, University Hospital of Bordeaux, Bordeaux, France
| | | | - Patricia Ribaud
- Quality Unit, Pôle Prébloc, Saint-Louis and Lariboisière Hospital Group, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean-Paul Mira
- Intensive Care Unit, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Yasmine Nivoix
- Pharmacy Department, Strasbourg University Hospitals, Strasbourg, France
| | | | - Jean-François Timsit
- Medical Intensive Care Unit, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Serge Alfandari
- Intensive Care and Infectious Disease Unit, Tourcoing Hospital, University of Lille, Tourcoing, France
| | - Raoul Herbrecht
- Department of Oncology and Hematology, Strasbourg University Hospitals and Strasbourg University, Strasbourg, France
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27
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Interpretation and Understanding of Clinical Drug Interactions Between Azoles and Immunosuppressants in Solid Organ Transplant Recipients. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00404-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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28
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Clinical Factors Affecting the Dose Conversion Ratio from Intravenous to Oral Tacrolimus Formulation among Pediatric Hematopoietic Stem Cell Transplantation Recipients. Ther Drug Monit 2020; 42:803-810. [PMID: 32732549 DOI: 10.1097/ftd.0000000000000793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Tacrolimus is converted from intravenous to oral formulation for the prophylaxis of graft-versus-host disease when patients can tolerate oral intake and graft-versus-host disease is under control. Oral tacrolimus formulation presents poor bioavailability with intraindividual and interindividual variations; however, some factors affecting its blood concentration among pediatric hematopoietic stem cell transplantation (HCT) recipients are still unclear. This study aimed to identify the clinical factors affecting tacrolimus blood concentrations after switching its formulation. METHODS Changes in the blood concentration/dose ratio (C/D) of tacrolimus in pediatric HCT recipients were analyzed after the switching of tacrolimus from intravenous to oral formulation. Clinical records of 57 pediatric patients who underwent allogenic HCT from January 2006 to April 2019 in our institute were retrospectively reviewed. The C/D of tacrolimus before discontinuation of intravenous infusion (C/Div) was compared with the tacrolimus trough level within 10 days after the initiation of oral administration (C/Dpo). Multiple linear regression analysis was performed to identify factors affecting (C/Dpo)/(C/Div). RESULTS The constant coefficient of (C/Dpo)/(C/Div) was 0.1692 [95% confidence interval (CI), 0.137-0.2011]. The concomitant use of voriconazole or itraconazole and female sex were significant variables with a beta coefficient of 0.0974 (95% CI, 0.062-0.133) and -0.0373 (95% CI, -0.072 to -0.002), respectively. CONCLUSIONS After switching of tacrolimus formulation, pediatric HCT recipients might need oral tacrolimus dose that is 5-6 and 3.5-4.5 times the intravenous dose to maintain tacrolimus blood concentrations and area under the concentration-time curve, respectively. With the concomitant use of voriconazole or itraconazole, an oral tacrolimus dose of 4-5 times the intravenous dose seemed appropriate to maintain blood tacrolimus concentration.
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29
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Wang Q, Ma JX, Li BH, Wang XQ, Hu Q, Zhang MX. [Clinical analysis of 67 cases of pure red cell aplastic anemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:506-510. [PMID: 32654466 PMCID: PMC7378292 DOI: 10.3760/cma.j.issn.0253-2727.2020.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Indexed: 11/17/2022]
Abstract
Objective: To investigate secondary factors, laboratory features, treatment options, and prognosis of pure red cell aplastic anemia (PRCA) . Methods: This was a multicenter retrospective clinical study. Patients aged above 18 years newly diagnosed with PRCA between June 1, 2010, and June 1, 2019, were recruited as the main study object. A comparative analysis of remission rate and overall survival rate was made according to different treatment schemes adopted by patients and different drug reduction rates. Results: A total of 67 patients with PRCA were included in this study and the secondary PRCA group accounted for 44.8% (30/67) . The most common secondary factors were thymoma (n=10) and T-cell large lymphocytic leukemia (T-LGLL) (n=6) . The overall response rate of PRCA was 85.7% and the 3-year overall survival rate of PRCA was (74.3±7.5) %. The remission rate of cyclosporine A alone was slightly higher than that of oral glucocorticoid alone or combined with glucocorticoid[90.0% (36/40) vs 75.0% (12/16) , P=0.147]. After patients applied with cyclosporine A treatment reached CR/PR and remained stable for 3-6 months, the dose of cyclosporine A was reduced by 25 mg each time. The cyclosporine A reduction interval of a 25 mg/d reduction in more than 1 month significantly prolonged the median disease-free survival compared with a 25 mg/d reduction in less than 1 month [not reached vs 15 (95% CI 7-23) months, P<0.001]. There were 62.5% (10/16) of patients who responded to the initial or incremental treatment regimen after relapse. Conclusion: PRCA has features of various secondary factors, high overall survival rate, and high remission rate. Treatment with cyclosporine A alone is preferred, and cyclosporine A should be slowly tapered to reduce the risk of later relapse after it takes effect and patients reach a steady state.
