1
|
Kitaya S, Nakano M, Katori Y, Yasuda S, Kanamori H. QTc Interval Prolongation as an Adverse Event of Azole Antifungal Drugs: Case Report and Literature Review. Microorganisms 2024; 12:1619. [PMID: 39203461 PMCID: PMC11356777 DOI: 10.3390/microorganisms12081619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Revised: 08/02/2024] [Accepted: 08/05/2024] [Indexed: 09/03/2024] Open
Abstract
QTc prolongation and torsade de pointes (TdP) are significant adverse events linked to azole antifungals. Reports on QTc interval prolongation caused by these agents are limited. In this study, we report a case of a 77-year-old male with cardiovascular disease who experienced QTc prolongation and subsequent TdP while being treated with fluconazole for Candida albicans-induced knee arthritis. Additionally, a literature review was conducted on cases where QTc prolongation and TdP were triggered as adverse events of azole antifungal drugs. The case study detailed the patient's experience, whereas the literature review analyzed cases from May 1997 to February 2023, focusing on patient demographics, underlying diseases, antifungal regimens, concurrent medications, QTc changes, and outcomes. The review identified 16 cases, mainly in younger individuals (median age of 29) and women (75%). Fluconazole (63%) and voriconazole (37%) were the most common agents. Concurrent medications were present in 75% of cases, and TdP occurred in 81%. Management typically involved discontinuing or switching antifungals and correcting electrolytes, with all patients surviving. Risk assessment and concurrent medication review are essential before starting azole therapy. High-risk patients require careful electrocardiogram monitoring to prevent arrhythmias. Remote monitoring may enhance safety for patients with implanted devices. Further studies are needed to understand risk factors and management strategies.
Collapse
Affiliation(s)
- Shiori Kitaya
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan;
- Laboratory Medicine, Department of Infectious Diseases, Kanazawa University, Kanazawa 920-8641, Ishikawa, Japan
| | - Makoto Nakano
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan; (M.N.); (S.Y.)
| | - Yukio Katori
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan;
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan; (M.N.); (S.Y.)
| | - Hajime Kanamori
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan
- Laboratory Medicine, Department of Infectious Diseases, Kanazawa University, Kanazawa 920-8641, Ishikawa, Japan
| |
Collapse
|
2
|
Khan SA, Emmanuel S, Shantha Kumar V, Nerella R, Shaman Ameen B, Patel D, David John J, Bodepudi R, Seher S, Penumetcha SS. Long QT Syndrome With Drugs Used in the Management of Arrhythmias: A Systematic Review. Cureus 2024; 16:e65857. [PMID: 39219930 PMCID: PMC11364149 DOI: 10.7759/cureus.65857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/31/2024] [Indexed: 09/04/2024] Open
Abstract
Long QT syndrome (LQTS) is a severe cardiac disorder characterized by an abnormally prolonged QTc interval on an electrocardiogram (ECG), which can result in life-threatening irregular heart rhythms. The use of certain medications, particularly anti-arrhythmic drugs such as quinidine, sotalol, and amiodarone, can lead to acquired LQTS by prolonging the QT interval through the inhibition of specific ion channels responsible for heart repolarization, which may present symptoms like fainting, seizures, and sudden cardiac arrest. This systematic review, conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, focused on analyzing the association between Long QT syndrome and drugs utilized for managing arrhythmias, involving a thorough examination of six selected studies from an initial pool of 68 articles. It was found that antiarrhythmic drugs such as amiodarone, sotalol, dofetilide, procainamide, quinidine, and flecainide have the potential to cause QT prolongation as a side effect, which is often influenced by factors including dosage, coexisting medical conditions, electrolyte imbalances, and other risk factors. Prolonged QT interval significantly elevates the risk of a life-threatening arrhythmia called torsade de pointes. The management of this side effect typically involves reducing the medication dosage or discontinuing it altogether and, in some cases, employing selective beta blockers. However, further research is essential to improve the understanding and implementation of strategies to prevent and manage QT prolongation caused by antiarrhythmic drugs. Additional clinical studies are warranted to enhance knowledge and provide comprehensive guidelines to healthcare practitioners regarding the appropriate use of these medications. Close monitoring of the QT interval is recommended for patients receiving anti-arrhythmic therapy, and consideration should be given to patient-specific risk factors for LQTS, including age, sex, and electrolyte imbalances.
