51
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Laub MR, Crow SA, Personett HA, Dierkhising R, Boilson B, Razonable R. Effects of clotrimazole troches on tacrolimus dosing in heart transplant recipients. Transpl Infect Dis 2018; 20:e12979. [PMID: 30120865 DOI: 10.1111/tid.12979] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 08/06/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tacrolimus is a cornerstone of immunosuppression after transplantation but is highly susceptible to changes from interacting variables and has a narrow therapeutic index. Clotrimazole troches are commonly used as a non-systemic antifungal to prevent oral candidiasis. Studies suggest that clotrimazole troches, though minimally absorbed systemically, may affect tacrolimus concentrations by inhibition of metabolic enzyme activity in the intestines. However, the magnitude of the impact of clotrimazole on tacrolimus dosing requirements to maintain goal levels is not well described. METHODS To assess this, tacrolimus dose adjustments and trough concentrations were retrospectively examined in 95 heart transplant recipients before and after the discontinuation of clotrimazole. RESULTS The median percent tacrolimus dose change was an increase of 66.7% (IQR 28.6%, 100%) after clotrimazole discontinuation, and the median trough concentration percent change from baseline to the first trough after clotrimazole discontinuation (in the absence of a dose change) was -42.5% (IQR -52.3%, -30.9%). Five cases of allograft rejection were observed. CONCLUSION In conclusion, clotrimazole troches exert a meaningful interaction with tacrolimus that requires close monitoring and dose adjustment. The data from this single-center study provide novel information that could guide providers on the degree of tacrolimus dose adjustment needed when discontinuing clotrimazole prophylaxis after heart transplantation.
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Affiliation(s)
- Melissa R Laub
- Division of Pharmacy Services, Mayo Clinic Hospital, Rochester, Minnesota
| | - Stacy A Crow
- Division of Pharmacy Services, Mayo Clinic Hospital, Rochester, Minnesota
| | | | - Ross Dierkhising
- Division of Biomedical Statistics and Informatics, Mayo Clinic Hospital, Rochester, Minnesota
| | - Barry Boilson
- Division of Cardiovascular Diseases, Mayo Clinic Hospital, Rochester, Minnesota
| | - Raymund Razonable
- Division of Infectious Diseases, Mayo Clinic Hospital, Rochester, Minnesota
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Trinh SA, Echenique IA, Penugonda S, Angarone MP. Safety and efficacy of chronic suppressive azole therapy for endemic fungal infections in solid organ transplant recipients. Transpl Infect Dis 2018; 20:e12963. [PMID: 29975443 DOI: 10.1111/tid.12963] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 05/10/2018] [Accepted: 06/27/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Although the research is limited, treatment guidelines recommend lifelong suppressive azole therapy for disseminated endemic fungal infection (EFI) after solid organ transplantation (SOT). Suppressive azole therapy may prevent EFI recurrence at the risk of hepatotoxicity and drug interactions. We present real-world safety and effectiveness data of chronic suppressive azole therapy for EFI in SOT recipients over a 10-year period at a single comprehensive transplant center. METHODS A retrospective analysis was conducted of SOT recipients diagnosed with EFI from January 1, 2005, to May 1, 2015. Chronic suppressive azole therapy was defined as treatment for more than 12 months after diagnosis. Effectiveness of suppression was defined as preventing EFI reactivation. Safety endpoints included adverse reactions and drug interactions. RESULTS Over a 10-year period, 28 SOT recipients were diagnosed with EFI: 16 histoplasmosis, 9 blastomycosis, and 3 coccidioidomycosis. Eighteen (64%) patients were treated with chronic suppressive azole therapy for a median length of 36 months (range 15-90). One patient had an adverse drug interaction requiring azole discontinuation. There were no episodes of azole-related hepatotoxicity, toxicity from antirejection medication, or EFI reactivation. CONCLUSIONS Chronic suppressive azole therapy was safe and effective in preventing reactivation of EFI in SOT recipients.
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Affiliation(s)
- Sonya A Trinh
- Department of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Sudhir Penugonda
- Department of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael P Angarone
- Department of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Kuriakose K, Nesbitt WJ, Greene M, Harris B. Posaconazole-Induced Pseudohyperaldosteronism. Antimicrob Agents Chemother 2018; 62:e02130-17. [PMID: 29530850 PMCID: PMC5923153 DOI: 10.1128/aac.02130-17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 03/02/2018] [Indexed: 12/27/2022] Open
Abstract
A woman in her late 60s with disseminated histoplasmosis was treated with posaconazole because first-line therapies were not tolerated. She subsequently presented with decompensated heart failure, hypertension, and hypokalemia. Laboratory tests revealed low renin and aldosterone levels. A potential mechanism is inhibition of the enzyme 11β-hydroxysteroid dehydrogenase 2, with resultant apparent mineralocorticoid excess.
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Affiliation(s)
- Kevin Kuriakose
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Whitney J Nesbitt
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew Greene
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bryan Harris
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Abstract
Limited data are available on micafungin breakthrough fungemia (MBF), fungemia that develops on administration of micafungin, in patients with hematological disorders. We reviewed medical and microbiological records of patients with hematological disorders who developed MBF between January 2008 and June 2015. A total of 39 patients with MBF were identified, and Candida (30 strains) and non-Candida (9 strains) fungal species were recognized as causative strains. Among 35 stored strains, Candida parapsilosis (14 strains), Trichosporon asahii (7 strains), Candida glabrata (5 strains), and other fungal species (9 strains) were identified by sequencing. Neutropenia was identified as an independent predictor of non-Candida fungemia (P = 0.023). T. asahii was the most common causative strain (7/19) during neutropenia. The 14-day crude mortality rate of patients treated with early micafungin change (EMC) to other antifungal agents was lower than that of the patients not treated with EMC (14% versus 43%, P = 0.044). Most of the stored causative Candida strains were susceptible (80%) or showed wild-type susceptibility (72%) to micafungin. The MICs of voriconazole for T. asahii were low (range, 0.015 to 0.12 μg/ml), whereas the MICs of amphotericin B for T. asahii were high (range, 2 to 4 μg/ml). MBF caused by non-Candida fungus should be considered, especially in patients with neutropenia. EMC could improve early mortality. Based on epidemiology and drug susceptibility profiling, empirical voriconazole-containing therapy might be suitable for treating MBF during neutropenia to cover for T. asahii.
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55
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Imataki O, Yamaguchi K, Uemura M, Fukuoka N. Voriconazole concentration is inversely correlated with corticosteroid usage in immunocompromised patients. Transpl Infect Dis 2018; 20:e12886. [DOI: 10.1111/tid.12886] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 01/13/2018] [Accepted: 02/04/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Osamu Imataki
- Division of Hematology and Stem Cell Transplantation; Department of Internal Medicine; Faculty of Medicine; Kagawa University; Kagawa Japan
| | | | - Makiko Uemura
- Division of Hematology and Stem Cell Transplantation; Department of Internal Medicine; Faculty of Medicine; Kagawa University; Kagawa Japan
| | - Noriyasu Fukuoka
- Department of Pharmacy; Kagawa University Hospital; Kagawa Japan
- Laboratory of Hospital Pharmacy; School of Pharmacy; Nihon University; Funabashi Chiba Japan
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56
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Launay M, Roux A, Beaumont L, Douvry B, Lecuyer L, Douez E, Picard C, Grenet D, Jullien V, Boussaud V, Guillemain R, Billaud EM. Posaconazole Tablets in Real-Life Lung Transplantation: Impact on Exposure, Drug-Drug Interactions, and Drug Management in Lung Transplant Patients, Including Those with Cystic Fibrosis. Antimicrob Agents Chemother 2018; 62:e02061-17. [PMID: 29311077 PMCID: PMC5826104 DOI: 10.1128/aac.02061-17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 12/14/2017] [Indexed: 01/02/2023] Open
Abstract
Appropriate exposure to posaconazole (PSZ) has been limited until the recent approval of the delayed-release oral tablet formulation. Our goal was to determine the exposure obtained by using the standard dose of 300 mg once a day in lung transplant (LT) patients, including patients with cystic fibrosis (CF). PSZ trough concentrations (C0) were determined using a liquid chromatography-tandem mass spectrometry assay. Indicative thresholds of interest were <0.7 mg/liter for prophylaxis and 1 to 3 mg/liter for cure. The tacrolimus (TRL) and everolimus (ERL) C0 measured during PSZ exposure were also collected. The interaction with proton-pump inhibitors (PPI) was evaluated. We recorded the results for 21 CF patients with LT (CFLT patients), 11 non-CF patients with LT (NCFLT patients), and 27 nontransplant (NT) patients in pneumology departments. The weights of the NCFLT, CFLT, and NT patients were 59.2 ± 8.4, 48.8 ± 8.4, and 63.7 ± 16.6 kg, respectively (P = 0.001* [asterisk means that statistical test is significant]), and the PSZ C0 exposures for these patients were 1.9 ± 1.5, 1.1 ± 0.8, and 2.4 ± 1.8 mg/liter, respectively (P < 0.00001*). More than 60% of the concentrations were in the therapeutic range. In CFLT patients, the administration of one 300-mg PSZ tablet quickly achieved an exposure similar to that achieved with the PSZ oral suspension formulation (OSF) administered 3 or 4 times a day for several months. The TRL C0/dose ratio (C0/D) was 7.4 ± 4.4 mg/liter with PSZ tablets, whereas it was 4.6 ± 0.8 mg/liter with the PSZ oral solution (P = 0.034*). The ERL C0/D was similar with both formulations. PPI had no impact on the PSZ concentration (1.49 ± 1.07 mg/liter without PPI versus 1.33 ± 1.17 mg/liter with PPI; P = 0.4134*). Despite the high levels of exposure, PSZ remained well tolerated (one case of diarrhea and one case of fatigue were reported). PSZ tablet administration allows satisfactory exposure, even in CFLT patients, with a dosage lower than that of the PSZ OSF. This once-a-day formulation was not impacted by PPI, which are extensively used in CF patients.
