51
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Perfect JR, Cornely OA, Heep M, Ostrosky-Zeichner L, Mullane KM, Maher R, Croos-Dabrera R, Lademacher C, Engelhardt M, Chen C, Marty FM. Isavuconazole treatment for rare fungal diseases and for invasive aspergillosis in patients with renal impairment: Challenges and lessons of the VITAL trial. Mycoses 2018; 61:420-429. [PMID: 29570857 PMCID: PMC6490690 DOI: 10.1111/myc.12769] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 03/12/2018] [Indexed: 01/22/2023]
Abstract
Invasive fungal disease (IFD) confers a substantial risk for morbidity and mortality to immunocompromised patients. Invasive aspergillosis (IA) is the most common IFD caused by moulds but the prevalence of other rare mould diseases, such as mucormycosis, hyalohyphomycosis and phaeohyphomycosis, may be increasing. Treatments are available for IA, but evidence to support efficacy and safety of antifungal agents for rare IFDs, or for IFDs in special patient populations, is limited or lacking. The VITAL trial was conducted to assess the efficacy and safety of isavuconazole for the treatment of patients with IA and renal impairment, or with IFDs caused by rare moulds, yeasts or dimorphic fungi. These patients stand to benefit most from a new treatment option but are unlikely to be included in a randomised, controlled trial. In this article, we review the challenges faced in the design and conduct of the VITAL trial. We also review the findings of VITAL, which included evidence of the efficacy and safety of isavuconazole. Finally, we consider the importance of trials such as VITAL to inform therapeutic decision making for clinicians faced with the challenge of treating patients with rare IFDs and as one paradigm of how to determine efficacy and safety of new drugs for rare and resistant infections without a suitable comparator.
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Affiliation(s)
- John R. Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, NC, USA
| | - Oliver A. Cornely
- Department I of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, Cologne, Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Markus Heep
- Basilea Pharmaceutica International Ltd, Basel, Switzerland
| | - Luis Ostrosky-Zeichner
- University of Texas Medical School at Houston, Houston, TX, USA
- Memorial Hermann Texas Medical Center, University of Texas, Houston, TX, USA
| | - Kathleen M. Mullane
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, Chicago, IL, USA
| | - Rochelle Maher
- Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | | | | | | | - Caroline Chen
- Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Francisco M. Marty
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, MA, USA
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52
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McCarthy MW, Moriyama B, Petraitiene R, Walsh TJ, Petraitis V. Clinical Pharmacokinetics and Pharmacodynamics of Isavuconazole. Clin Pharmacokinet 2018; 57:1483-1491. [DOI: 10.1007/s40262-018-0673-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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53
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Jenks JD, Salzer HJ, Prattes J, Krause R, Buchheidt D, Hoenigl M. Spotlight on isavuconazole in the treatment of invasive aspergillosis and mucormycosis: design, development, and place in therapy. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:1033-1044. [PMID: 29750016 PMCID: PMC5933337 DOI: 10.2147/dddt.s145545] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In recent decades, important advances have been made in the diagnosis and treatment of invasive aspergillosis (IA) and mucormycosis. One of these advances has been the introduction of isavuconazole, a second-generation broad spectrum triazole with a favorable pharmacokinetic and safety profile and few drug–drug interactions. Phase III trials in patients with IA and mucormycosis demonstrated that isavuconazole has similar efficacy to voriconazole for the treatment of IA (SECURE trial) and liposomal amphotericin B for the treatment of mucormycosis (VITAL trial with subsequent case–control analysis) and a favorable safety profile with significantly fewer ocular, hepatobiliary, and skin and soft tissue adverse events compared to voriconazole. As a result, recent IA guidelines recommend isavuconazole (together with voriconazole) as gold standard treatment for IA in patients with underlying hematological malignancies. In contrast to liposomal amphotericin B, isavuconazole can be safely administered in patients with reduced renal function and is frequently used for the treatment of mucormycosis in patients with reduced renal function. Updated guidelines on mucormycosis are needed to reflect the current evidence and give guidance on the use of isavuconazole for mucormycosis. Studies are needed to evaluate the role of isavuconazole for 1) anti-mold prophylaxis in high-risk patients, 2) salvage treatment for IA and mucormycosis, and 3) treatment for other mold infections such as Scedosporium apiospermum.