Collapse
Affiliation(s)
- Shenel A Khan
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Soniya Emmanuel
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Vivig Shantha Kumar
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Resheek Nerella
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Basim Shaman Ameen
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Dev Patel
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jabez David John
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ranita Bodepudi
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Saniya Seher
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sai Sri Penumetcha
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| |
Collapse
|
3
|
Cheng L, Liu Z, Yu M, Lin L, Xiong L, Dai Q. Hypokalemia and Hyponatremia in Adult Patients Receiving Voriconazole Therapeutic Drug Monitoring. J Clin Pharmacol 2024; 64:461-468. [PMID: 37910022 DOI: 10.1002/jcph.2381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/31/2023] [Indexed: 11/03/2023]
Abstract
Hypokalemia and hyponatremia are common but easily ignored adverse events in treatment with voriconazole (VCZ) that can lead to serious consequences. We intend to investigate the incidence of VCZ-induced hypokalemia and hyponatremia and their risk factors based on real-world data. A prospective study was conducted. A total of 272 patients with 414 VCZ plasma trough concentrations (C0) and VCZ N-oxide concentrations (CN) were included. The incidence of hypokalemia was 18.0% (48/266). A total of 81.2% (39/48) of patients developed hypokalemia within 14 days, whereas 56.2% (27/48) of patients developed hypokalemia within 1 week. The proportion of female patients in the hypokalemia group was higher than that in the nonhypokalemia group, as was the proportion of patients receiving intravenous VCZ. In the multivariate analysis, the independent risk factors for hypokalemia were sex, combined use of antibiotics, and VCZ CN/C0. The incidence of hyponatremia was 7.9% (21/266). The proportion of patients over 47 years of age in the hyponatremia group was 71.4% (15/21). The number of days of VCZ use in the hyponatremia group was greater than that in the nonhyponatremia group. A total of 47.6% (10/21) of patients in the hyponatremia group had supratherapeutic VCZ C0 (>5.0 µg/mL). In conclusion, hypokalemia is more likely to occur in females, in patients receiving intravenous VCZ, and in patients with the combined use of antibiotics. Hyponatremia is more likely to occur in patients older than 47 years who have been using VCZ for a long time and have higher VCZ C0 values.
Collapse
Affiliation(s)
- Lin Cheng
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhirui Liu
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Mingjie Yu
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Ling Lin
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Lirong Xiong
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Qing Dai
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| |
Collapse
|
4
|
Roy M, Karhana S, Shamsuzzaman M, Khan MA. Recent drug development and treatments for fungal infections. Braz J Microbiol 2023; 54:1695-1716. [PMID: 37219748 PMCID: PMC10484882 DOI: 10.1007/s42770-023-00999-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 04/27/2023] [Indexed: 05/24/2023] Open
Abstract
Fungal infections are now becoming a hazard to individuals which has paved the way for research to expand the therapeutic options available. Recent advances in drug design and compound screening have also increased the pace of the development of antifungal drugs. Although several novel potential molecules are reported, those discoveries have yet to be translated from bench to bedside. Polyenes, azoles, echinocandins, and flucytosine are among the few antifungal agents that are available for the treatment of fungal infections, but such conventional therapies show certain limitations like toxicity, drug interactions, and the development of resistance which limits the utility of existing antifungals, contributing to significant mortality and morbidity. This review article focuses on the existing therapies, the challenges associated with them, and the development of new therapies, including the ongoing and recent clinical trials, for the treatment of fungal infections. Advancements in antifungal treatment: a graphical overview of drug development, adverse effects, and future prospects.
Collapse
Affiliation(s)
- Madhura Roy
- Centre for Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
| | - Sonali Karhana
- Centre for Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
| | - Md Shamsuzzaman
- Department of Pharmaceutical Sciences, College of Pharmacy, Shaqra University, Sahqra, Kingdom of Saudi Arabia
| | - Mohd Ashif Khan
- Centre for Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India.
