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Irshad Z, Jenkins A, Lim HS, Maidment ID. Antifungal prophylaxis against invasive Candida and Aspergillus infection in adult heart transplant recipients: protocol for a systematic review and meta-analysis. Eur J Hosp Pharm 2024:ejhpharm-2024-004266. [PMID: 38960452 DOI: 10.1136/ejhpharm-2024-004266] [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: 06/06/2024] [Accepted: 06/18/2024] [Indexed: 07/05/2024] Open
Abstract
INTRODUCTION Invasive fungal infections (IFI) can contribute to increased mortality and morbidity rates after heart transplant in adults. The most common causes are Aspergillus and Candida species. There is uncertainty on how effective antifungal prophylaxis is against Candida spp infections and limited guidance on the prevention of Aspergillus spp infections. This systematic review and meta-analysis will assess the literature to see if antifungal prophylaxis reduces the incidence of IFI after heart transplant in adults. METHODS AND ANALYSIS This systematic review protocol follows the Preferred Reporting Items for Systematic reviews and Meta Analysis guidelines. A systematic search of the Cochrane Library, Web of Science, Scopus, Embase, MEDLINE, and Proquest databases will be undertaken. Reference lists of retrieved publications and conference abstracts will also be searched. Title, abstract and full-text screening will be undertaken by two reviewers. Discrepancies will be resolved by a third reviewer. Studies with paediatric patients, multi-organ transplants, or patients with a second heart transplant will be excluded, along with those who do not have clear definitions and diagnostic criteria for IFI. Risk of bias will be assessed using the Cochrane Risk of Bias 2 tool and the Risk of Bias in Non-randomised Studies of Interventions tool. A meta-analysis will be carried out, but if studies are not deemed to be sufficiently similar, only a narrative synthesis will be undertaken. ETHICS AND DISSEMINATION Ethical approval is not required for this systematic review as primary data will not be collected. The results of the review will be disseminated through publication in an academic journal and scientific conferences. PROSPERO REGISTRATION NUMBER CRD42024516588.
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Affiliation(s)
- Zahra Irshad
- Pharmacy, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Abi Jenkins
- Pharmacy, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hoong Sern Lim
- Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Albayrak A, Akkuzu E, Karahalil B. The impact of antimicrobial use on potential major drug-drug interactions in the pediatric Intensive Care Unit patients at University Hospital in Türkiye. Minerva Pediatr (Torino) 2024; 76:388-394. [PMID: 33858128 DOI: 10.23736/s2724-5276.21.06173-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Antimicrobials, especially antibiotics, are among the most widely used drugs in the pediatric intensive care unit. Pediatrics patients in intensive care unit are exposed to potential drug-drug interactions (PDDIs) and suffered from their adverse and side effects. The aim of this study is to evaluate the impact of antimicrobial use on PDDIs, as well as to examine the rate and the risk factors PDDIs, furthermore the management of PDDIs. METHODS The present retrospective cohort study included 179 patients under 18 years of age who were hospitalized in Pediatric Intensive Care Unit in Türkiye. Drug interactions were evaluated using the Lexicomp® (Macedonia, OH, USA) drug interaction tool which provides evidence-based drug information. RESULTS Our study results showed that the frequency of the use of antimicrobial drugs (antibiotic, antifungal, antiviral) was found to be statistically significantly higher (P<0.05) in the group with PDDIs compared to the group without PDDIs. Especially, the use of carbapenem, cephalosporin among the antibiotic groups significantly increased the frequency of PDDIs (P<0.05). While the probability PDDIs statistically significantly increased 3.73 times (OR [odds ratio] = 3.73; 95% CI=1.47-9.50) in patients who used a single antibiotic compared to patients who did not use antibiotics (P=0.006), the probability of the occurrence of PDDIs by using more than one antibiotic was statistically significantly 8.5 times (95% CI=3.30-21.89) (P<0.001). CONCLUSIONS Our study results showed that the use of antimicrobial drugs (antibiotic, antifungal, antiviral) was found to be statistically significantly higher (P<0.05) in the group with PDDIs.
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Affiliation(s)
- Aslınur Albayrak
- Department of Clinical Pharmacy, Faculty of Pharmacy, Gazi University, Ankara, Türkiye -
| | - Emine Akkuzu
- Department of Pediatric Intensive Care, Medical Faculty, Gazi University, Ankara, Türkiye
| | - Bensu Karahalil
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Gazi University, Ankara, Türkiye
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Liu MZ, Dai XH, Zeng MT, Chen EQ. Clinical treatment of cryptococcal meningitis: an evidence-based review on the emerging clinical data. J Neurol 2024; 271:2960-2979. [PMID: 38289535 DOI: 10.1007/s00415-024-12193-8] [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: 11/10/2023] [Revised: 01/07/2024] [Accepted: 01/13/2024] [Indexed: 05/30/2024]
Abstract
Cryptococcal meningitis (CM) is a fatal fungal central nervous system (CNS) infection caused by Cryptococcus infecting the meninges and/or brain parenchyma, with fever, headache, neck stiffness, and visual disturbances as the primary clinical manifestations. Immunocompromised individuals with human immunodeficiency virus (HIV) infection or who have undergone organ transplantation, as well as immunocompetent people can both be susceptible to CM. Without treatment, patients with CM may have a mortality rate of up to 100% after hospital admission. Even after receiving therapy, CM patients may still suffer from problems such as difficulty to cure, poor prognosis, and high mortality. Therefore, timely and effective treatment is essential to improve the mortality and prognosis of CM patients. Currently, the clinical outcomes of CM are frequently unsatisfactory due to limited drug choices, severe adverse reactions, drug resistance, etc. Here, we review the research progress of CM treatment strategies and discuss the suitable options for managing CM, hoping to provide a reference for physicians to select the most appropriate treatment regimens for CM patients.
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Affiliation(s)
- Mao-Zhu Liu
- Center of Infectious Diseases, West China Hospital, Sichuan University, No.37 Guo Xue Xiang, Wuhou District, Chengdu, 610041, China
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin-Hua Dai
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ming-Tang Zeng
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - En-Qiang Chen
- Center of Infectious Diseases, West China Hospital, Sichuan University, No.37 Guo Xue Xiang, Wuhou District, Chengdu, 610041, China.
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Patel SN, Thompson D, Roth N, Grodstein E. Cutaneous and renal aspergillosis resulting from orthotopic liver transplantation. BMJ Case Rep 2023; 16:e256974. [PMID: 37993141 PMCID: PMC10668145 DOI: 10.1136/bcr-2023-256974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023] Open
Affiliation(s)
- Shreeja Nirav Patel
- Medical School, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Dane Thompson
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Nitzan Roth
- Department of Hepatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Elliot Grodstein
- Department of Transplant Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
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Patanwala AE, Jager NGL, Radosevich JJ, Brüggemann R. An update on drug-drug interactions for care of the acutely ill in the era of COVID-19. Am J Health Syst Pharm 2023; 80:1301-1308. [PMID: 37368815 PMCID: PMC10516707 DOI: 10.1093/ajhp/zxad152] [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: 06/25/2023] [Indexed: 06/29/2023] Open
Abstract
PURPOSE To provide key pharmacological concepts underlying drug-drug interactions (DDIs), a decision-making framework, and a list of DDIs that should be considered in the context of contemporary acutely ill patients with COVID-19. SUMMARY DDIs are frequently encountered in the acutely ill. The implications of DDIs include either increased risk of drug toxicity or decreased effectiveness, which may have severe consequences in the acutely ill due to lower physiological and neurocognitive reserves in these patients. In addition, an array of additional therapies and drug classes have been used for COVID-19 that were not typically used in the acute care setting. In this update on DDIs in the acutely ill, we provide key pharmacological concepts underlying DDIs, including a discussion of the gastric environment, the cytochrome P-450 (CYP) isozyme system, transporters, and pharmacodynamics in relation to DDIs. We also provide a decision-making framework that elucidates the identification of DDIs, risk assessment, selection of alternative therapies, and monitoring. Finally, important DDIs pertaining to contemporary acute care clinical practice related to COVID-19 are discussed. CONCLUSION Interpreting and managing DDIs should follow a pharmacologically based approach and a systematic decision-making process to optimize patient outcomes.
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Affiliation(s)
- Asad E Patanwala
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Camperdown, New South Wales, and Department of Pharmacy, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Nynke G L Jager
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, and Radboudumc Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - John J Radosevich
- Department of Pharmacy Services, Dignity Health–St. Joseph’s Hospital & Medical Center, Phoenix, AZ, USA
| | - Roger Brüggemann
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, and Radboudumc Institute for Health Sciences Center of Expertise in Mycology Radboudumc/CWZ, Radboud University Medical Center, Nijmegen, the Netherlands
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Wang CB, Zhang YJ, Zhao MM, Zhao LM. Population pharmacokinetic analyses of tacrolimus in non-transplant patients: a systematic review. Eur J Clin Pharmacol 2023:10.1007/s00228-023-03503-6. [PMID: 37261481 DOI: 10.1007/s00228-023-03503-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 04/30/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Tacrolimus (TAC) has been increasingly used in patients with non-transplant settings. Because of its large between-subject variability, several population pharmacokinetic (PPK) studies have been performed to facilitate individualized therapy. This review summarized published PPK models of TAC in non-transplant patients, aiming to clarify factors affecting PKs of TAC and identify the knowledge gap that may require further research. METHODS The PubMed, Embase databases, and Cochrane Library, as well as related references, were searched from the time of inception of the databases to February 2023, to identify TAC population pharmacokinetic studies modeled in non-transplant patients using a non-linear mixed-effects modeling approach. RESULTS Sixteen studies, all from Asian countries (China and Korea), were included in this study. Of these studies, eleven and four were carried out in pediatric and adult patients, respectively. One-compartment models were the commonly used structural models for TAC. The apparent clearance (CL/F) of TAC ranged from 2.05 to 30.9 L·h-1 (median of 14.9 L·h-1). Coadministered medication, genetic factors, and weight were the most common covariates affecting TAC-CL/F, and variability in the apparent volume of distribution (V/F) was largely explained by weight. Coadministration with Wuzhi capsules reduced CL/F by about 19 to 43%. For patients with CYP3A5*1*1 and *1*3 genotypes, the CL/F was 39-149% higher CL/F than patients with CYP3A5*1*1. CONCLUSION The optimal TAC dosage should be adjusted based on the patient's co-administration, body weight, and genetic information (especially CYP3A5 genotype). Further studies are needed to assess the generalizability of the published models to other ethnic groups. Moreover, external validation should be frequently performed to improve the clinical practicality of the models.