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Affiliation(s)
- Jeffrey D Jenks
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Helmut Jf Salzer
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany.,German Center for Infection Research, Clinical Tuberculosis Center, Leibniz Lung Center, Borstel, Germany
| | - Juergen Prattes
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria.,CBmed - Center for Biomarker Research in Medicine, Graz, Austria
| | - Robert Krause
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria.,CBmed - Center for Biomarker Research in Medicine, Graz, Austria
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
| | - Martin Hoenigl
- Department of Medicine, University of California San Diego, San Diego, CA, USA.,German Center for Infection Research, Clinical Tuberculosis Center, Leibniz Lung Center, Borstel, Germany.,Division of Pulmonology, Medical University of Graz, Graz, Austria.,Division of Infectious Diseases, Department of Medicine, University of California San Diego, San Diego, CA, USA
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54
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Ledoux MP, Denis J, Nivoix Y, Herbrecht R. Isavuconazole: A new broad-spectrum azole. Part 2: pharmacokinetics and clinical activity. J Mycol Med 2018; 28:15-22. [DOI: 10.1016/j.mycmed.2018.02.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 02/04/2018] [Accepted: 02/05/2018] [Indexed: 12/15/2022]
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55
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Mellinghoff SC, Bassetti M, Dörfel D, Hagel S, Lehners N, Plis A, Schalk E, Vena A, Cornely OA. Isavuconazole shortens the QTc interval. Mycoses 2018; 61:256-260. [DOI: 10.1111/myc.12731] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 11/20/2017] [Accepted: 11/20/2017] [Indexed: 01/21/2023]
Affiliation(s)
- Sibylle C. Mellinghoff
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD); University of Cologne; Cologne Germany
- Department I of Internal Medicine; German Centre for Infection Research (DZIF); University of Cologne; Cologne Germany
| | - Matteo Bassetti
- Infectious Diseases Division; Santa Maria Misericordia University Hospital; Udine Italy
| | - Daniela Dörfel
- Department of Medical Oncology , Hematology, Immunology, Rheumatology and Pulmology; University Hospital Tübingen; Tübingen Germany
- Clinical Collaboration Unit Translational Immunology; German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ); Partner site Tübingen; Tübingen Germany
| | - Stefan Hagel
- Centre for Infectious Diseases and Infection Control; Jena University Hospital; Jena Germany
| | - Nicola Lehners
- Department V of Internal Medicine; University Hospital Heidelberg; Heidelberg Germany
| | - Andrzej Plis
- Department of Haematology, Oncology; Palliative Medicine and Transplantation Centre; University Hospital in Greifswald; Greifswald Germany
| | - Enrico Schalk
- Department of Haematology and Oncology; Medical Centre; Otto-von-Guericke University Magdeburg; Magdeburg Germany
| | - Antonio Vena
- Infectious Diseases Division; Santa Maria Misericordia University Hospital; Udine Italy
| | - Oliver A. Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD); University of Cologne; Cologne Germany
- Department I of Internal Medicine; German Centre for Infection Research (DZIF); University of Cologne; Cologne Germany
- Clinical Trials Centre Cologne (ZKS Köln); University of Cologne; Cologne Germany
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56
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Amsden JR, Gubbins PO. Pharmacogenomics of triazole antifungal agents: implications for safety, tolerability and efficacy. Expert Opin Drug Metab Toxicol 2017; 13:1135-1146. [DOI: 10.1080/17425255.2017.1391213] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Jarrett R. Amsden
- Department of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis, IN, USA
| | - Paul O. Gubbins
- Division of Pharmacy Practice and Administration, UMKC School of Pharmacy at MSU, Springfield, MO, USA
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57
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Groll AH, Townsend R, Desai A, Azie N, Jones M, Engelhardt M, Schmitt-Hoffman AH, Brüggemann RJM. Drug-drug interactions between triazole antifungal agents used to treat invasive aspergillosis and immunosuppressants metabolized by cytochrome P450 3A4. Transpl Infect Dis 2017; 19. [PMID: 28722255 DOI: 10.1111/tid.12751] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 05/15/2017] [Accepted: 05/15/2017] [Indexed: 01/03/2023]
Abstract
Patients undergoing treatment with immunosuppressant drugs following solid organ or hematopoietic stem cell transplantation are at particular risk for development of serious infections such as invasive aspergillosis. Four triazole antifungal drugs, voriconazole, posaconazole, itraconazole, and isavuconazole, are approved to treat invasive aspergillosis either as first- or second-line therapy. All of these agents are inhibitors of cytochrome P450 3A4, which plays a key role in metabolizing immunosuppressant drugs such as cyclosporine, tacrolimus, and sirolimus. Thus, co-administration of a triazole antifungal drug with these immunosuppressant drugs can potentially increase plasma concentrations of the immunosuppressant drugs, thereby resulting in toxicity, or upon discontinuation, inadvertently decrease the respective concentrations with increased risk of rejection or graft-versus-host disease. In this article, we review the evidence for the extent of inhibition of cytochrome P450 3A4 by each of these triazole antifungal drugs and assess their effects on cyclosporine, tacrolimus, and sirolimus. We also consider other factors affecting interactions of these two classes of drugs. Finally, we examine recommendations and strategies to evaluate and address those potential drug-drug interactions in these patients.