| |
Collapse
|
5
|
Sienkiewicz-Oleszkiewicz B, Salamonowicz-Bodzioch M, Słonka J, Kałwak K. Antifungal Drug-Drug Interactions with Commonly Used Pharmaceutics in European Pediatric Patients with Acute Lymphoblastic Leukemia. J Clin Med 2023; 12:4637. [PMID: 37510753 PMCID: PMC10380616 DOI: 10.3390/jcm12144637] [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: 05/17/2023] [Revised: 06/26/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023] Open
Abstract
Leukemia is one of the leading childhood malignancies, with acute lymphoblastic leukemia (ALL) being the most common type. Invasive fungal disease is a concerning problem also at pediatric hemato-oncology units. Available guidelines underline the need for antifungal prophylaxis and give recommendations for proper treatment in various clinical scenarios. Nonetheless, antifungal agents are often involved in drug-drug interaction (DDI) occurrence. The prediction of those interactions in the pediatric population is complicated because of the physiological differences in adults, and the lack of pharmacological data. In this review, we discuss the potential DDIs between antifungal agents and commonly used pharmaceutics in pediatric hemato-oncology settings, with special emphasis on the use of liposomal amphotericin B and ALL treatment. We obtained information from Micromedex® and Drugs.com® interaction checking databases and checked the EudraVigilance® database to source the frequency of severe adverse drug reactions that resulted from antifungal drug interactions. Several major DDIs were identified, showing a favorable safety profile of echinocandins and liposomal amphotericin B. Interestingly, although there are numerous available drug interaction checking tools facilitating the identification of potential serious DDIs, it is important to use more than one tool, as the presented searching results may differ between particular checking programs.
Collapse
Affiliation(s)
- Beata Sienkiewicz-Oleszkiewicz
- Department of Clinical Pharmacology, Faculty of Pharmacy, Wrocław Medical University, ul. Borowska 211a, 50-556 Wrocław, Poland
| | - Małgorzata Salamonowicz-Bodzioch
- Department and Clinic of Pediatric Oncology, Hematology and Bone Marrow Transplantation, Wrocław Medical University, Borowska 213, 50-556 Wrocław, Poland
| | - Justyna Słonka
- Gilead Sciences Poland Sp. z o.o., ul. Postepu 17A, 02-676 Warsaw, Poland
| | - Krzysztof Kałwak
- Department and Clinic of Pediatric Oncology, Hematology and Bone Marrow Transplantation, Wrocław Medical University, Borowska 213, 50-556 Wrocław, Poland
| |
Collapse
|
6
|
Chai S, Zhan JL, Zhao LM, Liu XD. Safety of triazole antifungals: a pharmacovigilance study from 2004 to 2021 based on FAERS. Ther Adv Drug Saf 2022; 13:20420986221143266. [PMID: 36545565 PMCID: PMC9761248 DOI: 10.1177/20420986221143266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022] Open
Abstract
Background Triazole antifungals are widely used as broad-spectrum antifungal activity; however, there are many undetected and unreported adverse events (AEs). Methods Data from the Food and Drug Administration Adverse Event Reporting System (FAERS) from the first quarter (Q1) of 2004 to the third quarter (Q3) of 2021 were selected for disproportionality analysis to assess the connection between antifungal triazoles, and AEs and important medical events (IMEs). Results A total of 22,566 records associated with triazole antifungals were identified, with 9584 triazole antifungal-IME pairs. The following system organ classes (SOCs) appeared as significant signals: 'Endocrine disorders' [reported odds ratio (ROR) = 167.94], 'Metabolism and nutrition disorders' (ROR = 46.30), and 'Skin and subcutaneous tissue disorders' (ROR = 21.37). Strong signals were observed with respiratory failure, rash, hepatic function abnormal, and hypokalemia. Uncommon security signals included a change in the QT interval, neurotoxicity, pseudoaldosteronism, and hallucinations. Conclusion Various triazole antifungals cause AEs of different types and intensities of association. Our results are broadly consistent with prescribing information and previous studies; however, additional pharmacoepidemiological studies are required to verify AEs with modest incidence but high signal. Plain Language Summary A study on the adverse effects of triazole antifungals Introduction: The triazole antifungals we studied include fluconazole, itraconazole, voriconazole, posaconazole, and isavuconazole. Triazole antifungals are widely used as broad-spectrum antifungals; however, there are many undetected and unreported adverse events (AEs).Materials and Methods: The Food and Drug Administration Adverse Event Reporting System (FAERS) database contains AEs reported to the FDA by different countries regarding post-marketing drugs. Through the FAERS database, we retrieved a total of 22,566 AE reports related to triazole antifungals. We not only counted information about patients' gender, age, weight, reporting country, outcome indicators, and indications but also analyzed the system organ classes (SOCs) of AEs, and the number of reported drug-related AEs and the degree of relevance.Results: We found a total of 22,566 records related to triazole antifungal agents, of which 9584 reports made important medical events (IMEs) about triazole antifungal agents, which are serious AEs. The following SOCs appear as important signals: 'endocrine disorders', 'metabolic and nutritional disorders', and 'skin and subcutaneous tissue disorders'. Triazole antifungals produce AEs, such as respiratory failure, rash, hepatic function abnormal, and hypokalemia. They also produce uncommon AEs, including changes in the QT interval, neurotoxicity, pseudoaldosteronism, and hallucinations.Conclusion: By analyzing data from the FAERS database, we identified more AEs associated with these five triazole antifungals than were indicated in the instructions and our findings provide additional insight into triazole-related AEs to inform clinicians before and during treatment.
