201
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Zalesak SM, Sanchez CR, Pich AA, Papich MG. Preliminary Pilot Study of Itraconazole After a Single Oral Dose of a Veterinary Formulation Solution in African Penguins ( Spheniscus demersus). J Avian Med Surg 2020; 34:52-56. [PMID: 32237682 DOI: 10.1647/1082-6742-34.1.52] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Aspergillosis is a common cause of morbidity and mortality in captive penguins. Itraconazole, an antifungal drug, is commonly used to treat aspergillosis infections in avian species; however, commercially available human formulations are costly, and studies have shown the effectiveness of compounded formulations to be unreliable. The US Food and Drug Administration (FDA) recently approved a veterinary formulation of itraconazole, Itrafungol, for use in cats. This study provides preliminary results from limited sampling evaluating whether this veterinary formulation is suitable for future studies in the African penguin (Spheniscus demersus). A 20 mg/kg PO itraconazole dose was administered to 9 African penguins. Blood samples were taken over the course of 24 hours; each sample was collected from a different bird to minimize stress to the animals. Plasma was analyzed by high-performance liquid chromatography for concentrations of itraconazole. The drug was absorbed in all penguins, and plasma concentrations in 5 of 9 penguins (56%) were found to be greater than the established therapeutic dose of 1.0 µg/ mL. To our knowledge, this is the first study that has investigated a 20 mg/kg dose of itraconazole in a penguin species. The small sample size limits the conclusions that can be drawn from this preliminary study. Nonetheless, we demonstrate encouraging evidence that the FDA-approved formulation of oral itraconazole solution should be considered for future study as a cost-effective treatment for aspergillosis in African penguins and other avian species.
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Affiliation(s)
- Selina M Zalesak
- College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA,
| | | | - Ashley A Pich
- College of Veterinary Medicine, Ohio State University, Columbus, OH 43210, USA
| | - Mark G Papich
- College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607, USA
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202
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Abstract
BACKGROUND Serum concentrations of voriconazole are difficult to predict, especially in pediatric patients, because of its complex pharmacokinetic characteristics. This study aimed to identify the factors associated with the concentration of voriconazole in pediatric patients. METHODS This cohort study was based on retrospective data collection and involved the administration of voriconazole to pediatric patients younger than 18 years, between January 2010 and August 2017. Electronic medical records of the patients were reviewed to collect demographic characteristics, voriconazole treatment regimen, and factors that could potentially influence voriconazole trough concentrations. A voriconazole trough serum concentration of less than 1.0 mcg/mL or greater than 5.5 mcg/mL was defined as outside the therapeutic range and was set as the outcome of this study. RESULTS Among the 114 patients enrolled, 61 patients were included in the analysis. Oral administration of a maintenance dose of voriconazole and C-reactive protein (CRP) level were significantly and independently associated with a low initial trough concentration of voriconazole (<1.0 mcg/mL). Alanine aminotransferase levels were a significant factor associated with a high initial trough concentration of voriconazole (>5.5 mcg/mL) after adjusting for sex, age, weight, and serum creatinine (odds ratio 5.42; 95% confidence interval 1.34-21.97). CONCLUSIONS Considering the variability of voriconazole concentrations in pediatric patients, monitoring certain parameters and considering the route of administration could help determine the therapeutic range of voriconazole and subsequently avoid unwanted effects.
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203
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Teng GJ, Bai XR, Zhang L, Liu HJ, Nie XH. Remission of hepatotoxicity in chronic pulmonary aspergillosis patients after lowering trough concentration of voriconazole. World J Clin Cases 2020; 8:4700-4707. [PMID: 33195637 PMCID: PMC7642544 DOI: 10.12998/wjcc.v8.i20.4700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 07/29/2020] [Accepted: 08/31/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Chronic pulmonary aspergillosis (CPA) is a rare syndrome that is often accompanied by gradual lung tissue destruction. Voriconazole is usually employed as the first-line agent for CPA treatment. However, some patients can develop hepatotoxicity and often were forced to stop voriconazole treatment.
AIM To record the improving trend of liver function and the therapeutic effects in patients after lowering the trough concentration of voriconazole.
METHODS This study retrospectively analyzed 12 adult CPA patients who developed hepatotoxicity during the voriconazole treatment. In these patients, the oral dose was reduced to 3/4 or 1/2 of the standard dose (4 mg/kg, twice daily), and the lower limit of voriconazole trough concentration was maintained more than 0.5 µg/mL. The trend of remission of liver toxicity after drug reduction in 12 patients was recorded. During the same period, 25 patients who received standard doses served as the control group. Data from the two groups were collected and analyzed for different parameters such as demographic characteristics, underlying pulmonary disorders, laboratory tests, and therapeutic effect. The differences between the two groups were statistically compared.
RESULTS Hepatotoxicity occurred in 12 patients within 28-65 d after oral voriconazole treatment. Hepatotoxicity was mainly manifested by the significantly increased level of gamma-glutamyltransferase and a slight increase of alanine aminotransferase and aspartate aminotransferase. The oral dose of voriconazole was reduced to approximately 3 mg/kg in seven patients and approximately 2 mg/kg in five patients. The average trough concentrations for the 12 patients before and after voriconazole oral dose reduction were 3.17 ± 1.47 µg/mL (1.5-6.0 µg/mL) and 1.70 ± 0.78 µg/mL (0.6-3.3 µg/mL), respectively (P = 0.02). After lowering the trough concentrations, the hepatotoxicity was alleviated in all the patients. However, gamma-glutamyltransferase levels declined slowly. After 4 mo of treatment, 7 of the 12 patients were successfully treated in the low trough concentrations group (41.7%). Similarly, 8 of the 25 patients in the standard treatment dose group (32.0%) were effectively treated. There was no statistical difference between the groups (P = 0.72).
CONCLUSION Reducing the lower limit of the voriconazole trough concentration to 0.5 µg/mL can alleviate the hepatotoxicity and maintained certain clinical efficacy in CPA patients; however, patients should be closely monitored.
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Affiliation(s)
- Guo-Jie Teng
- Department of Pulmonary and Critical Care Medicine, Xuanwu Hospital Capital Medical University, Beijing 100053, China
| | - Xiang-Rong Bai
- Pharmacy Department, Xuanwu Hospital Capital Medical University, Beijing 100053, China
| | - Lin Zhang
- Department of Pulmonary and Critical Care Medicine, Xuanwu Hospital Capital Medical University, Beijing 100053, China
| | - Hong-Jun Liu
- Department of Evidence-based Medicine, Xuanwu Hospital Capital Medical University, Beijing, China, Beijing 100053, China
| | - Xiu-Hong Nie
- Department of Pulmonary and Critical Care Medicine, Xuanwu Hospital Capital Medical University, Beijing 100053, China
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204
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Reslan Z, Lindsay J, Kerridge I, Gellatly R. Pharmacist review of high-risk haematology outpatients to improve appropriateness of antifungal prophylaxis. Int J Clin Pharm 2020; 42:1412-1418. [PMID: 33009604 DOI: 10.1007/s11096-020-01090-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 06/23/2020] [Indexed: 11/29/2022]
Abstract
Background Patients with haematological malignancies are at high risk of invasive fungal infections. However, there is a lack of information about the utilisation of the recommended Australian antifungal prophylaxis guidelines in haematology outpatients. Objective To assess the impact of a weekly pharmacist review of high-risk adult haematology outpatients on the utilisation of appropriate antifungal prophylaxis. Setting Outpatient cancer centre, tertiary referral hospital in Sydney, Australia. Method A 3-month pre-and post-interventional study was conducted. A retrospective audit was conducted to obtain baseline utilisation of antifungal guidelines in adult haematology outpatients with acute myeloid leukemia, acute lymphoblastic leukemia and myelodysplastic syndrome receiving chemotherapy. This was followed by a weekly pharmacist review over a 3-month period of all eligible outpatients assessing the appropriateness of antifungal agent, dose, use of therapeutic drug monitoring and presence of drug-interactions/contraindications. Recommendations to physicians were conveyed weekly and outcomes recorded. Main outcome measure Appropriate utilisation of antifungal prophylaxis guidelines in outpatient haematology patients before and after implementation of a 3-month weekly pharmacist review service. Results Forty patients were included in the retrospective group, equating to 348 reviews, while 42 patients equating to 269 reviews were included in the prospective group. Appropriate utilisation of antifungal prophylaxis guidelines increased from 31 to 54% post implementation of a pharmacist review (Odds Ratio = 2.44, 95% Confidence Interval: 1.07-5.58, p = 0.0344). The most common reason for nonadherence to guidelines in both groups was lack of therapeutic drug monitoring and failure to prescribe antifungal prophylaxis where indicated. The percentage of appropriate use of antifungal prophylaxis in patients with acute myeloid leukemia increased from 13 to 46% (p value < 0.01) after pharmacist intervention. The pharmacist made 153 recommendations from 269 reviews, with a percentage uptake of 40%. Moderate to severe drug interactions were identified in 19 reviews from 10 patients. One major azole antifungal-chemotherapy interaction was avoided. Conclusions Appropriate utilisation of antifungal prophylaxis guidelines can be improved through a regular pharmacist review. Future studies should identify whether improving adherence to antifungal guidelines leads to improved patient outcomes.
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Affiliation(s)
- Zainab Reslan
- Pharmacy Department, Royal North Shore Hospital, Level 1 ASB, Reserve Road, Sydney, NSW, Australia. .,Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia.
| | - Julian Lindsay
- Hematology and Bone Marrow Transplant Unit, Royal North Shore Hospital, Sydney, NSW, Australia.,National Centre for Infection in Cancer (NCIC), Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Ian Kerridge
- Hematology and Bone Marrow Transplant Unit, Royal North Shore Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health Science, University of Sydney, Sydney, NSW, Australia
| | - Rochelle Gellatly
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
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205
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Monserrat Villatoro J, García García I, Bueno D, de la Cámara R, Estébanez M, López de la Guía A, Abad-Santos F, Antón C, Mejía G, Otero MJ, Ramírez García E, Frías Iniesta J, Carcas A, Borobia AM. Randomised multicentre clinical trial to evaluate voriconazole pre-emptive genotyping strategy in patients with risk of aspergillosis: vorigenipharm study protocol. BMJ Open 2020; 10:e037443. [PMID: 33004392 PMCID: PMC7534724 DOI: 10.1136/bmjopen-2020-037443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Invasive aspergillosis is the most important cause of morbidity and mortality in patients with haematological diseases. At present, voriconazole is the first-line treatment for invasive fungal disease. The pharmacokinetic interindividual variability of voriconazole depends on genetic factors. CYP450 is involved in 70%-75% of total metabolism of voriconazole, mainly CYP3A4 and CYP2C19, with the remaining 25%-30% of metabolism conducted by monooxygenase flavins. CYP2C19 single nucleotide polymorphisms could explain 50%-55% of variability in voriconazole metabolism. MATERIALS AND METHODS The main objective is to compare efficiency of pre-emptive voriconazole genotyping with routine practice. The primary outcome is serum voriconazole on the fifth day within the therapeutic range. The secondary outcome is the combined variables of therapeutic failure and adverse events within 90 days of first administration, associated with voriconazole. A total of 146 patients at risk of invasive aspergillosis who will potentially receive voriconazole will be recruited, and CYP2C19 will be genotyped. If the patient ultimately receives voriconazole, they will be randomised (1:1 experimental/control). In the experimental arm, patients will receive a dose according to a pharmacogenetic algorithm, including CYP2C19 genotype and clinical and demographic information. In the control arm, patients will receive a dose according to clinical practice guidelines. In addition, a Spanish National Healthcare System (NHS) point-of-view cost-effectiveness evaluation will be performed. Direct cost calculations for each arm will be performed. CONCLUSION This trial will provide information about the viability and cost-effectiveness of the implementation of a pre-emptive voriconazole genotyping strategy in the Spanish NHS. ETHICS AND DISSEMINATION A Spanish version of this protocol has been evaluated and approved by the La Paz University Hospital Ethics Committee and the Spanish Agency of Medicines and Medical Devices. Trial results will be submitted for publication in an open peer-reviewed medical speciality-specific publication. TRIAL REGISTRATION NUMBER Eudra-CT: 2019-000376-41 and NCT04238884; Pre-results.