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Affiliation(s)
- Andreas H Groll
- Department of Pediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany
| | - Robert Townsend
- Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Amit Desai
- Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Nkechi Azie
- Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Mark Jones
- Basilea Pharmaceutica International Ltd, Basel, Switzerland
| | | | | | - Roger J M Brüggemann
- Department of Pharmacy, Radboud University Nijmegen Medical Centre, and Centre of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
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58
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Wiederhold NP. The antifungal arsenal: alternative drugs and future targets. Int J Antimicrob Agents 2017; 51:333-339. [PMID: 28890395 DOI: 10.1016/j.ijantimicag.2017.09.002] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 08/28/2017] [Accepted: 09/03/2017] [Indexed: 01/10/2023]
Abstract
Clinically available antifungals for the treatment of invasive fungal infections primarily target either ergosterol in the fungal cell membrane or 1,3-β-D-glucan in the fungal cell wall. These classes include the polyene amphotericin B, the triazoles, and the echinocandins. Although newer antifungals and improved formulations of others have advanced our ability to treat patients with invasive mycoses, these drugs are often limited by toxicities, drug interactions, and the need for intravenous administration. Several investigational agents are currently under development. These include those that also target either ergosterol or 1,3-β-D-glucan, but have advantages over currently available drugs. Among these are the tetrazoles VT-1129, VT-1161, and VT-1598 that are more specific for fungal Cyp51 and less so for mammalian CYP 450 enzymes, the echinocandin CD101 that has an extended half-life, and the glucan synthase inhibitor SCY-078, which is being developed for oral administration. In addition, several agents with novel mechanisms of action are also under development. These include the inositol acyltransferase AX001, the dihydroorotate dehydrogenase inhibitor F901318, and VL-2397, which is similar in structure to the siderophore ferrichrome. In addition to possibly overcoming the limitations of currently available antifungals, these newer agents may be less susceptible to mechanisms of resistance that may render antifungals ineffective. Each of these investigational agents has the potential to improve patient outcomes in the treatment of invasive mycoses.
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Affiliation(s)
- Nathan P Wiederhold
- Fungus Testing Laboratory, Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
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59
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Townsend R, Kato K, Hale C, Kowalski D, Lademacher C, Yamazaki T, Akhtar S, Desai A. Two Phase 1, Open-Label, Mass Balance Studies to Determine the Pharmacokinetics of 14 C-Labeled Isavuconazonium Sulfate in Healthy Male Volunteers. Clin Pharmacol Drug Dev 2017; 7:207-216. [PMID: 28750160 PMCID: PMC5811773 DOI: 10.1002/cpdd.376] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 06/06/2017] [Indexed: 12/12/2022]
Abstract
Isavuconazonium sulfate is the water‐soluble prodrug of the active triazole isavuconazole. Two phase 1 studies were conducted to identify the metabolic profile and mass balance of isavuconazole and BAL8728 (inactive cleavage product). Seven subjects in study 1 (isavuconazole mass balance) received a single oral dose of [cyano‐14C]isavuconazonium sulfate corresponding to 200 mg isavuconazole. Six subjects in study 2 (BAL8728 mass balance) received a single intravenous dose of [pyridinylmethyl‐14C]isavuconazonium sulfate corresponding to 75 mg BAL8728. Pharmacokinetic parameters of radioactivity in whole blood and plasma and of isavuconazole and BAL8728 in plasma were assessed. Radioactivity ratio of blood/plasma, percentage of dose, and cumulative percentage of radioactive dose recovered in urine and feces for isavuconazole and BAL8728 were assessed. Metabolic profiling was carried out by high‐performance liquid chromatography and mass spectrometry. Mean plasma isavuconazole pharmacokinetic parameters included apparent clearance (2.3 ± 0.7 L/h), apparent volume of distribution (301.8 ± 105.7 L), and terminal elimination half‐life (99.9 ± 44.6 hours). In study 1, isavuconazole‐derived radioactivity was recovered approximately equally in urine and feces (46.1% and 45.5%, respectively). In study 2, BAL8728‐derived radioactivity was predominantly recovered in urine (96.0%). Isavuconazole (study 1) and M4 (cleavage metabolite of BAL8728; study 2) were the predominant circulating components of radioactivity in plasma.