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Affiliation(s)
- Q Wang
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - J X Ma
- Department of Hematology, Huadong Hospital, Fudan University, Shanghai 200040, China
| | - B H Li
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - X Q Wang
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Q Hu
- Department of Hematology, Shanghai Hospital of Traditional Chinese Medicine, Shanghai 200071, China
| | - M X Zhang
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai 200040, China
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Beck KR, Telisman L, van Koppen CJ, Thompson GR, Odermatt A. Molecular mechanisms of posaconazole- and itraconazole-induced pseudohyperaldosteronism and assessment of other systemically used azole antifungals. J Steroid Biochem Mol Biol 2020; 199:105605. [PMID: 31982514 DOI: 10.1016/j.jsbmb.2020.105605] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 12/27/2022]
Abstract
Recent reports described cases of severe hypertension and hypokalemia accompanied by low renin and aldosterone levels during antifungal therapy with posaconazole and itraconazole. These conditions represent characteristics of secondary endocrine hypertension caused by mineralocorticoid excess. Different mechanisms can cause mineralocorticoid excess, including inhibition of the adrenal steroidogenic enzymes CYP17A1 and CYP11B1, inhibition of the peripheral cortisol oxidizing enzyme 11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2) or direct activation of the mineralocorticoid receptor (MR). Compared to previous experiments revealing a threefold more potent inhibition of 11β-HSD2 by itraconazole than with posaconazole, the current study found sevenfold stronger CYP11B1 inhibition by posaconazole over itraconazole. Both compounds most potently inhibited CYP11B2. The major pharmacologically active itraconazole metabolite hydroxyitraconazole (OHI) resembled the effects of itraconazole but was considerably less active. Molecular modeling calculations assessed the binding of posaconazole, itraconazole and OHI to 11β-HSD2 and the relevant CYP enzymes, and predicted important interactions not formed by the other systemically used azole antifungals, thus providing an initial explanation for the observed inhibitory activities. Together with available clinical observations, the presented data suggest that itraconazole primarily causes pseudohyperaldosteronism through cortisol-induced MR activation due to 11β-HSD2 inhibition, and posaconazole by CYP11B1 inhibition and accumulation of the mineralocorticoids 11-deoxycorticosterone and 11-deoxycortisol because of hypothalamus-pituitary-adrenal axis (HPA) feedback activation. Therapeutic drug monitoring and introduction of upper plasma target levels may help preventing the occurrence of drug-induced hypertension and hypokalemia. Furthermore, the systemically used azole antifungals voriconazole, isavuconazole and fluconazole did not affect any of the mineralocorticoid excess targets, offering alternative therapeutic options.
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Affiliation(s)
- Katharina R Beck
- Swiss Centre for Applied Human Toxicology (SCAHT) and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland.
| | - Lucija Telisman
- Swiss Centre for Applied Human Toxicology (SCAHT) and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland.
| | - Chris J van Koppen
- Department of Pharmaceutical and Medicinal Chemistry, Universitätscampus C2.3, 66123 Saarbrücken, Germany.
| | - George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases, University of California Davis Medical Center, Davis, California, USA.
| | - Alex Odermatt
- Swiss Centre for Applied Human Toxicology (SCAHT) and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland.
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Zgheib NK, Alameddine R, Massoud R, Nasr R, Zahreddine A, El Cheikh J, Mahfouz R, Bazarbachi A. The role of candidate genetic polymorphisms in the interaction between voriconazole and cyclosporine in patients undergoing allogeneic hematopoietic cell transplantation: An explorative study. Curr Res Transl Med 2020; 68:51-58. [PMID: 32094096 DOI: 10.1016/j.retram.2020.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/04/2020] [Accepted: 02/12/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To evaluate polymorphisms in genes of drug metabolizing enzymes and transporters involved in cyclosporine and/or voriconazole disposition among patients undergoing allogeneic hematopoietic cell transplantation (allo-HCT). METHODS DNA from forty patients was genotyped using the DMETPlus array. The average ratio of cyclosporine concentration/dose (C/D in (ng/mL)/(mg/kg)) per participant's weight was computed using available trough levels and daily doses. RESULTS The C/D cyclosporine ratio was significantly higher when it was administered with voriconazole as compared to when it was administered alone: median: 116.75 vs. 25.40 (ng/mL)/(mg/kg) with and without voriconazole respectively, (P < 0.001). There was also a significant association between the C/D cyclosporine ratio combined with voriconazole and the ABCB1 2677 G > T > A (rs2032582) genetic polymorphism (P = 0.05). In parallel, ABCB1 variant allele carriers had higher creatinine in combination therapy with a median creatinine (mg/dL) of 0.74 vs. 0.56 for variant allele carriers vs. reference; P = 0.003. Interestingly, CYP2C9, CYP2C19, and CYP3A5 extensive metabolizers tended to be associated with lower cyclosporine C/D ratio when combined with voriconazole, but the results were not statistically significant. CONCLUSION To the best of our knowledge, this is the first pharmacogenetic study on the interaction between voriconazole and cyclosporine in patients undergoing allo-HCT. Results suggest that the ABCB1 2677 G > T > A genetic polymorphism plays a role in this interaction with cyclosporine related nephrotoxicity. Pre-emptive genotyping for this genetic variant may be warranted for cyclosporine dose optimization. Larger studies are needed to potentially show significant associations with more candidate genes such as CYP3A4/5, CYP2C9, and CYP2C19, among others.
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Affiliation(s)
- Nathalie Khoueiry Zgheib
- Department of Pharmacology and Toxicology, American University of Beirut, Faculty of Medicine, Beirut, Lebanon
| | - Raafat Alameddine
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut, Faculty of Medicine, Beirut, Lebanon
| | - Radwan Massoud
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut, Faculty of Medicine, Beirut, Lebanon
| | - Rihab Nasr
- Department of Anatomy, Cell Biology and Physiology, American University of Beirut, Faculty of Medicine, Beirut, Lebanon
| | - Ammar Zahreddine
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut, Faculty of Medicine, Beirut, Lebanon
| | - Jean El Cheikh
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut, Faculty of Medicine, Beirut, Lebanon
| | - Rami Mahfouz
- Department of Pathology and Laboratory Medicine, American University of Beirut, Faculty of Medicine, Beirut, Lebanon
| | - Ali Bazarbachi
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut, Faculty of Medicine, Beirut, Lebanon.