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Affiliation(s)
| | - Irene García García
- Clinical Pharmacology Department, Hospital Universitario La Paz IdiPAZ, Madrid, Spain
| | - David Bueno
- Pediatric Oncology and Haematology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Rafael de la Cámara
- Haematology Department, Hospital Universitario de la Princesa, Madrid, Spain
| | - Miriam Estébanez
- Internal Medicine Department, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain
| | | | - Francisco Abad-Santos
- Clinical Pharmacology Department, Hospital Universitario de la Princesa, Madrid, Spain
- Pharmacology Department, Universidad Autonoma de Madrid, Madrid, Spain
| | - Cristina Antón
- Health Technology Assessment Department, Universidad Francisco de Vitoria, Pozuelo de Alarcon, Madrid, Spain
| | - Gina Mejía
- Clinical Pharmacology Department, Hospital Universitario de la Princesa, Madrid, Spain
| | - María José Otero
- Haematology Department, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain
| | - Elena Ramírez García
- Clinical Pharmacology Department, Hospital Universitario La Paz IdiPAZ, Madrid, Spain
- Pharmacology Department, Universidad Autonoma de Madrid, Madrid, Spain
| | - Jesús Frías Iniesta
- Clinical Pharmacology Department, Hospital Universitario La Paz IdiPAZ, Madrid, Spain
- Pharmacology Department, Universidad Autonoma de Madrid, Madrid, Spain
| | - Antonio Carcas
- Clinical Pharmacology Department, Hospital Universitario La Paz IdiPAZ, Madrid, Spain
- Pharmacology Department, Universidad Autonoma de Madrid, Madrid, Spain
| | - Alberto M Borobia
- Clinical Pharmacology Department, Hospital Universitario La Paz IdiPAZ, Madrid, Spain
- Pharmacology Department, Universidad Autonoma de Madrid, Madrid, Spain
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206
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Sarli V, Ciofi L, Lastella M, Muscatello B, Pisaturo F, Paolilli O, Luci G, Cucchiara F, Pellegrini G, Bocci G, Danesi R, Di Paolo A. Appropriateness of repetitive therapeutic drug monitoring and laboratory turnaround time. Clin Chem Lab Med 2020; 57:e331-e333. [PMID: 31188753 DOI: 10.1515/cclm-2019-0429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 05/19/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Valentina Sarli
- Department of Laboratory medicine, AOUP University Hospital, Pisa, Italy
| | - Laura Ciofi
- Department of Laboratory medicine, AOUP University Hospital, Pisa, Italy
| | - Marianna Lastella
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Fioravante Pisaturo
- Department of Technical Health Professionals, AOUP University Hospital, Pisa, Italy
| | - Ombretta Paolilli
- Department of Technical Health Professionals, AOUP University Hospital, Pisa, Italy
| | - Giacomo Luci
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, 56126 Pisa, Italy, Phone: +39-050-2218755, Fax: +39-050-996477
| | - Federico Cucchiara
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Guido Bocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Unit of Clinical Pharmacology and Pharmacogenetics, AOUP University Hospital, Pisa, Italy
| | - Romano Danesi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Unit of Clinical Pharmacology and Pharmacogenetics, AOUP University Hospital, Pisa, Italy
| | - Antonello Di Paolo
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Unit of Clinical Pharmacology and Pharmacogenetics, AOUP University Hospital, Pisa, Italy
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207
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Fraser M, Borman AM, Thorn R, Lawrance LM. Resistance to echinocandin antifungal agents in the United Kingdom in clinical isolates of Candida glabrata: Fifteen years of interpretation and assessment. Med Mycol 2020; 58:219-226. [PMID: 31111912 DOI: 10.1093/mmy/myz053] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/02/2019] [Accepted: 04/24/2019] [Indexed: 01/08/2023] Open
Abstract
Candidemia is widely reported as the fourth most common form of bloodstream infection worldwide. Reports of breakthrough cases of candidemia are increasing, especially in the context of a move away from azole antifungals as prophylactic or first line treatment toward the use of echinocandin agents. The global evaluation of echinocandin antifungal susceptibility since 2003 has included switches in testing methodologies and the move to a sentinel echinocandin approach for classification reporting. This study compiles previously unpublished data from echinocandin susceptibility testing of UK clinical isolates of C. glabrata received at the Public Health England Mycology Reference Laboratory from 2003 to 2016 and reevaluates the prevalence of resistance in light of currently accepted testing protocols. From 2015 onward, FKS gene mutation detection using a novel Pyrosequencing® assay was assessed as a predictor of echinocandin resistance alongside conventional susceptibility testing. Overall, our data show that echinocandin resistance in UK isolates of C. glabrata is a rare phenomenon and prevalence has not appreciably increased in the last 14 years. The pyrosequencing assay was able to successfully detect hot spot mutations in FKS1 and FKS2, although not all isolates that exhibited phenotypic resistance demonstrated detectable hot spot mutations. We propose that a rapid genomic based detection method for FKS mutations, as part of a multifactorial approach to susceptibility testing, could help provide accurate and timely management decisions especially in regions where echinocandin resistance has been reported to be emerging in this important pathogen.
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Affiliation(s)
- Mark Fraser
- UK National Mycology Reference Laboratory, Public Health England, Bristol, UK.,Centre for Research in Bioscience, University of the West of England, Coldharbour Lane, Bristol, UK
| | - Andrew M Borman
- UK National Mycology Reference Laboratory, Public Health England, Bristol, UK
| | - Robin Thorn
- Centre for Research in Bioscience, University of the West of England, Coldharbour Lane, Bristol, UK
| | - Lynne M Lawrance
- Centre for Research in Bioscience, University of the West of England, Coldharbour Lane, Bristol, UK
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208
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Impact of Albumin and Omeprazole on Steady-State Population Pharmacokinetics of Voriconazole and Development of a Voriconazole Dosing Optimization Model in Thai Patients with Hematologic Diseases. Antibiotics (Basel) 2020; 9:antibiotics9090574. [PMID: 32899425 PMCID: PMC7557832 DOI: 10.3390/antibiotics9090574] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/30/2020] [Accepted: 09/01/2020] [Indexed: 01/16/2023] Open
Abstract
This study aimed to identify factors that significantly influence the pharmacokinetics of voriconazole in Thai adults with hematologic diseases, and to determine optimal voriconazole dosing regimens. Blood samples were collected at steady state in 65 patients (237 concentrations) who were taking voriconazole to prevent or treat invasive aspergillosis. The data were analyzed using a nonlinear mixed-effects modeling approach. Monte Carlo simulation was applied to optimize dosage regimens. Data were fitted with the one-compartment model with first-order absorption and elimination. The apparent oral clearance (CL/F) was 3.43 L/h, the apparent volume of distribution (V/F) was 47.6 L, and the absorption rate constant (Ka) was fixed at 1.1 h−1. Albumin and omeprazole ≥ 40 mg/day were found to significantly influence CL/F. The simulation produced the following recommended maintenance doses of voriconazole: 50, 100, and 200 mg every 12 h for albumin levels of 1.5–3, 3.01–4, and 4.01–4.5 g/dL, respectively, in patients who receive omeprazole ≤ 20 mg/day. Patients who receive omeprazole ≥ 40 mg/day and who have serum albumin level 1.5–3 and 3.01–4.5 g/dL should receive voriconazole 50 and 100 mg, every 12 h, respectively. Albumin level and omeprazole dosage should be carefully considered when determining the appropriate dosage of voriconazole in Thai patients.
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209
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Bernardo V, Miles A, Fernandez AJ, Liverman R, Tippett A, Yildirim I. Initial posaconazole dosing to achieve therapeutic serum posaconazole concentrations among children, adolescents, and young adults receiving delayed-release tablet and intravenous posaconazole. Pediatr Transplant 2020; 24:e13777. [PMID: 32639095 DOI: 10.1111/petr.13777] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/20/2020] [Accepted: 05/29/2020] [Indexed: 02/06/2023]
Abstract
Posaconazole is a broad-spectrum antifungal used for prophylaxis and treatment of invasive fungal diseases. There are limited data on the optimal dosing, safety, and efficacy of the DRT and IV formulations in immunocompromised pediatric and adolescent patients. We describe our experience including dosing, plasma trough concentrations, safety, and tolerability. Plasma concentrations ≥.7 µg/mL were considered therapeutic for prophylaxis and ≥1.0 µg/mL for treatment. Fifty-four patients (median age of 16 years) received DRT or IV formulations of posaconazole. Thirty-one (57%) patients received posaconazole for treatment and 23 (43%) for prophylaxis. Overall, 36 (67%) patients achieved targeted initial plasma trough concentrations (median 1.3 µg/mL) (Figure 1). The median daily dose among patients <13 years of age who achieved the targeted initial concentrations was 7.3 mg/kg/day for the DRT formulation and 9.8 mg/kg/day for the IV formulation. The median daily dose among patients ≥13 years of age who achieved the targeted initial concentrations was 4.9 mg/kg/day for the DRT formulation and 5.6 mg/kg/day for the IV formulation. Thirty-six patients (67%) developed transaminitis, mostly grade 1. Our observations show that DRT and IV formulations are safe and effective in immunocompromised children, adolescents, and young adults. Higher dosing per body weight of DRT and IV posaconazole may be required in patients <13 years of age compared with patients 13 years of age and older to achieve therapeutic plasma concentrations. [Figure: see text].
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Affiliation(s)
| | - Alyssa Miles
- University of North Carolina Health Care, Chapel Hill, NC, USA
| | | | | | - Ashley Tippett
- Division of Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Inci Yildirim
- Children's Healthcare of Atlanta, Atlanta, GA, USA.,Division of Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
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210
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Linder KA, Kauffman CA, Patel TS, Fitzgerald LJ, Richards BJ, Miceli MH. Evaluation of targeted versus universal prophylaxis for the prevention of invasive fungal infections following lung transplantation. Transpl Infect Dis 2020; 23:e13448. [PMID: 33448560 DOI: 10.1111/tid.13448] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/11/2020] [Accepted: 08/01/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Antifungal prophylaxis to prevent invasive fungal infections (IFI) is widely used following lung transplantation, but the optimal strategy remains unclear. We compared universal with targeted antifungal prophylaxis for effectiveness in preventing IFI. METHODS Adult patients who underwent lung transplantation at the University of Michigan from /1 July 2014-31 December 2017 were studied for 18 months post-transplant. Universal prophylaxis consisted of itraconazole with or without inhaled liposomal amphotericin B. Using specific criteria, targeted prophylaxis was given with voriconazole for patients at risk for invasive pulmonary aspergillosis (IPA) and with fluconazole or micafungin for patients at risk for invasive candidiasis. Risk factors, occurrence of proven/probable IFI, and mortality were analyzed for the two prophylaxis cohorts. RESULTS Of 105 lung transplant recipients, 84 (80%) received a double lung transplant, and 38 (36%) of patients underwent transplant for pulmonary fibrosis. Fifty-nine (56%) patients received universal antifungal prophylaxis, and 46 (44%), targeted antifungal prophylaxis. Among 20 proven/probable IFI, there were 14 IPA, 4 invasive candidiasis, 1 cryptococcosis, and 1 deep sternal mold infection. Six (10%) IFI occurred in the universal prophylaxis cohort and 14 (30%) in the targeted prophylaxis cohort. Five of 6 (83%) IFI in the universal prophylaxis cohort, compared with 9/14 (64%) in the targeted prophylaxis cohort, were IPA Candida infections occurred only in the targeted prophylaxis cohort. The development of IFI was more likely in the targeted prophylaxis cohort than the universal prophylaxis cohort, HR = 4.32 (1.51-12.38), P = .0064. CONCLUSIONS Universal antifungal prophylaxis appears to be more effective than targeted antifungal prophylaxis for prevention of IFI after lung transplant.