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Affiliation(s)
- Robert Townsend
- Astellas Pharma Global Development Inc., Northbrook, IL, USA
| | - Kota Kato
- Analysis & Pharmacokinetics Research Laboratories, Astellas Pharma Inc, Osaka, Japan
| | | | - Donna Kowalski
- Astellas Pharma Global Development Inc., Northbrook, IL, USA
| | | | - Takao Yamazaki
- Astellas Pharma Global Development Inc., Northbrook, IL, USA
| | - Shahzad Akhtar
- Astellas Research Institute of America LLC, Skokie, IL, USA
| | - Amit Desai
- Astellas Pharma Global Development Inc., Northbrook, IL, USA
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60
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Bellmann R, Smuszkiewicz P. Pharmacokinetics of antifungal drugs: practical implications for optimized treatment of patients. Infection 2017; 45:737-779. [PMID: 28702763 PMCID: PMC5696449 DOI: 10.1007/s15010-017-1042-z] [Citation(s) in RCA: 196] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 06/25/2017] [Indexed: 02/08/2023]
Abstract
Introduction Because of the high mortality of invasive fungal infections (IFIs), appropriate exposure to antifungals appears to be crucial for therapeutic efficacy and safety. Materials and methods This review summarises published pharmacokinetic data on systemically administered antifungals focusing on co-morbidities, target-site penetration, and combination antifungal therapy. Conclusions and discussion Amphotericin B is eliminated unchanged via urine and faeces. Flucytosine and fluconazole display low protein binding and are eliminated by the kidney. Itraconazole, voriconazole, posaconazole and isavuconazole are metabolised in the liver. Azoles are substrates and inhibitors of cytochrome P450 (CYP) isoenzymes and are therefore involved in numerous drug–drug interactions. Anidulafungin is spontaneously degraded in the plasma. Caspofungin and micafungin undergo enzymatic metabolism in the liver, which is independent of CYP. Although several drug–drug interactions occur during caspofungin and micafungin treatment, echinocandins display a lower potential for drug–drug interactions. Flucytosine and azoles penetrate into most of relevant tissues. Amphotericin B accumulates in the liver and in the spleen. Its concentrations in lung and kidney are intermediate and relatively low myocardium and brain. Tissue distribution of echinocandins is similar to that of amphotericin. Combination antifungal therapy is established for cryptococcosis but controversial in other IFIs such as invasive aspergillosis and mucormycosis.
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Affiliation(s)
- Romuald Bellmann
- Clinical Pharmacokinetics Unit, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Piotr Smuszkiewicz
- Department of Anesthesiology, Intensive Therapy and Pain Treatment, University Hospital, Poznań, Poland
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61
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Update on Therapeutic Drug Monitoring of Antifungals for the Prophylaxis and Treatment of Invasive Fungal Infections. CURRENT FUNGAL INFECTION REPORTS 2017. [DOI: 10.1007/s12281-017-0287-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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62
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Keirns J, Desai A, Kowalski D, Lademacher C, Mujais S, Parker B, Schneidkraut MJ, Townsend R, Wojtkowski T, Yamazaki T, Yen M, Kowey PR. QT Interval Shortening With Isavuconazole: In Vitro and In Vivo Effects on Cardiac Repolarization. Clin Pharmacol Ther 2017; 101:782-790. [PMID: 28074556 PMCID: PMC5485736 DOI: 10.1002/cpt.620] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2017] [Indexed: 01/17/2023]
Abstract
The effects of isavuconazole (active moiety of isavuconazonium sulfate) on cardiac ion channels in vitro and cardiac repolarization clinically were assessed in a phase I, randomized, double-blind study in healthy individuals who received isavuconazole (after 2-day loading dose), at therapeutic or supratherapeutic doses daily for 11 days, moxifloxacin (400 mg q.d.), or placebo. A post-hoc analysis of the phase III SECURE trial assessed effects on cardiac safety. L-type Ca2+ channels were most sensitive to inhibition by isavuconazole. The 50% inhibitory concentrations for ion channels were higher than maximum serum concentrations of nonprotein-bound isavuconazole in vivo. In the phase I study (n = 161), isavuconazole shortened the QT interval in a dose- and plasma concentration-related manner. There were no serious treatment-emergent adverse events; palpitations and tachycardia were observed in placebo and supratherapeutic isavuconazole groups; no cardiac safety signals were detected in the SECURE study (n = 257). Isavuconazole was associated with a shortened cardiac QT interval.