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Hikasa S, Shimabukuro S, Osugi Y, Ikegame K, Kaida K, Fukunaga K, Higami T, Tada M, Tanaka K, Yanai M, Kimura T. Tacrolimus Concentration after Letermovir Initiation in Hematopoietic Stem Cell Transplantation Recipients Receiving Voriconazole: A Retrospective, Observational Study. Int J Med Sci 2020; 17:859-864. [PMID: 32308538 PMCID: PMC7163365 DOI: 10.7150/ijms.42011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/21/2020] [Indexed: 12/11/2022] Open
Abstract
Letermovir (LMV) is a new antiviral drug used to prevent cytomegalovirus infection in hematopoietic stem cell transplantation (HSCT) recipients. It has been reported to increase tacrolimus (TAC) exposure and decrease voriconazole (VRCZ) exposure in healthy participants. However, VRCZ inhibits the metabolism of TAC. Thus, the effects of LMV on TAC exposure in patients receiving VRCZ are unknown. This retrospective, observational, single-center study was conducted between May 2018 and April 2019. The TAC concentration/dose (C/D) ratio, VRCZ concentration, and VRCZ C/D ratio for 7 days before and for the first and second 7-day periods after the initiation of LMV administration were evaluated. Fourteen HSCT recipients receiving VRCZ were enrolled. There was no significant difference in the TAC C/D ratio for 7 days before and for the first and second 7-day periods after initiating LMV administration (median: 866 [IQR: 653-953], 842 [IQR: 636-1031], and 906 [IQR: 824-1210] [ng/mL]/[mg/kg], respectively). In contrast, the VRCZ C/D ratio and concentration for the first and second 7-day periods after LMV initiation were significantly lower than those before initiating LMV administration (mean 1.11 ± 0.07, 0.12 ± 0.08, and 0.22 ± 0.12 [μg/mL]/[mg/kg] and 0.7 ± 0.5, 0.8 ± 0.5, and 1.3 ± 0.7 μg/mL, respectively; n = 12). This can be explained by the increase in TAC concentration caused by CYP3A4 inhibition due to LMV and by the decrease in TAC concentration ascribed to the decrease in VRCZ concentration by CYP2C19 induction due to LMV. These results suggest that it is unnecessary to adjust the dose of TAC based on LMV initiation; however, it is necessary to adjust the dose of TAC based on conventional TAC concentration measurements.
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Affiliation(s)
- Shinichi Hikasa
- Department of Pharmacy, Hyogo College of Medicine College Hospital, Nishinomiya, Hyogo 663-8501, Japan
| | - Shota Shimabukuro
- Department of Pharmacy, Hyogo College of Medicine College Hospital, Nishinomiya, Hyogo 663-8501, Japan
| | - Yuko Osugi
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Kazuhiro Ikegame
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Katsuji Kaida
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Keiko Fukunaga
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Tomoko Higami
- Department of Pharmacy, Hyogo College of Medicine College Hospital, Nishinomiya, Hyogo 663-8501, Japan
| | - Masami Tada
- Department of Pharmacy, Hyogo College of Medicine College Hospital, Nishinomiya, Hyogo 663-8501, Japan
| | - Kuniyoshi Tanaka
- Department of Pharmacy, Hyogo College of Medicine College Hospital, Nishinomiya, Hyogo 663-8501, Japan
| | - Mina Yanai
- Department of Pharmacy, Hyogo College of Medicine College Hospital, Nishinomiya, Hyogo 663-8501, Japan
| | - Takeshi Kimura
- Department of Pharmacy, Hyogo College of Medicine College Hospital, Nishinomiya, Hyogo 663-8501, Japan
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Poleksic A, Xie L. Database of adverse events associated with drugs and drug combinations. Sci Rep 2019; 9:20025. [PMID: 31882773 PMCID: PMC6934730 DOI: 10.1038/s41598-019-56525-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 12/13/2019] [Indexed: 12/26/2022] Open
Abstract
Due to the aging world population and increasing trend in clinical practice to treat patients with multiple drugs, adverse events (AEs) are becoming a major challenge in drug discovery and public health. In particular, identifying AEs caused by drug combinations remains a challenging task. Clinical trials typically focus on individual drugs rather than drug combinations and animal models are unreliable. An added difficulty is the combinatorial explosion in the number of possible combinations that can be made using the increasingly large set of FDA approved chemicals. We present a statistical and computational technique for identifying AEs caused by two-drug combinations. Taking advantage of the large and increasing data deposited in FDA’s postmarketing reports, we demonstrate that the task of predicting AEs for 2-drug combinations is amenable to the Likelihood Ratio Test (LRT). Our pAERS database constructed with LRT contains almost 77 thousand associations between pairs of drugs and corresponding AEs caused solely by drug-drug interactions (DDIs). The DDIs stored in pAERS complement the existing data sets. Due to our stringent statistical test, we expect many of the associations in pAERS to be unrecorded or poorly documented in the literature.