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Affiliation(s)
- Kathleen A Linder
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Carol A Kauffman
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Twisha S Patel
- Department of Pharmacy, University of Michigan Health System, Ann Arbor, MI, USA
| | - Linda J Fitzgerald
- Department of Pharmacy, University of Michigan Health System, Ann Arbor, MI, USA
| | - Blair J Richards
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI, USA
| | - Marisa H Miceli
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI, USA
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211
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Safety studies and viral shedding of intramuscular administration of oncolytic vaccinia virus TG6002 in healthy beagle dogs. BMC Vet Res 2020; 16:307. [PMID: 32843040 PMCID: PMC7446062 DOI: 10.1186/s12917-020-02524-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 08/14/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Cancer is a leading cause of mortality for both humans and dogs. As spontaneous canine cancers appear to be relevant models of human cancers, developing new therapeutic approaches could benefit both species. Oncolytic virotherapy is a promising therapeutic approach in cancer treatment. TG6002 is a recombinant oncolytic vaccinia virus deleted in the thymidine kinase and ribonucleotide reductase genes and armed with the suicide gene FCU1 that encodes a protein which catalyses the conversion of the non-toxic 5-fluorocytosine into the toxic metabolite 5-fluorouracil. Previous studies have shown the ability of TG6002 to infect and replicate in canine tumor cell lines, and demonstrated its oncolytic potency in cell lines, xenograft models and canine mammary adenocarcinoma explants. Moreover, 5-fluorouracil synthesis has been confirmed in fresh canine mammary adenocarcinoma explants infected with TG6002 with 5-fluorocytosine. This study aims at assessing the safety profile and viral shedding after unique or repeated intramuscular injections of TG6002 in seven healthy Beagle dogs. RESULTS Repeated intramuscular administrations of TG6002 at the dose of 5 × 107 PFU/kg resulted in no clinical or biological adverse effects. Residual TG6002 in blood, saliva, urine and feces of treated dogs was not detected by infectious titer assay nor by qPCR, ensuring the safety of the virus in the dogs and their environment. CONCLUSIONS These results establish the good tolerability of TG6002 in healthy dogs with undetectable viral shedding after multiple injections. This study supports the initiation of further studies in canine cancer patients to evaluate the oncolytic potential of TG6002 and provides critical data for clinical development of TG6002 as a human cancer therapy.
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212
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Imai S, Momo K, Kashiwagi H, Miyai T, Sugawara M, Takekuma Y. Association of the ward pharmacy service with active implementation of therapeutic drug monitoring for vancomycin and teicoplanin-an epidemiological surveillance study using Japanese large health insurance claims database. J Pharm Health Care Sci 2020; 6:18. [PMID: 32832095 PMCID: PMC7436959 DOI: 10.1186/s40780-020-00174-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 08/11/2020] [Indexed: 12/04/2022] Open
Abstract
Background Ward pharmacists are required for the active implementation of therapeutic drug monitoring (TDM). This epidemiological study verified whether Japanese ward pharmacists contribute to improving the TDM implementation proportions of anti-methicillin-resistant Staphylococcus aureus (MRSA) agents using the large health insurance claims database. Methods The patients who received intravenous anti-MRSA agents from April 2012 to March 2017 were enrolled. We defined ward pharmacy service as the “drug management and guidance fee” and/or “inpatient pharmaceutical services premium”. In addition, implementation of TDM was identified by “the specific drug treatment management fee”. We compared the proportions of TDM implementation for vancomycin (VCM), teicoplanin (TEIC), and arbekacin (ABK) in the ward and non-ward pharmacy service groups. To avoid confounding, the propensity score method was employed. Moreover, the clinical variables affecting TDM implementation in each anti-MRSA agent were analyzed by using a multiple logistic regression model. Results The following number of patients were included in the study: VCM (n = 2138), TEIC (n = 596), and ABK (n = 142). After propensity score matching, the proportions of TDM implementation for VCM and TEIC were higher in the ward pharmacy service group than in the non-ward pharmacy service group (VCM: 69.2% vs 60.3%, TEIC: 51.4% vs 34.7%), while no significant difference was observed for ABK (21.2% vs 23.1%). As independent clinical variables affecting TDM implementation for VCM and TEIC, several clinical variables, including ward pharmacy services, were extracted. In contrast, no clinical variables were extracted for ABK. Conclusions We found that the ward pharmacy service is associated with the active implementation of TDM for anti-MRSA agents, such as VCM and TEIC.
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Affiliation(s)
- Shungo Imai
- Faculty of Pharmaceutical Sciences, Hokkaido University, Kita 12-jo Nishi 6-chome, Kita-ku, Sapporo, 060-0812 Japan
| | - Kenji Momo
- Department of Hospital Pharmaceutics, School of Pharmacy, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555 Japan
| | - Hitoshi Kashiwagi
- Faculty of Pharmaceutical Sciences, Hokkaido University, Kita 12-jo Nishi 6-chome, Kita-ku, Sapporo, 060-0812 Japan
| | - Takayuki Miyai
- Graduate School of Life Science, Hokkaido University, Kita 10-jo Nishi 8-chome, Kita-ku, Sapporo, 060-0810 Japan
| | - Mitsuru Sugawara
- Faculty of Pharmaceutical Sciences, Hokkaido University, Kita 12-jo Nishi 6-chome, Kita-ku, Sapporo, 060-0812 Japan.,Department of Pharmacy, Hokkaido University Hospital, Kita 14-jo, Nishi 5-chome, Kita-ku, Sapporo, 060-8648 Japan
| | - Yoh Takekuma
- Department of Pharmacy, Hokkaido University Hospital, Kita 14-jo, Nishi 5-chome, Kita-ku, Sapporo, 060-8648 Japan
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Pharmacokinetic/Pharmacodynamic Analysis of Voriconazole Against Candida spp. and Aspergillus spp. in Allogeneic Stem Cell Transplant Recipients. Ther Drug Monit 2020; 41:740-747. [PMID: 31136417 DOI: 10.1097/ftd.0000000000000657] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To evaluate the adequacy of different dosing regimens of voriconazole for the prophylaxis of invasive candidiasis and aspergillosis in adult allogeneic stem cell transplant recipients by means of population pharmacokinetic (PK) modelling and simulation. METHODS Allogeneic stem cell transplant recipients receiving voriconazole were included in this observational study. A population PK model was developed. Three oral voriconazole-dosing regimens were simulated: 200, 300, and 400 mg twice daily. The pharmacodynamic target was defined as fAUC0-24/0.7. A probability of target attainment ≥90% was considered optimal. The cumulative fraction of response was defined as the fraction of patients achieving the pharmacodynamic target when a population of simulated patients is matched with a simulated population of different Candida spp. and Aspergillus spp. The percentage of patients with trough plasma concentrations at steady state (Ctrough) within the reference range (1-5.5 mg/L) was also calculated. RESULTS A 2-compartment PK model was developed using data from 40 patients, which contributed 237 voriconazole plasma samples, including trough and maximum concentrations. Voriconazole 200, 300, and 400 mg twice daily achieved probability of target attainment ≥90% for minimal inhibitory concentration values ≤0.25, ≤0.38, and ≤0.50 mg/L, respectively. The cumulative fraction of response for A. niger, A. versicolor, and A. flavus increased >10% when increasing voriconazole dose from 200 to 400 mg twice daily (from 72.5% to 89.5% for A. niger; from 77.7% to 88.7% for A. versicolor; and from 82.4% to 94.9% for A flavus). The percentage of patients with Ctrough within the reference range increased 15% when voriconazole dose was increased from 200 to 300 mg twice daily. CONCLUSIONS The PK simulations in this study suggest that transplant recipients on voriconazole prophylaxis against invasive candidiasis or aspergillosis are likely to achieve the target concentrations associated with the desired treatment outcomes if the maintenance dose is 200 mg twice daily. However, Aspergillus spp. with high minimal inhibitory concentrations could require higher maintenance doses.
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214
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Alsultan A, Alghamdi WA, Alghamdi J, Alharbi AF, Aljutayli A, Albassam A, Almazroo O, Alqahtani S. Clinical pharmacology applications in clinical drug development and clinical care: A focus on Saudi Arabia. Saudi Pharm J 2020; 28:1217-1227. [PMID: 33132716 PMCID: PMC7584801 DOI: 10.1016/j.jsps.2020.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 08/14/2020] [Indexed: 01/10/2023] Open
Abstract
Drug development, from preclinical to clinical studies, is a lengthy and complex process. There is an increased interest in the Kingdom of Saudi Arabia (KSA) to promote innovation, research and local content including clinical trials (Phase I-IV). Currently, there are over 650 registered clinical trials in Saudi Arabia, and this number is expected to increase. An important part of drug development and clinical trials is to assure the safe and effective use of drugs. Clinical pharmacology plays a vital role in informed decision making during the drug development stage as it focuses on the effects of drugs in humans. Disciplines such as pharmacokinetics, pharmacodynamics and pharmacogenomics are components of clinical pharmacology. It is a growing discipline with a range of applications in all phases of drug development, including selecting optimal doses for Phase I, II and III studies, evaluating bioequivalence and biosimilar studies and designing clinical studies. Incorporating clinical pharmacology in research as well as in the requirements of regulatory agencies will improve the drug development process and accelerate the pipeline. Clinical pharmacology is also applied in direct patient care with the goal of personalizing treatment. Tools such as therapeutic drug monitoring, pharmacogenomics and model informed precision dosing are used to optimize dosing for patients at an individual level. In KSA, the science of clinical pharmacology is underutilized and we believe it is important to raise awareness and educate the scientific community and healthcare professionals in terms of its applications and potential. In this review paper, we provide an overview on the use and applications of clinical pharmacology in both drug development and clinical care.
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Affiliation(s)
- Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.,Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Wael A Alghamdi
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | - Jahad Alghamdi
- The Saudi Biobank, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abeer F Alharbi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh 11426, Saudi Arabia
| | | | - Ahmed Albassam
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | | | - Saeed Alqahtani
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.,Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia
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215
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De Rose DU, Cairoli S, Dionisi M, Santisi A, Massenzi L, Goffredo BM, Dionisi-Vici C, Dotta A, Auriti C. Therapeutic Drug Monitoring Is a Feasible Tool to Personalize Drug Administration in Neonates Using New Techniques: An Overview on the Pharmacokinetics and Pharmacodynamics in Neonatal Age. Int J Mol Sci 2020; 21:E5898. [PMID: 32824472 PMCID: PMC7460644 DOI: 10.3390/ijms21165898] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023] Open
Abstract
Therapeutic drug monitoring (TDM) should be adopted in all neonatal intensive care units (NICUs), where the most preterm and fragile babies are hospitalized and treated with many drugs, considering that organs and metabolic pathways undergo deep and progressive maturation processes after birth. Different developmental changes are involved in interindividual variability in response to drugs. A crucial point of TDM is the choice of the bioanalytical method and of the sample to use. TDM in neonates is primarily used for antibiotics, antifungals, and antiepileptic drugs in clinical practice. TDM appears to be particularly promising in specific populations: neonates who undergo therapeutic hypothermia or extracorporeal life support, preterm infants, infants who need a tailored dose of anticancer drugs. This review provides an overview of the latest advances in this field, showing options for a personalized therapy in newborns and infants.