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Affiliation(s)
- J Keirns
- Astellas Pharma Global Development, IncNorthbrookIllinoisUSA
| | - A Desai
- Astellas Pharma Global Development, IncNorthbrookIllinoisUSA
| | - D Kowalski
- Astellas Pharma Global Development, IncNorthbrookIllinoisUSA
| | - C Lademacher
- Astellas Pharma Global Development, IncNorthbrookIllinoisUSA
| | - S Mujais
- Astellas Pharma Global Development, IncNorthbrookIllinoisUSA
| | - B Parker
- Astellas Pharma Global Development, IncNorthbrookIllinoisUSA
| | - MJ Schneidkraut
- Astellas Pharma Global Development, IncNorthbrookIllinoisUSA
| | - R Townsend
- Astellas Pharma Global Development, IncNorthbrookIllinoisUSA
| | - T Wojtkowski
- Astellas Pharma Global Development, IncNorthbrookIllinoisUSA
| | - T Yamazaki
- Astellas Pharma Global Development, IncNorthbrookIllinoisUSA
| | - M Yen
- PAREXELGlendaleCaliforniaUSA
| | - PR Kowey
- Lankenau Medical Center and Institute for Medical Research, Main Line Health SystemWynnewoodPennsylvaniaUSA
- Jefferson Medical CollegePhiladelphiaPennsylvaniaUSA
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63
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McCarthy MW, Petraitis V, Walsh TJ. Combination therapy for the treatment of pulmonary mold infections. Expert Rev Respir Med 2017; 11:481-489. [PMID: 28467730 DOI: 10.1080/17476348.2017.1325322] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Pulmonary mold infections are caused by ubiquitous organisms found in soil, water, and decaying vegetation, including Aspergillus spp., the Mucormycetes, hyaline molds, and dematiaceous (black) molds. Areas covered: These infections are often a challenge to diagnose and even more difficult to treat. Recently, antifungal combination therapy has emerged as a promising strategy to treat some forms of invasive mycoses, including pulmonary mold infections. Historically, this approach has been limited due to non-uniform interpretation criteria, variations in pharmacodynamic/pharmacokinetic properties of antifungals used in combination, and an inability to predict clinical success based on in vitro data and animal models. However, recent advances have helped mitigate some of these challenges. Expert commentary: In this paper, we explore what is known about the antifungal combination therapy in the treatment of pulmonary mold infections and explore how it may impact clinical practice. We pay particular attention to novel combinations and the challenges associated with the development of new antifungal agents.
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Affiliation(s)
- Matthew William McCarthy
- a Hospital Medicine , Joan and Sanford I Weill Medical College of Cornell University , New York , NY , USA
| | - Vidmantas Petraitis
- b Transplantation-Oncology, Infectious Diseases Program , Weill Cornell Medical Center of Cornell University , New York , NY , USA
| | - Thomas J Walsh
- c Transplantation-Oncology Infectious Diseases Program , Weill Cornell Medical Center , New York , NY , USA
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64
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Cornely OA. Isavuconazole: is there a need for a new antifungal? J Antimicrob Chemother 2017; 72:i2-i4. [DOI: 10.1093/jac/dkx027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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65
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Natesan SK, Chandrasekar PH. Isavuconazole for the treatment of invasive aspergillosis and mucormycosis: current evidence, safety, efficacy, and clinical recommendations. Infect Drug Resist 2016; 9:291-300. [PMID: 27994475 PMCID: PMC5153275 DOI: 10.2147/idr.s102207] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The majority of invasive mold infections diagnosed in immunocompromised cancer patients include invasive aspergillosis (IA) and mucormycosis. Despite timely and effective therapy, mortality remains considerable. Antifungal agents currently available for the management of these serious infections include triazoles, polyenes, and echinocandins. Until recently, posaconazole has been the only triazole with a broad spectrum of anti-mold activity against both Aspergillus sp. and mucorales. Other clinically available triazoles voriconazole and itraconazole, with poor activity against mucorales, have significant drug interactions in addition to a side effect profile inherent for all triazoles. Polyenes including lipid formulations pose a problem with infusion-related side effects, electrolyte imbalance, and nephrotoxicity. Echinocandins are ineffective against mucorales and are approved as salvage therapy for refractory IA. Given that all available antifungal agents have limitations, there has been an unmet need for a broad-spectrum anti-mold agent with a favorable profile. Following phase III clinical trials that started in 2006, isavuconazole (ISZ) seems to fit this profile. It is the first novel triazole agent recently approved by the United States Food and Drug Administration (FDA) for the treatment of both IA and mucormycosis. This review provides a brief overview of the salient features of ISZ, its favorable profile with regard to spectrum of antifungal activity, pharmacokinetic and pharmacodynamic parameters, drug interactions and tolerability, clinical efficacy, and side effects.