Collapse
Affiliation(s)
- Shuang Chai
- Department of Pharmacy, Shengjing Hospital of
China Medical University, Shenyang, China,Department of the Second Clinical Pharmacy,
School of Pharmacy, China Medical University, Shenyang, China
| | - Jing-Lun Zhan
- Department of Pharmacy, Shengjing Hospital of
China Medical University, Shenyang, China,Department of the Second Clinical Pharmacy,
School of Pharmacy, China Medical University, Shenyang, China
| | - Li-Mei Zhao
- Department of Pharmacy, Shengjing Hospital of
China Medical University, Shenyang, China,Department of the Second Clinical Pharmacy,
School of Pharmacy, China Medical University, Shenyang, China
| | | |
Collapse
|
7
|
Challenges in the Treatment of Invasive Aspergillosis in Immunocompromised Children. Antimicrob Agents Chemother 2022; 66:e0215621. [PMID: 35766509 PMCID: PMC9295552 DOI: 10.1128/aac.02156-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Invasive aspergillosis (IA) is associated with significant morbidity and mortality. Voriconazole remains the drug of choice for the treatment of IA in children; however, the complex kinetics of voriconazole in children make dosing challenging and therapeutic drug monitoring (TDM) essential for treatment success. The overarching goal of this review is to discuss the role of voriconazole, posaconazole, isavuconazole, liposomal amphotericin B, echinocandins, and combination antifungal therapy for the treatment of IA in children. We also provide a detailed discussion of antifungal TDM in children.
Collapse
|
8
|
Ertem O, Tufekci O, Oren H, Tuncok Y, Ergon MC, Gumustekin M. Evaluation of voriconazole related adverse events in pediatric patients with hematological malignancies. J Oncol Pharm Pract 2022:10781552221086887. [PMID: 35285751 DOI: 10.1177/10781552221086887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite therapeutic drug monitoring and pharmacogenetic-guided dose selection are recommended for pediatric patients, safety of voriconazole is mostly monitored by clinical assessment. Having comprehensive knowledge of safety profile and distinguishing incidental events from the reactions that are truly related to voriconazole use are crucial for safer and uninterrupted treatment. OBJECTIVES This study aimed to address adverse reactions during the first month of voriconazole use by systematically evaluating retrospective records of all adverse events. Patients/Methods: It is a single-center, retrospective analysis of patients who received voriconazole from 1 September 2010 to 1 September 2020. Severity of abnormal findings in medical records were systematically graded. Causality between voriconazole and the events was evaluated by Liverpool Causality Assessment Tool (LCAT), Naranjo Algorithm and World Health Organization Causality Assessment System. The events with possible or probable causal relation to voriconazole are classified as adverse reaction. RESULTS Records of 45 patients included in the study. The overall frequency of adverse reactions was 51.1%. Hepatobiliary laboratory adverse reactions identified in 48.9% of the patients and led to treatment discontinuation in 20.0%. Amylase and lipase elevation (2.2%), ventricular extra systoles (2.2%), hallucination and nightmares (2.2%) were other adverse reactions. CONCLUSIONS Hepatobiliary abnormalities were the most common adverse reactions and the most common cause of treatment discontinuation. For safer treatment in critically ill patients, the dose should be personalized. To clearly identify the accurate frequency and the causality of all adverse reactions, prospective studies with much larger sample size are needed.