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Affiliation(s)
- Domenico Umberto De Rose
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
| | - Sara Cairoli
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Marco Dionisi
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Alessandra Santisi
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
| | - Luca Massenzi
- Neonatal Intensive Care Unit and Neonatal Pathology, Fatebenefratelli Hospital, 00186 Rome, Italy;
| | - Bianca Maria Goffredo
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Carlo Dionisi-Vici
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Andrea Dotta
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
| | - Cinzia Auriti
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
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216
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Lee J, Ng P, Hamandi B, Husain S, Lefebvre MJ, Battistella M. Effect of Therapeutic Drug Monitoring and Cytochrome P450 2C19 Genotyping on Clinical Outcomes of Voriconazole: A Systematic Review. Ann Pharmacother 2020; 55:509-529. [DOI: 10.1177/1060028020948174] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objectives To examine current knowledge on the clinical utility of therapeutic drug monitoring (TDM) in voriconazole therapy, the impact of CYP2C19 genotype on voriconazole plasma concentrations, and the role of CYP2C19 genotyping in voriconazole therapy. Data Sources Three literature searches were conducted for original reports on (1) TDM and voriconazole outcomes and (2) voriconazole and CYP2C19 polymorphisms. Searches were conducted through EMBASE, MEDLINE/PubMed, Scopus, and Cochrane Central Register of Controlled Trials from inception to June 2020. Study Selection and Data Extraction Randomized controlled trials, cohort studies, and case series with ≥10 patients were included. Only full-text references in English were eligible. Data Synthesis A total of 63 studies were reviewed. TDM was recommended because of established concentration and efficacy/toxicity relationships. Voriconazole trough concentrations ≥1.0 mg/L were associated with treatment success; supratherapeutic concentrations were associated with increased neurotoxicity; and hepatotoxicity associations were more prevalent in Asian populations. CYP2C19 polymorphisms significantly affect voriconazole metabolism, but no relationship with efficacy/safety were found. Genotype-guided dosing with TDM was reported to increase chances of achieving therapeutic range. Relevance to Patient Care and Clinical Practice Genotype-guided dosing with TDM is a potential solution to optimizing voriconazole efficacy while avoiding treatment failures and common toxicities. Conclusions Voriconazole plasma concentrations and TDM are treatment outcome predictors, but research is needed to form a consensus target therapeutic range and dosage adjustment guidelines based on plasma concentrations. CYP2C19 polymorphisms are a predictor of voriconazole concentrations and metabolism, but clinical implications are not established. Large-scale, high-methodological-quality trials are required to investigate the role for prospective genotyping and establish CYP2C19-guided voriconazole dosing recommendations.
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Affiliation(s)
| | - Patrick Ng
- University Health Network, Toronto, ON, Canada
| | - Bassem Hamandi
- University of Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Shahid Husain
- University of Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | | | - Marisa Battistella
- University of Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
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217
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Lin S, Kuo C, Shen L, Chen Y, Hung C, Wu FL. Implementation and outcomes of a therapeutic drug monitoring program for antifungal and antiretroviral agents in a tertiary medical center in Taiwan. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Shu‐Wen Lin
- Graduate Institute of Clinical Pharmacy National Taiwan University College of Medicine Taipei Taiwan
- School of Pharmacy National Taiwan University College of Medicine Taipei Taiwan
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
| | - Ching‐Hua Kuo
- School of Pharmacy National Taiwan University College of Medicine Taipei Taiwan
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
| | - Li‐Jiuan Shen
- Graduate Institute of Clinical Pharmacy National Taiwan University College of Medicine Taipei Taiwan
- School of Pharmacy National Taiwan University College of Medicine Taipei Taiwan
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
| | - Yee‐Chun Chen
- Department of Internal Medicine National Taiwan University Hospital, National Taiwan University College of Medicine Taipei Taiwan
| | - Chien‐Ching Hung
- Department of Internal Medicine National Taiwan University Hospital, National Taiwan University College of Medicine Taipei Taiwan
- Department of Tropical Medicine and Parasitology National Taiwan University College of Medicine Taipei Taiwan
| | - Fe‐Lin Lin Wu
- Graduate Institute of Clinical Pharmacy National Taiwan University College of Medicine Taipei Taiwan
- School of Pharmacy National Taiwan University College of Medicine Taipei Taiwan
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
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218
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Elkheir LYM, Haroun R, Mohamed MA, Fahal AH. Madurella mycetomatis causing eumycetoma medical treatment: The challenges and prospects. PLoS Negl Trop Dis 2020; 14:e0008307. [PMID: 32853199 PMCID: PMC7452721 DOI: 10.1371/journal.pntd.0008307] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Lamis Y. M. Elkheir
- The Mycetoma Research Centre, University of Khartoum, Khartoum, Sudan
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
| | - Rayan Haroun
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
| | - Magdi Awadalla Mohamed
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
- Department of Pharmaceutical Chemistry, College of Pharmacy, Jouf University, Jouf, KSA
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219
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da Rosa Monte Machado G, Diedrich D, Ruaro TC, Zimmer AR, Lettieri Teixeira M, de Oliveira LF, Jean M, Van de Weghe P, de Andrade SF, Baggio Gnoatto SC, Fuentefria AM. Quinolines derivatives as promising new antifungal candidates for the treatment of candidiasis and dermatophytosis. Braz J Microbiol 2020; 51:1691-1701. [PMID: 32737869 PMCID: PMC7394049 DOI: 10.1007/s42770-020-00348-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/23/2020] [Indexed: 12/20/2022] Open
Abstract
Fungal infections have emerged as a current serious global public health problem. The main problem involving these infections is the expansion of multidrug resistance. Therefore, the prospection of new compounds with efficacy antifungal becomes necessary. Thus, this study evaluated the antifungal profile and toxicological parameters of quinolines derivatives against Candida spp. and dermatophyte strains. As a result, a selective anti-dermatophytic action was demonstrated by compound 5 (geometric means (GM = 19.14 μg ml−1)). However, compounds 2 (GM = 50 μg ml−1) and 3 (GM = 47.19 μg ml−1) have presented only anti-Candida action. Compounds 3 and 5 did not present cytotoxic action. Compound 5 did not produce dermal and mucosal toxicity. In addition, this compound showed the absence of genotoxic potential, suggesting safety for topical and systemic use. Quinolines demonstrated a potent anti-dermatophytic and anti-yeast action. Moreover, compound 5 presented an excellent toxicological profile, acting as a strong candidate for the development of a new effective and safe compound against dermatophytosis of difficult treatment.
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Affiliation(s)
- Gabriella da Rosa Monte Machado
- Postgraduate Program in Agricultural Microbiology and Environment, Federal University of Rio Grande do Sul, Sarmento Leite n° 500, Farroupilha, Porto Alegre, RS, 90050-170, Brazil. .,Laboratory of Applied Mycology - Faculty of Pharmacy, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
| | - Denise Diedrich
- Postgraduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Avenue Ipiranga, n° 2752 - Azenha, Porto Alegre, RS, 90610-000, Brazil
| | - Thaís Carine Ruaro
- Postgraduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Avenue Ipiranga, n° 2752 - Azenha, Porto Alegre, RS, 90610-000, Brazil
| | - Aline Rigon Zimmer
- Postgraduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Avenue Ipiranga, n° 2752 - Azenha, Porto Alegre, RS, 90610-000, Brazil
| | - Mário Lettieri Teixeira
- Pharmacology Laboratory, Federal Catarinense Institute, Highway SC 283 - Fragosos, Concórdia, SC, 89703-720, Brazil
| | - Luís Flávio de Oliveira
- Cell Toxicology Research Laboratory, Federal University of Pampa, BR 472 - Km 585, Uruguaiana, RS, 97501-970, Brazil
| | - Mickael Jean
- Natural Products Syntheses and Medicinal Chemistry Laboratory, Rennes University 1, Street du Thabor, 35000, Rennes, France
| | - Pierre Van de Weghe
- Natural Products Syntheses and Medicinal Chemistry Laboratory, Rennes University 1, Street du Thabor, 35000, Rennes, France
| | - Saulo Fernandes de Andrade
- Postgraduate Program in Agricultural Microbiology and Environment, Federal University of Rio Grande do Sul, Sarmento Leite n° 500, Farroupilha, Porto Alegre, RS, 90050-170, Brazil.,Postgraduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Avenue Ipiranga, n° 2752 - Azenha, Porto Alegre, RS, 90610-000, Brazil
| | - Simone Cristina Baggio Gnoatto
- Postgraduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Avenue Ipiranga, n° 2752 - Azenha, Porto Alegre, RS, 90610-000, Brazil
| | - Alexandre Meneghello Fuentefria
- Postgraduate Program in Agricultural Microbiology and Environment, Federal University of Rio Grande do Sul, Sarmento Leite n° 500, Farroupilha, Porto Alegre, RS, 90050-170, Brazil.,Postgraduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Avenue Ipiranga, n° 2752 - Azenha, Porto Alegre, RS, 90610-000, Brazil
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220
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Saito J, Tanzawa A, Kojo Y, Maruyama H, Isayama T, Shoji K, Ito Y, Yamatani A. A sensitive method for analyzing fluconazole in extremely small volumes of neonatal serum. J Pharm Health Care Sci 2020; 6:14. [PMID: 32626595 PMCID: PMC7329421 DOI: 10.1186/s40780-020-00170-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/27/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The need for a large volume of serum sample significantly reduces the feasibility of neonatal pharmacokinetic studies in daily practice, which must often rely on scavenged or opportunistic sampling. This problem is most apparent in preterm newborns, where ethical and practical considerations prohibit the collection of large sample volumes. Most of the fluconazole analysis assays published thus far required a minimum serum sample of 50 to 100 μL for a single assay. The purpose of the present study was to develop and validate a sensitive method requiring a smaller sample volume (10 μL) to satisfy clinically relevant research requirements. METHODS Following simple protein precipitation and centrifugation, the filtrated supernatant was injected into a liquid chromatography system and separated with a C18 reverse-phase column. Fluconazole and the internal standard (IS, fluconazole-d4) were detected and quantified using tandem mass spectrometry. The method was validated with reference to the Food and Drug Administration's Guidance for Industry. Accuracy and precision were evaluated at six quality control concentration levels (ranging from 0.01 to 100 μg/mL). RESULTS Investigated calibration curves were linear in the 0.01-100 μg/mL range. Intra- and inter-day accuracy (- 7.7 to 7.4%) and precision (0.3 to 6.0%) were below 15%. The calculated limit of detection and the lower limit of quantification (LLOQ) was 0.0019 μg/mL and 0.0031 μg/mL, respectively. Fluconazole in the prepared samples was stable for at least 4 months at - 20 °C and - 80 °C. This method was applied to analyze 234 serum samples from ten neonates who received fosfluconazole, a water-soluble phosphate prodrug of fluconazole which converts to fluconazole in the body, as part of a pharmacokinetic study using daily scavenged laboratory samples. The median (range) concentration up to 72 h after fosfluconazole administration was 2.9 (0.02 to 26.8 μg/mL) μg/mL, which was within the range of the calibration curve. CONCLUSION Fluconazole was able to be detected in an extremely small volume (10 μL) of serum from neonates receiving fosfluconazole. The method presented here can be used to quantify fluconazole concentrations for pharmacokinetic studies of the neonatal population by using scavenged samples.
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Affiliation(s)
- Jumpei Saito
- Department of Pharmacy, National Center for Child Health and Development, 157-8535, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan
| | - Ayano Tanzawa
- Department of Pharmacy, National Center for Child Health and Development, 157-8535, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan
| | - Yuka Kojo
- Department of Pharmacy, National Center for Child Health and Development, 157-8535, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan
| | - Hidehiko Maruyama
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Tetsuya Isayama
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kensuke Shoji
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
| | - Yushi Ito
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Akimasa Yamatani
- Department of Pharmacy, National Center for Child Health and Development, 157-8535, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan
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221
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Kosmidis C, Rodriguez-Goncer I, Rautemaa-Richardson R, Richardson MD, Moore CB, Denning DW. Therapeutic drug monitoring and adverse events of delayed-release posaconazole tablets in patients with chronic pulmonary aspergillosis. J Antimicrob Chemother 2020; 74:1056-1061. [PMID: 30590533 DOI: 10.1093/jac/dky539] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/12/2018] [Accepted: 11/24/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Posaconazole delayed-release tablets offer better bioavailability than the liquid suspension, but no post-marketing data are available in immunocompetent hosts such as those with chronic pulmonary aspergillosis (CPA). OBJECTIVES To explore the pharmacokinetics and adverse event (AE) profile of posaconazole tablets in patients with CPA. METHODS Patients started on posaconazole tablets at the National Aspergillosis Centre (NAC), Manchester, UK between February 2014 and October 2015 were identified from the NAC database and analysed retrospectively. The medical records were reviewed for factors that could affect posaconazole serum levels and the development of AEs. RESULTS Seventy-two patients were included; 50 (69%) were male and the mean age was 48.5 ± 12 years. Therapeutic levels (≥1 mg/L) were achieved in 90% of cases on 200 mg versus 90% of cases on 300 mg daily (P = not significant). Based on multivariate analysis, female sex (P = 0.041), a 100 mg daily dose (P < 0.001), asthma (P = 0.01) and bronchiectasis (P = 0.001) were associated with subtherapeutic levels. Forty-nine (68%) patients developed AEs, mainly fatigue (37%), dyspnoea (18%) and nausea (12%). AEs were present on 115/196 (59%) occasions on 300 mg/day and on 45/115 (39%) occasions on 200 mg/day (P < 0.01). The mean level was 1.81 ± 0.96 mg/L for patients reporting no AEs and 1.90 ± 1.11 mg/L for those reporting AEs (P = not significant). Factors associated with AEs of grade ≥2 were a daily dose of 300 versus 200 mg (P = 0.001) and asthma (P = 0.008). CONCLUSIONS A lower-than-recommended posaconazole tablet dose achieved therapeutic levels in most patients and was better tolerated. Males were more likely to achieve a therapeutic level. Underlying conditions affected the degree and frequency of AEs.