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Affiliation(s)
- Aleksandar Poleksic
- Department of Computer Science, University of Northern Iowa, Cedar Falls, Iowa, 50614, USA.
| | - Lei Xie
- Department of Computer Science, Hunter College, The City University of New York, New York, New York, 10065, USA. .,Ph.D. Program in Computer Science, Biochemistry and Biology, The Graduate Center, The City University of New York, New York, New York, 10065, USA.
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Uno T, Wada K, Hosomi K, Matsuda S, Ikura MM, Takenaka H, Terakawa N, Oita A, Yokoyama S, Kawase A, Takada M. Drug interactions between tacrolimus and clotrimazole troche: a data mining approach followed by a pharmacokinetic study. Eur J Clin Pharmacol 2019; 76:117-125. [PMID: 31654150 DOI: 10.1007/s00228-019-02770-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 09/24/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE This study investigated the effects of clotrimazole troche on the risk of transplant rejection and the pharmacokinetics of tacrolimus. METHODS The data mining approach was used to investigate whether the use of clotrimazole increased the risk of transplant rejection in patients receiving tacrolimus therapy. Patient data were acquired from the US Food and Drug Administration's Adverse Event Reporting System (FAERS) from the first quarter of 2004 to the end of 2017. Next, we retrospectively investigated the effect of clotrimazole troche on tacrolimus pharmacokinetics in seven patients who underwent heart transplantation between March and December 2017. RESULTS The FAERS subset data indicated a significant association between transplant rejection and tacrolimus with clotrimazole [reporting odds ratio 1.92, 95% two-sided confidence interval (95% CI) 1.43-2.58, information component 0.81, 95% CI 0.40-1.23]. The pharmacokinetic study demonstrated a significant correlation between trough concentration (C0) and area under the concentration-time curve of tacrolimus after discontinuation of clotrimazole (R2 = 0.60, P < 0.05) but not before its discontinuation. Furthermore, the median clearance/bioavailability of tacrolimus after discontinuation of clotrimazole was 2.2-fold greater than that before its discontinuation (0.27 vs. 0.59 L/h/kg, P < 0.05). The median C0 decreased from 10.7 ng/mL on the day after discontinuation of clotrimazole to 6.5 ng/mL at 1 day and 5.3 ng/mL at 2 days after its discontinuation. CONCLUSION Immediate dose adjustments of tacrolimus may be beneficial to avoid transplant rejection when clotrimazole troche is added or discontinued.
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Affiliation(s)
- Takaya Uno
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, Higashi-osaka, Japan
- Division of Cardiovascular Drugs, Therapy, Kindai University Graduate School of Pharmacy, Higashi-osaka, Japan
| | - Kyoichi Wada
- Education and Research Center for Clinical Pharmacy, Osaka University of Pharmaceutical Sciences, Takatsuki, Japan
| | - Kouichi Hosomi
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, Higashi-osaka, Japan
- Division of Cardiovascular Drugs, Therapy, Kindai University Graduate School of Pharmacy, Higashi-osaka, Japan
| | - Sachi Matsuda
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Megumi Morii Ikura
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiromi Takenaka
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nobue Terakawa
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akira Oita
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Yokoyama
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, Higashi-osaka, Japan
- Division of Cardiovascular Drugs, Therapy, Kindai University Graduate School of Pharmacy, Higashi-osaka, Japan
| | - Atsushi Kawase
- Department of Pharmacy, Faculty of Pharmacy, Kindai University, Higashi-osaka, Japan
| | - Mitsutaka Takada
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, Higashi-osaka, Japan.
- Division of Cardiovascular Drugs, Therapy, Kindai University Graduate School of Pharmacy, Higashi-osaka, Japan.
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Abstract
Introduction: Graft-versus-host disease (GVHD) is the most common complication of hematopoietic stem cell transplantation (HSCT); therefore, the prevention of GVHD is important for a successful treatment. Tacrolimus (Tac), a calcineurin inhibitor, has been widely used for the prophylaxis of GVHD in HSCT recipients. Areas covered: This review introduces phase II/III of clinical trials related with Tac's roles in the prevention of GVHD in HSCT. Furthermore, we discuss the normal ranges of Tac concentrations, pharmacogenetics, and drug interactions of Tac, as well as its side effects in adult HSCT recipients. Expert opinion: A series of studies has established the efficacy and safety of Tac alone or in combination with other agents in HSCT. However, successful administration of Tac is complicated by its narrow therapeutic window, inter-patient pharmacokinetic variability, and a spectrum of undesirable side effects. It is necessary to maintain concentrations of Tac within the desired ranges for GVHD prophylaxis. Moreover, various factors contribute to significant variability in Tac pharmacokinetics, including drug interactions and genomic variation.
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Affiliation(s)
- Yuan Gao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Soochow University , Suzhou , China
| | - Jingjing Ma
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Soochow University , Suzhou , China
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Thompson GR, Beck KR, Patt M, Kratschmar DV, Odermatt A. Posaconazole-Induced Hypertension Due to Inhibition of 11 β-Hydroxylase and 11 β-Hydroxysteroid Dehydrogenase 2. J Endocr Soc 2019; 3:1361-1366. [PMID: 31286100 PMCID: PMC6608555 DOI: 10.1210/js.2019-00189] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 05/31/2019] [Indexed: 11/29/2022] Open
Abstract
We describe two cases of hypertension and hypokalemia due to mineralocorticoid excess caused by posaconazole treatment of coccidioidomycosis and rhinocerebral mucormycosis infections, respectively. Clinical laboratory evaluations, including a comprehensive analysis of blood and urine steroid profiles, revealed low renin and aldosterone and indicated as the underlying mechanism primarily a block of 11β-hydroxylase activity in patient 1, whereas patient 2 displayed weaker 11β-hydroxylase but more pronounced 11β-hydroxysteroid dehydrogenase 2 inhibition. The results show that both previously suggested mechanisms must be considered and emphasize significant interindividual differences in the contribution of each enzyme to the observed mineralocorticoid excess phenotype. The mineralocorticoid symptoms of patient 1 resolved after replacement of posaconazole therapy by isavoconazole, and posaconazole dosage de-escalation ameliorated the effects in patient 2. By providing a thorough analysis of the patients’ blood and urine steroid metabolites, this report adds further evidence for two individually pronounced mechanisms of posaconazole-induced hypertension and hypokalemia. The elucidation of the factors responsible for the individual phenotype warrants further research.