Collapse
Affiliation(s)
- Ozge Ertem
- Medical Pharmacology, University of Health Sciences Izmir Bozyaka Education and Research Hospital, Karabaglar/Izmir, Turkey
| | - Ozlem Tufekci
- Division of Pediatric Hematology, Department of Pediatrics, Dokuz Eylul University School of Medicine, Balcova/Izmir, Turkey
| | - Hale Oren
- Division of Pediatric Hematology, Department of Pediatrics, Dokuz Eylul University School of Medicine, Balcova/Izmir, Turkey
| | - Yesim Tuncok
- Department of Medical Pharmacology, Dokuz Eylul University School of Medicine, Balcova/Izmir, Turkey
| | - Mahmut Cem Ergon
- Department of Medical Microbiology, Dokuz Eylul University School of Medicine, Balcova/Izmir, Turkey
| | - Mukaddes Gumustekin
- Department of Medical Pharmacology, Dokuz Eylul University School of Medicine, Balcova/Izmir, Turkey
| |
Collapse
|
9
|
Lai CC, Yu WL. COVID-19 associated with pulmonary aspergillosis: A literature review. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 54:46-53. [PMID: 33012653 PMCID: PMC7513876 DOI: 10.1016/j.jmii.2020.09.004] [Citation(s) in RCA: 134] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/01/2020] [Accepted: 09/12/2020] [Indexed: 02/06/2023]
Abstract
Bacterial or virus co-infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported in many studies, however, the knowledge on Aspergillus co-infection among patients with coronavirus disease 2019 (COVID-19) was limited. This literature review aims to explore and describe the updated information about COVID-19 associated with pulmonary aspergillosis. We found that Aspergillus spp. can cause co-infections in patients with COVID-19, especially in severe/critical illness. The incidence of IPA in COVID-19 ranged from 19.6% to 33.3%. Acute respiratory distress syndrome requiring mechanical ventilation was the common complications, and the overall mortality was high, which could be up to 64.7% (n = 22) in the pooled analysis of 34 reported cases. The conventional risk factors of invasive aspergillosis were not common among these specific populations. Fungus culture and galactomannan test, especially from respiratory specimens could help early diagnosis. Aspergillus fumigatus was the most common species causing co-infection in COVID-19 patients, followed by Aspergillus flavus. Although voriconazole is the recommended anti-Aspergillus agent and also the most commonly used antifungal agent, aspergillosis caused by azole-resistant Aspergillus is also possible. Additionally, voriconazole should be used carefully in the concern of complicated drug-drug interaction and enhancing cardiovascular toxicity on anti-SARS-CoV-2 agents. Finally, this review suggests that clinicians should keep alerting the possible occurrence of pulmonary aspergillosis in severe/critical COVID-19 patients, and aggressively microbiologic study in addition to SARS-CoV-2 via respiratory specimens should be indicated.
Collapse
Affiliation(s)
- Chih-Cheng Lai
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Tainan Branch, Tainan, Taiwan
| | - Weng-Liang Yu
- Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan; Department of Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| |
Collapse
|
10
|
Mourad A, Stiber JA, Perfect JR, Johnson MD. Real-world implications of QT prolongation in patients receiving voriconazole and amiodarone. J Antimicrob Chemother 2020; 74:228-233. [PMID: 30295798 DOI: 10.1093/jac/dky392] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/31/2018] [Indexed: 01/23/2023] Open
Abstract
Objectives Voriconazole, a triazole antifungal, is frequently prescribed in a complex patient population with comorbidities that require concomitant administration of QT interval-prolonging medications. We sought to evaluate QT interval prolongation in patients receiving concomitant therapy with voriconazole and amiodarone and to assess the development of any potentially fatal cardiac arrhythmias as a result. Methods We conducted a retrospective observational study of patients who had received amiodarone and voriconazole concomitantly between 2005 and 2015, with a prior period of monotherapy, who had ECG data during monotherapy (baseline) and concomitant therapy (follow-up). Results We included 46 patients in our final analysis. Overall, the mean change in QT corrected (QTc) from baseline to follow-up was 49.0 ms (P < 0.001). Eighteen (39.1%) patients had a follow-up QTc interval ≥500 ms, with 17 (37.0%) having a change in QTc interval ≥60 ms from baseline to follow-up. Men were more likely to have a follow-up QTc interval of ≥500 ms. In multivariate analysis, only low serum potassium concentration and concomitant 'possible' QT-prolonging drugs were associated with a follow-up QTc interval ≥500 ms and a lower baseline QTc interval was associated with a change in QTc interval of ≥60 ms. Discharge diagnoses of cardiac arrhythmias and events were assessed and none was found to be related to concomitant therapy. Conclusions Concomitant therapy with amiodarone and voriconazole significantly prolonged the QTc interval to a degree greater than that on monotherapy. However, no clinically significant cardiac events were observed.