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Affiliation(s)
- Suganthini Krishnan Natesan
- Division of Infectious Diseases, Department of Internal Medicine, Wayne State University
- John D Dingell VA Medical Center, Detroit, MI, USA
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66
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Shirley M, Scott LJ. Isavuconazole: A Review in Invasive Aspergillosis and Mucormycosis. Drugs 2016; 76:1647-1657. [DOI: 10.1007/s40265-016-0652-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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67
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Desai A, Yamazaki T, Dietz AJ, Kowalski D, Lademacher C, Pearlman H, Akhtar S, Townsend R. Pharmacokinetic and Pharmacodynamic Evaluation of the Drug-Drug Interaction Between Isavuconazole and Warfarin in Healthy Subjects. Clin Pharmacol Drug Dev 2016; 6:86-92. [PMID: 27278712 PMCID: PMC5298089 DOI: 10.1002/cpdd.283] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/18/2016] [Accepted: 06/03/2016] [Indexed: 12/11/2022]
Abstract
This phase 1 trial evaluated pharmacokinetic and pharmacodynamic interactions between the novel triazole antifungal agent isavuconazole and warfarin in healthy adults. Multiple doses of isavuconazole were administered as the oral prodrug, isavuconazonium sulfate (372 mg 3 times a day for 2 days loading dose, then 372 mg once daily thereafter; equivalent to isavuconazole 200 mg), in the presence and absence of single doses of oral warfarin sodium 20 mg. Coadministration with isavuconazole increased the mean area under the plasma concentration‐time curves from time 0 to infinity of S‐ and R‐warfarin by 11% and 20%, respectively, but decreased the mean maximum plasma concentrations of S‐ and R‐warfarin by 12% and 7%, respectively, relative to warfarin alone. Mean area under the international normalized ratio curve and maximum international normalized ratio were 4% lower in the presence vs absence of isavuconazole. Mean warfarin area under the prothrombin time curve and maximum prothrombin time were 3% lower in the presence vs absence of isavuconazole. There were no serious treatment‐emergent adverse events (TEAEs), and no subjects discontinued the study due to TEAEs. All TEAEs were mild in intensity. These findings indicate that coadministration with isavuconazole has no clinically relevant effects on warfarin pharmacokinetics or pharmacodynamics.