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Affiliation(s)
- Manon Launay
- Laboratory of Pharmacology and Toxicology, European Hospital Georges Pompidou-APHP, Paris, France
| | - Antoine Roux
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
- Université Versailles Saint-Quentin, Versailles, France
| | - Laurence Beaumont
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Benoit Douvry
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Lucien Lecuyer
- Thoracic Transplantation, European Hospital Georges Pompidou-APHP, Paris, France
| | - Emmanuel Douez
- Laboratory of Pharmacology and Toxicology, European Hospital Georges Pompidou-APHP, Paris, France
| | - Clément Picard
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Dominique Grenet
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Vincent Jullien
- Laboratory of Pharmacology and Toxicology, European Hospital Georges Pompidou-APHP, Paris, France
| | - Véronique Boussaud
- Thoracic Transplantation, European Hospital Georges Pompidou-APHP, Paris, France
| | - Romain Guillemain
- Thoracic Transplantation, European Hospital Georges Pompidou-APHP, Paris, France
| | - Eliane M Billaud
- Laboratory of Pharmacology and Toxicology, European Hospital Georges Pompidou-APHP, Paris, France
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57
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Chen M, Zhuang JL, Duan MH, Zhang W, Li J, Zhu TN, Cai HC, Cao XX, Feng J, Yang C, Zhang Y, Zhang L, Zhou DB, Han B. [Posaconazole as primary prevention of fungal infection in intensive immunosuppressive therapy for severe aplastic anemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 39:128-131. [PMID: 29562447 PMCID: PMC7342574 DOI: 10.3760/cma.j.issn.0253-2727.2018.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Indexed: 11/30/2022]
Abstract
Objective: To Evaluate the efficacy and safety of posaconazole as primary prevention of invasive fungal disease (IFD) in patients with severe aplastic anemia (SAA) treated with anti-thymus/lymphocyte immunoglobulin (ATG/ALG) combined with cyclosporine intensive immunosuppressive therapy (IST). Methods: A retrospective analysis of clinical data of 58 SAA patients who received IST of anti-thymocyte immunoglobulin combining cyclosporine and antifungal prophylaxis during April 2013 to May 2017 in Peking Union Medical College Hospital was performed. The patients were divided into posaconazole prophylaxis group and the control group (itraconazole or fluconazole). The disease characteristics, IFD prevention effect and adverse drug reaction, curative effect and prognosis of the two groups were compared. Results: Posaconazole was used to prevent fungal infection in 20 patients. The other 38 patients were used as the control group. Retrospective analysis showed comparable characteristics (gender, age, disease severity, etiology, interval between the onset of disease to treatment, ATG/ALG type) of both groups. The incidence of IFD were 0 and 15.8% in posaconazole prophylaxis group and the control group, respectively (P=0.084). In the control group, there were 6 cases diagnosed as IFD. Of them, 2 were confirmed, 2 suspected and 2 not identified. Five of the 6 cases were pulmonary infection, 1 bloodstream infections. Of the 6 IFD cases, 5 were very severe aplastic anemia (VSAA). There was no obvious adverse reaction in posaconazole prophylaxis group. Conclusion: Posaconazole is safe and effective for primary prevention of fungal infection of SAA patients receiving IST, especially for the VSAA.
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Affiliation(s)
- M Chen
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100730, China
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58
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Watanabe N, Higashi H, Nakamura S, Nomura K, Adachi Y, Taguchi M. The possible clinical impact of risperidone on P-glycoprotein-mediated transport of tacrolimus: A case report and in vitro
study. Biopharm Drug Dispos 2017; 39:30-37. [DOI: 10.1002/bdd.2109] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 09/11/2017] [Accepted: 10/02/2017] [Indexed: 12/14/2022]
Affiliation(s)
- Nao Watanabe
- Graduate School of Medical and Pharmaceutical Sciences; University of Toyama; 2630 Sugitani Toyama 930-0194 Japan
| | - Hiroki Higashi
- Graduate School of Medical and Pharmaceutical Sciences; University of Toyama; 2630 Sugitani Toyama 930-0194 Japan
| | - Saki Nakamura
- Graduate School of Medical and Pharmaceutical Sciences; University of Toyama; 2630 Sugitani Toyama 930-0194 Japan
| | - Keiko Nomura
- Graduate School of Medical and Pharmaceutical Sciences; University of Toyama; 2630 Sugitani Toyama 930-0194 Japan
| | - Yuichi Adachi
- Graduate School of Medical and Pharmaceutical Sciences; University of Toyama; 2630 Sugitani Toyama 930-0194 Japan
| | - Masato Taguchi
- Graduate School of Medical and Pharmaceutical Sciences; University of Toyama; 2630 Sugitani Toyama 930-0194 Japan
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59
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Hoenigl M, Prattes J, Neumeister P, Wölfler A, Krause R. Real-world challenges and unmet needs in the diagnosis and treatment of suspected invasive pulmonary aspergillosis in patients with haematological diseases: An illustrative case study. Mycoses 2017; 61:201-205. [PMID: 29112326 DOI: 10.1111/myc.12727] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/27/2017] [Accepted: 10/28/2017] [Indexed: 12/25/2022]
Abstract
Recent years have seen important advances in the diagnosis of invasive pulmonary aspergillosis (IPA), complemented by the introduction of new therapies. Despite this, IPA remains a major cause of infection-related mortality in patients with haematological diseases. There are two main reasons for this. First, diagnosis of IPA remains a challenge, since risk factors and the clinical, radiological and mycological presentations vary not only by fungal disease stage, but also by patient group (eg neutropenic vs non-neutropenic patients). Diagnosis is particularly challenging in patients receiving mould-active prophylactic or empirical treatment, which reduces the sensitivity of all diagnostic tests for IPA. Second, treatment of IPA is complex due to unpredictable pharmacokinetic profiles of antifungal agents, small therapeutic window in terms of exposure and adverse events, and multiple drug-drug interactions through the CYP450 system. Here we report a case of a 23-year-old male with severe aplastic anaemia and subpleural nodules. Diagnostic tests for IPA obtained during ongoing mould-active empirical treatment were negative. Intravenous voriconazole was stopped after visual disturbances and hallucinations. The patient then had an anaphylactic reaction to liposomal amphotericin B and was switched to intravenous posaconazole, which had to be discontinued due to a significant increase in transaminase levels. He was treated with oral isavuconazole with reduced dosage, triggered by increasing transaminases under the standard dosage. Even under reduced dosage, blood concentrations of isavuconazole were high and treatment was successful. The case illustrates real-world challenges and unmet needs in the diagnosis and treatment of IPA in patients with haematological diseases.
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Affiliation(s)
- Martin Hoenigl
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University Graz, Graz, Austria.,Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.,CBmed - Center for Biomarker Research in Medicine, Graz, Austria.,Division of Infectious Diseases, Department of Medicine, University of California-San Diego, San Diego, CA, USA
| | - Juergen Prattes
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University Graz, Graz, Austria.,CBmed - Center for Biomarker Research in Medicine, Graz, Austria
| | - Peter Neumeister
- Division of Haematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Albert Wölfler
- Division of Haematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Robert Krause
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University Graz, Graz, Austria.,CBmed - Center for Biomarker Research in Medicine, Graz, Austria
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60
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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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61
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Engle JA, Fair C. Sirolimus and mirabegron interaction in a hematopoietic cell transplant patient. J Oncol Pharm Pract 2017; 24:627-631. [PMID: 28814193 DOI: 10.1177/1078155217726161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Hematopoietic cell transplant patients are exposed to numerous classes of medications. Transplant practitioners must vigilantly monitor for drug interactions especially involving immunosuppressants. We report a hematopoietic cell transplant patient receiving sirolimus who developed supratherapeutic serum concentrations after initiating mirabegron. SUMMARY A 31-year-old, 98 kg female received a second umbilical cord blood transplant four years after the first transplant for relapsed acute myeloid leukemia. Mycophenolate mofetil and sirolimus were utilized for graft versus host disease prophylaxis. The patient was receiving sirolimus 2 mg daily and the serum concentration on day 26 post-transplant (day + 26) was within therapeutic range (6.7 μg/L, goal range 3-12 μg/L). Her post-transplant course was complicated by BK viruria-associated cystitis for which she was started on mirabegron. Six days after starting the new medication (day + 33), the sirolimus serum concentration increased to 19.2 μg/L. Thus mirabegron was discontinued and sirolimus was held. Sirolimus was restarted once the serum concentration was within goal and subsequently stabilized with a combination of 1 mg and 2 mg daily for a total weekly dose of 10 mg. The proposed mechanisms of interaction include: (1) sirolimus inhibition of organic anion transporting polypeptide leading to increased mirabegron in the intestinal lumen; (2) mirabegron inhibition of P-glycoprotein leading to increased absorption of sirolimus and; (3) increased sirolimus absorption leading to increased sirolimus serum concentrations. CONCLUSION To our knowledge, this is the first report of a potential drug interaction between sirolimus and mirabegron. Transplant specialists should be aware of this potential interaction when considering the concurrent use of these medications.