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Affiliation(s)
- Cheng-Bin Wang
- Department of Pharmacy, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning Province, People's Republic of China
| | - Yu-Jia Zhang
- Department of Pharmacy, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning Province, People's Republic of China
| | - Ming-Ming Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning Province, People's Republic of China
| | - Li-Mei Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning Province, People's Republic of China.
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Impact of antithymocyte globulin on blood cyclosporin A levels in aplastic anemia patients. Ann Hematol 2023; 102:463-465. [PMID: 36435888 DOI: 10.1007/s00277-022-05063-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 11/13/2022] [Indexed: 11/28/2022]
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Rombauts A, Bodro M, Daniel Gumucio V, Carbonell I, Favà À, Lladó L, González-Costello J, Oppenheimer F, Castel-Lavilla MÁ, Len O, Marquez-Algaba E, Nuvials-Casals X, Martínez González D, Lacasa JS, Carratalà J, Sabé N. Antifungal prophylaxis with nebulized amphotericin-B in solid-organ transplant recipients with severe COVID-19: a retrospective observational study. Front Cell Infect Microbiol 2023; 13:1165236. [PMID: 37180450 PMCID: PMC10174318 DOI: 10.3389/fcimb.2023.1165236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/07/2023] [Indexed: 05/16/2023] Open
Abstract
COVID-19-associated pulmonary aspergillosis (CAPA) has emerged as a frequent complication in the intensive care unit (ICU). However, little is known about this life-threatening fungal superinfection in solid organ transplant recipients (SOTRs), including whether targeted anti-mold prophylaxis might be justified in this immunosuppressed population. We performed a multicentric observational retrospective study of all consecutive ICU-admitted COVID-19 SOTRs between August 1, 2020 and December 31, 2021. SOTRs receiving antifungal prophylaxis with nebulized amphotericin-B were compared with those without prophylaxis. CAPA was defined according the ECMM/ISHAM criteria. Sixty-four SOTRs were admitted to ICU for COVID-19 during the study period. One patient received antifungal prophylaxis with isavuconazole and was excluded from the analysis. Of the remaining 63 SOTRs, nineteen (30.2%) received anti-mold prophylaxis with nebulized amphotericin-B. Ten SOTRs who did not receive prophylaxis developed pulmonary mold infections (nine CAPA and one mucormycosis) compared with one who received nebulized amphotericin-B (22.7% vs 5.3%; risk ratio 0.23; 95%CI 0.032-1.68), but with no differences in survival. No severe adverse events related to nebulized amphotericin-B were recorded. SOTRs admitted to ICU with COVID-19 are at high risk for CAPA. However, nebulized amphotericin-B is safe and might reduce the incidence of CAPA in this high-risk population. A randomized clinical trial to confirm these findings is warranted.
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Affiliation(s)
- Alexander Rombauts
- Department of Infectious Diseases, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
- *Correspondence: Alexander Rombauts,
| | - Marta Bodro
- Department of Infectious Diseases, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Victor Daniel Gumucio
- Department of Intensive Care Medicine, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Irene Carbonell
- Department of Infectious Diseases, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Àlex Favà
- Renal Transplant Unit, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Laura Lladó
- Liver Transplant Unit, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - José González-Costello
- Heart Transplant Unit, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | | | | | - Oscar Len
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Ester Marquez-Algaba
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier Nuvials-Casals
- Department of Intensive Care Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Judith Sacanell Lacasa
- Department of Intensive Care Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), L´Hospitalet de Llobregat, Barcelona, Spain
| | - Nuría Sabé
- Department of Infectious Diseases, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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Prospective Prediction of Dapaconazole Clinical Drug-Drug Interactions Using an In Vitro to In Vivo Extrapolation Equation and PBPK Modeling. Pharmaceuticals (Basel) 2022; 16:ph16010028. [PMID: 36678526 PMCID: PMC9861162 DOI: 10.3390/ph16010028] [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: 11/06/2022] [Revised: 12/15/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022] Open
Abstract
This study predicted dapaconazole clinical drug−drug interactions (DDIs) over the main Cytochrome P450 (CYP) isoenzymes using static (in vitro to in vivo extrapolation equation, IVIVE) and dynamic (PBPK model) approaches. The in vitro inhibition of main CYP450 isoenzymes by dapaconazole in a human liver microsome incubation medium was evaluated. A dapaconazole PBPK model (Simcyp version 20) in dogs was developed and qualified using observed data and was scaled up for humans. Static and dynamic models to predict DDIs following current FDA guidelines were applied. The in vitro dapaconazole inhibition was observed for all isoforms investigated, including CYP1A2 (IC50 of 3.68 µM), CYP2A6 (20.7 µM), 2C8 (104.1 µM), 2C9 (0.22 µM), 2C19 (0.05 µM), 2D6 (0.87 µM), and 3A4 (0.008−0.03 µM). The dynamic (PBPK) and static DDI mechanistic model-based analyses suggest that dapaconazole is a weak inhibitor (AUCR > 1.25 and <2) of CYP1A2 and CYP2C9, a moderate inhibitor (AUCR > 2 and <5) of CYP2C8 and CYP2D6, and a strong inhibitor (AUCR ≥ 5) of CYP2C19 and CYP3A, considering a clinical scenario. The results presented may be a useful guide for future in vivo and clinical dapaconazole studies.
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Effect of posaconazole on the concentration of intravenous and oral cyclosporine in patients undergoing hematopoietic stem cell transplantation. Eur J Clin Pharmacol 2022; 78:1677-1685. [PMID: 36045212 DOI: 10.1007/s00228-022-03378-z] [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: 05/06/2022] [Accepted: 08/25/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE This study aimed to investigate the interactions between posaconazole (POS) and intravenously/orally administered cyclosporine A (CsA) in allogeneic hematopoietic stem cell transplant (HSCT) recipients. METHODS We included 118 allogeneic HSCT patients who received CsA and POS simultaneously between January 2017 and June 2020 in this study. The ratio of CsA blood concentration (ng/mL) to dosage (mg/day) (C/D) before and after POS initiation was compared. RESULTS After the initiation of POS, the level of CsA increased 1 to 2 times in 66% (78/118) of patients compared to those without POS. However, the CsA C/D ratio increased by more than threefold in 6% (7/118) of patients after POS initiation, with an increase of more than fourfold in two patients. The median C/D ratio of CsA increased from 0.89 to 1.23 (P < 0.001) and 0.78 to 1.22 (P < 0.001) after POS initiation when CsA was administered intravenously and orally, respectively. In patients who received POS at the time of transition from intravenous to oral CsA, the value increased from 1.01 to 1.38 (P = 0.001). The route of administration had no significant effect on the change in the CsA C/D ratio (P = 0.615). Additionally, we observed the time required for the C/D ratio to reach a plateau after POS initiation was similar on days 13, 8, and 15 under various scenarios. CONCLUSION POS treatment increased blood CsA levels. A large variability was found in the fold-change in the CsA C/D ratio. Therefore, CsA doses should be adjusted by closely monitoring the blood levels of CsA after POS initiation.
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Dark Mold Infections in Solid Organ Transplant Recipients. CURRENT FUNGAL INFECTION REPORTS 2022. [DOI: 10.1007/s12281-022-00436-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gago‐Sánchez AI, Font P, Cárdenas M, Aumente MD, Del Prado JR, Calleja MÁ. Real clinical impact of drug-drug interactions of immunosuppressants in transplant patients. Pharmacol Res Perspect 2021; 9:e00892. [PMID: 34755493 PMCID: PMC8578873 DOI: 10.1002/prp2.892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/23/2021] [Indexed: 11/27/2022] Open
Abstract
The main objective was to determine the prevalence of real drug-drug interactions (DDIs) of immunosuppressants in transplant patients. We conducted a prospective, observational 1-year study at a tertiary hospital, including all transplanted patients. We evaluated data from monitoring blood concentrations of immunosuppressive drugs and adverse drug events (ADEs) caused by DDIs. The DDIs were classified as C, D, or X according to their Lexi-Interact rating (C = monitor therapy, D = consider therapy modification, X = avoid combination). The clinical importance of real DDIs was expressed in terms of patient outcomes. The causality of DDIs was determined using Drug Interaction Probability Scale. The data were analyzed using Statistical Package for Social Sciences v. 25.0. A total of 309 transplant patients were included. Their mean age was 52.0 ± 14.7 years (18-79) and 69.9% were male. The prevalence of real DDIs was 21.7%. Immunosuppressive drugs administered with antifungal azoles and tacrolimus (TAC) with nifedipine have a great clinical impact. Real DDIs caused ADEs in 22 patients. The most common clinical outcome was nephrotoxicity (1.6%; n = 5), followed by hypertension (1.3%; n = 4). Suggestions for avoiding category D and X DDIs included: changing the immunosuppressant dosage, using paracetamol instead of non-steroidal anti-inflammatory drugs, and interrupting atorvastatin. The number of drugs prescribed and having been prescribed TAC was associated with an increased risk of real DDIs. There are many potential DDIs described in the literature but only a small percentage proved to be real DDIs, based on the patients´ outcomes.