Collapse
Affiliation(s)
- Ahmad Mourad
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jonathan A Stiber
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - John R Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Melissa D Johnson
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
11
|
Cheng MP, Orejas JL, Arbona-Haddad E, Bold TD, Solomon IH, Chen K, Pandit A, Kusztos AE, Cummins KC, Liakos A, Marty FM, Koo S, Hammond SP. Use of triazoles for the treatment of invasive aspergillosis: A three-year cohort analysis. Mycoses 2019; 63:58-64. [PMID: 31587405 DOI: 10.1111/myc.13013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 09/26/2019] [Accepted: 10/01/2019] [Indexed: 02/06/2023]
Abstract
In a 3-year cohort study of adult patients with proven or probable IA, fewer patients initially treated with isavuconazole experienced adverse events compared with voriconazole, but more patients required a change in therapy due to lack of clinical efficacy.
Collapse
Affiliation(s)
- Matthew P Cheng
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - José L Orejas
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Esther Arbona-Haddad
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Tyler D Bold
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Isaac H Solomon
- Harvard Medical School, Boston, Massachusetts.,Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kaiwen Chen
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Alisha Pandit
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amanda E Kusztos
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kaelyn C Cummins
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Alexis Liakos
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Francisco M Marty
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sophia Koo
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sarah P Hammond
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
12
|
Gueta I, Klempfner R, Markovits N, Halkin H, Segev S, Rott D, Peled Y, Loebstein R. Clinically significant incidental QTc prolongation is subject to within-individual variability. Ann Noninvasive Electrocardiol 2019; 25:e12699. [PMID: 31498534 DOI: 10.1111/anec.12699] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/15/2019] [Accepted: 08/04/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Prolonged QTc interval observed in daily practice is often deemed to be drug induced and might result in drug discontinuation, with possible therapeutic consequences. However, whether clinically significant prolonged QTc may be due to within-individual variability occurs has yet to be described. METHODS A retrospective cohort study documenting within-individual QTc variability in subjects attending annual routine medical evaluation. At each visit, QT interval was measured and corrected for heart rate using Bazett and three other commonly used formulae. Outcome measures were rates of ΔQTc ≥60 msec, absolute QTc ≥500 msec and QTc ≥25% from baseline. RESULTS A total of 188 subjects [54 (29%)] females were recruited. Mean age at first ECG was 54 ± 12.8 years with mean time interval of 12.2 ± 1.1 months between measurements. Mean Bazett QTc was higher compared to the other 3 formulae: 412 ± 20 vs. 400 ± 16 msec. Using Bazett formula, 18/188 (9.6%) and 5/188 (2.7%) subjects showed at least one measurement with ΔQTc ≥60 msec and QTc ≥500 msec, respectively. Of the former, 5/18 (27.8%) showed QTc ≥25% prolongation. In multivariate analysis, QTc ≥500 msec was significantly associated with number of measurements (HR: 5.01, 95%CI: 1.21-20.78, p = .026) with no effect of other known confounders. Lower rates were demonstrated with the other three formulae. CONCLUSION In clinical practice, significant prolonged QTc may be attributed to within-individual variability, particularly when adjusting the QT interval with Bazett correction. This should be taken into consideration when decisions on changing current drug regimens are to be made.
Collapse
Affiliation(s)
- Itai Gueta
- The Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Robert Klempfner
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Olga and Lev Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Noa Markovits
- The Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hillel Halkin
- The Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomo Segev
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Institute for Medical Screening, Sheba Medical Center, Tel Hashomer, Israel
| | - David Rott
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Olga and Lev Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Yael Peled
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Olga and Lev Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Ronen Loebstein
- The Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
13
|
Barreto JN, Cullen MW, Mara KC, Grove ME, Sierzchulski AG, Dahl NJ, Tosh PK, Dierkhising RA, Patnaik MM, Ackerman MJ. QT prolongation in patients with acute leukemia or high-risk myelodysplastic syndrome prescribed antifungal prophylaxis during chemotherapy-induced neutropenia. Leuk Lymphoma 2019; 60:3512-3520. [PMID: 31298598 DOI: 10.1080/10428194.2019.1639165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Benefits of serial electrocardiographic (ECG) monitoring to detect QT prolongation in patients with hematological malignancies remain unclear. This retrospective, single-center, study evaluated 316 adult acute leukemia and high-risk MDS patients who received 11,775 patient-days of voriconazole prophylaxis during induction chemotherapy. Of these, 37 patients (16.2%) experienced QTc prolongation. Medications associated with QTc prolongation included furosemide, haloperidol, metronidazole, mirtazapine, prochlorperazine, and venlafaxine. Hypokalemia and hypomagnesemia were also significantly associated with QTc prolongation (HR 3.15; p = .003 and HR 6.47, p = .007, respectively). Management modifications due to QTc prolongation included discontinuation of QT prolonging medications (n = 25), more aggressive electrolyte repletion (n = 5), and enhanced ECG monitoring (n = 3). One patient with multiple QT prolonging factors experienced possible Torsades de Pointes. Overall mortality was 15% with no cardiac-related deaths. Serial ECG monitoring during induction chemotherapy can be tailored proportionally to QT-prolonging risk factors. Management should include aggressive electrolyte repletion and avoidance of concurrent QT prolonging medications.