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Affiliation(s)
- Jeff A Engle
- Department of Pharmacy, University of Minnesota Medical Center, Minneapolis, USA
| | - Christina Fair
- Department of Pharmacy, University of Minnesota Medical Center, Minneapolis, USA
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62
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Cutaneous fungal infections in solid organ transplant recipients. Transplant Rev (Orlando) 2017; 31:158-165. [DOI: 10.1016/j.trre.2017.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/05/2017] [Accepted: 03/06/2017] [Indexed: 12/29/2022]
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63
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Pemán J, Aguilar G, Valía JC, Salavert M, Navarro D, Zaragoza R. Jávea consensus guidelines for the treatment of Candida peritonitis and other intra-abdominal fungal infections in non-neutropenic critically ill adult patients. Rev Iberoam Micol 2017; 34:130-142. [DOI: 10.1016/j.riam.2016.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/24/2016] [Accepted: 12/02/2016] [Indexed: 12/28/2022] Open
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64
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Intérêt du suivi thérapeutique pharmacologique dans le cadre des infections pulmonaires. Rev Mal Respir 2017; 34:693-705. [DOI: 10.1016/j.rmr.2016.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 08/30/2016] [Indexed: 12/31/2022]
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65
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Miloh T, Barton A, Wheeler J, Pham Y, Hewitt W, Keegan T, Sanchez C, Bulut P, Goss J. Immunosuppression in pediatric liver transplant recipients: Unique aspects. Liver Transpl 2017; 23:244-256. [PMID: 27874250 DOI: 10.1002/lt.24677] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 11/03/2016] [Indexed: 02/07/2023]
Abstract
Pediatric liver transplantation has experienced improved outcomes over the last 50 years. This can be attributed in part to establishing optimal use of immunosuppressive agents to achieve a balance between minimizing the risks of allograft rejection and infection. The management of immunosuppression in children is generally more complex and can be challenging when compared with the use of these agents in adult liver transplant patients. Physiologic differences in children alter the pharmacokinetics of immunosuppressive agents, which affects absorption, distribution, metabolism, and drug excretion. Children also have a longer expected period of exposure to immunosuppression, which can impact growth, risk of infection (bacterial, viral, and fungal), carcinogenesis, and likelihood of nonadherence. This review discusses immunosuppressive options for pediatric liver transplant recipients and the unique issues that must be addressed when managing this population. Further advances in the field of tolerance and accommodation are needed to relieve the acute and cumulative burden of chronic immunosuppression in children. Liver Transplantation 23 244-256 2017 AASLD.
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Affiliation(s)
- Tamir Miloh
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Andrea Barton
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | | | - Yen Pham
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | | | | | | | | | - John Goss
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX
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Beck KR, Bächler M, Vuorinen A, Wagner S, Akram M, Griesser U, Temml V, Klusonova P, Yamaguchi H, Schuster D, Odermatt A. Inhibition of 11β-hydroxysteroid dehydrogenase 2 by the fungicides itraconazole and posaconazole. Biochem Pharmacol 2017; 130:93-103. [PMID: 28131847 DOI: 10.1016/j.bcp.2017.01.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 01/23/2017] [Indexed: 02/01/2023]
Abstract
Impaired 11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2)-dependent cortisol inactivation can lead to electrolyte dysbalance, hypertension and cardiometabolic disease. Furthermore, placental 11β-HSD2 essentially protects the fetus from high maternal glucocorticoid levels, and its impaired function has been associated with altered fetal growth and a higher risk for cardio-metabolic diseases in later life. Despite its important role, 11β-HSD2 is not included in current off-target screening approaches. To identify potential 11β-HSD inhibitors among approved drugs, a pharmacophore model was used for virtual screening, followed by biological assessment of selected hits. This led to the identification of several azole fungicides as 11β-HSD inhibitors, showing a significant structure-activity relationship between azole scaffold size, 11β-HSD enzyme selectivity and inhibitory potency. A hydrophobic linker connecting the azole ring to the other, more polar end of the molecule was observed to be favorable for 11β-HSD2 inhibition and selectivity over 11β-HSD1. The most potent 11β-HSD2 inhibition, using cell lysates expressing recombinant human 11β-HSD2, was obtained for itraconazole (IC50 139±14nM), its active metabolite hydroxyitraconazole (IC50 223±31nM) and posaconazole (IC50 460±98nM). Interestingly, experiments with mouse and rat kidney homogenates showed considerably lower inhibitory activity of these compounds towards 11β-HSD2, indicating important species-specific differences. Thus, 11β-HSD2 inhibition by these compounds is likely to be overlooked in preclinical rodent studies. Inhibition of placental 11β-HSD2 by these compounds, in addition to the known inhibition of cytochrome P450 enzymes and P-glycoprotein efflux transport, might contribute to elevated local cortisol levels, thereby affecting fetal programming.
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Affiliation(s)
- Katharina R Beck
- Swiss Center for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, Pharmazentrum, University of Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland.
| | - Murielle Bächler
- Swiss Center for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, Pharmazentrum, University of Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland.
| | - Anna Vuorinen
- Swiss Center for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, Pharmazentrum, University of Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland.
| | - Sandra Wagner
- Institute of Pharmacy/Pharmaceutical Chemistry and Center for Molecular Biosciences Innsbruck (CMBI), Computer Aided Molecular Design Group, University of Innsbruck, Innrain 80/82, 6020 Innsbruck, Austria.
| | - Muhammad Akram
- Institute of Pharmacy/Pharmaceutical Chemistry and Center for Molecular Biosciences Innsbruck (CMBI), Computer Aided Molecular Design Group, University of Innsbruck, Innrain 80/82, 6020 Innsbruck, Austria.
| | - Ulrich Griesser
- Institute of Pharmacy/Pharmaceutical Technology, University of Innsbruck, Innrain 80/82, 6020 Innsbruck, Austria.
| | - Veronika Temml
- Institute of Pharmacy/Pharmaceutical Chemistry and Center for Molecular Biosciences Innsbruck (CMBI), Computer Aided Molecular Design Group, University of Innsbruck, Innrain 80/82, 6020 Innsbruck, Austria.
| | - Petra Klusonova
- Swiss Center for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, Pharmazentrum, University of Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland.
| | - Hideaki Yamaguchi
- Department of Applied Biological Chemistry, Meijo University, Nagoya 468-8502, Japan.
| | - Daniela Schuster
- Institute of Pharmacy/Pharmaceutical Chemistry and Center for Molecular Biosciences Innsbruck (CMBI), Computer Aided Molecular Design Group, University of Innsbruck, Innrain 80/82, 6020 Innsbruck, Austria.
| | - Alex Odermatt
- Swiss Center for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, Pharmazentrum, University of Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland.
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Mishima E, Maruyama K, Nakazawa T, Abe T, Ito S. Acute Kidney Injury from Excessive Potentiation of Calcium-channel Blocker via Synergistic CYP3A4 Inhibition by Clarithromycin Plus Voriconazole. Intern Med 2017; 56:1687-1690. [PMID: 28674358 PMCID: PMC5519471 DOI: 10.2169/internalmedicine.56.8313] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
CYP3A4-inhibitors can potentiate the hypotensive effect of calcium-channel blockers. However, insufficient attention to such drug interactions may result in serious adverse reactions. A 71-year-old hypertensive man prescribed nifedipine was hospitalized for infectious endophthalmitis. Antimicrobial therapy with voriconazole lowered the blood pressure, and then clarithromycin further lowered it through the excessively elevated nifedipine concentration, leading to ischemic acute kidney injury. After the discontinuation of clarithromycin and voriconazole, the blood pressure and renal function were recovered. The combination of CYP3A4-inhibitors such as clarithromycin plus voriconazole can synergistically potentiate calcium-channel blockers. Co-prescription of multiple CYP3A4-inhibitors with calcium-channel blockers increases the risk of hypotension and acute kidney injury.
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Affiliation(s)
- Eikan Mishima
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Kazuichi Maruyama
- Department of Ophthalmology, Tohoku University Graduate School of Medicine, Japan
| | - Toru Nakazawa
- Department of Ophthalmology, Tohoku University Graduate School of Medicine, Japan
| | - Takaaki Abe
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
- Division of Medical Science, Tohoku University Graduate School of Biomedical Engineering, Japan
| | - Sadayoshi Ito
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
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Masoumi HT, Hadjibabaie M, Vaezi M, Ghavamzadeh A. Evaluation of the Interaction of Intravenous and Oral Voriconazole with Oral Cyclosporine in Iranian HSCT Patients. J Res Pharm Pract 2017; 6:77-82. [PMID: 28616429 PMCID: PMC5463553 DOI: 10.4103/jrpp.jrpp_16_163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Voriconazole as a triazole antifungal agent is widely used for prophylaxis or treatment of fungal infections in allogeneic hematopoietic stem cell transplantation (HSCT). It can increase blood concentrations of other medications including cyclosporine A (CsA) which are substrates for cytochrome P450 3A4. The aim of this study was to evaluate comparatively the interaction between oral/intravenous (IV) voriconazole and oral CsA. METHODS Twenty-nine recipients of allogeneic HSCT who had been already on a steady dose of CsA and were started on oral or IV voriconazole were evaluated in a prospective cohort study. Blood concentration of CsA was determined before and 5-8 days after voriconazole initiation. Plasma concentration of voriconazole was measured in steady state. The changes in blood concentration of CsA after administration of voriconazole were evaluated. FINDINGS The concentration/dose (C/D) ratio of CsA increased significantly (P < 0.001) after voriconazole initiation in both routes of administration (8.40%-174.10% increase in C/D ratio). The C/D ratio alteration of CsA did not differ significantly between oral and IV voriconazole group (P = 0.405). There was a significant correlation in all patients between plasma concentration of voriconazole and percentage of CsA C/D ratio increment (P = 0.046). CONCLUSION There was a significant intrapatient variability in the magnitude of CsA blood concentration increment after voriconazole initiation. We also demonstrated that magnitude of drug interaction did not differ in IV and oral voriconazole administration. Furthermore, we found that the magnitude of drug interaction was correlated with plasma concentration of voriconazole.