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Affiliation(s)
- Ana Isabel Gago‐Sánchez
- Pharmacy DepartmentHospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/University of CórdobaCórdobaSpain
| | - Pilar Font
- Rheumatology DepartmentHospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/University of CórdobaCórdobaSpain
| | - Manuel Cárdenas
- Pharmacy DepartmentHospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/University of CórdobaCórdobaSpain
| | - María Dolores Aumente
- Pharmacy DepartmentHospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/University of CórdobaCórdobaSpain
| | - José Ramón Del Prado
- Pharmacy DepartmentHospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/University of CórdobaCórdobaSpain
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Cheng F, Li Q, Wang J, Zeng F, Zhang Y. Effects and safety evaluation of Wuzhi Capsules combined with tacrolimus for the treatment of kidney transplantation recipients. J Clin Pharm Ther 2021; 46:1636-1649. [PMID: 34342024 DOI: 10.1111/jcpt.13493] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 01/06/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Tacrolimus (FK506), an effective and potent calcineurin inhibitor, is the cornerstone of immunosuppression after kidney transplantation. Wuzhi capsule (WZC), a prescribed ethanol extract of Nan-Wuweizi (Schisandra sphenanthera), is widely prescribed for kidney transplant recipients for the maintenance of tacrolimus concentration in clinical settings. Previous studies have demonstrated that WZC can increase the blood concentration of tacrolimus. However, it remains controversial whether to use WZC can be used to increase tacrolimus concentration in clinical practice. Our study aimed to evaluate the efficacy and safety of WZC combined with tacrolimus in the treatment of kidney transplant recipients. METHODS One hundred and ninety four Chinese kidney transplant recipients were included in this retrospective study. The recipients were divided into two groups (non-WZC group and WZC group). We investigated the effects of WZC on tacrolimus in terms of tacrolimus metabolism, laboratory tests, pharmacogenomics, renal function and adverse reactions. RESULTS AND DISCUSSION The concentration/dose (C0 /D) of tacrolimus was significantly higher in the WZC group than the non-WZC group. The laboratory findings of blood routine tests, liver and kidney function were not significantly different between the two groups. The CYP3A5 genotype showed clearly associated with tacrolimus C0 /D, whereas no significant difference was observed in patients with CYP3A4*1B, CYP3A4*22, ABCB1, ABCC2, POR*28 or PXR alleles. The improvement of C0 /D by administration of WZC was significant in CYP3A5 expressers compared to non-expressers. Furthermore, the WZC group had a remarkably higher proportion of subjects who reached the target tacrolimus concentration than the non-WZC group. No significant differences in renal function and adverse reactions were observed between the groups. WHAT IS NEW AND CONCLUSION Wuzhi capsule can increase tacrolimus concentration without negative effects on renal function and adverse reactions, especially in CYP3A5 expressers. Efficient and economical synergistic effects can be achieved by the combined administration of WZC in kidney transplant recipients.
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Affiliation(s)
- Fang Cheng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Qiang Li
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Jinglin Wang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Fang Zeng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Yu Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
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14
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Li L, Zhu M, Li DY, Guo HL, Hu YH, Xu ZY, Jing X, Chen F, Zhao F, Li YM, Xu J, Jiao Z. Dose tailoring of tacrolimus based on a non-linear pharmacokinetic model in children with refractory nephrotic syndrome. Int Immunopharmacol 2021; 98:107827. [PMID: 34284341 DOI: 10.1016/j.intimp.2021.107827] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/13/2021] [Accepted: 05/25/2021] [Indexed: 10/20/2022]
Abstract
The population pharmacokinetics (PPK) of tacrolimus (TAC) in children with refractory nephrotic syndrome (RNS) have not been well-characterized. This study aimed to investigate the significant factors affecting the TAC PPK characteristics of children with RNS and to optimize the dosing regimen. A total of 494 concentrations from 108 children were obtained from routine therapeutic drug monitoring between 2016 and 2018. Information regarding the demographic features, laboratory test results, genetic polymorphisms of CYP3A5 (rs776746) and co-therapy medications were collected. PPK analysis was performed using the nonlinear mixed-effects modelling (NONMEM) software and two modelling strategies (the linear one-compartment model and nonlinear Michaelis-Menten model) were evaluated and compared. CYP3A5 genotype, weight, daily dose of TAC and daily dose of diltiazem were retained in the final linear model. The absorption rate constant (Ka) was set at 4.48 h-1 in the linear model, and the apparent clearance (CL/F) and volume of distribution (V/F) in the final linear model were 14.2 L/h and 172 L, respectively. CYP3A5 genotype, weight and daily dose of diltiazem were the significant factors retained in the final nonlinear model. The maximal dose rate (Vmax) and the average steady-state concentration at half-Vmax (Km) in the final nonlinear model were 2.15 mg/day and 0.845 ng/ml, respectively. The nonlinear model described the pharmacokinetic data of TAC better than the linear model in children with RNS. A dosing regimen was proposed based on weight, CYP3A5 genotype and daily dose of diltiazem according to the final nonlinear PK model, which may facilitate individualized drug therapy with TAC.
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Affiliation(s)
- Ling Li
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China; School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Min Zhu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China; Department of Pharmacy, Shanghai Chest Hospital, Shanghai, China
| | - De-Yi Li
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Hong-Li Guo
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ya-Hui Hu
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ze-Yue Xu
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China; School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Xia Jing
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Feng Chen
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.
| | - Fei Zhao
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yun-Man Li
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Jing Xu
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai, China.
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15
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Tomiyama T, Motomura T, Iseda N, Morinaga A, Shimagaki T, Kurihara T, Wang H, Toshima T, Nagao Y, Itoh S, Harada N, Yoshizumi T, Mori M. Acute death caused by invasive aspergillosis after living-donor liver transplantation despite good graft function: a case report. Surg Case Rep 2021; 7:118. [PMID: 33978845 PMCID: PMC8116460 DOI: 10.1186/s40792-021-01203-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background Invasive aspergillosis (IA) is one of the most serious causes of death after liver transplantation (LT). IA is the second most common fungal infection, and its mortality rate exceeds 80%. Case presentation A 67-year-old man presented to our hospital because of fulminant hepatitis caused by hepatitis B virus. Candidiasis was detected in his sputum, and micafungin had already been administered. Living-donor LT was performed using a right lobe graft donated from his daughter with no intraoperative complications. Although he appeared to have good graft function, his oxygenation was inadequate, and a chest radiograph showed many invasive shadows on postoperative day 1. A computed tomography scan also showed many invasive shadows with the halo sign. A blood examination revealed positivity for Aspergillus antigen, and Aspergillus species were detected in his sputum. IA was diagnosed. The antifungal therapy was soon modified to amphotericin B combined with caspofungin. Despite good graft blood flow through the portal vein and hepatic artery and good graft function, the patient died of IA on postoperative day 3. The median time from LT to IA among reports published to date ranges from 18 to 25 days. Conclusions The present report describes the first case of very early onset of IA after LT.
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Affiliation(s)
- Takahiro Tomiyama
- Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University Hospital, Kyushu University, 3 Chome-1-1 Maidashi, Higashiku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Takashi Motomura
- Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University Hospital, Kyushu University, 3 Chome-1-1 Maidashi, Higashiku, Fukuoka, Fukuoka, 812-8582, Japan.
| | - Norifumi Iseda
- Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University Hospital, Kyushu University, 3 Chome-1-1 Maidashi, Higashiku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Akinari Morinaga
- Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University Hospital, Kyushu University, 3 Chome-1-1 Maidashi, Higashiku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Tomonari Shimagaki
- Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University Hospital, Kyushu University, 3 Chome-1-1 Maidashi, Higashiku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Takeshi Kurihara
- Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University Hospital, Kyushu University, 3 Chome-1-1 Maidashi, Higashiku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Huanlin Wang
- Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University Hospital, Kyushu University, 3 Chome-1-1 Maidashi, Higashiku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Takeo Toshima
- Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University Hospital, Kyushu University, 3 Chome-1-1 Maidashi, Higashiku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Yoshihiro Nagao
- Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University Hospital, Kyushu University, 3 Chome-1-1 Maidashi, Higashiku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Shinji Itoh
- Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University Hospital, Kyushu University, 3 Chome-1-1 Maidashi, Higashiku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Noboru Harada
- Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University Hospital, Kyushu University, 3 Chome-1-1 Maidashi, Higashiku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University Hospital, Kyushu University, 3 Chome-1-1 Maidashi, Higashiku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Masaki Mori
- Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University Hospital, Kyushu University, 3 Chome-1-1 Maidashi, Higashiku, Fukuoka, Fukuoka, 812-8582, Japan
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16
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Neofytos D, Garcia-Vidal C, Lamoth F, Lichtenstern C, Perrella A, Vehreschild JJ. Invasive aspergillosis in solid organ transplant patients: diagnosis, prophylaxis, treatment, and assessment of response. BMC Infect Dis 2021; 21:296. [PMID: 33761875 PMCID: PMC7989085 DOI: 10.1186/s12879-021-05958-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/04/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Invasive aspergillosis (IA) is a rare complication in solid organ transplant (SOT) recipients. Although IA has significant implications on graft and patient survival, data on diagnosis and management of this infection in SOT recipients are still limited. METHODS Discussion of current practices and limitations in the diagnosis, prophylaxis, and treatment of IA and proposal of means of assessing treatment response in SOT recipients. RESULTS Liver, lung, heart or kidney transplant recipients have common as well as different risk factors to the development of IA, thus each category needs a separate evaluation. Diagnosis of IA in SOT recipients requires a high degree of awareness, because established diagnostic tools may not provide the same sensitivity and specificity observed in the neutropenic population. IA treatment relies primarily on mold-active triazoles, but potential interactions with immunosuppressants and other concomitant therapies need special attention. CONCLUSIONS Criteria to assess response have not been sufficiently evaluated in the SOT population and CT lesion dynamics, and serologic markers may be influenced by the underlying disease and type and severity of immunosuppression. There is a need for well-orchestrated efforts to study IA diagnosis and management in SOT recipients and to develop comprehensive guidelines for this population.