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Affiliation(s)
- George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases and the Department of Medical Microbiology and Immunology, University of California Davis Medical Center, Davis, California
| | - Katharina R Beck
- Swiss Centre for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Melanie Patt
- Swiss Centre for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Denise V Kratschmar
- Swiss Centre for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Alex Odermatt
- Swiss Centre for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
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Impact of CYP3A5, POR, and CYP2C19 Polymorphisms on Trough Concentration to Dose Ratio of Tacrolimus in Allogeneic Hematopoietic Stem Cell Transplantation. Int J Mol Sci 2019; 20:ijms20102413. [PMID: 31096684 PMCID: PMC6566597 DOI: 10.3390/ijms20102413] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/09/2019] [Accepted: 05/14/2019] [Indexed: 12/16/2022] Open
Abstract
Single nucleotide polymorphisms in drug-metabolizing genes may affect tacrolimus pharmacokinetics. Here, we investigated the influence of genotypes of CYP3A5, CYP2C19, and POR on the concentration/dose (C/D) ratio of tacrolimus and episodes of acute graft-versus-host disease (GVHD) in Japanese recipients of allogeneic hematopoietic stem cell transplantation (HSCT). Thirty-six patients receiving the first HSCT using tacrolimus-based GVHD prophylaxis were enrolled with written informed consent. During continuous intravenous infusion, HSCT recipients carrying the CYP3A5*1 allele, particularly those with at least one POR*28 allele, had a significantly lower tacrolimus C/D ratio throughout all three post-HSCT weeks compared to that in recipients with POR*1/*1 (p < 0.05). The CYP3A5*3/*3 genotype and the concomitant use of voriconazole were independent predictors of an increased tacrolimus C/D ratio during the switch from continuous intravenous infusion to oral administration (p < 0.05). In recipients receiving concomitant administration of voriconazole, our results suggest an impact of not only CYP3A5 and CYP2C19 genotypes, but also plasma voriconazole concentration. Although switching from intravenous to oral administration at a ratio of 1:5 was seemingly appropriate in recipients with CYP3A5*1, a lower conversion ratio (1:2-3) was appropriate in recipients with CYP3A5*3/*3. Our results suggest that CYP3A5, POR, and CYP2C19 polymorphisms are useful biomarkers for individualized dosage adjustment of tacrolimus in HSCT recipients.
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Sparkes T, Lemonovich TL. Interactions between anti-infective agents and immunosuppressants-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13510. [PMID: 30817021 DOI: 10.1111/ctr.13510] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/12/2019] [Indexed: 01/14/2023]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation provide an update on potential drug-drug interactions between anti-infectives and immunosuppressants, which are most notable with calcineurin and mTOR inhibitors. Drug-drug interactions may occur through pharmacokinetic mechanisms leading to altered drug concentrations of either the anti-infective or immunosuppressive drug, or by pharmacodynamic interactions increasing or decreasing the efficacy or toxicity of the medications. Many of the significant pharmacokinetic interactions occur through inhibition or induction of the cytochrome 3A4 system by anti-infective agents leading to increased or decreased immunosuppressive agent levels, respectively. The membrane transporter P-glycoprotein is also often involved in drug interactions. Since the last iteration of these guidelines, multiple new hepatitis C virus direct-acting antivirals have become available for use in SOT recipients. Of these agents, some are substrates of cytochrome and drug transporter systems, while others inhibit these systems and may affect immunosuppressive agents. Due to the high risk for drug-drug interactions in the solid organ transplant population, practitioners must be aware of potential interactions and be vigilant in monitoring and adjusting drug dosing when appropriate.
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Affiliation(s)
- Tracy Sparkes
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland
| | - Tracy L Lemonovich
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
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Husain S, Camargo JF. Invasive Aspergillosis in solid-organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13544. [PMID: 30900296 DOI: 10.1111/ctr.13544] [Citation(s) in RCA: 147] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/18/2019] [Indexed: 12/13/2022]
Abstract
These updated AST-IDCOP guidelines provide information on epidemiology, diagnosis, and management of Aspergillus after organ transplantation. Aspergillus is the most common invasive mold infection in solid-organ transplant (SOT) recipients, and it is the most common invasive fungal infection among lung transplant recipients. Time from transplant to diagnosis of invasive aspergillosis (IA) is variable, but most cases present within the first year post-transplant, with shortest time to onset among liver and heart transplant recipients. The overall 12-week mortality of IA in SOT exceeds 20%; prognosis is worse among those with central nervous system involvement or disseminated disease. Bronchoalveolar lavage galactomannan is preferred for the diagnosis of IA in lung and non-lung transplant recipients, in combination with other diagnostic modalities (eg, chest CT scan, culture). Voriconazole remains the drug of choice to treat IA, with isavuconazole and lipid formulations of amphotericin B regarded as alternative agents. The role of combination antifungals for primary therapy of IA remains controversial. Either universal prophylaxis or preemptive therapy is recommended in lung transplant recipients, whereas targeted prophylaxis is favored in liver and heart transplant recipients. In these guidelines, we also discuss newer antifungals and diagnostic tests, antifungal susceptibility testing, and special patient populations.