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Affiliation(s)
| | - Molouk Hadjibabaie
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Vaezi
- Hematology-Oncology and Stem Cell Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ardeshir Ghavamzadeh
- Hematology-Oncology and Stem Cell Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Girmenia C, Iori AP. An update on the safety and interactions of antifungal drugs in stem cell transplant recipients. Expert Opin Drug Saf 2016; 16:329-339. [PMID: 28004589 DOI: 10.1080/14740338.2017.1273900] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Invasive fungal diseases (IFDs) are a major cause of morbidity and mortality in patients undergoing allogeneic hematopoietic stem cell transplant (HSCT). Improvement in the management of IFDs have been achieved with the availability of new effective and safe antifungal drugs, however, many of these newer treatments have some limitations in their variable toxicity and unique predisposition for pharmacokinetic drug-drug interactions. Areas covered: This article is an update of a previous review published in this journal evaluating the safety profile of the antifungal drugs. Interesting new features include the availability of the new drug isavuconazole and the new tablet and intravenous formulations of posaconazole. Different dosages and new ways of administration of liposomal Amphotericin B (L-AmB) and echinocandins may be considered in the HSCT practice. Expert opinion: Nephrotoxicity continues to be a clinically relevant and frequent side effect of L-AmB which may cause a reduced clearance of other renally eliminated drugs frequently used in HSCT patients. Echinocandins are favorable therapeutic options in view of their low toxicity and uncommon drug-drug interactions. Important limitations of triazoles are represented by hepatic toxicity and certain side effects particularly after prolonged treatments. The new triazole isavuconazole and the new tablet formulation of posaconazole will be probably increasingly used in the HSCT setting not only due to their efficacy but in particular for their interesting toxicity profile and pharmacokinetic characteristics. The knowledge of these pharmacological findings is crucial in the daily care of allogeneic HSCT patients.
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Affiliation(s)
- Corrado Girmenia
- a Dipartimento di Ematologia, Oncologia, Anatomia Patologica e Medicina Rigenerativa, Azienda Policlinico Umberto I , Sapienza University , Rome , Italy
| | - Anna Paola Iori
- a Dipartimento di Ematologia, Oncologia, Anatomia Patologica e Medicina Rigenerativa, Azienda Policlinico Umberto I , Sapienza University , Rome , Italy
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Al Hammadi A, Ostrosky-Zeichner L. Epidemiology and Management of Candidiasis in Solid Organ Transplant Recipients. CURRENT FUNGAL INFECTION REPORTS 2016. [DOI: 10.1007/s12281-016-0269-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Dauchy FA, Bonhivers M, Landrein N, Dacheux D, Courtois P, Lauruol F, Daulouède S, Vincendeau P, Robinson DR. Trypanosoma brucei CYP51: Essentiality and Targeting Therapy in an Experimental Model. PLoS Negl Trop Dis 2016; 10:e0005125. [PMID: 27855164 PMCID: PMC5113867 DOI: 10.1371/journal.pntd.0005125] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 10/24/2016] [Indexed: 01/03/2023] Open
Abstract
Trypanosoma brucei gambiense is the main causative agent of Human African Trypanosomiasis (HAT), also known as sleeping sickness. Because of limited alternatives and treatment toxicities, new therapeutic options are urgently needed for patients with HAT. Sterol 14alpha-demethylase (CYP51) is a potential drug target but its essentiality has not been determined in T. brucei. We used a tetracycline-inducible RNAi system to assess the essentiality of CYP51 in T. brucei bloodstream form (BSF) cells and we evaluated the effect of posaconazole, a well-tolerated triazole drug, within a panel of virulent strains in vitro and in a murine model. Expression of CYP51 in several T. brucei cell lines was demonstrated by western blot and its essentiality was demonstrated by RNA interference (CYP51RNAi) in vitro. Following reduction of TbCYP51 expression by RNAi, cell growth was reduced and eventually stopped compared to WT or non-induced cells, showing the requirement of CYP51 in T. brucei. These phenotypes were rescued by addition of ergosterol. Additionally, CYP51RNAi induction caused morphological defects with multiflagellated cells (p<0.05), suggesting cytokinesis dysfunction. The survival of CYP51RNAi Doxycycline-treated mice (p = 0.053) and of CYP51RNAi 5-day pre-induced Doxycycline-treated mice (p = 0.008) were improved compared to WT showing a CYP51 RNAi effect on trypanosomal virulence in mice. The posaconazole concentrations that inhibited parasite growth by 50% (IC50) were 8.5, 2.7, 1.6 and 0.12 μM for T. b. brucei 427 90-13, T. b. brucei Antat 1.1, T. b. gambiense Feo (Feo/ITMAP/1893) and T. b. gambiense Biyamina (MHOM/SD/82), respectively. During infection with these last three virulent strains, posaconazole-eflornithine and nifurtimox-eflornithine combinations showed similar improvement in mice survival (p≤0.001). Our results provide support for a CYP51 targeting based treatment in HAT. Thus posaconazole used in combination may represent a therapeutic alternative for trypanosomiasis.
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Affiliation(s)
- Frédéric-Antoine Dauchy
- University of Bordeaux, laboratoire de parasitologie, France
- IRD-CIRAD-University of Bordeaux, France
- University Hospital of Bordeaux, Department of infectious and tropical diseases, Hôpital Pellegrin, France
- * E-mail:
| | - Mélanie Bonhivers
- University of Bordeaux, Microbiologie Fondamentale et Pathogénicité, France
- CNRS, Microbiologie Fondamentale et Pathogénicité, France
| | - Nicolas Landrein
- University of Bordeaux, Microbiologie Fondamentale et Pathogénicité, France
- CNRS, Microbiologie Fondamentale et Pathogénicité, France
| | - Denis Dacheux
- University of Bordeaux, Microbiologie Fondamentale et Pathogénicité, France
- CNRS, Microbiologie Fondamentale et Pathogénicité, France
- Bordeaux INP, ENSTBB, Microbiologie Fondamentale et Pathogénicité, France
| | - Pierrette Courtois
- University of Bordeaux, laboratoire de parasitologie, France
- IRD-CIRAD-University of Bordeaux, France
| | - Florian Lauruol
- University of Bordeaux, laboratoire de parasitologie, France
- IRD-CIRAD-University of Bordeaux, France
| | - Sylvie Daulouède
- University of Bordeaux, laboratoire de parasitologie, France
- IRD-CIRAD-University of Bordeaux, France
| | - Philippe Vincendeau
- University of Bordeaux, laboratoire de parasitologie, France
- IRD-CIRAD-University of Bordeaux, France
- University Hospital of Bordeaux, laboratoire de parasitologie, Hôpital Pellegrin, France
| | - Derrick R. Robinson
- University of Bordeaux, Microbiologie Fondamentale et Pathogénicité, France
- CNRS, Microbiologie Fondamentale et Pathogénicité, France
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Pieper JB, Dirikolu L, Campbell KL, Li Z, Mitchell MA. Evaluation of the effect of fluconazole on the pharmacokinetics of cyclosporin A in healthy dogs after a single dose and at steady-state. J Vet Pharmacol Ther 2016; 40:304-308. [DOI: 10.1111/jvp.12352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 07/18/2016] [Indexed: 11/28/2022]
Affiliation(s)
- J. B. Pieper
- Department of Veterinary Clinical Medicine; University of Illinois; Urbana IL USA
| | - L. Dirikolu
- Department of Comparative Biomedical Sciences; Louisiana State University; Baton Rouge LA USA
| | - K. L. Campbell
- Department of Veterinary Clinical Medicine; University of Illinois; Urbana IL USA
| | - Z. Li
- Metabolomics Center of Roy J. Carver Biotechnology Center; University of Illinois; Urbana IL USA
| | - M. A. Mitchell
- Department of Veterinary Clinical Medicine; University of Illinois; Urbana IL USA
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Antifungal Prophylaxis in Immunocompromised Patients. Mediterr J Hematol Infect Dis 2016; 8:e2016040. [PMID: 27648203 PMCID: PMC5016014 DOI: 10.4084/mjhid.2016.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 07/04/2016] [Indexed: 11/08/2022] Open
Abstract
Invasive fungal infections (IFIs) represent significant complications in patients with hematological malignancies. Chemoprevention of IFIs may be important in this setting, but most antifungal drugs have demonstrated poor efficacy, particularly in the prevention of invasive aspergillosis. Antifungal prophylaxis in hematological patients is currently regarded as the gold standard in situations with a high risk of infection, such as acute leukemia, myelodysplastic syndromes, and autologous or allogeneic hematopoietic stem cell transplantation. Over the years, various scientific societies have established a series of recommendations for antifungal prophylaxis based on prospective studies performed with different drugs. However, the prescription of each agent must be personalized, adapting its administration to the characteristics of individual patients and taking into account possible interactions with concomitant medication.
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Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Geertsma F, Hoover SE, Johnson RH, Kusne S, Lisse J, MacDonald JD, Meyerson SL, Raksin PB, Siever J, Stevens DA, Sunenshine R, Theodore N. 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clin Infect Dis 2016; 63:e112-46. [PMID: 27470238 DOI: 10.1093/cid/ciw360] [Citation(s) in RCA: 319] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 12/17/2022] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.Coccidioidomycosis, also known as San Joaquin Valley fever, is a systemic infection endemic to parts of the southwestern United States and elsewhere in the Western Hemisphere. Residence in and recent travel to these areas are critical elements for the accurate recognition of patients who develop this infection. In this practice guideline, we have organized our recommendations to address actionable questions concerning the entire spectrum of clinical syndromes. These can range from initial pulmonary infection, which eventually resolves whether or not antifungal therapy is administered, to a variety of pulmonary and extrapulmonary complications. Additional recommendations address management of coccidioidomycosis occurring for special at-risk populations. Finally, preemptive management strategies are outlined in certain at-risk populations and after unintentional laboratory exposure.