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Affiliation(s)
- Dionysios Neofytos
- Service des Maladies Infectieuses, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, Geneva, Switzerland.
| | - Carolina Garcia-Vidal
- Servicio de Enfermedades Infecciosas, Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, FungiCLINIC Research group (AGAUR), Barcelona, Spain
| | - Frédéric Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, 1011, Lausanne, Switzerland
- Department of Laboratories, Institute of Microbiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Christoph Lichtenstern
- Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, Heidelberg, Germany
| | - Alessandro Perrella
- VII Department of Infectious Disease and Immunology, Hospital D. Cotugno, Naples, Italy
- CLSE-Liver Transplant Unit, Hospital A. Cardarelli, Naples, Italy
| | - Jörg Janne Vehreschild
- Medical Department II, Hematology and Oncology, University Hospital of Frankfurt, Frankfurt, Germany
- Department I for Internal Medicine, University Hospital of Cologne, Cologne, Germany
- German Centre for Infection Research, partner site Bonn-Cologne, University of Cologne, Cologne, Germany
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17
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Pérez-Jacoiste Asín MA, López-Medrano F, Fernández-Ruiz M, Silva JT, San Juan R, Kontoyiannis DP, Aguado JM. Risk factors for the development of invasive aspergillosis after kidney transplantation: Systematic review and meta-analysis. Am J Transplant 2021; 21:703-716. [PMID: 32780498 DOI: 10.1111/ajt.16248] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/05/2020] [Accepted: 07/25/2020] [Indexed: 01/25/2023]
Abstract
To investigate risk factors for invasive aspergillosis (IA) after kidney transplantation (KT), we conducted a systematic search in PubMed and EMBASE to identify studies published until June 2020. We included case-control or cohort design studies comprising KT recipients with a diagnosis of IA, defined according to the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group criteria, and assessed risk factors for the development of IA. Random-effect models meta-analysis served to pool data. We identified eleven case-control studies (319 IA cases and 835 controls). There was an increased risk of IA among recipients with underlying chronic lung diseases (odds ratio [OR] = 7.26; 95% confidence interval [CI] = 1.05-50.06) and among those with diabetic nephropathy (OR = 1.65; 95% CI = 1.10-2.48). Requiring posttransplant hemodialysis (OR = 3.69; 95% CI = 2.13-6.37) or surgical reintervention (OR = 6.28; 95% CI = 1.67-23.66) were also associated with an increased risk. Moreover, a positive link was identified between IA and posttransplant bacterial infection (OR = 7.51; 95% CI = 4.37-12.91), respiratory tract viral infection (OR = 7.75; 95% CI = 1.60-37.57), cytomegalovirus infection or disease (OR = 2.67; 95% CI = 1.12-6.32), and acute graft rejection (OR = 3.01; 95% CI = 1.78-5.09). In contrast, receiving a kidney from a living donor was associated with a reduced risk (OR = 0.65; 95% CI = 0.46-0.93). KT recipients that accumulate several of these conditions should be closely monitored and a low threshold of suspicion for IA should be maintained. Future studies should explore the benefit of mold-active prophylaxis to this subgroup of KT recipients at highest risk.
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Affiliation(s)
- María Asunción Pérez-Jacoiste Asín
- Unit of Infectious Diseases, Department of Internal Medicine, University Hospital 12 de Octubre, Madrid, Spain.,Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Department of Internal Medicine, University Hospital 12 de Octubre, Madrid, Spain.,Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Department of Internal Medicine, University Hospital 12 de Octubre, Madrid, Spain.,Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Jose Tiago Silva
- Unit of Infectious Diseases, Department of Internal Medicine, University Hospital 12 de Octubre, Madrid, Spain.,Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Rafael San Juan
- Unit of Infectious Diseases, Department of Internal Medicine, University Hospital 12 de Octubre, Madrid, Spain.,Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - José María Aguado
- Unit of Infectious Diseases, Department of Internal Medicine, University Hospital 12 de Octubre, Madrid, Spain.,Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
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18
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Cheng S, Tang M, Du J, Yin T. Effects of antifungal drugs on the plasma concentrations and dosage of tacrolimus in kidney transplant patients. Eur J Hosp Pharm 2020; 29:202-206. [PMID: 33020057 DOI: 10.1136/ejhpharm-2020-002385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Tacrolimus is one of the three basic immunosuppressants used following kidney transplantation, and its plasma concentration is susceptible to antifungal drugs. Abnormal tacrolimus concentrations may lead to adverse outcomes for patients. Adjustment of the tacrolimus dose after administering antifungal drugs to patients with fungal infection after transplantations therefore has important clinical significance. Our objective is to measure the impact of antifungal drugs on the plasma concentration of tacrolimus in kidney transplant patients. METHODS A retrospective study was carried out in 109 kidney transplant recipients treated with a tacrolimus-based regimen and antifungal drugs simultaneously. Tacrolimus levels and dosage requirements were compared before and during antifungal therapy. RESULTS The plasma levels of tacrolimus were significantly increased after the combination with voriconazole and fluconazole (p<0.05). Consequently, the daily dose of tacrolimus was significantly reduced after the combination (p<0.05). However, although the tacrolimus concentration was significantly decreased after the administration of caspofungin (p<0.05), no apparent change in the daily dose of tacrolimus was found. Moreover, there were no significant changes in the tacrolimus levels and the daily dose after the combination with micafungin (p>0.05). CONCLUSIONS Our results suggest that there is considerable variability in the interaction between tacrolimus and different antifungal drugs. The dose of tacrolimus should be reduced by two-thirds and one-third before the combination with voriconazole and fluconazole, respectively. It is not recommended that the dose should be adjusted before combination with other antifungal drugs, and the dose should be adjusted under the guidance of therapeutic drug monitoring.
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Affiliation(s)
- Shuqiao Cheng
- Department of Pharmacy, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Mimi Tang
- Department of Pharmacy, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jie Du
- Department of Pharmacy, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Tao Yin
- Department of Pharmacy, Xiangya Hospital of Central South University, Changsha, Hunan, China
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19
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Sari S, Koçak E, Kart D, Özdemir Z, Acar MF, Sayoğlu B, Karakurt A, Dalkara S. Azole derivatives with naphthalene showing potent antifungal effects against planktonic and biofilm forms of Candida spp.: an in vitro and in silico study. Int Microbiol 2020; 24:93-102. [DOI: 10.1007/s10123-020-00144-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/20/2020] [Accepted: 08/28/2020] [Indexed: 12/21/2022]
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20
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Veenhof H, Schouw HM, Besouw MTP, Touw DJ, Gracchi V. Flucloxacillin decreases tacrolimus blood trough levels: a single-center retrospective cohort study. Eur J Clin Pharmacol 2020; 76:1667-1673. [PMID: 32712713 PMCID: PMC7661399 DOI: 10.1007/s00228-020-02968-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/16/2020] [Indexed: 12/21/2022]
Abstract
Purpose Tacrolimus and everolimus are widely used to prevent allograft rejection. Both are metabolized by the hepatic cytochrome P450 (CYP) enzyme CYP3A4 and are substrate for P-glycoprotein (P-gp). Drugs influencing the activity or expression of CYP enzymes and P-gp can cause clinically relevant changes in the metabolism of immunosuppressants. Several case reports have reported that flucloxacillin appeared to decrease levels of drugs metabolized by CYP3A4 and P-gp. The magnitude of this decrease has not been reported yet. Methods In this single-center retrospective cohort study, we compared the tacrolimus and everolimus blood trough levels (corrected for the dose) before, during, and after flucloxacillin treatment in eleven transplant patients (tacrolimus n = 11 patients, everolimus n = 1 patient, flucloxacillin n = 11 patients). Results The median tacrolimus blood trough level decreased by 37.5% (interquartile range, IQR 26.4–49.7%) during flucloxacillin treatment. After discontinuation of flucloxacillin, the tacrolimus blood trough levels increased by a median of 33.7% (IQR 22.5–51.4%). A Wilcoxon signed-rank test showed statistically significantly lower tacrolimus trough levels during treatment with flucloxacillin compared with before (p = 0.009) and after flucloxacillin treatment (p = 0.010). In the only available case with concomitant everolimus and flucloxacillin treatment, the same pattern was observed. Conclusions Flucloxacillin decreases tacrolimus trough levels, possibly through a CYP3A4 and/or P-gp-inducing effect. It is strongly recommended to closely monitor tacrolimus and everolimus trough levels during flucloxacillin treatment and up to 2 weeks after discontinuation of flucloxacillin. Electronic supplementary material The online version of this article (10.1007/s00228-020-02968-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Herman Veenhof
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Hugo M Schouw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Martine T P Besouw
- Department of Pediatric Nephrology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.,Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Valentina Gracchi
- Department of Pediatric Nephrology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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21
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Stemler J, Koehler P, Maurer C, Müller C, Cornely OA. Antifungal prophylaxis and novel drugs in acute myeloid leukemia: the midostaurin and posaconazole dilemma. Ann Hematol 2020; 99:1429-1440. [PMID: 32514626 PMCID: PMC7316674 DOI: 10.1007/s00277-020-04107-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/27/2020] [Indexed: 12/21/2022]
Abstract
With the advent of new targeted drugs in hematology and oncology patient prognosis is improved. Combination with antifungal prophylaxis challenges clinicians due to pharmacological profiles prone to drug–drug interactions (DDI). Midostaurin is a novel agent for FLT3-TKD/-ITDmut-acute myeloid leukemia (AML) and metabolized via cytochrome P450 3A4 (CYP3A4). Posaconazole is a standard of care antifungal agent used for prophylaxis during induction treatment of AML and a strong CYP3A4 inhibitor. Concomitant administration of both drugs leads to elevated midostaurin exposure. Both drugs improve overall survival at low numbers needed to treat. The impact of CYP3A4-related DDI remains to be determined. Severe adverse events have been observed; however, it remains unclear if they can be directly linked to DDI. The lack of prospective clinical studies assessing incidence of invasive fungal infections and clinical impact of DDI contributes to neglecting live-saving antifungal prophylaxis. Management strategies to combine both drugs have been proposed, but evidence on which approach to use is scarce. In this review, we discuss several approaches in the specific clinical setting of concomitant administration of midostaurin and posaconazole and give examples from everyday clinical practice. Therapeutic drug monitoring will become increasingly important to individualize and personalize antineoplastic concomitant and antifungal treatment in the context of DDI. Pharmaceutical companies addressing the issue in clinical trials may take a pioneer role in this field. Other recently developed and approved drugs for the treatment of AML likely inhere potential of DDI marking a foreseeable issue in future treatment of this life-threatening disease.