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Affiliation(s)
- Shahid Husain
- Division of Infectious Diseases, Multi-Organ Transplant Unit, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jose F Camargo
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
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Jorgenson MR, Descourouez JL, Cardinale B, Lyu B, Astor BC, Garg N, Saddler CM, Smith JA, Mandelbrot DA. Risk of opportunistic infection in kidney transplant recipients with cytomegalovirus infection and associated outcomes. Transpl Infect Dis 2019; 21:e13080. [DOI: 10.1111/tid.13080] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/30/2019] [Accepted: 03/12/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Margaret R. Jorgenson
- Department of Pharmacy University of Wisconsin Hospital and Clinics Madison Wisconsin
| | | | | | - Beini Lyu
- Department of Medicine and Population Health Sciences University of Wisconsin‐Madison School of Medicine and Public Health Madison Wisconsin
| | - Brad C. Astor
- Department of Medicine and Population Health Sciences University of Wisconsin‐Madison School of Medicine and Public Health Madison Wisconsin
| | - Neetika Garg
- Department of Medicine University of Wisconsin‐Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics Madison Wisconsin
| | - Christopher M. Saddler
- Department of Medicine University of Wisconsin‐Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics Madison Wisconsin
| | - Jeannina A. Smith
- Department of Medicine University of Wisconsin‐Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics Madison Wisconsin
| | - Didier A. Mandelbrot
- Department of Medicine University of Wisconsin‐Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics Madison Wisconsin
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Baddley JW, Forrest GN. Cryptococcosis in solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13543. [PMID: 30900315 DOI: 10.1111/ctr.13543] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 02/15/2019] [Accepted: 03/15/2019] [Indexed: 02/06/2023]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of cryptococcosis in the pre- and post-transplant period. The current update now includes a discussion of cryptococcosis, which is the third most common invasive fungal infection in SOT recipients. Infection often occurs a year after transplantation; however, early infections occur and donor-derived infections have been described within 3 months after transplant. There are two main species that cause infection, Cryptococcus neoformans and C gattii. Clinical onset may be insidious, but headaches, fevers, and mental status changes should warrant diagnostic testing. The lateral flow cryptococcal antigen assay is now the preferred test from serum and cerebrospinal fluid due to its rapidity, accuracy, and cost. A lumbar puncture with measurement of opening pressure is recommended for patients with suspected or proven cryptococcosis. Lipid amphotericin B plus 5-flucytosine is used as initial treatment of meningitis, disseminated infection, and moderate-to-severe pulmonary infection, followed by fluconazole as consolidation therapy. Fluconazole is effective for mild-to-moderate pulmonary infection. Immunosuppression reduction as part of management may lead to immune reconstitution syndrome that may resemble active disease.
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Affiliation(s)
- John W Baddley
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
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Dermatological Disorders following Liver Transplantation: An Update. Can J Gastroenterol Hepatol 2019; 2019:9780952. [PMID: 31058114 PMCID: PMC6463607 DOI: 10.1155/2019/9780952] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 02/24/2019] [Accepted: 03/11/2019] [Indexed: 02/08/2023] Open
Abstract
Patients undergoing liver transplantation (LT) are at a high risk of dermatological complications compared to the general population as a result of long-term use of immunosuppressant. However, the risk is not as high as other solid organ transplantations (SOT), particularly for skin cancer. The liver is considered as an immune privileged organ since it has a low prevalence of humoral rejection in contrast to other SOT, and thus, LT requires a minimal amount of immunosuppressants compared to other SOT recipients. However, because of the large volume of the liver, patients with LT have higher donor lymphocytes that sometimes may trigger graft-versus-host-disease, yet it is rare. On the other hand, the vast majority of the nonspecific dermatological lesions linked with cirrhosis improve after removal of diseased liver or due to the immunosuppressant used after LT. Nevertheless, dermatological infections related to bacteria, viruses, and fungus after LT are not uncommon. Additionally, the incidence of IgE-mediated food allergies develops in 12.2% of LT patients and may present as life-threatening conditions such as urticaria and/or angioedema and hypersensitivity. Moreover, skin malignancies after LT are a matter of concern. Thus, posttransplant dermatological care should be provided to all LT patients for any suspicious dermatological lesions. Our goal is to give an outline of the dermatological manifestation associated with LT for the clinicians by collecting the published data from all archived case reports.