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Affiliation(s)
| | - Neil M Ampel
- Division of Infectious Diseases, University of Arizona, Tucson
| | - Janis E Blair
- Division of Infectious Diseases, Mayo Clinic, Scottsdale, Arizona
| | - Antonino Catanzaro
- Division of Pulmonary and Critical Care, University of California, San Diego
| | - Francesca Geertsma
- Department of Pediatrics, Infectious Diseases, Stanford University School of Medicine, California
| | | | - Royce H Johnson
- David Geffen School of Medicine at UCLA, Department of Medicine, Kern Medical Center, Bakersfield, California
| | - Shimon Kusne
- Division of Infectious Diseases, Mayo Clinic, Scottsdale, Arizona
| | - Jeffrey Lisse
- Department of Rheumatology, University of Arizona, Tucson
| | - Joel D MacDonald
- Department of Neurosurgery School of Medicine, University of Utah, Salt Lake City
| | - Shari L Meyerson
- Division of Thoracic Surgery, Northwestern University, Feinberg School of Medicine
| | - Patricia B Raksin
- Division of Neurosurgery, John H. Stroger Jr Hospital of Cook County, Chicago, Illinois
| | | | - David A Stevens
- Division of Infectious Diseases, Stanford University School of Medicine, California
| | - Rebecca Sunenshine
- Career Epidemiology Field Officer Program, Division of State and Local Readiness, Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention Maricopa County Department of Public Health
| | - Nicholas Theodore
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
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Deyo JC, Nicolsen N, Lachiewicz A, Kozlowski T. Salvage Treatment of Mucormycosis Post-Liver Transplant With Posaconazole During Sirolimus Maintenance Immunosuppression. J Pharm Pract 2016; 30:261-265. [PMID: 26864621 DOI: 10.1177/0897190016628702] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We describe the first successful case of posaconazole salvage therapy for mucormycosis with concomitant sirolimus (SRL) maintenance immunosuppression following liver transplantation, despite black box drug interaction following intolerance to first-line tacrolimus and amphotericin due to nephrotoxicity and neurotoxicity. This case describes a 55-year-old female who developed rhinocerebral mucormycosis 108 days after liver transplantation. After 3 months of posaconazole therapy, the patient remains free of disease at 3 years posttransplant. This case report illustrates successful resolution of mucormycosis without SRL toxicity to resolve nephrotoxicity of long-term amphotericin on top of already nephrotoxic immunosuppression. With higher bioavailability of recently FDA-approved posaconazole delayed release tablets, this azole may be a therapeutic option for transplant patients who need to remain on CYP3A4-metabolized immunosuppressive agents.
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Affiliation(s)
- Jennifer C Deyo
- 1 Department of Pharmacy, University of North Carolina, Memorial Hospital, Chapel Hill, NC, USA
| | - Nicole Nicolsen
- 2 Department of Pharmacy, Vidant Medical Center, Greenville, NC, USA
| | - Anne Lachiewicz
- 3 Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Tomasz Kozlowski
- 4 Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
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Wasko JA, Westholder JS, Jacobson PA. Rifampin-sirolimus-voriconazole interaction in a hematopoietic cell transplant recipient. J Oncol Pharm Pract 2016; 23:75-79. [PMID: 26763003 DOI: 10.1177/1078155215624263] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose Patients undergoing hematopoietic cell transplantation are treated with multiple medications, potentially complicated by drug-drug interactions. Drug interactions with sirolimus, voriconazole, and rifampin are particularly difficult because of the complex and simultaneous enzyme inhibition and induction mechanisms. We report a hematopoietic cell transplantation patient receiving sirolimus and voriconazole who was given rifampin while being treated for presumed methicillin-resistant Staphylococcus aureus meningitis. Summary A 31 year-old female received a nonmyeloablative allogeneic umbilical cord hematopoietic cell transplantation for myelodysplastic syndrome transformed to acute myeloid leukemia (AML). Her graft versus host disease and antifungal prophylaxis included sirolimus and voriconazole, respectively. Therapeutic drug monitoring prior to admission revealed a stable outpatient sirolimus regimen of 0.4 mg orally daily (trough goal 3-12 mcg/L). She was admitted to the inpatient hematopoietic cell transplantation service and diagnosed with methicillin-resistant Staphylococcus aureus bacteremia and presumed bacterial meningitis 217 days after transplant. Intravenous rifampin and vancomycin were initiated and voriconazole was changed to micafungin. Sirolimus trough concentrations were undetectable two days after starting rifampin. Therapeutic sirolimus concentrations were achieved four days later, at a sirolimus dose of 16-18 mg orally daily. Rifampin was discontinued after nine days and the sirolimus dose was adjusted accordingly, maintaining therapeutic levels throughout follow-up. The patient suffered a flare of chronic skin graft versus host disease requiring etanercept, high-dose systemic steroids, and topical steroids. Conclusion To the best of our knowledge, this is the first report describing the management of sirolimus during the transition from voriconazole inhibition to rifampin induction. Clinicians should be aware of potential drug-drug interactions.
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Affiliation(s)
- Justin A Wasko
- 1 Department of Pharmacy, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - James S Westholder
- 1 Department of Pharmacy, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Pamala A Jacobson
- 2 Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, USA
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Management of Everolimus and Voriconazole Interaction in Lung Transplant Patients. Ther Drug Monit 2016; 38:305-12. [DOI: 10.1097/ftd.0000000000000294] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yamashita T, Fujishima N, Miura M, Niioka T, Abumiya M, Shinohara Y, Ubukawa K, Nara M, Fujishima M, Kameoka Y, Tagawa H, Hirokawa M, Takahashi N. Effects of CYP3A5 polymorphism on the pharmacokinetics of a once-daily modified-release tacrolimus formulation and acute kidney injury in hematopoietic stem cell transplantation. Cancer Chemother Pharmacol 2016; 78:111-8. [PMID: 27217047 PMCID: PMC4921119 DOI: 10.1007/s00280-016-3060-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 05/10/2016] [Indexed: 12/12/2022]
Abstract
Background Tacrolimus is metabolized by cytochrome P450 (CYP) 3A4 and 3A5. We investigated the influence of CYP3A5 polymorphism and concurrent use of azole antifungal agents (AZ) on the pharmacokinetics of a once-daily modified-release tacrolimus formulation (Tac-QD) in patients after hematopoietic stem cell transplantation (HSCT). Design and methods Twenty-four patients receiving allogeneic HSCT were enrolled. Genotyping for CYP3A5*3 was done by a PCR-restriction fragment length polymorphism method. Trough blood concentrations (C0) of tacrolimus were measured by chemiluminescence magnetic microparticle immunoassay. Continuous infusion of tacrolimus was administered from the day before transplantation and was switched to Tac-QD after adequate oral intake. Results Thirteen patients had a CYP3A5*3/*3 genotype, and 11 patients had a CYP3A5*1/*1 or *1/*3 genotype. No significant difference was observed in daily dosages and the C0 of tacrolimus between the two genotype groups without AZ. However, in patients who were co-administered AZ, the C0 values of tacrolimus were higher in patients with the CYP3A5*3/*3 allele than with the CYP3A5*1 allele (P = 0.034), although daily doses of Tac-QD in patients with CYP3A5*3/*3 were significantly lower than those with the CYP3A5*1 allele (P = 0.041). The cumulative incidence of acute kidney injury was higher in patients with the CYP3A5*3/*3 than with the CYP3A5*1 allele when AZ was co-administered. The decrement for daily dosage of Tac-QD was significantly greater in patients expressing the CYP3A5*3/*3 than the CYP3A5*1 allele. Conclusions CYP3A5 genotyping may be useful for safe and effective immunosuppressive therapy with Tac-QD in HSCT patients in whom the use of AZ is anticipated. Electronic supplementary material The online version of this article (doi:10.1007/s00280-016-3060-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Takaya Yamashita
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Naohito Fujishima
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan. .,Division of Blood Transfusion, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan.
| | - Masatomo Miura
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Takenori Niioka
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Maiko Abumiya
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Yoshinori Shinohara
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Kumi Ubukawa
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Miho Nara
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Masumi Fujishima
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yoshihiro Kameoka
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Hiroyuki Tagawa
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Makoto Hirokawa
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan.,Department of General Internal Medicine and Clinical Laboratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Naoto Takahashi
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
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80
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Schmidt F, Marx-Stoelting P, Haider W, Heise T, Kneuer C, Ladwig M, Banneke S, Rieke S, Niemann L. Combination effects of azole fungicides in male rats in a broad dose range. Toxicology 2016; 355-356:54-63. [PMID: 27234313 DOI: 10.1016/j.tox.2016.05.018] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 05/21/2016] [Indexed: 12/16/2022]
Abstract
Two 28-day feeding studies were performed in male rats to investigate combination effects of azole fungicides in a broad dose range. Following separate administration of cyproconazole, epoxiconazole, prochloraz, propiconazole, and tebuconazole at five dose levels, the first three compounds were selected to be administered in two different mixtures at three dose levels including very low doses. Here we present the data obtained by clinical observations, pathology, histopathology, clinical chemistry and haematology. The liver was the common main target organ of all compounds and their mixtures. In addition, epoxiconazole exhibited an effect on the adrenals. Furthermore, food consumption and efficiency and body weight (gain) were affected. Adverse effects of the combinations were observed at dose levels at which the individual substances caused similar effects. No evidence of adverse effects was found at dose levels below the previously established NOAELs. Our findings indicate that the concept of dose additivity appears sufficiently protective for risk assessment of the fungicides examined. Besides toxicological testing, tissue residues of the azole compounds in liver, testis and kidney were determined revealing remarkable differences following administration of the single substances and of the mixtures.