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Affiliation(s)
- Chris Kosmidis
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,National Aspergillosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Manchester, UK
| | - Isabel Rodriguez-Goncer
- National Aspergillosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Manchester, UK
| | - Riina Rautemaa-Richardson
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,National Aspergillosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Manchester, UK.,Mycology Reference Centre Manchester, ECMM Centre of Excellence, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Malcolm D Richardson
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Mycology Reference Centre Manchester, ECMM Centre of Excellence, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Caroline B Moore
- Mycology Reference Centre Manchester, ECMM Centre of Excellence, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - David W Denning
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,National Aspergillosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Manchester, UK
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222
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Patel D, Popple S, Claydon A, Modha DE, Gaillard EA. Posaconazole therapy in children with cystic fibrosis and Aspergillus-related lung disease. Med Mycol 2020; 58:11-21. [PMID: 30877757 DOI: 10.1093/mmy/myz015] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/30/2019] [Accepted: 02/16/2019] [Indexed: 01/08/2023] Open
Abstract
There is emerging evidence for the role of posaconazole in the management of Aspergillus-related cystic fibrosis (CF) lung disease. The tolerability and efficacy of posaconazole in paediatric CF is not well established. We report a prospective study over a fifty-three month period evaluating the safety, tolerability, and efficacy of posaconazole in pediatric CF. Fourteen children (seven males, median age 13 years, range 3-17 years) received a total of twenty-three courses of posaconazole (13 oral suspension and 10 tablet formulation). Of these patient episodes, nine received posaconazole for emerging or active allergic bronchopulmonary aspergillosis (ABPA) and two required a combination of posaconazole and systemic corticosteroids for difficult-to-treat ABPA. A subgroup of patients (n = 12) with persistent isolates of Aspergillus fumigatus, in the absence of serological markers of ABPA, received posaconazole monotherapy for pulmonary exacerbations not responding to conventional broad-spectrum antibiotic treatment. Posaconazole levels, full blood count, electrolytes, and liver function were monitored on day 7 of treatment and then monthly. Posaconazole was well tolerated in all but three patients. Therapeutic plasma levels >1 mg/l were achieved in all receiving the tablet formulation in comparison to 60% on the liquid preparation. There was a modest but significant improvement in FEV1 (% predicted) demonstrated for the cohort as a whole (p = 0.015) following posaconazole therapy. Posaconazole is well tolerated in children as young as six years old, improvements in lung function are observed, and therapeutic plasma levels are readily achieved in patients taking the tablet formulation and in adherent patients taking the liquid formulation.
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Affiliation(s)
- Deepa Patel
- Department of Respiratory Sciences, NIHR Biomedical Research Centre (Respiratory theme) and Institute for Lung Health, University of Leicester, Leicester, United Kingdom.,Department of Paediatric Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Sarah Popple
- Department of Paediatric Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Alison Claydon
- Department of Paediatric Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Deborah E Modha
- Department of Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Erol A Gaillard
- Department of Respiratory Sciences, NIHR Biomedical Research Centre (Respiratory theme) and Institute for Lung Health, University of Leicester, Leicester, United Kingdom.,Department of Paediatric Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
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223
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Kim HY, Märtson AG, Dreesen E, Spriet I, Wicha SG, McLachlan AJ, Alffenaar JW. Saliva for Precision Dosing of Antifungal Drugs: Saliva Population PK Model for Voriconazole Based on a Systematic Review. Front Pharmacol 2020; 11:894. [PMID: 32595511 PMCID: PMC7304296 DOI: 10.3389/fphar.2020.00894] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 06/01/2020] [Indexed: 12/16/2022] Open
Abstract
Precision dosing for many antifungal drugs is now recommended. Saliva sampling is considered as a non-invasive alternative to plasma sampling for therapeutic drug monitoring (TDM). However, there are currently no clinically validated saliva models available. The aim of this study is firstly, to conduct a systematic review to evaluate the evidence supporting saliva-based TDM for azoles, echinocandins, amphotericin B, and flucytosine. The second aim is to develop a saliva population pharmacokinetic (PK) model for eligible drugs, based on the evidence. Databases were searched up to July 2019 on PubMed® and Embase®, and 14 studies were included in the systematic review for fluconazole, voriconazole, itraconazole, and ketoconazole. No studies were identified for isavuconazole, posaconazole, flucytosine, amphotericin B, caspofungin, micafungin, or anidulafungin. Fluconazole and voriconazole demonstrated a good saliva penetration with an average S/P ratio of 1.21 (± 0.31) for fluconazole and 0.56 (± 0.18) for voriconazole, both with strong correlation (r = 0.89-0.98). Based on the evidence for TDM and available data, population PK analysis was performed on voriconazole using Nonlinear Mixed Effects Modeling (NONMEM 7.4). 137 voriconazole plasma and saliva concentrations from 11 patients (10 adults, 1 child) were obtained from the authors of the included study. Voriconazole pharmacokinetics was best described by one-compartment PK model with first-order absorption, parameterized by clearance of 4.56 L/h (36.9% CV), volume of distribution of 60.7 L, absorption rate constant of 0.858 (fixed), and bioavailability of 0.849. Kinetics of the voriconazole distribution from plasma to saliva was identical to the plasma kinetics, but the extent of distribution was lower, modeled by a scale factor of 0.5 (4% CV). A proportional error model best accounted for the residual variability. The visual and simulation-based model diagnostics confirmed a good predictive performance of the saliva model. The developed saliva model provides a promising framework to facilitate saliva-based precision dosing of voriconazole.
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Affiliation(s)
- Hannah Yejin Kim
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia
- Marie Bashir Institute of Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia
| | - Anne-Grete Märtson
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, Netherlands
| | - Erwin Dreesen
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Sebastian G. Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Andrew J. McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Jan-Willem Alffenaar
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia
- Marie Bashir Institute of Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia
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224
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Gómez-López A. Antifungal therapeutic drug monitoring: focus on drugs without a clear recommendation. Clin Microbiol Infect 2020; 26:1481-1487. [PMID: 32535150 DOI: 10.1016/j.cmi.2020.05.037] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The goal of therapeutic drug monitoring (TDM) is to determine the appropriate exposure of difficult-to-manage medications to optimize the clinical outcomes in patients in various clinical situations. Concerning antifungal treatment, and knowing that this procedure is expensive and time-consuming, TDM is particularly recommended for certain systemic antifungals: i.e., agents with a well-defined exposure-response relationship and unpredictable pharmacokinetic profile or narrow therapeutic index. Little evidence supports the routine use of TDM for polyenes (amphotericin B), echinocandins, fluconazole or new azoles such as isavuconazole, despite the fact that a better understanding of antifungal exposure may lead to a better response. AIMS The aim of this work is to review published pharmacokinetic/pharmacodynamic data on systemically administered antifungals, focusing on those for which monitoring is not routinely recommended by experts. SOURCES A MEDLINE search of the literature in English was performed introducing the following search terms: amphotericin B, fluconazole, itraconazole, voriconazole, posaconazole, triazoles, caspofungin, micafungin, anidulafungin, echinocandins, pharmacokinetics, pharmacodynamics, and therapeutic drug monitoring. Review articles and guidelines were also screened. CONTENT This review collects different pharmacokinetic/pharmacodynamic aspects of systemic antifungals and summarizes recent threshold values for clinical outcomes and adverse events. Although for polyenes, echinocandins, fluconazole and isavuconazole extensive clinical validation is still required for a clear threshold and a routine monitoring recommendation, particular points such as liposome structure or complex pathophysiological conditions affecting final exposure are discussed. For the rest, their better-defined exposure-response/toxicity relationships allow access to useful threshold values and to justify routine monitoring. Additionally, clinical data are needed to better define thresholds that can minimize the development of antifungal resistance. IMPLICATIONS General TDM for all systemic antifungals is not recommended; however, this approach may help to establish an adequate antifungal exposure for a favourable response, prevention of toxicity or development of resistance in special clinical circumstances.
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Affiliation(s)
- A Gómez-López
- Mycology Reference and Research Laboratory, Centro Nacional de Microbiología, Instituto de Salud Carlos III (CNM-ISCIII), Majadahonda, 28220, Madrid, Spain.
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225
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Kaindl T, Andes D, Engelhardt M, Saulay M, Larger P, Groll AH. Variability and exposure-response relationships of isavuconazole plasma concentrations in the Phase 3 SECURE trial of patients with invasive mould diseases. J Antimicrob Chemother 2020; 74:761-767. [PMID: 30476108 PMCID: PMC6376854 DOI: 10.1093/jac/dky463] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 10/10/2018] [Accepted: 10/12/2018] [Indexed: 12/02/2022] Open
Abstract
Objectives This analysis evaluated the variability of isavuconazole plasma concentrations between subjects and between sampling times, and assessed their relationship to outcomes for subjects with invasive fungal disease (IFD) in the SECURE trial. Methods Isavuconazole-treated subjects received 372 mg of isavuconazonium sulphate (corresponding to 200 mg of isavuconazole) three times daily for 2 days, then once daily. Plasma samples were collected after day 4 and analysis sets were constructed as follows: analysis set 1 included all samples from subjects with proven/probable/possible IFD who received ≥1 dose of isavuconazole; analysis set 2 included samples from subjects in analysis set 1 who had provided >1 sample; and analysis set 3 included samples from subjects in analysis set 1 with proven/probable invasive aspergillosis. Assessments included overall distributions of plasma concentrations and variability between samples (analysis sets 1 and 2) as well as relationships to outcomes [all-cause mortality (day 42), overall response (end of treatment) and treatment-emergent adverse events; analysis sets 1 and 3]. Results Analysis sets 1, 2 and 3 included samples from 160, 97 and 98 subjects, respectively. Trough concentrations for each were distributed similarly [mean (SD): 3406.6 (1511.5), 3495.6 (1503.3) and 3368.1 (1523.2) ng/mL, respectively]. The mean coefficient of variation between samples in analysis set 2 was 23.2%; differences between concentrations in first samples and subsequent samples were <2-fold for 85/97 subjects. In quartiles of subject data, no concentration-dependent relationships were observed for efficacy or safety. Conclusions Plasma concentrations of isavuconazole were reasonably consistent between subjects and sampling times, and were not associated with differences in outcomes.