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Affiliation(s)
- Jannik Stemler
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
| | - Philipp Koehler
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Christian Maurer
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
| | - Carsten Müller
- Centre of Pharmacology, Therapeutic Drug Monitoring, Faculty of Medicine, Cologne, University Hospital of Cologne, Cologne, Germany
| | - Oliver A Cornely
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany. .,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany. .,German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany. .,Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany.
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22
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Hays SM, Johnson HL, Taylor LA. A Toddler With Sudden-Onset Tremors and Change in Temperament. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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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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24
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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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Population pharmacokinetics of cyclosporine in Chinese children receiving hematopoietic stem cell transplantation. Acta Pharmacol Sin 2019; 40:1603-1610. [PMID: 31341257 PMCID: PMC7471407 DOI: 10.1038/s41401-019-0277-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/21/2019] [Accepted: 06/23/2019] [Indexed: 12/11/2022] Open
Abstract
Cyclosporine (CsA) is characterized by a narrow therapeutic window and high interindividual pharmacokinetic variability, particularly in juvenile patients. The aims of this study were to build a population pharmacokinetic model of CsA in Chinese children with hematopathy who received allogeneic hematopoietic stem cell transplantation (allo-HSCT) and to identify covariates affecting CsA pharmacokinetics. A total of 86 Chinese children aged 8.4 ± 3.8 years (range 1.1–16.8 years) who received allo-HSCT were enrolled. Whole blood samples were collected before allo-HSCT. Genotyping was performed using an Agena MassARRAY system. A total of 1010 trough plasma concentration values of CsA and clinical data were collected. The population pharmacokinetic model of CsA was constructed using nonlinear mixed-effects modeling (NONMEM) software. The stability and performance of the final model were validated using bootstrapping and normalized prediction distribution errors. We showed that a one-compartment model with first-order elimination adequately described the pharmacokinetics of CsA. The typical values for clearance (CL) and volume of distribution (V) were 42.3 L/h and 3100 L, respectively. Body weight, postoperative days, CYP3A4*1 G genotype, estimated glomerular filtration rate and coadministration of triazole antifungal drugs were identified as significant covariates for CL. Weight and postoperative days were significant covariates for the V of CsA. Our model can be adopted to optimize the CsA dosing regimen for Chinese children with hematopathy receiving allo-HSCT.
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Abstract
Introduction: Graft-versus-host disease (GVHD) is the most common complication of hematopoietic stem cell transplantation (HSCT); therefore, the prevention of GVHD is important for a successful treatment. Tacrolimus (Tac), a calcineurin inhibitor, has been widely used for the prophylaxis of GVHD in HSCT recipients. Areas covered: This review introduces phase II/III of clinical trials related with Tac's roles in the prevention of GVHD in HSCT. Furthermore, we discuss the normal ranges of Tac concentrations, pharmacogenetics, and drug interactions of Tac, as well as its side effects in adult HSCT recipients. Expert opinion: A series of studies has established the efficacy and safety of Tac alone or in combination with other agents in HSCT. However, successful administration of Tac is complicated by its narrow therapeutic window, inter-patient pharmacokinetic variability, and a spectrum of undesirable side effects. It is necessary to maintain concentrations of Tac within the desired ranges for GVHD prophylaxis. Moreover, various factors contribute to significant variability in Tac pharmacokinetics, including drug interactions and genomic variation.
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Affiliation(s)
- Yuan Gao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Soochow University , Suzhou , China
| | - Jingjing Ma
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Soochow University , Suzhou , China
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Warris A, Lehrnbecher T, Roilides E, Castagnola E, Brüggemann RJM, Groll AH. ESCMID-ECMM guideline: diagnosis and management of invasive aspergillosis in neonates and children. Clin Microbiol Infect 2019; 25:1096-1113. [PMID: 31158517 DOI: 10.1016/j.cmi.2019.05.019] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 05/19/2019] [Accepted: 05/23/2019] [Indexed: 01/01/2023]
Abstract
SCOPE Presenting symptoms, distributions and patterns of diseases and vulnerability to invasive aspergillosis (IA) are similar between children and adults. However, differences exist in the epidemiology and underlying conditions, the usefulness of newer diagnostic tools, the pharmacology of antifungal agents and in the evidence from interventional phase 3 clinical trials. Therefore, the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) and the European Confederation of Medical Mycology (ECMM) have developed a paediatric-specific guideline for the diagnosis and management of IA in neonates and children. METHODS Review and discussion of the scientific literature and grading of the available quality of evidence was performed by the paediatric subgroup of the ESCMID-ECMM-European Respiratory Society (ERS) Aspergillus disease guideline working group, which was assigned the mandate for the development of neonatal- and paediatric-specific recommendations. QUESTIONS Questions addressed by the guideline included the epidemiology of IA in neonates and children; which paediatric patients may benefit from antifungal prophylaxis; how to diagnose IA in neonates and children; which antifungal agents are available for use in neonates and children; which antifungal agents are suitable for prophylaxis and treatment of IA in neonates and children; what is the role of therapeutic drug monitoring of azole antifungals; and which management strategies are suitable to be used in paediatric patients. This guideline provides recommendations for the diagnosis, prevention and treatment of IA in the paediatric population, including neonates. The aim of this guideline is to facilitate optimal management of neonates and children at risk for or diagnosed with IA.
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Affiliation(s)
- A Warris
- MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands.
| | - T Lehrnbecher
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands
| | - E Roilides
- Infectious Diseases Unit, 3rd Department of Paediatrics, Faculty of Medicine, Aristotle University 96 School of Health Sciences, Thessaloniki, Greece; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands
| | - E Castagnola
- Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini Children's Hospital, Genoa, Italy; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG)
| | - R J M Brüggemann
- Radboud Center for Infectious Diseases, Radboud University Medical Centre, Center of Expertise in Mycology Radboudumc/CWZ, European Confederation of Medical Mycology (ECMM) Excellence Center of Medical Mycology, Nijmegen, the Netherlands; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG)
| | - A H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Paediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands
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Consensus recommendations for the role and competencies of the EBMT clinical pharmacist and clinical pharmacologist involved in hematopoietic stem cell transplantation. Bone Marrow Transplant 2019; 55:62-69. [PMID: 31101890 DOI: 10.1038/s41409-019-0538-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 04/24/2019] [Accepted: 04/27/2019] [Indexed: 11/09/2022]
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Miller R, Assi M. Endemic fungal infections in solid organ transplant recipients-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13553. [PMID: 30924967 DOI: 10.1111/ctr.13553] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/22/2019] [Indexed: 02/07/2023]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention and management of blastomycosis, histoplasmosis, and coccidioidomycosis in the pre- and post-transplant period. Though each of these endemic fungal infections has unique epidemiology and clinical manifestations, they all share a predilection for primary pulmonary infection and may cause disseminated infection, particularly in immunocompromised hosts. Culture remains the gold standard for definitive diagnosis, but more rapid diagnosis may be achieved with direct visualization of organisms from clinical specimens and antigen-based enzyme immunoassay assays. Serology is of limited utility in transplant recipients. The mainstay of treatment for severe infections remains liposomal amphotericin followed by a step-down azole therapy. Cases of mild to moderate severity with no CNS involvement may be treated with azole therapy alone. The newer generation azoles provide additional treatment options, but supported currently with limited clinical efficacy data. Azole therapy in transplant recipients presents a unique challenge owing to the drug-drug interactions with immunosuppressant agents. Therapeutic drug monitoring of azole levels is an essential component of effective and safe therapy. Infection prevention centers around minimizing epidemiological exposures, early clinical recognition, and azole prophylaxis in selected individuals.
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Affiliation(s)
- Rachel Miller
- Department of Internal Medicine, Division of Infectious Diseases, Duke University, Durham, North Carolina
| | - Maha Assi
- Department of Internal Medicine, University of Kansas School of Medicine Wichita, Wichita, Kansas
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Dermatological Disorders following Liver Transplantation: An Update. Can J Gastroenterol Hepatol 2019; 2019:9780952. [PMID: 31058114 PMCID: PMC6463607 DOI: 10.1155/2019/9780952] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 02/24/2019] [Accepted: 03/11/2019] [Indexed: 02/08/2023] Open
Abstract
Patients undergoing liver transplantation (LT) are at a high risk of dermatological complications compared to the general population as a result of long-term use of immunosuppressant. However, the risk is not as high as other solid organ transplantations (SOT), particularly for skin cancer. The liver is considered as an immune privileged organ since it has a low prevalence of humoral rejection in contrast to other SOT, and thus, LT requires a minimal amount of immunosuppressants compared to other SOT recipients. However, because of the large volume of the liver, patients with LT have higher donor lymphocytes that sometimes may trigger graft-versus-host-disease, yet it is rare. On the other hand, the vast majority of the nonspecific dermatological lesions linked with cirrhosis improve after removal of diseased liver or due to the immunosuppressant used after LT. Nevertheless, dermatological infections related to bacteria, viruses, and fungus after LT are not uncommon. Additionally, the incidence of IgE-mediated food allergies develops in 12.2% of LT patients and may present as life-threatening conditions such as urticaria and/or angioedema and hypersensitivity. Moreover, skin malignancies after LT are a matter of concern. Thus, posttransplant dermatological care should be provided to all LT patients for any suspicious dermatological lesions. Our goal is to give an outline of the dermatological manifestation associated with LT for the clinicians by collecting the published data from all archived case reports.