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Affiliation(s)
- F Schmidt
- Federal Institute for Risk Assessment (BfR), Max-Dohrn-Strasse 8-10, D-10589 Berlin, Germany
| | - P Marx-Stoelting
- Federal Institute for Risk Assessment (BfR), Max-Dohrn-Strasse 8-10, D-10589 Berlin, Germany.
| | - W Haider
- Institute for Veterinary Pathology, Schönhauser Strasse 62, D-13127 Berlin, Germany
| | - T Heise
- Federal Institute for Risk Assessment (BfR), Max-Dohrn-Strasse 8-10, D-10589 Berlin, Germany
| | - C Kneuer
- Federal Institute for Risk Assessment (BfR), Max-Dohrn-Strasse 8-10, D-10589 Berlin, Germany
| | - M Ladwig
- Federal Institute for Risk Assessment (BfR), Max-Dohrn-Strasse 8-10, D-10589 Berlin, Germany; Faculty for Veterinary Medicine, Free University of Berlin, Königsweg 67, 14163 Berlin, Germany
| | - S Banneke
- Federal Institute for Risk Assessment (BfR), Max-Dohrn-Strasse 8-10, D-10589 Berlin, Germany
| | - S Rieke
- Federal Institute for Risk Assessment (BfR), Max-Dohrn-Strasse 8-10, D-10589 Berlin, Germany
| | - L Niemann
- Federal Institute for Risk Assessment (BfR), Max-Dohrn-Strasse 8-10, D-10589 Berlin, Germany
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81
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Viesselmann CW, Descourouez JL, Jorgenson MR, Radke NA, Odorico JS. Clinically Significant Drug Interaction Between Clotrimazole and Tacrolimus in Pancreas Transplant Recipients and Associated Risk of Allograft Rejection. Pharmacotherapy 2016; 36:335-41. [DOI: 10.1002/phar.1718] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Chris W. Viesselmann
- Department of Pharmacy; University of Wisconsin Hospital and Clinics; Madison Wisconsin
| | | | - Margaret R. Jorgenson
- Department of Pharmacy; University of Wisconsin Hospital and Clinics; Madison Wisconsin
| | - Nancy A. Radke
- Division of Transplant; Department of Surgery; University of Wisconsin Hospital and Clinics; Madison Wisconsin
| | - Jon S. Odorico
- Division of Transplant; Department of Surgery; University of Wisconsin-Madison School of Medicine and Public Health; University of Wisconsin Hospital and Clinics; Madison Wisconsin
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82
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Nakabayashi K, Matsumura A, Abiko Y, Mori H. Controlled Synthesis of Thiazole-Based Polymers and Block Copolymers by RAFT Polymerization of Azolyl S-Vinyl Sulfides and Metal Complexation. Macromolecules 2016. [DOI: 10.1021/acs.macromol.5b02573] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Kazuhiro Nakabayashi
- Department of Polymer Science and Engineering and ‡Department of Organic Device Engineering, Graduate School of Science and Engineering, Yamagata University, 4-3-16, Jonan, Yonezawa 992-8510, Japan
| | - Aiko Matsumura
- Department of Polymer Science and Engineering and ‡Department of Organic Device Engineering, Graduate School of Science and Engineering, Yamagata University, 4-3-16, Jonan, Yonezawa 992-8510, Japan
| | - Yohei Abiko
- Department of Polymer Science and Engineering and ‡Department of Organic Device Engineering, Graduate School of Science and Engineering, Yamagata University, 4-3-16, Jonan, Yonezawa 992-8510, Japan
| | - Hideharu Mori
- Department of Polymer Science and Engineering and ‡Department of Organic Device Engineering, Graduate School of Science and Engineering, Yamagata University, 4-3-16, Jonan, Yonezawa 992-8510, Japan
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83
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Mochizuki E, Furuhashi K, Fujisawa T, Enomoto N, Inui N, Nakamura Y, Kono M, Hamada E, Maekawa M, Suda T. A case of treatment with voriconazole for chronic progressive pulmonary aspergillosis in a patient receiving tacrolimus for dermatomyositis-associated interstitial lung disease. Respir Med Case Rep 2016; 16:163-5. [PMID: 26744690 PMCID: PMC4681998 DOI: 10.1016/j.rmcr.2015.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 10/25/2015] [Accepted: 10/29/2015] [Indexed: 11/28/2022] Open
Abstract
We report a successful treatment with voriconazole (VRCZ) for chronic progressive pulmonary aspergillosis (CPPA) in a patient with dermatomyositis-associated interstitial lung disease (DM-ILD) treated with tacrolimus. A 73-year-old man with DM-ILD, treated with tacrolimus and prednisolone, complained of productive cough and his chest X-ray showed infiltration in the left upper lung field. We diagnosed CPPA and added VRCZ. Although we reduced the dose of tacrolimus for drug interaction, serum VRCZ level increased after the treatment. The patient was found to have cytochrome P450 (CYP) 2C19 *2/*2, a genetic polymorphism in poor metabolizers of VRCZ. We adjusted the doses of both drugs and treated him successfully. We recommend performing individual therapeutic drug monitoring (TDM) in CYP-mediated drug interactions and considering the effect of CYP polymorphisms.
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Affiliation(s)
- Eisuke Mochizuki
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kazuki Furuhashi
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomoyuki Fujisawa
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Noriyuki Enomoto
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naoki Inui
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yutaro Nakamura
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Masato Kono
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan; Department of Laboratory Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Etsuko Hamada
- Department of Laboratory Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Masato Maekawa
- Department of Laboratory Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
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84
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Guerra CM, Formica RN, Kulkarni S, Asch WS, Tichy EM. Duration of Prophylaxis against Fungal Infection in Kidney Transplant Recipients. Prog Transplant 2015; 25:311-5. [DOI: 10.7182/pit2015929] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objective— To compare the efficacy of 2 strategies that use nystatin to prevent thrush and Candida esophagitis in kidney transplant recipients. Methods— A retrospective chart review was conducted of adult kidney transplant recipients at our center, where the protocol for prophylaxis against fungal infection was changed in March 2013. Before the protocol change, kidney transplant recipients received nystatin for 1 month (before group) and after the change they received nystatin for the duration of admission (after group). The primary outcome measure was the incidence of thrush and Candida esophagitis within 3 months after transplant. Analyses were conducted on all kidney transplant recipients (intention to treat) and on only those kidney transplant recipients who received at least 1 dose of nystatin (modified intention to treat). Additional data collected included the duration of nystatin and immunosuppression regimens. The Student t test and Fisher exact test were used to calculate P values for continuous and categorical data. Results— A total of 84 kidney transplant recipients, 42 in each cohort, were included in the analysis. The groups did not differ significantly at baseline. Nystatin was administered for a mean of 29 days in the before group and 5.74 days in the after group. Overall, 3 kidney transplant recipients (4%), all from the after group, experienced an episode of thrush and no patients experienced Candida esophagitis. Two recipients who experienced thrush did not receive any nystatin. Conclusions— Limiting the administration of nystatin to the duration of admission after transplant may be sufficient for prophylaxis of fungal infections in kidney transplant recipients.
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Affiliation(s)
- Christina M. Guerra
- Yale-New Haven Health System (CMG, RNF, SK, WSA, EMT), Yale University School of Medicine (RNF, SK, WSA), New Haven, Connecticut
| | - Richard N. Formica
- Yale-New Haven Health System (CMG, RNF, SK, WSA, EMT), Yale University School of Medicine (RNF, SK, WSA), New Haven, Connecticut
| | - Sanjay Kulkarni
- Yale-New Haven Health System (CMG, RNF, SK, WSA, EMT), Yale University School of Medicine (RNF, SK, WSA), New Haven, Connecticut
| | - William S. Asch
- Yale-New Haven Health System (CMG, RNF, SK, WSA, EMT), Yale University School of Medicine (RNF, SK, WSA), New Haven, Connecticut
| | - Eric M. Tichy
- Yale-New Haven Health System (CMG, RNF, SK, WSA, EMT), Yale University School of Medicine (RNF, SK, WSA), New Haven, Connecticut
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85
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Rybak JM, Marx KR, Nishimoto AT, Rogers PD. Isavuconazole: Pharmacology, Pharmacodynamics, and Current Clinical Experience with a New Triazole Antifungal Agent. Pharmacotherapy 2015; 35:1037-51. [DOI: 10.1002/phar.1652] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jeffrey M. Rybak
- Department of Clinical Pharmacy; University of Tennessee Health Science Center; Memphis Tennessee
| | - Kayleigh R. Marx
- Division of Pharmacy; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Andrew T. Nishimoto
- Department of Clinical Pharmacy; University of Tennessee Health Science Center; Memphis Tennessee
| | - P. David Rogers
- Department of Clinical Pharmacy; University of Tennessee Health Science Center; Memphis Tennessee
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86
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Role of New Antifungal Agents in the Treatment of Invasive Fungal Infections in Transplant Recipients: Isavuconazole and New Posaconazole Formulations. J Fungi (Basel) 2015; 1:345-366. [PMID: 29376915 PMCID: PMC5753129 DOI: 10.3390/jof1030345] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 10/06/2015] [Accepted: 10/06/2015] [Indexed: 11/30/2022] Open
Abstract
Invasive fungal infections are a major cause of morbidity and mortality among solid organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) recipients. Transplant patients are at risk for such invasive fungal infections. The most common invasive fungal infections are invasive candidiasis in the SOT and invasive aspergillosis in the HSCT. In this article, we will discuss the epidemiology of invasive fungal infections in the transplant recipients and susceptibility patterns of the fungi associated with these infections. Additionally, the pharmacology and clinical efficacy of the new antifungal, isavuconazole, and the new posaconazole formulations will be reviewed. Isavuconazole is a new extended-spectrum triazole that was recently approved for the treatment of invasive aspergillosis and mucormycosis. Advantages of this triazole include the availability of a water-soluble intravenous formulation, excellent bioavailability of the oral formulation, and predictable pharmacokinetics in adults. Posaconazole, a broad-spectrum triazole antifungal agent, is approved for the prevention of invasive aspergillosis and candidiasis in addition to the treatment of oropharyngeal candidiasis. Posaconazole oral suspension solution has shown some limitations in the setting of fasting state absorption, elevated gastrointestinal pH, and increased motility. The newly approved delayed-release oral tablet and intravenous solution formulations provide additional treatment options by reducing interpatient variability and providing flexibility in these set of critically ill patients. This review will detail these most recent studies.