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Uno T, Wada K, Matsuda S, Terada Y, Oita A, Kawase A, Takada M. Impact of the CYP3A5*1 Allele on the Pharmacokinetics of Tacrolimus in Japanese Heart Transplant Patients. Eur J Drug Metab Pharmacokinet 2019; 43:665-673. [PMID: 29691732 DOI: 10.1007/s13318-018-0478-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVE Tacrolimus, a major immunosuppressant used after transplantation, is associated with large interindividual variation involving genetic polymorphisms in metabolic processes. A common variant of the cytochrome P450 (CYP) 3A5 gene, CYP3A5*3, affects blood concentrations of tacrolimus. However, tacrolimus pharmacokinetics at the early stage of transplantation have not been adequately studied in heart transplantation. We retrospectively examined the impact of the CYP3A5 genotype on tacrolimus pharmacokinetics at the early stage of heart transplantation. METHODS The tacrolimus pharmacokinetic profile was obtained from 65 patients during the first 5 weeks after heart transplantation. Differences in the patients' characteristics and tacrolimus pharmacokinetic parameters between the CYP3A5 expresser (*1/*1 or *1/*3 genotypes) and non-expresser (*3/*3 genotype) groups were assessed by the Chi-square test, Student's t test, or Mann-Whitney U test. RESULTS The CYP3A5 *1/*1, *1/*3, and *3/*3 genotypes were detected in 5, 22, and 38 patients, respectively. All patients started clotrimazole therapy approximately 1 week after starting tacrolimus. Apparent clearance and dose/weight to reach the target trough concentration (C0) were significantly higher in the expresser group than in the non-expresser group (0.32 vs. 0.19 L/h/kg, p = 0.0003; 0.052 vs. 0.034 mg/kg/day, p = 0.0002); there were no significant differences in the area under the concentration-time curve from 0 to 12 h (AUC0-12) and concentrations at any sampling time point between the two groups. CONCLUSION Similar concentration-time curves for tacrolimus were obtained in the expresser and non-expresser groups by dose adjustment based on therapeutic drug monitoring. These results demonstrate the importance of the CYP3A5 genotype in tacrolimus dose optimization based on therapeutic drug monitoring after heart transplantation.
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Affiliation(s)
- Takaya Uno
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
- Division of Clinical Drug Informatics, Faculty of Pharmacy, Kindai University, Higashi-osaka, Japan
- Division of Cardiovascular Drugs, Therapy, Kindai University Graduate School of Pharmacy, Higashi-osaka, Japan
| | - Kyoichi Wada
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
- Division of Cardiovascular Drugs, Therapy, Kindai University Graduate School of Pharmacy, Higashi-osaka, Japan
| | - Sachi Matsuda
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuka Terada
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akira Oita
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Atsushi Kawase
- Department of Pharmacy, Faculty of Pharmacy, Kindai University, Higashi-osaka, Japan
| | - Mitsutaka Takada
- Division of Clinical Drug Informatics, Faculty of Pharmacy, Kindai University, Higashi-osaka, Japan.
- Division of Cardiovascular Drugs, Therapy, Kindai University Graduate School of Pharmacy, Higashi-osaka, Japan.
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45
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Collins J, Shea K, Parsad S, Plach K, Lee P. The impact of initiating posaconazole on tacrolimus pharmacokinetics in allogeneic stem cell transplantation. J Oncol Pharm Pract 2019; 26:5-12. [DOI: 10.1177/1078155219833440] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Posaconazole reduces the risk of invasive Aspergillus in transplant patients, but significantly inhibits tacrolimus metabolism. One study demonstrated that a three-fold dose reduction of tacrolimus was required to obtain therapeutic concentrations when used with posaconazole. However, with empiric dose reduction, there is a risk of subtherapeutic tacrolimus levels and subsequent graft failure or graft-versus-host disease. Overall, the existing data on the impact of posaconazole on tacrolimus pharmacokinetics is limited. Objective The purpose of this study is to determine whether tacrolimus doses should be decreased upon initiation of posaconazole in patients receiving an allogeneic stem cell transplant. Methods This is a retrospective chart review at an academic medical center. All allogeneic stem cell transplant adults who received concomitant posaconazole and tacrolimus from February 2016 through December 2017 were included. Results Seventy-nine patients identified using an internal electronic database were analyzed. The median time to therapeutic tacrolimus concentration was significantly longer in patients who did not receive an empiric dose reduction (0% DR, 10d; 1–30% DR, 4d; 31–65% DR, 5d; >65% DR, 4d; p = 0.0395). The rate of supratherapeutic levels was highest amongst patients who did not receive an empiric DR, and was noted to be significant compared to the group that had 31–65% DR ( p < 0.001). Conclusion This study validates our current practice of instituting an empiric 50% dose reduction of oral tacrolimus to 0.03 mg/kg/day when used concomitantly with posaconazole to achieve therapeutic levels in allogeneic stem cell transplant patients.
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Affiliation(s)
| | | | | | - Kelly Plach
- Barnes-Jewish Hospital, Saint Louis, MO, USA
| | - Pauline Lee
- University of Chicago Medicine, Chicago, IL, USA
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Abstract
Binding of small inhibitory compounds to human cytochrome P450 3A4 (CYP3A4) could interfere with drug metabolism and lead to drug-drug interactions, the underlying mechanism of which is not fully understood due to insufficient structural information. This study investigated the interaction of recombinant CYP3A4 with a nonspecific inhibitor metyrapone, antifungal drug fluconazole, and protease inhibitor phenylmethanesulfonyl fluoride (PMSF). Metyrapone and fluconazole are classic type II ligands that inhibit CYP3A4 with medium strength by ligating to the heme iron, whereas PMSF, lacking the heme-ligating moiety, acts as a weak type I ligand and inhibitor of CYP3A4. High-resolution crystal structures revealed that the orientation of metyrapone is similar but not identical to that in the previously reported 1W0G model, whereas the flexible fluconazole adapts a conformer markedly different from that observed in the target CYP51 enzymes, which could explain its high potential for cross-reactivity. Besides hydrophobic and aromatic interactions with the heme and active site residues, both drugs establish water-mediated contacts that stabilize the inhibitory complexes. PMSF also binds near the catalytic center, with the phenyl group parallel to the heme. However, it does not displace the water ligand and is held in place via strong H-bonds formed by the sulfofluoride moiety with Ser119 and Arg212. Collectively, our data suggest that PMSF might have multiple binding sites and likely occupies the high-affinity site in the crystal structure. Moreover, its hydrolysis product, phenylmethanesulfonic acid, can also access and be retained in the CYP3A4 active site. Therefore, to avoid experimental artifacts, PMSF should be excluded from purification and assay solutions.