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Prakash K, Richman D. A case report of disseminated histoplasmosis and concurrent cryptococcal meningitis in a patient treated with ruxolitinib. BMC Infect Dis 2019; 19:287. [PMID: 30917797 PMCID: PMC6437885 DOI: 10.1186/s12879-019-3922-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 03/19/2019] [Indexed: 12/22/2022] Open
Abstract
Background Ruxolitinib is a highly potent janus kinase inhibitor that places its users at risk for various bacterial infections and viral reactivation. However new reports are also emerging that suggest greater immunosuppression and risk for fungal disease. Case presentation We report the case of a 51 year-old veteran from Guam, treated with ruxolitinib for polycythemia vera, who developed disseminated histoplasmosis and concurrent cryptococcal meningitis. Conclusion This case draws attention to the degree of immunosuppression that may be seen with this drug and the need for heightened vigilance for opportunistic infections in those treated with inhibitors of janus kinase/signal transducers and activators of transcription (JAK/STAT) such as ruxolitinib.
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Affiliation(s)
- Katya Prakash
- Division of Infectious Diseases, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0711, USA.
| | - Douglas Richman
- Division of Infectious Diseases, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0711, USA.,VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA, 92161, USA
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Hand J. Strategies for Antimicrobial Stewardship in Solid Organ Transplant Recipients. Infect Dis Clin North Am 2018; 32:535-550. [PMID: 30146022 DOI: 10.1016/j.idc.2018.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Complications of antimicrobial therapy, such as multidrug-resistant organisms and Clostridium difficile, commonly affect solid-organ transplant recipients and have been associated with graft loss and mortality. Although opportunities are abundant, antimicrobial stewardship practices guiding appropriate therapy have been infrequently reported in transplant patients. A patient-centered, multidisciplinary structure, using established antimicrobial optimization principles, is needed to create nuanced approaches to protect patients and antimicrobials and improve outcomes.
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Affiliation(s)
- Jonathan Hand
- Department of Infectious Diseases, The University of Queensland School of Medicine, Ochsner Clinical School, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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Laub MR, Crow SA, Personett HA, Dierkhising R, Boilson B, Razonable R. Effects of clotrimazole troches on tacrolimus dosing in heart transplant recipients. Transpl Infect Dis 2018; 20:e12979. [PMID: 30120865 DOI: 10.1111/tid.12979] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 08/06/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tacrolimus is a cornerstone of immunosuppression after transplantation but is highly susceptible to changes from interacting variables and has a narrow therapeutic index. Clotrimazole troches are commonly used as a non-systemic antifungal to prevent oral candidiasis. Studies suggest that clotrimazole troches, though minimally absorbed systemically, may affect tacrolimus concentrations by inhibition of metabolic enzyme activity in the intestines. However, the magnitude of the impact of clotrimazole on tacrolimus dosing requirements to maintain goal levels is not well described. METHODS To assess this, tacrolimus dose adjustments and trough concentrations were retrospectively examined in 95 heart transplant recipients before and after the discontinuation of clotrimazole. RESULTS The median percent tacrolimus dose change was an increase of 66.7% (IQR 28.6%, 100%) after clotrimazole discontinuation, and the median trough concentration percent change from baseline to the first trough after clotrimazole discontinuation (in the absence of a dose change) was -42.5% (IQR -52.3%, -30.9%). Five cases of allograft rejection were observed. CONCLUSION In conclusion, clotrimazole troches exert a meaningful interaction with tacrolimus that requires close monitoring and dose adjustment. The data from this single-center study provide novel information that could guide providers on the degree of tacrolimus dose adjustment needed when discontinuing clotrimazole prophylaxis after heart transplantation.
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Affiliation(s)
- Melissa R Laub
- Division of Pharmacy Services, Mayo Clinic Hospital, Rochester, Minnesota
| | - Stacy A Crow
- Division of Pharmacy Services, Mayo Clinic Hospital, Rochester, Minnesota
| | | | - Ross Dierkhising
- Division of Biomedical Statistics and Informatics, Mayo Clinic Hospital, Rochester, Minnesota
| | - Barry Boilson
- Division of Cardiovascular Diseases, Mayo Clinic Hospital, Rochester, Minnesota
| | - Raymund Razonable
- Division of Infectious Diseases, Mayo Clinic Hospital, Rochester, Minnesota
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34
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Vicenzi EB, Cesaro S. Posaconazole in immunocompromised pediatric patients. Expert Rev Anti Infect Ther 2018; 16:543-553. [DOI: 10.1080/14787210.2018.1490177] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Edoardo Bruno Vicenzi
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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Jawale P, Gulwani H. Histoplasmosis presenting as laryngeal ulcer in a post-renal transplant male: An unusual case from India. J Mycol Med 2017; 27:573-576. [DOI: 10.1016/j.mycmed.2017.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/22/2017] [Accepted: 06/06/2017] [Indexed: 12/29/2022]
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36
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Al-Wabli RI, Al-Ghamdi AR, Ghabbour HA, Al-Agamy MH, Attia MI. Synthesis, Single Crystal X-ray Analysis, and Antifungal Profiling of Certain New Oximino Ethers Bearing Imidazole Nuclei. Molecules 2017; 22:molecules22111895. [PMID: 29099797 PMCID: PMC6150221 DOI: 10.3390/molecules22111895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 10/30/2017] [Accepted: 10/31/2017] [Indexed: 11/16/2022] Open
Abstract
Fungal infections threaten human health, particularly in immune-compromised patients worldwide. Although there are a large number of antifungal agents available, the desired clinical attributes for the treatment of fungal infections have not yet been achieved. Azoles are the mainstay class of the clinically used antifungal agents. In the current study, the synthesis, spectroscopic characterization, and antifungal activity of certain new oximino ethers Va–n bearing imidazole nuclei are reported. The (E)-configuration of the imine double bond of the synthesized compounds Va–n has been confirmed via single crystal X-ray analysis of compound Vi as a representative example of this class of compounds. The molecular structure of compound Vi was crystallized in the monoclinic, P21/c, a = 18.7879(14) Å, b = 5.8944(4) Å, c = 16.7621(12) Å, β = 93.063(3)°, V = 1855.5(2) Å3, Z = 4. The in vitro antifungal activity of the synthesized compounds Va–n were evaluated using diameter of the inhibition zone (DIZ) and minimum inhibitory concentration (MIC) assays against different fungal strains. Compound Ve manifested anti-Candida albicans activity with an MIC value of 0.050 µmol/mL, being almost equipotent with the reference antifungal drug fluconazole (FLC),while compounds Vi and Vn are the most active congeners against Candida parapsilosis, being equipotent and about twenty-three times more potent than FLC with an MIC value of 0.002 µmol/mL. The results of the current report might support the development of new potent and safer antifungal azoles.
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Affiliation(s)
- Reem I Al-Wabli
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh 11451, Saudi Arabia.
| | - Alwah R Al-Ghamdi
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh 11451, Saudi Arabia.
| | - Hazem A Ghabbour
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh 11451, Saudi Arabia.
- Department of Medicinal Chemistry, Faculty of Pharmacy, Mansoura University, Mansoura 35516, Egypt.
| | - Mohamed H Al-Agamy
- Department of Pharmaceutics, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh 11451, Saudi Arabia.
- Microbiology and Immunology Department, Faculty of Pharmacy, Al-Azhar University, Cairo 11884, Egypt.
| | - Mohamed I Attia
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh 11451, Saudi Arabia.
- Medicinal and Pharmaceutical Chemistry Department, Pharmaceutical and Drug Industries Research Division, National Research Centre (ID: 60014618), El Bohooth Street, Dokki, Giza 12622, Egypt.
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Repurposing antipsychotic drugs into antifungal agents: Synergistic combinations of azoles and bromperidol derivatives in the treatment of various fungal infections. Eur J Med Chem 2017; 139:12-21. [DOI: 10.1016/j.ejmech.2017.07.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/16/2017] [Accepted: 07/17/2017] [Indexed: 01/02/2023]
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Groll AH, Townsend R, Desai A, Azie N, Jones M, Engelhardt M, Schmitt-Hoffman AH, Brüggemann RJM. Drug-drug interactions between triazole antifungal agents used to treat invasive aspergillosis and immunosuppressants metabolized by cytochrome P450 3A4. Transpl Infect Dis 2017; 19. [PMID: 28722255 DOI: 10.1111/tid.12751] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 05/15/2017] [Accepted: 05/15/2017] [Indexed: 01/03/2023]
Abstract
Patients undergoing treatment with immunosuppressant drugs following solid organ or hematopoietic stem cell transplantation are at particular risk for development of serious infections such as invasive aspergillosis. Four triazole antifungal drugs, voriconazole, posaconazole, itraconazole, and isavuconazole, are approved to treat invasive aspergillosis either as first- or second-line therapy. All of these agents are inhibitors of cytochrome P450 3A4, which plays a key role in metabolizing immunosuppressant drugs such as cyclosporine, tacrolimus, and sirolimus. Thus, co-administration of a triazole antifungal drug with these immunosuppressant drugs can potentially increase plasma concentrations of the immunosuppressant drugs, thereby resulting in toxicity, or upon discontinuation, inadvertently decrease the respective concentrations with increased risk of rejection or graft-versus-host disease. In this article, we review the evidence for the extent of inhibition of cytochrome P450 3A4 by each of these triazole antifungal drugs and assess their effects on cyclosporine, tacrolimus, and sirolimus. We also consider other factors affecting interactions of these two classes of drugs. Finally, we examine recommendations and strategies to evaluate and address those potential drug-drug interactions in these patients.