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Affiliation(s)
- Thomas Kaindl
- Basilea Pharmaceutica International Ltd, Basel, Switzerland
| | - David Andes
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | | | | | - Patrice Larger
- Basilea Pharmaceutica International Ltd, Basel, Switzerland
| | - Andreas H Groll
- Department of Paediatric Haematology/Oncology, University Children's Hospital Münster, Münster, Germany
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226
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García IG, Carcas AJ, Borobia AM. Strategy to effectively and efficiently implement voriconazole pharmacogenetics in clinical practice. Pharmacogenomics 2020; 21:647-649. [PMID: 32486895 DOI: 10.2217/pgs-2020-0029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Irene García García
- Clinical Pharmacology Department, La Paz University Hospital. School of Medicine, Universidad Autónoma de Madrid, IdiPAZ, Madrid, 28046, Spain
| | - Antonio J Carcas
- Clinical Pharmacology Department, La Paz University Hospital. School of Medicine, Universidad Autónoma de Madrid, IdiPAZ, Madrid, 28046, Spain
| | - Alberto M Borobia
- Clinical Pharmacology Department, La Paz University Hospital. School of Medicine, Universidad Autónoma de Madrid, IdiPAZ, Madrid, 28046, Spain
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227
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Van Daele R, Spriet I, Maertens J. Posaconazole in prophylaxis and treatment of invasive fungal infections: a pharmacokinetic, pharmacodynamic and clinical evaluation. Expert Opin Drug Metab Toxicol 2020; 16:539-550. [DOI: 10.1080/17425255.2020.1764939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Ruth Van Daele
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
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228
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Nev OA, Jepson A, Beardmore RE, Gudelj I. Predicting community dynamics of antibiotic-sensitive and -resistant species in fluctuating environments. J R Soc Interface 2020; 17:20190776. [PMID: 32453982 DOI: 10.1098/rsif.2019.0776] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Microbes occupy almost every niche within and on their human hosts. Whether colonizing the gut, mouth or bloodstream, microorganisms face temporal fluctuations in resources and stressors within their niche but we still know little of how environmental fluctuations mediate certain microbial phenotypes, notably antimicrobial-resistant ones. For instance, do rapid or slow fluctuations in nutrient and antimicrobial concentrations select for, or against, resistance? We tackle this question using an ecological approach by studying the dynamics of a synthetic and pathogenic microbial community containing two species, one sensitive and the other resistant to an antibiotic drug where the community is exposed to different rates of environmental fluctuation. We provide mathematical models, supported by experimental data, to demonstrate that simple community outcomes, such as competitive exclusion, can shift to coexistence and ecosystem bistability as fluctuation rates vary. Theory gives mechanistic insight into how these dynamical regimes are related. Importantly, our approach highlights a fundamental difference between resistance in single-species populations, the context in which it is usually assayed, and that in communities. While fast environmental changes are known to select against resistance in single-species populations, here we show that they can promote the resistant species in mixed-species communities. Our theoretical observations are verified empirically using a two-species Candida community.
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Affiliation(s)
- Olga A Nev
- Biosciences and Living Systems Institute, University of Exeter, Exeter EX4 4QD, UK
| | - Alys Jepson
- Biosciences and Living Systems Institute, University of Exeter, Exeter EX4 4QD, UK
| | - Robert E Beardmore
- Biosciences and Living Systems Institute, University of Exeter, Exeter EX4 4QD, UK
| | - Ivana Gudelj
- Biosciences and Living Systems Institute, University of Exeter, Exeter EX4 4QD, UK
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229
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Oral absorption of voriconazole is affected by SLCO2B1 c.*396T>C genetic polymorphism in CYP2C19 poor metabolizers. THE PHARMACOGENOMICS JOURNAL 2020; 20:792-800. [PMID: 32461666 DOI: 10.1038/s41397-020-0166-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 05/07/2020] [Accepted: 05/14/2020] [Indexed: 11/08/2022]
Abstract
High pharmacokinetic variability of voriconazole is mainly explained by CYP2C19 phenotype, but there are still unknown factors affecting the variability. In this study, the effect of solute carrier organic anion transporter family member 2B1 (SLCO2B1) genotype on the pharmacokinetics (PKs) of voriconazole was evaluated in 12 healthy CYP2C19 poor metabolizers after a single administration of voriconazole 200 mg intravenously and orally. In addition, the influence of CYP3A4 enzyme activity was also explored. The oral absorption of voriconazole was decreased and delayed in the subjects with the SLCO2B1 c.*396T>C variant compared to the subjects with wild type. However, the CYP3A activity markers measured in this study did not show significant association with metabolism of voriconazole. The results suggest that the SLCO2B1 c.*396T>C may be associated with the decreased function of intestinal OATP2B1, and it could contribute to interindividual PK variability of voriconazole.
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230
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Assaf A, Faure E, Sermet K, Loridant S, Leroy J, Goeminne C, Dozier A, Chopin MC, Panaget S, Faure K, Vuotto F. Successful treatment of Aspergillus fumigatus sternal osteomyelitis with isavuconazole in a heart transplant recipient. Transpl Infect Dis 2020; 22:e13313. [PMID: 32386273 DOI: 10.1111/tid.13313] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/24/2020] [Accepted: 04/25/2020] [Indexed: 12/23/2022]
Abstract
A 65-year-old man was diagnosed with an invasive Aspergillus fumigatus infection with sternal osteomyelitis 4 months after heart transplantation. Unfortunately, after 8 weeks patient developed severe cutaneous and neurological toxicities induced by voriconazole leading to drug discontinuation. Therefore, isavuconazole was chosen as second-line therapy. The patient presented a favorable outcome and tolerance was excellent after ten months monotherapy. Here, we report for a first time, an successful isavuconazole-based treatment of sternal osteomyelitis aspergillosis in a cardiac recipient.
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Affiliation(s)
- Ady Assaf
- Service de Maladies Infectieuses, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Emmanuel Faure
- Service de Maladies Infectieuses, Centre Hospitalier Universitaire de Lille, Lille, France.,CNRS UMR9017, Inserm U1019, CHRU Lille, Institut Pasteur de Lille, CIIL - Center for Infection and Immunity of Lille, Universitaire de Lille, Lille, France
| | - Kevin Sermet
- Service de Maladies Infectieuses, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Severine Loridant
- Laboratoire de Parasitologie Mycologie, Centre Hospitalier Universitaire de Lille, INSERM U995, LIRIC - Lille Inflammation Research International Centre, Universitaire de Lille, Lille, France
| | - Jordan Leroy
- Laboratoire de Parasitologie Mycologie, Centre Hospitalier Universitaire de Lille, INSERM U995, LIRIC - Lille Inflammation Research International Centre, Universitaire de Lille, Lille, France
| | - Celine Goeminne
- Service de Cardiologie, Hôpital cardiologique Centre Hospitalier Universitaire de Lille, Lille, France
| | - Aurelie Dozier
- Service de Maladies Infectieuses, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Marie-Charlotte Chopin
- Service de Maladies Infectieuses, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Sophie Panaget
- Service de Maladies Infectieuses, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Karine Faure
- Service de Maladies Infectieuses, Centre Hospitalier Universitaire de Lille, Lille, France.,CNRS UMR9017, Inserm U1019, CHRU Lille, Institut Pasteur de Lille, CIIL - Center for Infection and Immunity of Lille, Universitaire de Lille, Lille, France
| | - Fanny Vuotto
- Service de Maladies Infectieuses, Centre Hospitalier Universitaire de Lille, Lille, France
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231
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Ruhnke M, Cornely OA, Schmidt-Hieber M, Alakel N, Boell B, Buchheidt D, Christopeit M, Hasenkamp J, Heinz WJ, Hentrich M, Karthaus M, Koldehoff M, Maschmeyer G, Panse J, Penack O, Schleicher J, Teschner D, Ullmann AJ, Vehreschild M, von Lilienfeld-Toal M, Weissinger F, Schwartz S. Treatment of invasive fungal diseases in cancer patients-Revised 2019 Recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Mycoses 2020; 63:653-682. [PMID: 32236989 DOI: 10.1111/myc.13082] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/05/2020] [Accepted: 03/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Invasive fungal diseases remain a major cause of morbidity and mortality in cancer patients undergoing intensive cytotoxic therapy. The choice of the most appropriate antifungal treatment (AFT) depends on the fungal species suspected or identified, the patient's risk factors (eg length and depth of granulocytopenia) and the expected side effects. OBJECTIVES Since the last edition of recommendations for 'Treatment of invasive fungal infections in cancer patients' of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) in 2013, treatment strategies were gradually moving away from solely empirical therapy of presumed or possible invasive fungal diseases (IFDs) towards pre-emptive therapy of probable IFD. METHODS The guideline was prepared by German clinical experts for infections in cancer patients in a stepwise consensus process. MEDLINE was systematically searched for English-language publications from January 1975 up to September 2019 using the key terms such as 'invasive fungal infection' and/or 'invasive fungal disease' and at least one of the following: antifungal agents, cancer, haematological malignancy, antifungal therapy, neutropenia, granulocytopenia, mycoses, aspergillosis, candidosis and mucormycosis. RESULTS AFT of IFDs in cancer patients may include not only antifungal agents but also non-pharmacologic treatment. In addition, the armamentarium of antifungals for treatment of IFDs has been broadened (eg licensing of isavuconazole). Additional antifungals are currently under investigation or in clinical trials. CONCLUSIONS Here, updated recommendations for the treatment of proven or probable IFDs are given. All recommendations including the levels of evidence are summarised in tables to give the reader rapid access to key information.
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Affiliation(s)
- Markus Ruhnke
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Oliver A Cornely
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | | | - Nael Alakel
- Department I of Internal Medicine, Haematology and Oncology, University Hospital Dresden, Dresden, Germany
| | - Boris Boell
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation & Oncology, University Medical Center Eppendorf, Hamburg, Germany
| | - Justin Hasenkamp
- Clinic for Haematology and Medical Oncology with Department for Stem Cell Transplantation, University Medicine Göttingen, Göttingen, Germany
| | - Werner J Heinz
- Schwerpunkt Infektiologie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Marcus Hentrich
- Hämatologie und Internistische Onkologie, Innere Medizin III, Rotkreuzklinikum München, München, Germany
| | - Meinolf Karthaus
- Department of Haematology & Oncology, Municipal Hospital Neuperlach, München, Germany
| | - Michael Koldehoff
- Klinik für Knochenmarktransplantation, Westdeutsches Tumorzentrum Essen, Universitätsklinikum Essen (AöR), Essen, Germany
| | - Georg Maschmeyer
- Department of Hematology, Onclogy and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Jens Panse
- Klinik für Onkologie, Hämatologie und Stammzelltransplantation, Universitätsklinikum Aachen, Aachen, Germany
| | - Olaf Penack
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Rudolf Virchow, Berlin, Germany
| | - Jan Schleicher
- Klinik für Hämatologie Onkologie und Palliativmedizin, Katharinenhospital, Stuttgart, Germany
| | - Daniel Teschner
- III. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Andrew John Ullmann
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Maria Vehreschild
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Zentrum für Innere Medizin, Infektiologie, Goethe Universität Frankfurt, Frankfurt am Main, Deutschland.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Bonn-Köln, Deutschland
| | - Marie von Lilienfeld-Toal
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Florian Weissinger
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Stefan Schwartz
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Benjamin Franklin, Berlin, Germany
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Beck KR, Telisman L, van Koppen CJ, Thompson GR, Odermatt A. Molecular mechanisms of posaconazole- and itraconazole-induced pseudohyperaldosteronism and assessment of other systemically used azole antifungals. J Steroid Biochem Mol Biol 2020; 199:105605. [PMID: 31982514 DOI: 10.1016/j.jsbmb.2020.105605] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 12/27/2022]
Abstract
Recent reports described cases of severe hypertension and hypokalemia accompanied by low renin and aldosterone levels during antifungal therapy with posaconazole and itraconazole. These conditions represent characteristics of secondary endocrine hypertension caused by mineralocorticoid excess. Different mechanisms can cause mineralocorticoid excess, including inhibition of the adrenal steroidogenic enzymes CYP17A1 and CYP11B1, inhibition of the peripheral cortisol oxidizing enzyme 11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2) or direct activation of the mineralocorticoid receptor (MR). Compared to previous experiments revealing a threefold more potent inhibition of 11β-HSD2 by itraconazole than with posaconazole, the current study found sevenfold stronger CYP11B1 inhibition by posaconazole over itraconazole. Both compounds most potently inhibited CYP11B2. The major pharmacologically active itraconazole metabolite hydroxyitraconazole (OHI) resembled the effects of itraconazole but was considerably less active. Molecular modeling calculations assessed the binding of posaconazole, itraconazole and OHI to 11β-HSD2 and the relevant CYP enzymes, and predicted important interactions not formed by the other systemically used azole antifungals, thus providing an initial explanation for the observed inhibitory activities. Together with available clinical observations, the presented data suggest that itraconazole primarily causes pseudohyperaldosteronism through cortisol-induced MR activation due to 11β-HSD2 inhibition, and posaconazole by CYP11B1 inhibition and accumulation of the mineralocorticoids 11-deoxycorticosterone and 11-deoxycortisol because of hypothalamus-pituitary-adrenal axis (HPA) feedback activation. Therapeutic drug monitoring and introduction of upper plasma target levels may help preventing the occurrence of drug-induced hypertension and hypokalemia. Furthermore, the systemically used azole antifungals voriconazole, isavuconazole and fluconazole did not affect any of the mineralocorticoid excess targets, offering alternative therapeutic options.