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87
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Lempers VJC, Martial LC, Schreuder MF, Blijlevens NM, Burger DM, Aarnoutse RE, Brüggemann RJM. Drug-interactions of azole antifungals with selected immunosuppressants in transplant patients: strategies for optimal management in clinical practice. Curr Opin Pharmacol 2015. [DOI: 10.1016/j.coph.2015.07.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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88
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Effect of Genetic Polymorphism of CYP3A5 and CYP2C19 and Concomitant Use of Voriconazole on Blood Tacrolimus Concentration in Patients Receiving Hematopoietic Stem Cell Transplantation. Ther Drug Monit 2015; 37:581-8. [DOI: 10.1097/ftd.0000000000000182] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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89
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Chau MM, Kong DCM, van Hal SJ, Urbancic K, Trubiano JA, Cassumbhoy M, Wilkes J, Cooper CM, Roberts JA, Marriott DJE, Worth LJ. Consensus guidelines for optimising antifungal drug delivery and monitoring to avoid toxicity and improve outcomes in patients with haematological malignancy, 2014. Intern Med J 2015; 44:1364-88. [PMID: 25482746 DOI: 10.1111/imj.12600] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Antifungal agents may be associated with significant toxicity or drug interactions leading to sub-therapeutic antifungal drug concentrations and poorer clinical outcomes for patients with haematological malignancy. These risks may be minimised by clinical assessment, laboratory monitoring, avoidance of particular drug combinations and dose modification. Specific measures, such as the optimal timing of oral drug administration in relation to meals, use of pre-hydration and electrolyte supplementation may also be required. Therapeutic drug monitoring (TDM) of antifungal agents is warranted, especially where non-compliance, non-linear pharmacokinetics, inadequate absorption, a narrow therapeutic window, suspected drug interaction or unexpected toxicity are encountered. Recommended indications for voriconazole and posaconazole TDM in the clinical management of haematology patients are provided. With emerging knowledge regarding the impact of pharmacogenomics upon metabolism of azole agents (particularly voriconazole), potential applications of pharmacogenomic evaluation to clinical practice are proposed.
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Affiliation(s)
- M M Chau
- Pharmacy Department, The Royal Melbourne Hospital, Melbourne Health, Parkville, Victoria
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90
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Cho E, Chan H, Nguyen HM, Shayani S, Nakamura R, Pon D. Management of Drug Interaction between Posaconazole and Sirolimus in Patients Who Undergo Hematopoietic Stem Cell Transplant. Pharmacotherapy 2015; 35:578-85. [DOI: 10.1002/phar.1600] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Eunah Cho
- Department of Pharmacy; Sharp HealthCare; San Diego California
| | - Holly Chan
- Department of Pharmacy; City of Hope National Medical Center; Duarte California
| | - Huan Mark Nguyen
- College of Pharmacy; Western University of Health Sciences; Pomona California
- Department of Pharmacy; St. Mary Medical Center; Long Beach California
| | - Sepideh Shayani
- Department of Pharmacy; City of Hope National Medical Center; Duarte California
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Stem Cell Transplantation; City of Hope National Medical Center; Duarte California
| | - Doreen Pon
- Department of Pharmacy; City of Hope National Medical Center; Duarte California
- College of Pharmacy; Western University of Health Sciences; Pomona California
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91
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Abstract
Objective: To review the pharmacology, chemistry, in vitro susceptibility, pharmacokinetics, clinical efficacy, safety, tolerability, dosage, and administration of isavuconazole, a triazole antifungal agent. Data Sources: Studies and reviews were identified through an English language MEDLINE search (1978 to March 2015) and from http://www.clinicaltrials.gov , Food and Drug Administration (FDA) briefing documents, program abstracts from international symposia, and the manufacturer’s Web site. Study Selection and Data Extraction: All published and unpublished trials, abstracts, in vitro and preclinical studies, and FDA briefing documents were reviewed. Data Synthesis: Isavuconazole has activity against a number of clinically important yeasts and molds, including Candida spp, Aspergillus spp, Cryptococcus neoformans, and Trichosporon spp and variable activity against the Mucorales. Isavuconazole, available for both oral and intravenous administration, is characterized by slow elimination allowing once-daily dosing, extensive tissue distribution, and high (>99%) protein binding. The most commonly reported adverse events, which are mild and limited in nature, include nausea, diarrhea, and elevated liver function tests. Its drug interaction potential appears to be similar to other azole antifungals but less than those observed with voriconazole. Comparative trials are under way or have been recently completed for the treatment of candidemia, invasive candidiasis and aspergillosis, and rare mold infections. Conclusions: Isavuconazole has a broad spectrum of activity and favorable pharmacokinetic properties, providing an advantage over other currently available broad-spectrum azole antifungals and a clinically useful alternative to voriconazole for the treatment of invasive aspergillosis. It may also prove useful for the treatment of candidemia and invasive mold infections; however, these indications await the results of clinical trials.
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Affiliation(s)
- Natasha N. Pettit
- University of Chicago Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Peggy L. Carver
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
- University of Michigan Health System, Ann Arbor, MI, USA
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92
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Oda K, Yamano K, Otsuka Y. In vitro-in vivoextrapolations to evaluate the effect of concomitant drugs on tacrolimus (FK506) exposure. Biopharm Drug Dispos 2015; 36:265-74. [DOI: 10.1002/bdd.1938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 01/07/2015] [Accepted: 01/09/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Kazuo Oda
- Analysis and Pharmacokinetics Research Laboratories; Astellas Pharma Inc.; Yodogawa-ku Osaka 532-8514 Japan
| | - Katsuhiro Yamano
- Analysis and Pharmacokinetics Research Laboratories; Astellas Pharma Inc.; Yodogawa-ku Osaka 532-8514 Japan
| | - Yukio Otsuka
- Analysis and Pharmacokinetics Research Laboratories; Astellas Pharma Inc.; Yodogawa-ku Osaka 532-8514 Japan
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93
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Barchiesi F, Mazzocato S, Mazzanti S, Gesuita R, Skrami E, Fiorentini A, Singh N. Invasive aspergillosis in liver transplant recipients: epidemiology, clinical characteristics, treatment, and outcomes in 116 cases. Liver Transpl 2015; 21:204-12. [PMID: 25348192 DOI: 10.1002/lt.24032] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 10/13/2014] [Accepted: 10/19/2014] [Indexed: 12/31/2022]
Abstract
Invasive aspergillosis (IA) in liver transplant recipients is associated with grave outcomes. We reviewed 116 individual cases reported in the literature from 1985 to 2013. IA was diagnosed after a median of 25 days after transplantation and involved a single organ in 51% of the cases, whereas in the remaining cases, multiple sites were involved. The most common infecting Aspergillus species were Aspergillus fumigatus (73%), Aspergillus flavus (14%), and Aspergillus terreus (8%). Amphotericin B was the drug most frequently used, and it was followed by voriconazole and itraconazole. Combination regimens were used in 51% of the cases. The overall 1-year cumulative survival probability was 35% [95% confidence interval (CI) = 24.6%-49.6%]. Survival was significantly higher for patients reported from the year 2000 and thereafter (P < 0.001), for those diagnosed with IA more than 30 days after transplantation versus those diagnosed earlier (P = 0.019), and for patients without renal failure (P = 0.020). Additionally, the use of voriconazole was significantly associated with a higher probability of survival (P < 0.001). Cox regression analysis showed that subjects with the involvement of multiple sites had a 2.52 times higher risk of a negative outcome (95% CI = 1.08-5.87) than those with the involvement of a single site. Thus, IA causes life-threatening infections in liver transplant recipients. Predictors associated with poor outcomes may help clinicians to optimize the management of this infection.
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Affiliation(s)
- Francesco Barchiesi
- Infectious Diseases Clinic, Università Politecnica delle Marche, Ancona, Italy
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94
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Safety of voriconazole and sirolimus coadministration after allogeneic hematopoietic SCT. Bone Marrow Transplant 2015; 50:438-43. [PMID: 25599164 DOI: 10.1038/bmt.2014.286] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Revised: 10/27/2014] [Accepted: 11/04/2014] [Indexed: 12/21/2022]
Abstract
Antifungal prophylaxis with azoles is considered standard in allogeneic hematopoietic SCT (allo-HSCT). Although sirolimus is being used increasingly for the prevention of GVHD, it is a substrate of CYP3A4, which is inhibited by voriconazole, and concurrent administration can lead to significantly increased exposure to sirolimus. We identified 67 patients with hematologic malignancies who underwent allo-HSCT with sirolimus, tacrolimus and low-dose MTX and received concomitant voriconazole prophylaxis from April 2008 to June 2011. All patients underwent a non-myeloablative or reduced-intensity conditioned allo-HSCT. Patients received sirolimus and voriconazole concurrently for a median of 113 days. The median daily dose reduction of sirolimus at the start of coadministration was 90%. The median serum sirolimus trough levels before and at steady state of coadministration were 5.8 ng/mL (range: 0-47.6) and 6.1 ng/mL (range: 1-14.2) (P=0.45), respectively. One patient with an average sirolimus level of 6 ng/mL developed sirolimus-related thrombotic microangiopathy that resolved after sirolimus discontinuation. No sinusoidal obstructive syndrome was reported. Seventeen patients (25%) prematurely discontinued voriconazole because of the adverse events. Only two patients (3%) presented with possible invasive fungal infections at day 100. We demonstrate that sirolimus and voriconazole coadministration with an empiric 90% sirolimus dose reduction and close monitoring of sirolimus trough levels is safe and well tolerated.