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Affiliation(s)
- Andreas H Groll
- Department of Pediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany
| | - Robert Townsend
- Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Amit Desai
- Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Nkechi Azie
- Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Mark Jones
- Basilea Pharmaceutica International Ltd, Basel, Switzerland
| | | | | | - Roger J M Brüggemann
- Department of Pharmacy, Radboud University Nijmegen Medical Centre, and Centre of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
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39
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Pyrpasopoulou A, Iosifidis E, Roilides E. Current and potential treatment options for invasiveCandidainfections. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1379392] [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: 10/18/2022]
Affiliation(s)
- A. Pyrpasopoulou
- Infectious Diseases Unit, 3rd Department of Paediatrics, Aristotle University School of Health Sciences, Thessaloniki, Greece
- 2nd Department of Propedeutic Internal Medicine, Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | - E. Iosifidis
- Infectious Diseases Unit, 3rd Department of Paediatrics, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | - E. Roilides
- Infectious Diseases Unit, 3rd Department of Paediatrics, Aristotle University School of Health Sciences, Thessaloniki, Greece
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Hamdy RF, Zaoutis TE, Seo SK. Antifungal stewardship considerations for adults and pediatrics. Virulence 2017; 8:658-672. [PMID: 27588344 PMCID: PMC5626349 DOI: 10.1080/21505594.2016.1226721] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 08/05/2016] [Accepted: 08/11/2016] [Indexed: 10/21/2022] Open
Abstract
Antifungal stewardship refers to coordinated interventions to monitor and direct the appropriate use of antifungal agents in order to achieve the best clinical outcomes and minimize selective pressure and adverse events. Antifungal utilization has steadily risen over time in concert with the increase in number of immunocompromised adults and children at risk for invasive fungal infections (IFI). Challenges in diagnosing IFI often lead to delays in treatment and poorer outcomes. There are also emerging data linking prior antifungal exposure and suboptimal dosing to the emergence of antifungal resistance, particularly for Candida. Antimicrobial stewardship programs can take a multi-pronged bundle approach to ensure suitable prescribing of antifungals via post-prescription review and feedback and/or prior authorization. Institutional guidelines can also be developed to guide diagnostic testing in at-risk populations; appropriate choice, dose, and duration of antifungal agent; therapeutic drug monitoring; and opportunities for de-escalation and intravenous-to-oral conversion.
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Affiliation(s)
- Rana F. Hamdy
- Division of Infectious Diseases, Children's National Health System, Washington, DC, USA
| | - Theoklis E. Zaoutis
- Division of Infectious Diseases, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan K. Seo
- Department of Medicine, Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Agrawal S, Barnes R, Brüggemann RJ, Rautemaa-Richardson R, Warris A. The role of the multidisciplinary team in antifungal stewardship. J Antimicrob Chemother 2017; 71:ii37-ii42. [PMID: 27880668 DOI: 10.1093/jac/dkw395] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
There are a variety of challenges faced in the management of invasive fungal diseases (IFD), including high case-fatality rates, high cost of antifungal drugs and development of antifungal resistance. The diagnostic challenges and poor outcomes associated with IFD have resulted in excessive empirical use of antifungals in various hospital settings, exposing many patients without IFD to potential drug toxicities as well as causing spiralling antifungal drug costs. Further complexity arises as different patient groups show marked variation in their risk for IFD, fungal epidemiology, sensitivity and specificity of diagnostic tests and the pharmacokinetics and pharmacodynamics of antifungal drugs. To address these issues and to ensure optimal management of IFD, specialist knowledge and experience from a range of backgrounds is required, which extends beyond the remit of most antibiotic stewardship programmes. The first step in the development of any antifungal stewardship (AFS) programme is to build a multidisciplinary team encompassing the necessary expertise in the management of IFD to develop and implement the AFS programme. The specific roles of the key individuals within the AFS team and the importance of collaboration are discussed in this article.
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Affiliation(s)
- Samir Agrawal
- Division of Haemato-Oncology, St Bartholomew's Hospital and Blizard Institute, Queen Mary University, London, UK
| | - Rosemary Barnes
- Department of Medical Microbiology and Infectious Diseases, Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Roger J Brüggemann
- Department of Pharmacy and Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Riina Rautemaa-Richardson
- Manchester Academic Health Science Centre, Institute of Inflammation and Repair, University of Manchester, Manchester, UK.,University Hospital of South Manchester, Wythenshawe Hospital, Manchester, UK
| | - Adilia Warris
- Aberdeen Fungal Group, MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
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42
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Oberlin KE, Nichols AJ, Rosa R, Dejman A, Mattiazzi A, Guerra G, Elgart GW, Abbo LM. Phaeohyphomycosis due toExophialainfections in solid organ transplant recipients: Case report and literature review. Transpl Infect Dis 2017; 19. [DOI: 10.1111/tid.12723] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 01/18/2017] [Accepted: 02/19/2017] [Indexed: 02/01/2023]
Affiliation(s)
- Kate E. Oberlin
- Department of Dermatology and Cutaneous Surgery; Jackson Health System/University of Miami Miller School of Medicine; Miami FL USA
| | - Anna J. Nichols
- Department of Dermatology and Cutaneous Surgery; Jackson Health System/University of Miami Miller School of Medicine; Miami FL USA
| | - Rossana Rosa
- Department of Medicine; Division of Infectious Diseases; Jackson Health System/University of Miami Miller School of Medicine; Miami FL USA
| | - Adriana Dejman
- Department of Medicine; Division of Nephrology; University of Miami Miller School of Medicine; Miami FL USA
| | - Adela Mattiazzi
- Department of Medicine; Division of Nephrology; University of Miami Miller School of Medicine; Miami FL USA
| | - Giselle Guerra
- Department of Medicine; Division of Nephrology; University of Miami Miller School of Medicine; Miami FL USA
| | - George W. Elgart
- Department of Dermatology and Cutaneous Surgery; Jackson Health System/University of Miami Miller School of Medicine; Miami FL USA
| | - Lilian M. Abbo
- Department of Medicine; Division of Infectious Diseases; Jackson Health System/University of Miami Miller School of Medicine; Miami FL USA
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Liu AW, Bateman AC, Greenbaum A, Garvin K, Clarridge J, Grim J. Cutaneous phaeohyphomycosis in a hematopoietic stem cell transplant patient caused by Alternaria rosae: First case report. Transpl Infect Dis 2017; 19. [PMID: 28295973 DOI: 10.1111/tid.12698] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 09/29/2016] [Accepted: 12/30/2016] [Indexed: 11/29/2022]
Abstract
Alternaria species have been reported as a rare cause of fungal infection in organ and stem cell transplant recipients, but to date, no reports have been published of infection in humans caused by Alternaria rosae. Here, we report cutaneous A. rosae infection in a 66-year-old farmer with a history of primary myelofibrosis who had undergone allogeneic unrelated donor hematopoietic stem cell transplantation. Forty-nine days post transplant, he presented with a nodule on the thumb with no findings suggestive of disseminated infection. Pathology, culture, and molecular speciation showed the nodule was caused by cutaneous A. rosae. He had been on voriconazole as antifungal prophylaxis, but was found to have a subtherapeutic voriconazole level. He was switched to posaconazole based on published in vitro data showing its superior efficacy in Alternaria treatment. Susceptibility testing showed that the A. rosae isolate was indeed susceptible to posaconazole. His cutaneous lesion remained stable, but he died from respiratory failure secondary to lobar pneumonia. At lung autopsy, A. rosae was not identified in the lungs. We believe this to be the first published report, to our knowledge, of A. rosae infection in humans.
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Affiliation(s)
- Amy W Liu
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Allen C Bateman
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Adam Greenbaum
- Division of Hematology, University of Washington, Seattle, WA, USA.,Division of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Kanishka Garvin
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Jill Clarridge
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA.,Pathology and Laboratory Medicine Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Jonathan Grim
- Division of Medical Oncology, University of Washington, Seattle, WA, USA.,Hospital and Specialty Medicine, Medical Oncology Section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Efficacy of Propolis on the Denture Stomatitis Treatment in Older Adults: A Multicentric Randomized Trial. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2017; 2017:8971746. [PMID: 28396692 PMCID: PMC5371226 DOI: 10.1155/2017/8971746] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/20/2017] [Accepted: 02/26/2017] [Indexed: 11/17/2022]
Abstract
Our hypothesis tested the efficacy and safety of a mucoadhesive oral gel formulation of Brazilian propolis extract compared to miconazole oral gel for the treatment of denture stomatitis due to Candida spp. infection in older adults. Forty patients were randomly allocated in a noninferiority clinical trial into two groups. The control group (MIC) received 20 mg/g miconazole oral gel and the study group (PROP) received mucoadhesive formulation containing standardized extract of 2% (20 mg/g) propolis (EPP-AF®) during 14 days. Patients were examined on days 1, 7, and 14. The Newton's score was used to classify the severity of denture stomatitis. The colony forming unity count (CFU/mL) was quantified and identified (CHROMagar Candida®) before and after the treatment. Baseline characteristics did not differ between groups. Both treatments reduced Newton's score (P < 0.0001), indicating a clinical improvement of the symptoms of candidiasis with a clinical cure rate of 70%. The microbiological cure with significant reduction in fungal burden on T14 was 70% in the miconazole group and 25% in the EPP-AF group. The EPP-AF appears to be noninferior to miconazole considering the clinical cure rate and could be recommended as an alternative treatment in older patients.
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Martial LC, Aarnoutse RE, Mulder M, Schellekens A, Brüggemann RJM, Burger DM, Schene AH, Batalla A. Dried Blood Spot sampling in psychiatry: Perspectives for improving therapeutic drug monitoring. Eur Neuropsychopharmacol 2017; 27:205-216. [PMID: 28130001 DOI: 10.1016/j.euroneuro.2017.01.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 12/02/2016] [Accepted: 01/05/2017] [Indexed: 01/04/2023]
Abstract
Assessment of drug concentrations is indicated to guide dosing of a selected number of drugs used in psychiatry. Conventionally this is done by vena puncture. Novel sampling strategies such as dried blood spot (DBS) sampling have been developed for various drugs, including antipsychotics, antidepressants and mood-stabilizers. DBS sampling is typically performed by means of a finger prick. This method allows for remote sampling, which means that patients are not required to travel to a health care facility. The number of DBS assays for drugs used in psychiatry has increased over the last decade and includes antidepressants (tricyclic and serotonin and/or norepinephrine reuptake inhibitors), mood stabilizers and first- and second-generation antipsychotics. Available assays often comply with analytical validation criteria but are seldom used in routine clinical care. Little attention has been paid to the clinical validation and implementation processes of home sampling. Ideally, not only medicines but also clinical chemistry parameters should be measured within the same sample. This article reflects on the position of DBS remote sampling in psychiatry and provides insight in the requisites of making such a sampling tool successful.