Collapse
Affiliation(s)
| | - Michael W Cullen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | | | - Nathan J Dahl
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Pritish K Tosh
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ross A Dierkhising
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael J Ackerman
- Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
14
|
Pasternak Y, Shechter N, Loebstein R, Markovits N, Gueta I, Halkin H, Yarden‐Bilavsky H. Voriconazole-induced QTc prolongation in a paediatric population. Acta Paediatr 2019; 108:1128-1132. [PMID: 30456871 DOI: 10.1111/apa.14652] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/28/2018] [Accepted: 11/16/2018] [Indexed: 11/27/2022]
Abstract
AIM To evaluate Corrected QT (QTc) interval prolongation (QTcP) in paediatric patients treated with voriconazole (VRC) and identify its associated risk factors in this setting. METHODS Clinical, VRC-related and QTc interval data were collected retrospectively from the electronic medical records of VRC-treated paediatric patients attending a large tertiary medical centre in 2011-2016 who underwent electrocardiography before and during therapy. Paired comparison of QTc intervals before and during VRC treatment was performed, adjusted for concurrent medications, electrolyte disturbances and co-morbidities. RESULTS Fifty-five patients (mean age 10.1 ± 5.4 years) met the inclusion criteria; 34 had an oncologic or hemato-oncologic diagnosis. Mean QTc interval was 402.8 ± 27.9 msec before VRC treatment and 440.0 ± 45.3 msec on treatment (p < 0.001). During treatment, 38 patients (61.8%) had QTcP ≥30 msec and 17 (30.9%), QTcP ≥60 msec; 10 patients (18.2%) had QTc ≥500 msec of whom one acquired torsades de pointes. On multivariate analysis, older age (p = 0.025), lower potassium level (p = 0.025) and longer baseline QTc (0.032) were associated QTcP ≥60 msec, but not daily or cumulative dose of VRC. CONCLUSION This study demonstrated a high rate of clinically significant QTcP in VRC-treated children. Proper QTc monitoring, together with laboratory monitoring and electrolyte imbalance correction, is important to prevent cardiac arrhythmias in this patient population.
Collapse
Affiliation(s)
- Y Pasternak
- Department of Pediatrics A Schneider Children's Medical Center of Israel Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - N Shechter
- Department of Pediatrics B Schneider Children's Medical Center of Israel Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - R Loebstein
- Institute of Clinical Pharmacology and Toxicology Sheba Medical Center Tel Hashomer Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - N Markovits
- Institute of Clinical Pharmacology and Toxicology Sheba Medical Center Tel Hashomer Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - I Gueta
- Institute of Clinical Pharmacology and Toxicology Sheba Medical Center Tel Hashomer Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - H Halkin
- Institute of Clinical Pharmacology and Toxicology Sheba Medical Center Tel Hashomer Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - H Yarden‐Bilavsky
- Department of Pediatrics A Schneider Children's Medical Center of Israel Petach Tikva Israel
- Institute of Clinical Pharmacology and Toxicology Sheba Medical Center Tel Hashomer Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| |
Collapse
|
15
|
|
16
|
Buonomo AR, Viceconte G, Compare D, Vargas M, Iacovazzo C, Zappulo E, Nardone G, Servillo G, Borgia G, Gentile I. Invasive pulmonary aspergillosis and pulmonary tuberculosis in a patient treated with infliximab for Crohn's disease. IDCases 2019; 17:e00537. [PMID: 31384555 PMCID: PMC6667483 DOI: 10.1016/j.idcr.2019.e00537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/12/2019] [Accepted: 04/12/2019] [Indexed: 12/20/2022] Open
Abstract
Pulmonary TB together with invasive pulmonary aspergillosis due to infliximab therapy has been occasionally described. Other than tuberculosis reactivation, TNF-α antagonists may be associated with other opportunistic infections such as invasive aspergillosis. Interactions among rifamycins, antifungal and antiarrhythmic drugs are complex and may require the choice of second line therapies. Isavuconazole may have a better interaction profile with amiodarone and antitubercular therapy than voriconazole.