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Affiliation(s)
- Irina Sevrioukova
- Department of Molecular Biology and Biochemistry, University of California, Irvine, California 92697-3900
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Ferguson-Paul K, Park C, Childress S, Arnold S, Ault B, Bagga B. Disseminated histoplasmosis in pediatric kidney transplant recipients-A report of six cases and review of the literature. Pediatr Transplant 2018; 22:e13274. [PMID: 30076688 DOI: 10.1111/petr.13274] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 06/13/2018] [Accepted: 07/06/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND We report a case series of histoplasmosis in KTx patients in a children's hospital in an endemic area. METHODS All KTx cases from January 1, 2002, to August 31, 2016, were reviewed to identify those with disseminated histoplasmosis. RESULTS The attack rate of histoplasmosis among our KTx patients was 6.9 per 100 cases. The median age at the time of diagnosis was 16 years (11-18). Comorbidities included glomerulosclerosis (3), medullary cystic disease (1), and obstructive uropathy (2) and HIV (1). There were 5 deceased and 1 living-related donor transplants, and no patient had a history of rejection prior to histoplasmosis. Median time from transplant to histoplasmosis was 14.8 months (IQR 2.2-38.3) and 33% occurred in the first year after transplant. Urine and/or serum antigens were positive in all patients. They were either treated with amphotericin B and transitioned to an azole or received azole monotherapy. Most (83%) received chronic suppression with itraconazole. No patients died and relapse occurred in 1 patient after repeat transplant. CONCLUSIONS KTx patients in endemic areas are at risk for disseminated histoplasmosis. Further study is needed to determine which factors portend the need for fungal prophylaxis in this subset of patients.
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Affiliation(s)
- Kenice Ferguson-Paul
- Department of Pediatrics, Division of General Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, Tennessee.,Department of Pediatrics, Division of General Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Catherine Park
- Department of Pediatrics, Division of General Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee.,Department of Pediatrics, Division of Nephrology, Emory University, Atlanta, Georgia
| | - Sandra Childress
- Department of Pediatrics, Division of Nephrology, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Sandra Arnold
- Department of Pediatrics, Division of General Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, Tennessee.,Department of Pediatrics, Division of Infectious Diseases, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Bettina Ault
- Department of Pediatrics, Division of Nephrology, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Bindiya Bagga
- Department of Pediatrics, Division of General Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, Tennessee.,Department of Pediatrics, Division of Infectious Diseases, University of Tennessee Health Sciences Center, Memphis, Tennessee
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48
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Chiu YC, Ho MH, Chen TW, Hsieh CB, Fan HL. Twice-Weekly Tacrolimus Can Overcome Pharmacologic Interaction and Help in the Successful Treatment of Pulmonary Aspergillosis in a Liver Transplant Recipient. EXP CLIN TRANSPLANT 2018; 17:838-840. [PMID: 30373507 DOI: 10.6002/ect.2017.0171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Drug-drug interactions between azoles and calcineurin inhibitors can cause issues for organ transplant specialists. Clinical practice guidelines for the treatment of solid-organ transplant recipients with invasive aspergillosis infection are lacking. Here, we present a patient who developed pulmonary aspergillosis after liver transplant. The patient had prolonged treatment with echinocandin that was not effective. A drug-drug interaction between azoles and tacrolimus caused issues for the clinical physician. We adjusted the doses, and the patient was successfully treated. A reduction in the tacrolimus dose, intensive monitoring of associated parameters, and elimination of risk exposures are important for a favorable outcome.
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Affiliation(s)
- Yu-Cheng Chiu
- From the Division of General Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Shumaker AC, Bullard HM, Churpek J, Knoebel RW. Posaconazole–digoxin drug–drug interaction mediated by inhibition of P-glycoprotein. J Oncol Pharm Pract 2018; 25:1758-1761. [DOI: 10.1177/1078155218801055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Drug–drug interactions between digoxin and the triazole antifungal agents, mediated via various cytochrome P450 isozymes, have been described in the literature. Posaconazole is not extensively metabolized by these isozymes but is both a p-glycoprotein (P-gp) substrate and inhibitor. To our knowledge, there have been no published cases of clinically significant posaconazole-digoxin drug–drug interactions. We report an interaction between posaconazole (300 mg by mouth daily) and digoxin (0.25 mg by mouth daily, Monday through Friday) resulting in atrial fibrillation with slow ventricular response and degenerating into polymorphic ventricular tachycardia.
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Affiliation(s)
| | - Heather M Bullard
- Department of Pharmacy, The University of Chicago Medicine, Chicago, IL, USA
| | - Jane Churpek
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago Medicine, Chicago, IL, USA
| | - Randall W Knoebel
- Department of Pharmacy, The University of Chicago Medicine, Chicago, IL, USA
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50
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Effects of clotrimazole on tacrolimus pharmacokinetics in patients with heart transplants with different CYP3A5 genotypes. Eur J Clin Pharmacol 2018; 75:67-75. [DOI: 10.1007/s00228-018-2558-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 09/14/2018] [Indexed: 01/18/2023]
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