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Affiliation(s)
- Katharina R Beck
- Swiss Centre for Applied Human Toxicology (SCAHT) and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland.
| | - Lucija Telisman
- Swiss Centre for Applied Human Toxicology (SCAHT) and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland.
| | - Chris J van Koppen
- Department of Pharmaceutical and Medicinal Chemistry, Universitätscampus C2.3, 66123 Saarbrücken, Germany.
| | - George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases, University of California Davis Medical Center, Davis, California, USA.
| | - Alex Odermatt
- Swiss Centre for Applied Human Toxicology (SCAHT) and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland.
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Safety of Isavuconazonium Sulfate in Pediatrics Patients With Hematologic Malignancies and Hematopoietic Cell Transplantation With Invasive Fungal Infections: A Real World Experience. J Pediatr Hematol Oncol 2020; 42:261-265. [PMID: 32218096 DOI: 10.1097/mph.0000000000001787] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE Primary objective is to evaluate safety of isavuconazonium sulfate (ISA) in pediatrics below 18 years old. Exploratory endpoint includes mortality due to probable and proven invasive fungal infection (IFI) and overall morality in this population. PATIENTS AND METHODS Retrospective review of patients below 18 years receiving ISA for ≥7 days for possible, probable, or proven IFI or prophylaxis between June 2015 and March 2018. Descriptive analysis performed to calculate median, frequency, and percentages. RESULTS Safety analysis included 18 patients and a subgroup of 11/18 patients were assessed for efficacy. Median age 12.5 years (4 to 17 y), median weight 50.25 kg (19 to 118 kg), 50% male, 77% acute leukemias, 94% hematopoietic cell transplant recipients, 50% matched unrelated donors and 78% in remission. Elevated alanine aminotransferase 3 times baseline within 30 days of ISA occurred in 22% (4/18). No patients had elevated bilirubin or increase in serum creatinine. All-cause mortality at 90 days was 22% (4/18) and 27% (3/11) in patients with probable or proven IFI. Clinical response rates: 14-day: 45% (5/11) partial, 27% (3/11) stable; 30-day: 45% (5/11) partial, 36% (4/11) stable; 90-day: 54% (6/11) had either partial (n=3) or complete (n=3) response to ISA. CONCLUSIONS ISA is safe in pediatric patients for the treatment of IFI. Prospective, randomized controlled trials are warranted to determine efficacy and safety of ISA in pediatric patients with hematologic malignancies and hematopoietic cell transplant.
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Susceptibility Profile of Candida albicans Biofilms on Polyvinyl Chloride Endotracheal Tube to Antifungal Azoles. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2020. [DOI: 10.22207/jpam.14.2.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Scott G, Field CL, Papich MG, Harms CA. Plasma concentrations of itraconazole following a single oral dose in juvenile California sea lions (Zalophus californianus). J Vet Pharmacol Ther 2020; 43:377-380. [PMID: 32286696 DOI: 10.1111/jvp.12865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/25/2020] [Accepted: 03/19/2020] [Indexed: 11/26/2022]
Abstract
The objective of this study was to establish a single-dose pharmacokinetic profile for orally administered itraconazole in California sea lions (Zalophus californianus). Twenty healthy rehabilitated juvenile California sea lions were included in this study. Itraconazole capsules were administered orally with food at a target dose of 5-10 mg/kg. Blood samples were collected from each animal at 0 hr and at two of the following timepoints: 0.5, 1, 2, 4, 6, 8, 12, 24, 48, and 72 hr. Quantitative analysis of itraconazole in plasma samples was performed by high-performance liquid chromatography. An average maximum concentration of 0.22 µg/ml ± 0.11 was detected 4 hr after administration. The average concentration fell to 0.12 µg/ml ± 0.11 by 6 hr and 0.02 µg/ml ± 0.02 at 12 hr. At no point did concentrations reach 0.5 µg/ml, the concentration commonly accepted for therapeutic efficacy. While this formulation was well tolerated by the sea lions, oral absorption was poor and highly variable among individuals. These data indicate that a single oral dose of itraconazole given as a capsule at 5-10 mg/kg, under the conditions used in this study, does not achieve therapeutic plasma concentrations in California sea lions.
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Affiliation(s)
- Gregory Scott
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA.,Center for Marine Sciences and Technology, North Carolina State University, Morehead City, NC, USA
| | - Cara L Field
- Veterinary Science Department, The Marine Mammal Center, Sausalito, CA, USA
| | - Mark G Papich
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
| | - Craig A Harms
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA.,Center for Marine Sciences and Technology, North Carolina State University, Morehead City, NC, USA
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Abstract
Posaconazole is a triazole antifungal with activity against Rhizopus, but data on its use and pharmacokinetics in preterm infants are scarce. In this case, a 24 4/7-week neonate's Rhizopus infection is successfully treated with debridement and combination antifungal therapy with amphotericin B, micafungin and enteral posaconazole. This is the first reported posaconazole use in a preterm neonate with Rhizopus.
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Abstract
Neonates and immunosuppressed/immunocompromised pediatric patients are at high risk of invasive fungal diseases. Appropriate antifungal selection and optimized dosing are imperative to the successful prevention and treatment of these life-threatening infections. Conventional amphotericin B was the mainstay of antifungal therapy for many decades, but dose-limiting nephrotoxicity and infusion-related adverse events impeded its use. Despite the development of several new antifungal classes and agents in the past 20 years, and their now routine use in at-risk pediatric populations, data to guide the optimal dosing of antifungals in children are limited. This paper reviews the spectra of activity for approved antifungal agents and summarizes the current literature specific to pediatric patients regarding pharmacokinetic/pharmacodynamic data, dosing, and therapeutic drug monitoring.
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Affiliation(s)
- Kevin J Downes
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 2716 South Street, Suite 10360, Philadelphia, PA, 19146, USA.
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Brian T Fisher
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 2716 South Street, Suite 10360, Philadelphia, PA, 19146, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nicole R Zane
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Märtson AG, Sturkenboom MGG, Stojanova J, Cattaneo D, Hope W, Marriott D, Patanwala AE, Peloquin CA, Wicha SG, van der Werf TS, Tängdén T, Roberts JA, Neely MN, Alffenaar JWC. How to design a study to evaluate therapeutic drug monitoring in infectious diseases? Clin Microbiol Infect 2020; 26:1008-1016. [PMID: 32205294 DOI: 10.1016/j.cmi.2020.03.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/03/2020] [Accepted: 03/10/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) is a tool to personalize and optimize dosing by measuring the drug concentration and subsequently adjusting the dose to reach a target concentration or exposure. The evidence to support TDM is however often ranked as expert opinion. Limitations in study design and sample size have hampered definitive conclusions of the potential added value of TDM. OBJECTIVES We aim to give expert opinion and discuss the main points and limitations of available data from antibiotic TDM trials and emphasize key elements for consideration in design of future clinical studies to quantify the benefits of TDM. SOURCES The sources were peer-reviewed publications, guidelines and expert opinions from the field of TDM. CONTENT This review focuses on key aspects of antimicrobial TDM study design: describing the rationale for a TDM study, assessing the exposure of a drug, assessing susceptibility of pathogens and selecting appropriate clinical endpoints. Moreover we provide guidance on appropriate study design. IMPLICATIONS This is an overview of different aspects relevant for the conduct of a TDM study. We believe that this paper will help researchers and clinicians to design and conduct high-quality TDM studies.
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Affiliation(s)
- A-G Märtson
- University of Groningen, University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - M G G Sturkenboom
- University of Groningen, University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - J Stojanova
- Interdisciplinary Centre for Health Studies (CIESAL), Universidad de Valparaíso, Valparaíso, Chile
| | - D Cattaneo
- ASST Fatebenefratelli Sacco University Hospital, Unit of Clinical Pharmacology, Department of Laboratory Medicine, Milan, Italy
| | - W Hope
- University of Liverpool, Antimicrobial Pharmacodynamics and Therapeutics, Liverpool, UK; Royal Liverpool Broadgreen University Hospital Trust, Liverpool, United Kingdom
| | - D Marriott
- St Vincent's Hospital, Sydney, Australia
| | - A E Patanwala
- The University of Sydney, Sydney Pharmacy School, Sydney, New South Wales, Australia; Royal Prince Alfred Hospital, Sydney, Australia
| | - C A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - S G Wicha
- University of Hamburg, Department of Clinical Pharmacy, Institute of Pharmacy, Hamburg, Germany
| | - T S van der Werf
- University of Groningen, University Medical Centre Groningen, Department of Pulmonary Diseases and Tuberculosis, Groningen, the Netherlands; University of Groningen, University Medical Centre Groningen, Department of Internal Medicine, Groningen, the Netherlands
| | - T Tängdén
- Uppsala University, Department of Medical Sciences, Uppsala, Sweden
| | - J A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine & Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia; Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - M N Neely
- Children's Hospital of Los Angeles, Laboratory of Applied Pharmacokinetics and Bioinformatics, Los Angeles, CA, USA
| | - J-W C Alffenaar
- University of Groningen, University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands; The University of Sydney, Sydney Pharmacy School, Sydney, New South Wales, Australia; Westmead Hospital, Sydney, Australia; Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia.
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Myint T, Leedy N, Villacorta Cari E, Wheat LJ. HIV-Associated Histoplasmosis: Current Perspectives. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2020; 12:113-125. [PMID: 32256121 PMCID: PMC7090190 DOI: 10.2147/hiv.s185631] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 02/27/2020] [Indexed: 12/12/2022]
Abstract
Histoplasmosis is an endemic mycosis caused by Histoplasma capsulatum. Infection develops by inhalation of microconidia from environmental sites inhabited by birds and bats. Disseminated disease is the usual presentation due to impaired cellular immunity. Common clinical manifestations include fever, fatigue, malaise, anorexia, weight loss, and respiratory symptoms. Histoplasma antigen detection is the most sensitive method for diagnosis. The sensitivity of the MVista® Quantitative Histoplasma antigen enzyme immunoassay is 95-100% in urine, over 90% in serum and bronchoalveolar lavage (BAL) antigen and 78% in cerebral spinal fluid (CSF). A proven diagnosis can be established by culture or pathology with sensitivities between 70% and 80%. The sensitivity of antibody detection by immunodiffusion or complement fixation was between 60% and 70%. Diagnosis using molecular methods has not been adequately validated for implementation and FDA cleared assays are unavailable. Liposomal amphotericin B should be used for 1-2 weeks followed by itraconazole for at least one year until CD4 counts are above 150 cells/mm3, HIV viral load is below 400 copies/mL and Histoplasma urine antigen is negative. Serum itraconazole level should be monitored to avoid drug toxicity. Antigen should be measured periodically to establish that treatment is effective and to assist in identifying relapse. The incidence of immune reconstitution inflammatory syndrome is low but it must be considered in patients who are thought to be failing antifungal treatment as it does not respond to changing antifungal agents but rather to initiation of corticosteroid therapy. In this review, we discuss pathogenesis, clinical manifestations, diagnosis and treatment based on personal experience and relevant publications.