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95
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Eschenauer GA, Kwak EJ, Humar A, Potoski BA, Clarke LG, Shields RK, Abdel-Massih R, Silveira FP, Vergidis P, Clancy CJ, Nguyen MH. Targeted versus universal antifungal prophylaxis among liver transplant recipients. Am J Transplant 2015; 15:180-9. [PMID: 25359455 PMCID: PMC4365781 DOI: 10.1111/ajt.12993] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 08/08/2014] [Accepted: 08/25/2014] [Indexed: 02/06/2023]
Abstract
Guidelines recommend targeted antifungal prophylaxis for liver transplant (LT) recipients based on tiers of risk, rather than universal prophylaxis. The feasibility and efficacy of tiered, targeted prophylaxis is not well established. We performed a retrospective study of LT recipients who received targeted prophylaxis (n = 145; voriconazole [VORI; 54%], fluconazole [8%], no antifungal [38%]) versus universal VORI prophylaxis (n = 237). Median durations of targeted and universal prophylaxis were 11 and 6 days, respectively (p < 0.0001). The incidence of invasive fungal infections (IFIs) in targeted and universal groups was 6.9% and 4.2% (p = 0.34). Overall, intra-abdominal candidiasis (73%) was the most common IFI. Posttransplant bile leaks (p = 0.001) and living donor transplants (p = 0.04) were independent risk factors for IFI. IFIs occurred in 6% of high-risk transplants who received prophylaxis and 4% of low-risk transplants who did not receive prophylaxis (p = 1.0). Mortality rates (100 days) were 10% (targeted) and 7% (universal) (p = 0.26); attributable mortality due to IFI was 10%. Compliance with prophylaxis recommendations was 97%. Prophylaxis was discontinued for toxicity in 2% of patients. Targeted antifungal prophylaxis in LT recipients was feasible and safe, effectively prevented IFIs and reduced the number of patients exposed to antifungals. Bile leaks and living donor transplants should be considered high-risk indications for prophylaxis.
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Affiliation(s)
- GA Eschenauer
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA,Antibiotic Management Program, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - EJ Kwak
- Antibiotic Management Program, University of Pittsburgh Medical Center, Pittsburgh, PA,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - A Humar
- Department of Surgery, University of Pittsburgh, and Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - BA Potoski
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA,Antibiotic Management Program, University of Pittsburgh Medical Center, Pittsburgh, PA,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - LG Clarke
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA,Antibiotic Management Program, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - RK Shields
- Antibiotic Management Program, University of Pittsburgh Medical Center, Pittsburgh, PA,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - R Abdel-Massih
- Antibiotic Management Program, University of Pittsburgh Medical Center, Pittsburgh, PA,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - FP Silveira
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - P Vergidis
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - CJ Clancy
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - MH Nguyen
- Antibiotic Management Program, University of Pittsburgh Medical Center, Pittsburgh, PA,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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96
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Evans JDW, Morris PJ, Knight SR. Antifungal prophylaxis in liver transplantation: a systematic review and network meta-analysis. Am J Transplant 2014; 14:2765-76. [PMID: 25395336 DOI: 10.1111/ajt.12925] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 06/09/2014] [Accepted: 07/04/2014] [Indexed: 01/25/2023]
Abstract
Invasive fungal infections (IFIs) cause significant morbidity and mortality in liver transplant recipients, but the need and best agent for prophylaxis is uncertain. A comprehensive literature search was performed to identify randomized controlled trials comparing regimens for antifungal prophylaxis in liver transplant recipients. Direct comparisons were made between treatments using random-effects meta-analysis and a Bayesian network meta-analysis was performed for the primary end point of proven IFI. Fourteen studies met inclusion criteria, reporting comparisons of fluconazole, liposomal amphotericin B (L-AmB), itraconazole, micafungin and placebo. Overall, antifungal prophylaxis reduced the rate of proven IFI (odds ratio [OR] 0.37, confidence interval [CI] 0.19-0.72, p = 0.003), suspected or proven IFI (OR 0.40, CI 0.25-0.66, p = 0.0003) and mortality due to IFI (OR 0.32, CI 0.10-0.83, p = 0.02) when compared to placebo. All-cause mortality was not significantly affected. There was no difference in risk of adverse events requiring cessation of prophylaxis (OR 1.11, 95% CI 0.48-2.55, p = 0.81). In the network meta-analysis an equivalent reduction in the rate of IFI was seen with fluconazole (OR 0.21, CI 0.06-0.57) and L-AmB (OR 0.21, CI 0.05-0.71) compared with placebo. Routine prophylaxis with fluconazole or L-AmB reduces the incidence of IFI following liver transplantation, and the available evidence suggests that the two are equivalent in efficacy.
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Affiliation(s)
- J D W Evans
- Department of Medicine, Cambridge University, Cambridge, UK; Centre for Evidence in Transplantation, Royal College of Surgeons of England and the London School of Hygiene and Tropical Medicine, London, UK
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97
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Gavaldà J, Meije Y, Fortún J, Roilides E, Saliba F, Lortholary O, Muñoz P, Grossi P, Cuenca-Estrella M. Invasive fungal infections in solid organ transplant recipients. Clin Microbiol Infect 2014; 20 Suppl 7:27-48. [DOI: 10.1111/1469-0691.12660] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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98
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Peksa GD, Schultz K, Fung HC. Dosing algorithm for concomitant administration of sirolimus, tacrolimus, and an azole after allogeneic hematopoietic stem cell transplantation. J Oncol Pharm Pract 2014; 21:409-15. [PMID: 24938293 DOI: 10.1177/1078155214539825] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplant patients are at risk of invasive fungal infections and prophylaxis with azole agents is common practice. The concomitant use of these agents with sirolimus and tacrolimus for the prevention of graft-versus-host disease may result in excessive immunosuppression or toxicity. METHODS This retrospective study identified hospitalized patients who underwent allogeneic hematopoietic stem cell transplantation between August 2009 and April 2011 at Rush University Medical Center. From this group, patients who underwent concomitant tacrolimus, sirolimus, and azole therapy were included for evaluation. The immunosuppression dosing in conjunction with azole use at discharge was analyzed to develop a dosing algorithm dependent on whether fluconazole, posaconazole, or voriconazole was used. RESULTS A total of 36 patients were screened for inclusion, of which 8 were excluded due to acute renal failure and/or hemolysis. The remaining patients were stratified by the azole they were concomitantly taking with tacrolimus and sirolimus. The fluconazole arm required the lowest magnitude of dose reductions, while voriconazole required the greatest. CONCLUSION Dose reductions of 50-75% for both sirolimus and tacrolimus, in combination with standard dosing of azole antifungal agents, were necessary to achieve therapeutic drug concentrations for immunosuppressants and potentially avoid toxicities.
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Affiliation(s)
- Gary D Peksa
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA
| | - Kathryn Schultz
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA
| | - Henry C Fung
- Division of Hematology, Oncology and Stem Cell Transplant, Rush University Medical Center, Chicago, IL, USA
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99
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Akan H, Antia VP, Kouba M, Sinkó J, Tănase AD, Vrhovac R, Herbrecht R. Preventing invasive fungal disease in patients with haematological malignancies and the recipients of haematopoietic stem cell transplantation: practical aspects. J Antimicrob Chemother 2014; 68 Suppl 3:iii5-16. [PMID: 24155144 DOI: 10.1093/jac/dkt389] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Invasive fungal disease (IFD), predominantly aspergillosis, is associated with significant morbidity and mortality in immunocompromised patients, especially those with haematological malignancies and recipients of allogeneic haematopoietic stem cell transplantation. There has been a great deal of scientific debate as to the effectiveness of antifungal prophylaxis in preventing infection in different patient groups and in which patients it is an appropriate management option. Deciding on an appropriate prophylaxis regimen for IFD is challenging as the incidence varies among different patient groups, due to the varied nature of their underlying haematological disease, and in different regions and centres. Attempts have been made to define risk factors and include them in treatment protocols. Impaired immune status of the patient, especially neutropenia, is a key risk factor for IFD and can sometimes be related to specific polymorphisms of genes controlling innate immunity. Risk factors also vary according to the type of fungal pathogen. Consequently, prophylaxis needs to be tailored to individual patient groups. Furthermore, the choice of antifungal agent for prophylaxis depends on the potential for drug-drug interactions with the patients' concomitant medications. Additional challenges are optimal timing of antifungal prophylaxis, when to change from prophylaxis to antifungal treatment and how to prevent recurrence of IFD. This article considers the use of antifungal prophylaxis for patients at risk of IFD in daily clinical practice, with clinical profiles that may be distinct from those covered by guidelines, and aims to provide practical advice for treatment of these patient groups.
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Affiliation(s)
- Hamdi Akan
- Department of Hematology, Ankara University Medical Faculty, Ankara, Turkey
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100
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Tischer S, Fontana RJ. Drug-drug interactions with oral anti-HCV agents and idiosyncratic hepatotoxicity in the liver transplant setting. J Hepatol 2014; 60:872-84. [PMID: 24280292 PMCID: PMC4784678 DOI: 10.1016/j.jhep.2013.11.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 11/14/2013] [Accepted: 11/17/2013] [Indexed: 02/06/2023]
Abstract
Studies of boceprevir and telaprevir based antiviral therapy in liver transplant (LT) recipients with hepatitis C genotype 1 infection have demonstrated dramatic increases in tacrolimus, cyclosporine, and mTOR inhibitor exposure. In addition to empiric dose reductions, daily monitoring of immunosuppressant blood levels is required when initiating as well as discontinuing the protease inhibitors to maximize patient safety. Although improved suppression of HCV replication is anticipated, 20 to 40% of treated subjects have required early treatment discontinuation due to various adverse events including anemia (100%), infection (30%), nephrotoxicity (20%) and rejection (5 to 10%). Simeprevir and faldaprevir will likely have improved efficacy and safety profiles but potential drug interactions with other OATP1B1 substrates and unconjugated hyperbilirubinemia are expected. In contrast, sofosbuvir and daclatasvir based antiviral therapy are not expected to lead to clinically significant drug-drug interactions in LT recipients but confirmatory studies are needed. Liver transplant recipients may also be at increased risk of developing drug induced liver injury (DILI). Establishing a diagnosis of DILI in the transplant setting is very difficult with the variable latency, laboratory features and histopathological manifestations of hepatotoxicity associated with a given drug, the need to exclude competing causes of allograft injury, and the lack of an objective and verifiable confirmatory test. Nonetheless, a heightened awareness of the possibility of DILI is warranted in light of the large number of medications used in LT recipients and the potential adverse impact that DILI may have on patient outcomes.
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Affiliation(s)
- Sarah Tischer
- Department of Pharmacy Services, University of Michigan Medical Center, Ann Arbor, MI 48109, United States
| | - Robert J Fontana
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI 48109, United States.
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