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Affiliation(s)
- Amit Desai
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Takao Yamazaki
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | - Donna Kowalski
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | - Helene Pearlman
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Shahzad Akhtar
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Robert Townsend
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
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Groll AH, Desai A, Han D, Howieson C, Kato K, Akhtar S, Kowalski D, Lademacher C, Lewis W, Pearlman H, Mandarino D, Yamazaki T, Townsend R. Pharmacokinetic Assessment of Drug-Drug Interactions of Isavuconazole With the Immunosuppressants Cyclosporine, Mycophenolic Acid, Prednisolone, Sirolimus, and Tacrolimus in Healthy Adults. Clin Pharmacol Drug Dev 2016; 6:76-85. [PMID: 27273343 PMCID: PMC5298005 DOI: 10.1002/cpdd.284] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/18/2016] [Accepted: 06/03/2016] [Indexed: 11/19/2022]
Abstract
This report summarizes phase 1 studies that evaluated pharmacokinetic interactions between the novel triazole antifungal agent isavuconazole and the immunosuppressants cyclosporine, mycophenolic acid, prednisolone, sirolimus, and tacrolimus in healthy adults. Healthy subjects received single oral doses of cyclosporine (300 mg; n = 24), mycophenolate mofetil (1000 mg; n = 24), prednisone (20 mg; n = 21), sirolimus (2 mg; n = 22), and tacrolimus (5 mg; n = 24) in the presence and absence of clinical doses of oral isavuconazole (200 mg 3 times daily for 2 days; 200 mg once daily thereafter). Coadministration with isavuconazole increased the area under the concentration‐time curves (AUC0–∞) of tacrolimus, sirolimus, and cyclosporine by 125%, 84%, and 29%, respectively, and the AUCs of mycophenolic acid and prednisolone by 35% and 8%, respectively. Maximum concentrations (Cmax) of tacrolimus, sirolimus, and cyclosporine were 42%, 65%, and 6% higher, respectively; Cmax of mycophenolic acid and prednisolone were 11% and 4% lower, respectively. Isavuconazole pharmacokinetics were mostly unaffected by the immunosuppressants. Two subjects experienced elevated creatinine levels in the cyclosporine study; most adverse events were not considered to be of clinical concern. These results indicate that isavuconazole is an inhibitor of cyclosporine, mycophenolic acid, sirolimus, and tacrolimus metabolism.
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Affiliation(s)
- Andreas H Groll
- Department of Paediatric Haematology/Oncology, University Children's Hospital Münster, Münster, Germany
| | - Amit Desai
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | - Corrie Howieson
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Kota Kato
- Analysis & Pharmacokinetics Research Laboratories, Astellas Pharma Inc, Osaka, Japan
| | - Shahzad Akhtar
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Donna Kowalski
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | | | - Helene Pearlman
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | - Takao Yamazaki
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Robert Townsend
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
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Yamazaki T, Desai A, Han D, Kato K, Kowalski D, Akhtar S, Lademacher C, Kovanda L, Townsend R. Pharmacokinetic Interaction Between Isavuconazole and a Fixed-Dose Combination of Lopinavir 400 mg/Ritonavir 100 mg in Healthy Subjects. Clin Pharmacol Drug Dev 2016; 6:93-101. [PMID: 27273248 PMCID: PMC5297880 DOI: 10.1002/cpdd.282] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/18/2016] [Accepted: 06/03/2016] [Indexed: 12/29/2022]
Abstract
This phase 1, open‐label study evaluated the pharmacokinetic effects of coadministration of the antifungal agent, isavuconazole (administered as its water‐soluble prodrug isavuconazonium sulfate), with the antiretroviral agent lopinavir/ritonavir in healthy adults. In part 1, 13 subjects were randomized to 2 arms to receive multiple doses of oral isavuconazole 100 mg either alone or with lopinavir/ritonavir 400/100 mg. In part 2, a different group of 55 subjects were randomized to 3 arms to receive multiple doses of oral isavuconazole 200 mg, either alone or with lopinavir/ritonavir 400/100 mg, or to receive oral lopinavir/ritonavir 400/100 mg alone. Mean area under the concentration‐time curve (AUC) following the last dose (AUCτ) and Cmax of isavuconazole increased by 113% and 96% in part 1 and by 96% and 74% in part 2 in the presence vs absence of lopinavir/ritonavir, respectively. Mean AUCτ and Cmax of lopinavir were 27% and 23% lower, and mean AUCτ and Cmax of ritonavir were 31% and 33% lower in the presence vs absence of isavuconazole, respectively. Mild to moderate gastrointestinal disorders were the most common adverse events experienced. These findings indicate that coadministration of lopinavir/ritonavir with isavuconazole can decrease the exposure of lopinavir/ritonavir and increase the exposure of isavuconazole. Patients should be monitored for reduced antiviral efficacy if these agents are coadministered.