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Affiliation(s)
- Thein Myint
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Nicole Leedy
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Evelyn Villacorta Cari
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
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Treating Allergic Bronchopulmonary Aspergillosis with Short-Term Prednisone and Itraconazole in Cystic Fibrosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2608-2614.e3. [PMID: 32147521 DOI: 10.1016/j.jaip.2020.02.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/21/2020] [Accepted: 02/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction to Aspergillus fumigatus contributing to cystic fibrosis (CF) lung disease. OBJECTIVE To evaluate the combination of oral prednisone for 18 days together with itraconazole therapy for at least 12 months in CF-related ABPA with regard to long-term pulmonary function and side effects. METHODS Sixty-five patients with CF treated for ABPA and 127 patients with CF without ABPA serving as matched controls were retrospectively analyzed for a median period of 4.8 years. Serial lung functions were analyzed alongside clinical, microbiological, and laboratory data including itraconazole therapeutic drug monitoring. RESULTS The used ABPA treatment regimen restored FEV1 values to pre-ABPA levels within 3 months (P < .0001). Long-term FEV1 courses of patients showed no difference when compared with those of ABPA-free controls. Glucocorticoid treatment was not associated with increased CF-related diabetes incidence, growth restriction, or Pseudomonas aeruginosa acquisition. Patients who experienced ABPA relapses displayed lower itraconazole trough levels during the first 3 months of treatment (P < .05). A decreased risk of ABPA recurrence was further associated with P aeruginosa colonization. CONCLUSIONS The proposed treatment scheme for CF-related ABPA is effective in preserving lung function capacity over years in affected individuals without the known glucocorticoid-associated side effects. Itraconazole therapeutic drug monitoring seems useful to prevent disease flares, for which P aeruginosa-negative patients with CF might be particularly susceptible.
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Abstract
Objectives The objectives of this study were to investigate the population pharmacokinetics of posaconazole in immunocompromised children, evaluate the influence of patient characteristics on posaconazole exposure and perform simulations to recommend optimal starting doses. Methods Posaconazole plasma concentrations from paediatric patients undergoing therapeutic drug monitoring were extracted from a tertiary paediatric hospital database. These were merged with covariates collected from electronic sources and case-note reviews. An allometrically scaled population-pharmacokinetic model was developed to investigate the effect of tablet and suspension relative bioavailability, nonlinear bioavailability of suspension, followed by a step-wise covariate model building exercise to identify other important sources of variability. Results A total of 338 posaconazole plasma concentrations samples were taken from 117 children aged 5 months to 18 years. A one-compartment model was used, with tablet apparent clearance standardised to a 70-kg individual of 15 L/h. Suspension was found to have decreasing bioavailability with increasing dose; the estimated suspension dose to yield half the tablet bioavailability was 99 mg/m2. Diarrhoea and proton pump inhibitors were also associated with reduced suspension bioavailability. Conclusions In the largest population-pharmacokinetic study to date in children, we have found similar covariate effects to those seen in adults, but low bioavailability of suspension in patients with diarrhoea or those taking concurrent proton pump inhibitors, which may in particular limit the use of posaconazole in these patients. Electronic supplementary material The online version of this article (10.1007/s40262-018-0658-1) contains supplementary material, which is available to authorized users.
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Therapeutic Drug Monitoring of Antifungal Drugs: Another Tool to Improve Patient Outcome? Infect Dis Ther 2020; 9:137-149. [PMID: 32026399 PMCID: PMC7054538 DOI: 10.1007/s40121-020-00280-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Indexed: 01/28/2023] Open
Abstract
Introduction This study aimed to examine the relationship among adequate dose, serum concentration and clinical outcome in a non-selected group of hospitalized patients receiving antifungals. Methods Prospective cross-sectional study performed between March 2015 and June 2015. Dosage of antifungals was considered adequate according to the IDSA guidelines, whereas trough serum concentrations (determined with HPLC) were considered adequate as follows: fluconazole > 11 µg/ml, echinocandins > 1 µg/ml, voriconazole 1–5.5 µg/ml and posaconazole > 0.7 µg/ml. Results During the study period, 84 patients (65.4% male, 59.6 years) received antifungals for prophylaxis (40.4%), targeted (31.0%) and empirical therapy (28.6%). The most frequent drug was micafungin (28/84; 33.3%) followed by fluconazole (23/84; 27.4%), voriconazole (15/84; 17.9%), anidulafungin (8/84; 9.5%), posaconazole (7/84; 8.3%) and caspofungin (3/84; 3.6%). Considerable interindividual variability was observed for all antifungals with a large proportion of the patients (64.3%) not attaining adequate trough serum concentrations, despite receiving an adequate antifungal dose. Attaining the on-target serum antifungal level was significantly associated with a favorable clinical outcome (OR = 0.02; 95% CI 0.01–0.64; p = 0.03), whereas the administration of an adequate antifungal dosage was not. Conclusions With the standard antifungal dosage, a considerable proportion of patients have low drug concentrations, which are associated with poor clinical outcome.
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Population Pharmacokinetics of Intravenous Isavuconazole in Solid-Organ Transplant Recipients. Antimicrob Agents Chemother 2020; 64:AAC.01728-19. [PMID: 31767725 DOI: 10.1128/aac.01728-19] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 11/01/2019] [Indexed: 12/14/2022] Open
Abstract
Isavuconazole (ISA) is a triazole antifungal with activity against yeasts and molds. We established a population pharmacokinetic (pop PK) model of intravenous (i.v.) ISA to identify covariates that affect pharmacokinetics, using plasma samples from solid-organ transplant (SOT) recipients receiving peritransplant prophylaxis. Samples (n = 471) from 79 SOT recipients were utilized for pop PK analysis using nonlinear mixed-effect modeling NONMEM software. ISA (i.v.) PK parameters were best described by a two-compartment model. Significant covariates were sex on clearance (∼53% higher in women than men) and body mass index on peripheral volume of distribution. Incorporating drug exposure into Monte Carlo simulations, we demonstrated that standard ISA dosing is likely to attain the PK-pharmacodynamic (PD) target (area under the concentration curve/MIC ratio [AUC/MIC]) for treatment effectiveness against almost all infections caused by Aspergillus fumigatus isolates exhibiting MICs of ≤0.5 μg/ml (modal MIC). In contrast, standard dosing is predicted to attain PK-PD targets against <20% of infections caused by Candida albicans and Candida glabrata isolates exhibiting MICs of ≥0.016 and ≥0.5 μg/ml, respectively (modal MICs). These data are consistent with our SOT program's experience with ISA breakthrough infections, where 3 of 4 were caused by C. glabrata for which probabilities of PK-PD target attainment (PTA) were only 70% and 0% for isolates with MICs of 0.25 μg/ml and 1 μg/ml. Our findings provide important new insights into how ISA use might be optimized following SOT.
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Stohs E, Zimmer A. An Approach to Suspected Invasive Fungal Infection in Patients with Hematologic Malignancy and HCT Recipients with Persistent Neutropenic Fever Despite Mold-Active Prophylaxis. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00375-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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A prospective evaluation on the interaction of fluconazole and voriconazole on serum concentrations of budesonide in patients treated for gastrointestinal GVHD. Bone Marrow Transplant 2020; 55:1085-1092. [PMID: 31953533 DOI: 10.1038/s41409-020-0786-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/13/2019] [Accepted: 01/03/2020] [Indexed: 11/08/2022]
Abstract
The gastrointestinal (GI) tract is commonly affected by acute and chronic graft-versus-host disease (GVHD) in patients who have undergone allogeneic hematopoietic stem cell transplantation (allo-HSCT). For patients developing GI GVHD, nonabsorbable corticosteroids such as budesonide may be used alone to reduce the risk of systemic corticosteroid toxicities or combined with systemic steroids to enhance clinical responses and to allow more rapid tapering of systemic corticosteroid doses. This prospective crossover study was conducted to evaluate what effect two commonly used antifungal agents, fluconazole, and voriconazole, would have on the trough (Cmin) and peak (Cmax) levels of budesonide in adult patients who had undergone allo-HSCT who subsequently developed clinical GI GVHD. Fifteen subjects were enrolled and nine completed the study and were evaluable. When coadministered with budesonide, voriconazole significantly increased the geometric mean of budesonide Cmin and Cmax levels by 8.52- and 6.63-fold, respectively. The cohort to evaluate the interaction with fluconazole did not meet accrual goals to reach definitive conclusions. In conclusion, this prospective study demonstrated that when patients with GI GVHD are treated with budesonide concurrently with voriconazole, the systemic concentrations of budesonide increase substantially which could increase the risk of steroid-associated toxicities.
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Applying Pharmacogenomics to Antifungal Selection and Dosing: Are We There Yet? CURRENT FUNGAL INFECTION REPORTS 2020; 14:63-75. [PMID: 32256938 DOI: 10.1007/s12281-020-00371-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Purpose of Review This review summarizes recent literature for applying pharmacogenomics to antifungal selection and dosing, providing an approach to implementing antifungal pharmacogenomics in clinical practice. Recent Findings The Clinical Pharmacogenetics Implementation Consortium published guidelines on CYP2C19 and voriconazole, with recommendations to use alternative antifungals or adjust voriconazole dose with close therapeutic drug monitoring (TDM). Recent studies demonstrate an association between CYP2C19 phenotype and voriconazole levels, clinical outcomes, and adverse events. Additionally, CYP2C19-guided preemptive dose adjustment demonstrated benefit in two prospective studies for prophylaxis. Pharmacokinetic-pharmacodynamic modeling studies have generated proposed voriconazole treatment doses based on CYP2C19 phenotypes, with further validation studies needed. Summary Sufficient evidence is available for implementing CYP2C19-guided voriconazole selection and dosing among select patients at risk for invasive fungal infections. The institution needs appropriate infrastructure for pharmacogenomic testing, integration of results in the clinical decision process, with TDM confirmation of goal trough achievement, to integrate antifungal pharmacogenomics into routine clinical care.
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Fungal Infections and ABPA. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Floros L, Pagliuca A, Taie AA, Weidlich D, Rita Capparella M, Georgallis M, Sung AHY. The cost-effectiveness of isavuconazole compared to the standard of care in the treatment of patients with invasive fungal infection prior to differential pathogen diagnosis in the United Kingdom. J Med Econ 2020; 23:86-97. [PMID: 31262225 DOI: 10.1080/13696998.2019.1638789] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Aims: To estimate the cost-effectiveness of isavuconazole compared with the standard of care, voriconazole, for the treatment of patients with invasive fungal infection disease when differential diagnosis of the causative pathogen has not yet been achieved at treatment initiation.Materials and methods: The economic model was developed from the perspective of the UK National Health Service (NHS) and used a decision-tree approach to reflect real-world treatment of patients with invasive fungal infection (IFI) prior to differential pathogen diagnosis. It was assumed that 7.8% of patients with IFI prior to differential pathogen diagnosis at treatment initiation actually had mucormycosis, and confirmation of pathogen identification was achieved for 50% of all patients during treatment. To extrapolate to a lifetime horizon, the model considered expected survival based on the patients' underlying condition. The model estimated the incremental costs (costs of drugs, laboratory analysis, hospitalization, and management of adverse events) and clinical outcomes (life-years (LYs) and quality-adjusted life-years (QALYs)) of first-line treatment with isavuconazole compared with voriconazole. The robustness of the results was assessed by conducting deterministic and probabilistic sensitivity analyses.Results: Isavuconazole delivered 0.48 more LYs and 0.39 more QALYs per patient at an incremental cost of £3,228, compared with voriconazole in the treatment of patients with IFI prior to differential pathogen diagnosis. This equates to an incremental cost-effectiveness ratio (ICER) of £8,242 per additional QALY gained and £6,759 per LY gained. These results were driven by a lack of efficacy of voriconazole in mucormycosis. Results were most sensitive to the mortality of IA patients and treatment durations.Conclusions: At a willingness to pay (WTP) threshold of £30,000 per additional QALY, the use of isavuconazole for the treatment of patients with IFI prior to differential pathogen diagnosis in the UK can be considered a cost-effective allocation of healthcare resources compared with voriconazole.
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Cheng L, Xiang R, Liu F, Li Y, Chen H, Yao P, Sun F, Xia P. Therapeutic drug monitoring and safety of voriconazole in elderly patients. Int Immunopharmacol 2020; 78:106078. [DOI: 10.1016/j.intimp.2019.106078] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/22/2019] [Accepted: 11/22/2019] [Indexed: 02/08/2023]
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