Stereoselective determination of the epimer mixtures of itraconazole in human blood plasma using HPLC and fluorescence detection

Enantiomeric separation and molecular docking study of seven imidazole antifungal drugs on a cellulose tris-(3,5-dimethylphenylcarbamate) chiral stationary phase

Chiral separation and molecular docking study of seven imidazole antifungal drugs were performed on a cellulose tris-(3,5-dimethylphenylcarbamate) chiral stationary phase (Chiralcel OD-RH).

Quantitative analysis of drugs in biological matrices by HPLC hyphenated to fluorescence detection

An overview of the state-of-the art in HPLC coupled with fluorescence detection is presented. Over the last 20 years, the increasing number of methodological papers on this topic (4082 between 1994 and 2004 and 7725 between 2004 and 2014) is testament to its utility in bioanalytical applications. Compared with conventional UV absorbance detection used in HPLC, fluorescence detection can greatly enhance the sensitivity leading to limits of detection similar to those obtained with mass spectrometry, offering researchers a sensitive, robust and relatively inexpensive instrumental method. This work will focus on the analysis of pharmaceutical compounds in different biological matrices, either naturally fluorescent or derivatized with a fluorescent agent, and some of them chiral. Therapeutic applications, sample preparation and derivatization, sensitivity for each example are described.

Optimizing azole antifungal therapy in the prophylaxis and treatment of fungal infections

PURPOSE OF REVIEW

Azole antifungals are widely used in the prophylaxis and treatment of fungal infections, but are associated with a range of pharmacokinetic challenges and safety issues that necessitate individualized therapy to achieve optimal clinical outcomes. Recent advances in our knowledge of azole exposure-response relationships, therapeutic drug monitoring and individualized dosing strategies are reviewed as follows.

RECENT FINDINGS

Recent studies have significantly improved the understanding of exposure-response relationships for efficacy and toxicity, increasing confidence in target exposure ranges for azole antifungal agents. Population pharmacokinetic modelling of voriconazole has led to studies demonstrating the feasibility of model-guided dose individualization strategies with the drug, which holds significant promise for optimizing therapy. The recent approval of a solid oral tablet formulation of posaconazole with improved bioavailability and once-daily dosing has significantly improved the clinical utility of this agent. Further clinical experience with the investigational azole isavuconazole is needed to determine the role of individualized therapy.

SUMMARY

The coordination of CYP2C19 pharmacogenomic testing with model-guided dose individualization holds significant promise for optimizing therapy with voriconazole. Pharmacokinetic challenges with itraconazole, voriconazole and posaconazole oral suspension continue to require therapeutic drug monitoring to individualize therapy and optimize treatment outcomes.

Antifungal use and therapeutic monitoring of plasma concentrations of itraconazole in heart and lung transplantation patients

BACKGROUND

The prophylactic use of itraconazole has dramatically reduced the incidence of fungal infections in patients after solid-organ transplantation. To further reduce this incidence, it has been suggested that plasma concentrations of itraconazole be monitored and maintained above a putative minimum target concentration of 500 ng/mL.

METHODS

A retrospective audit was undertaken of patients who had had a heart or lung transplant over a 14-month period (between January 1, 2010 and March 31, 2011). The itraconazole prophylaxis regimen (dose, time of last dose, time of blood collection) and plasma concentrations were recorded together with the use of concomitant antacid medication. Details of breakthrough fungal infections were documented.

RESULTS

Eighty-four heart or lung organ transplantations were undertaken in the study period; 57 were treated prophylactically with itraconazole. Plasma concentrations of itraconazole were monitored in 56% (n = 32) of these cases. Considerable interpatient (range, 50-2000 ng/mL) and intrapatient variability in plasma concentrations was observed. The putative target was not achieved consistently in the majority of cases. All patients were taking a proton pump inhibitor. Six of the cohort developed an invasive fungal infection. None of the 3 patients for whom plasma concentrations were monitored was above the target concentration.

CONCLUSIONS

Further clinical studies, involving monitoring of the active metabolite and attention to the importance of the stereoisomers of itraconazole, may give better insight into the appropriateness of the currently suggested minimum target concentration, whose validity remains uncertain. Formulations with improved absorption characteristics could reduce the variability of absorption with the goal of further reducing the incidence of infrequent, but life-threatening, invasive fungal infections.