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Affiliation(s)
- Takao Yamazaki
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Amit Desai
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | - Kota Kato
- Analysis & Pharmacokinetics Research Laboratories, Astellas Pharma Inc, Osaka, Japan
| | - Donna Kowalski
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Shahzad Akhtar
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | - Laura Kovanda
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Robert Townsend
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
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Yamazaki T, Desai A, Goldwater R, Han D, Lasseter KC, Howieson C, Akhtar S, Kowalski D, Lademacher C, Rammelsberg D, Townsend R. Pharmacokinetic Interactions Between Isavuconazole and the Drug Transporter Substrates Atorvastatin, Digoxin, Metformin, and Methotrexate in Healthy Subjects. Clin Pharmacol Drug Dev 2016; 6:66-75. [PMID: 27273004 PMCID: PMC5297980 DOI: 10.1002/cpdd.280] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 06/03/2016] [Indexed: 11/21/2022]
Abstract
This article summarizes 4 phase 1 trials that explored interactions between the novel, triazole antifungal isavuconazole and substrates of the drug transporters breast cancer resistance protein (BCRP), multidrug and toxin extrusion protein‐1 (MATE1), organic anion transporters 1/3 (OAT1/OAT3), organic anion‐transporting polypeptide 1B1 (OATP1B1), organic cation transporters 1/2 (OCT1/OCT2), and P‐glycoprotein (P‐gp). Healthy subjects received single doses of atorvastatin (20 mg; OATP1B1 and P‐gp substrate), digoxin (0.5 mg; P‐gp substrate), metformin (850 mg; OCT1, OCT2, and MATE1 substrate), or methotrexate (7.5 mg; BCRP, OAT1, and OAT3 substrate) in the presence and absence of clinical doses of isavuconazole (200 mg 3 times a day for 2 days; 200 mg once daily thereafter). Coadministration with isavuconazole increased mean area under the plasma concentration‐time curves (90% confidence interval) of atorvastatin, digoxin, and metformin to 137% (129, 145), 125% (117, 134), and 152% (138, 168) and increased mean maximum plasma concentrations to 103% (88, 121), 133% (119, 149), and 123% (109, 140), respectively. Methotrexate parameters were unaffected by isavuconazole. There were no serious adverse events. These findings indicate that isavuconazole is a weak inhibitor of P‐gp, as well as OCT1, OCT2, MATE1, or a combination thereof but not of BCRP, OATP1B1, OAT1, or OAT3.
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Affiliation(s)
| | - Amit Desai
- Astellas Pharma Global Development, Northbrook, IL, USA
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Yamazaki T, Desai A, Goldwater R, Han D, Howieson C, Akhtar S, Kowalski D, Lademacher C, Pearlman H, Rammelsberg D, Townsend R. Pharmacokinetic Effects of Isavuconazole Coadministration With the Cytochrome P450 Enzyme Substrates Bupropion, Repaglinide, Caffeine, Dextromethorphan, and Methadone in Healthy Subjects. Clin Pharmacol Drug Dev 2016; 6:54-65. [PMID: 27273149 PMCID: PMC5297975 DOI: 10.1002/cpdd.281] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/18/2016] [Accepted: 06/03/2016] [Indexed: 01/01/2023]
Abstract
This report describes phase 1 clinical trials performed to assess interactions of oral isavuconazole at the clinically targeted dose (200 mg, administered as isavuconazonium sulfate 372 mg, 3 times a day for 2 days; 200 mg once daily [QD] thereafter) with single oral doses of the cytochrome P450 (CYP) substrates: bupropion hydrochloride (CYP2B6; 100 mg; n = 24), repaglinide (CYP2C8/CYP3A4; 0.5 mg; n = 24), caffeine (CYP1A2; 200 mg; n = 24), dextromethorphan hydrobromide (CYP2D6/CYP3A4; 30 mg; n = 24), and methadone (CYP2B6/CYP2C19/CYP3A4; 10 mg; n = 23). Compared with each drug alone, coadministration with isavuconazole changed the area under the concentration‐time curves (AUC∞) and maximum concentrations (Cmax) as follows: bupropion, AUC∞ reduced 42%, Cmax reduced 31%; repaglinide, AUC∞ reduced 8%, Cmax reduced 14%; caffeine, AUC∞ increased 4%, Cmax reduced 1%; dextromethorphan, AUC∞ increased 18%, Cmax increased 17%; R‐methadone, AUC∞ reduced 10%, Cmax increased 3%; S‐methadone, AUC∞ reduced 35%, Cmax increased 1%. In all studies, there were no deaths, 1 serious adverse event (dextromethorphan study; perioral numbness, numbness of right arm and leg), and adverse events leading to study discontinuation were rare. Thus, isavuconazole is a mild inducer of CYP2B6 but does not appear to affect CYP1A2‐, CYP2C8‐, or CYP2D6‐mediated metabolism.
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Affiliation(s)
- Takao Yamazaki
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Amit Desai
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | | | - Corrie Howieson
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Shahzad Akhtar
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Donna Kowalski
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | - Helene Pearlman
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | - Robert Townsend
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
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