We report a case of concurrent development of active pulmonary tuberculosis and invasive pulmonary aspergillosis (IPA) in a patient who received therapy with infliximab for Crohn’s disease. He has been treated with antitubercular therapy and liposomal amphotericin B for 8 weeks. His clinical course was complicated by paroxysmal atrial fibrillation requiring maintenance therapy with amiodarone, respiratory failure due both to pneumonia caused by methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum beta-lactamases (ESBL)-producing Klebsiella pneumoniae and pleural effusion requiring chest drainage. At discharge, a maintenance regimen based on the administration of isavuconazole 200 mg daily, moxifloxacin 400 mg daily and isoniazid 300 mg daily was chosen to avoid multiple drug-drug interaction between rifamycins, antifungal triazole agents and antiarrhythmic drugs. At 3 months of follow-up his clinical conditions were dramatically improved, high resolution chest tomography (HRCT) showed reduction of parenchymal lesions and no changes both in sinus rhythm and QTc interval were noticed. Besides the complexity and the peculiarity of the clinical scenario, this case underlines the risk of invasive fungal infections linked to the administration of TNF-α antagonists in gastroenterological setting and the importance of accurate evaluation of drug-drug interactions when choosing the antimicrobial therapies.
Collapse
Affiliation(s)
- Antonio Riccardo Buonomo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Italy
| | - Giulio Viceconte
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Italy
| | - Debora Compare
- Department of Clinical Medicine and Surgery, Section of Gastroenterology, University Federico II of Naples, Naples, Italy
| | - Maria Vargas
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", via Pansini, Naples, Italy
| | - Carmine Iacovazzo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", via Pansini, Naples, Italy
| | - Emanuela Zappulo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Italy
| | - Gerardo Nardone
- Department of Clinical Medicine and Surgery, Section of Gastroenterology, University Federico II of Naples, Naples, Italy
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", via Pansini, Naples, Italy
| | - Guglielmo Borgia
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Italy
| | - Ivan Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Italy
| |
Collapse
|
17
|
Bassetti M, Carnelutti A, Righi E. Issues in the management of invasive pulmonary aspergillosis in non-neutropenic patients in the intensive care unit: A role for isavuconazole. IDCases 2018; 12:7-9. [PMID: 29850401 PMCID: PMC5966628 DOI: 10.1016/j.idcr.2018.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 02/27/2018] [Accepted: 02/27/2018] [Indexed: 12/11/2022] Open
Abstract
Background Almost half of all cases of invasive aspergillosis (IA) occur in the intensive care unit (ICU), with mortality rates of 70–80% for probable or proven cases. IA has become a major concern among non-neutropenic patients in the ICU with chronic obstructive pulmonary disease (COPD) but although prompt, appropriate antifungal therapy is crucial, diagnosis in this situation is challenging. Criteria for a probable diagnosis in critically ill patients have been proposed to help to expedite therapy. Methods A case of probable invasive pulmonary aspergillosis (IPA) in a non-neutropenic patient admitted to the ICU was used to illustrate potential issues in the diagnostic work-up and management of patients in this setting. Results A non-neutropenic 69-year-old man with COPD receiving clomipramine was diagnosed in the ICU with probable invasive aspergillosis based on the presence of severe chronic obstructive pulmonary disease, suspected X-linked granulomatous disease, nodular infiltrates and galactogamman positivity on bronchoalveolar lavage (BAL) fluid. Voriconazole was unsuitable due to the patient's prolonged QT interval and risk of a drug–drug interaction with clomipramine. Isavuconazole was initiated and the patient's condition improved. The three-month course of isavuconazole treatment was well-tolerated and resulted in compete recovery of the patient. Conclusions Voriconazole is a standard first-line treatment for IA but intravenous therapy is associated with toxicity and the potential for drug–drug interactions. Isavuconazole is another first-line therapy which was effective and safe in the management of this critically ill non-neutropenic patient with baseline QT prolongation and potential drug–drug interactions with voriconazole.
Collapse
Affiliation(s)
- Matteo Bassetti
- Corresponding author at: Clinica Malattie Infettive, Azienda Ospedaliera Universitaria Santa Maria della Misericordia, Piazzale Santa Maria della Misericordia 15, 33100, Udine, Italy.
| | | | | |
Collapse
|