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Affiliation(s)
- Lisa C Martial
- Radboud University Medical Center, Department of Pharmacy, Nijmegen, The Netherlands; Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Rob E Aarnoutse
- Radboud University Medical Center, Department of Pharmacy, Nijmegen, The Netherlands; Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Martina Mulder
- Radboud University Medical Center, Department of Psychiatry, Reinier Postlaan 10, Route 966, 6500 HB Nijmegen, The Netherlands
| | - Arnt Schellekens
- Radboud University Medical Center, Department of Psychiatry, Reinier Postlaan 10, Route 966, 6500 HB Nijmegen, The Netherlands; Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen, Nijmegen, The Netherlands; Radboud University, Nijmegen Institute for Scientist-Practitioners in Addiction, Nijmegen, The Netherlands
| | - Roger J M Brüggemann
- Radboud University Medical Center, Department of Pharmacy, Nijmegen, The Netherlands; Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - David M Burger
- Radboud University Medical Center, Department of Pharmacy, Nijmegen, The Netherlands; Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Aart H Schene
- Radboud University Medical Center, Department of Psychiatry, Reinier Postlaan 10, Route 966, 6500 HB Nijmegen, The Netherlands; Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Albert Batalla
- Radboud University Medical Center, Department of Psychiatry, Reinier Postlaan 10, Route 966, 6500 HB Nijmegen, The Netherlands; Radboud University, Nijmegen Institute for Scientist-Practitioners in Addiction, Nijmegen, The Netherlands.
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Chen WY, Lee CY, Lin PY, Hsieh CE, Ko CJ, Lin KH, Lin CC, Ming YZ, Chen YL. Betel Nut Chewing Is Associated With Reduced Tacrolimus Concentration in Taiwanese Liver Transplant Recipients. Transplant Proc 2017; 49:326-329. [PMID: 28219593 DOI: 10.1016/j.transproceed.2016.11.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/20/2016] [Accepted: 11/16/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE Studies have shown that arecoline, the major alkaloid component of betel nuts, alters the activity of enzymes in the cytochrome P450 (CYP-450) family. Tacrolimus, an immunosuppressant that protects against organ rejection in transplant recipients, not only is mainly metabolized by CYP3A enzymes but also has a narrow therapeutic range. We aimed to investigate whether dose-adjusted blood trough levels of tacrolimus differed over time between betel nut-chewing and non-betel nut-chewing liver transplant recipients. METHODS In this retrospective case-control study, 14 active betel nut-using liver recipients were matched at a 1:2 ratio to 28 non-betel nut-using liver recipients by sex, age, graft source, duration of follow-up after liver transplantation, and estimated glomerular filtration rate. Differences in liver function index, renal function index, and dose-adjusted blood trough levels of tacrolimus over an 18-month period were compared between the 2 groups by using the Generalized Estimating Equation approach. RESULTS Dose-adjusted blood trough levels of tacrolimus tended to be significantly (P = .04) lower in betel nut chewers (mean = 0.81, medium = 0.7, 95% confidence interval [CI] = 0.73 to 0.90) than in nonchewers (mean = 1.12, medium = 0.88, 95% CI = 1.03 to 1.22) during the 18-month study period. However, there was no significant difference in renal and liver function index between the 2 groups. CONCLUSION Liver transplant recipients receiving tacrolimus tend to have lower blood trough levels of the drug over time if they chew betel nuts.
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Affiliation(s)
- W-Y Chen
- Department of Pharmacy, Changhua Christian Hospital, Changhua, Taiwan
| | - C-Y Lee
- Department of Pharmacy, Changhua Christian Hospital, Changhua, Taiwan
| | - P-Y Lin
- Transplant Medicine & Surgery Research Centre, Changhua Christian Hospital, Changhua, Taiwan
| | - C-E Hsieh
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - C-J Ko
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - K-H Lin
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - C-C Lin
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Y-Z Ming
- Transplantation Center, Third Xiangya Hospital of Central South University, Changsha, China
| | - Y-L Chen
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan; Transplant Medicine & Surgery Research Centre, Changhua Christian Hospital, Changhua, Taiwan; Transplantation Center, Third Xiangya Hospital of Central South University, Changsha, China; School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Studies on the interaction between promethazine and human serum albumin in the presence of flavonoids by spectroscopic and molecular modeling techniques. Colloids Surf B Biointerfaces 2016; 145:820-829. [PMID: 27315330 DOI: 10.1016/j.colsurfb.2016.06.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 05/31/2016] [Accepted: 06/01/2016] [Indexed: 12/23/2022]
Abstract
Fluorescence, absorption, time-correlated single photon counting (TCSPC), and circular dichroism (CD) spectroscopic techniques as well as molecular modeling methods were used to study the binding characterization of promethazine (PMT) to human serum albumin (HSA) and the influence of flavonoids, rutin and baicalin, on their affinity. The results indicated that the fluorescence quenching mechanism of HSA by PMT is a static quenching due to the formation of complex. The reaction was spontaneous and mainly mediated by hydrogen bonds and hydrophobic interactions. The binding distance between the tryptophan residue of HSA and PMT is less than 8nm, which indicated that the energy transfer from the tryptophan residue of HSA to PMT occurred. The binding site of PMT on HSA was located in sites I and the presence of PMT can cause the conformational changes of HSA. There was the competitive binding to HSA between PMT and flavonoids because of the overlap of binding sites in HSA. The flavonoids could decrease the association constant and increase the binding distance. In addition, their synergistic effect can further change the conformation of HSA. The decrease in the affinities of PMT binding to HSA in the presence of flavonoids may lead to the increase of free drug in blood, which would affect the transportation or disposition of drug and evoke an adverse or toxic effect. Hence, rationalising dosage and diet regimens should be taken into account in clinical application of PMT.
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Yamashita T, Fujishima N, Miura M, Niioka T, Abumiya M, Shinohara Y, Ubukawa K, Nara M, Fujishima M, Kameoka Y, Tagawa H, Hirokawa M, Takahashi N. Effects of CYP3A5 polymorphism on the pharmacokinetics of a once-daily modified-release tacrolimus formulation and acute kidney injury in hematopoietic stem cell transplantation. Cancer Chemother Pharmacol 2016; 78:111-8. [PMID: 27217047 PMCID: PMC4921119 DOI: 10.1007/s00280-016-3060-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 05/10/2016] [Indexed: 12/12/2022]
Abstract
Background Tacrolimus is metabolized by cytochrome P450 (CYP) 3A4 and 3A5. We investigated the influence of CYP3A5 polymorphism and concurrent use of azole antifungal agents (AZ) on the pharmacokinetics of a once-daily modified-release tacrolimus formulation (Tac-QD) in patients after hematopoietic stem cell transplantation (HSCT). Design and methods Twenty-four patients receiving allogeneic HSCT were enrolled. Genotyping for CYP3A5*3 was done by a PCR-restriction fragment length polymorphism method. Trough blood concentrations (C0) of tacrolimus were measured by chemiluminescence magnetic microparticle immunoassay. Continuous infusion of tacrolimus was administered from the day before transplantation and was switched to Tac-QD after adequate oral intake. Results Thirteen patients had a CYP3A5*3/*3 genotype, and 11 patients had a CYP3A5*1/*1 or *1/*3 genotype. No significant difference was observed in daily dosages and the C0 of tacrolimus between the two genotype groups without AZ. However, in patients who were co-administered AZ, the C0 values of tacrolimus were higher in patients with the CYP3A5*3/*3 allele than with the CYP3A5*1 allele (P = 0.034), although daily doses of Tac-QD in patients with CYP3A5*3/*3 were significantly lower than those with the CYP3A5*1 allele (P = 0.041). The cumulative incidence of acute kidney injury was higher in patients with the CYP3A5*3/*3 than with the CYP3A5*1 allele when AZ was co-administered. The decrement for daily dosage of Tac-QD was significantly greater in patients expressing the CYP3A5*3/*3 than the CYP3A5*1 allele. Conclusions CYP3A5 genotyping may be useful for safe and effective immunosuppressive therapy with Tac-QD in HSCT patients in whom the use of AZ is anticipated. Electronic supplementary material The online version of this article (doi:10.1007/s00280-016-3060-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Takaya Yamashita
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Naohito Fujishima
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan. .,Division of Blood Transfusion, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan.
| | - Masatomo Miura
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Takenori Niioka
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Maiko Abumiya
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Yoshinori Shinohara
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Kumi Ubukawa
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Miho Nara
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Masumi Fujishima
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yoshihiro Kameoka
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Hiroyuki Tagawa
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Makoto Hirokawa
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan.,Department of General Internal Medicine and Clinical Laboratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Naoto Takahashi
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
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A clinically relevant pharmacokinetic interaction between cyclosporine and imatinib. Eur J Clin Pharmacol 2016; 72:719-23. [PMID: 26965514 PMCID: PMC4865545 DOI: 10.1007/s00228-016-2038-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 03/01/2016] [Indexed: 01/01/2023]
Abstract
Purpose Cyclosporine A (CsA) and imatinib are both CYP3A4 and P-glycoprotein substrates. Concomitant use after hematopoietic stem cell transplantation (HSCT) for chronic myeloid leukemia (CML) or Philadelphia chromosome-positive (Ph+) acute lymphatic leukemia (ALL) may therefore result in a pharmacokinetic interaction. Although case reports and a recent small study in children indeed suggested there is a relevant pharmacokinetic interaction, a larger study in adults is lacking. In this study, we assessed the presence and extent of this interaction in patients with CML or Ph+ ALL undergoing HSCT. Methods From a large database containing data of all patients receiving HSCT in our center between 2005 and 2015, we selected 16 patients using this drug combination. The average dose-corrected CsA concentration was calculated before and after initiation of imatinib. Results The average dose-corrected CsA concentration increased during imatinib use in all patients, on average by 94 % (p < 0.001). Based on measured drug concentrations, the CsA dosage needed to be reduced, on average, by 27 % after initiation of imatinib (p = 0.004). Conclusions Imatinib significantly increases CsA concentrations in HSCT patients, putting these patients at increased risk of CsA toxicity. We recommend intensive monitoring of CsA concentrations after initiation of imatinib; a pre-emptive CsA dose reduction of 25 % might be considered.
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