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Fungal Infections in Lung Transplantation. CURRENT TRANSPLANTATION REPORTS 2022. [DOI: 10.1007/s40472-022-00363-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Abstract
Purpose of Review
We aim to understand the most common fungal infections associated with the post-lung transplant period, how to diagnose, treat, and prevent them based on the current guidelines published and our center’s experience.
Recent Findings
Different fungi inhabit specific locations. Diagnosis of invasive fungal infections (IFIs) depends on symptoms, radiologic changes, and a positive microbiological or pathology data. There are several molecular tests that have been used for diagnosis. Exposure to fungal prophylaxis can predispose lung transplant recipients to these emerging molds. Understanding and managing medication interactions and drug monitoring are essential in successfully treating IFIs.
Summary
With the increasing rate of lung transplantations being performed, and the challenges posed by the immunosuppressive regimen, understanding the risk and managing the treatment of fungal infections are imperative to the success of a lung transplant recipient. There are many ongoing clinical trials being conducted in hopes of developing novel antifungals.
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Vergidis P, Rao A, Moore CB, Rautemaa-Richardson R, Sweeney LC, Morton M, Johnson EM, Borman AM, Richardson MD, Augustine T. Talaromycosis in a renal transplant recipient returning from South China. Transpl Infect Dis 2020; 23:e13447. [PMID: 32794335 DOI: 10.1111/tid.13447] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/11/2020] [Accepted: 07/25/2020] [Indexed: 01/22/2023]
Abstract
Talaromycosis is a fungal infection endemic in Southeast Asia. We report a case of a renal transplant recipient who developed infection after a trip to South China. She presented with constitutional symptoms and was found to have an FDG-avid lung mass. Histopathology demonstrated small yeast cells and culture grew Talaromyces marneffei. The patient was treated with 2 weeks of liposomal amphotericin B followed by itraconazole. The dose of tacrolimus was significantly reduced because of the interaction with itraconazole. Mycophenolate mofetil was discontinued. After 12 months of treatment, the mass had completely resolved. Talaromycosis has mainly been reported in patients with AIDS and is uncommon among solid organ transplant recipients. The immune response against T. marneffei infection is mediated predominantly by T cells and macrophages. The diagnosis may not be suspected outside of endemic areas. We propose a therapeutic approach in transplant patients by extrapolating the evidence from the HIV literature and following practices applied to other endemic mycoses.
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Affiliation(s)
- Paschalis Vergidis
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Anirudh Rao
- Department of Renal Medicine and Transplant Nephrology, Royal Liverpool and Broadgreen University Hospitals, Liverpool, UK
| | - Caroline B Moore
- Mycology Reference Centre Manchester, ECMM Excellence Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Riina Rautemaa-Richardson
- Mycology Reference Centre Manchester, ECMM Excellence Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Department of Infectious Diseases, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Louise C Sweeney
- Department of Microbiology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Muir Morton
- Department of Renal Medicine and Transplant Nephrology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Elizabeth M Johnson
- Public Health England UK National Mycology Reference Laboratory, Science Quarter, Southmead Hospital, Bristol, UK.,Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Andrew M Borman
- Public Health England UK National Mycology Reference Laboratory, Science Quarter, Southmead Hospital, Bristol, UK.,Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Malcolm D Richardson
- Mycology Reference Centre Manchester, ECMM Excellence Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Titus Augustine
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK
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3
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Uno T, Wada K, Hosomi K, Matsuda S, Ikura MM, Takenaka H, Terakawa N, Oita A, Yokoyama S, Kawase A, Takada M. Drug interactions between tacrolimus and clotrimazole troche: a data mining approach followed by a pharmacokinetic study. Eur J Clin Pharmacol 2019; 76:117-125. [PMID: 31654150 DOI: 10.1007/s00228-019-02770-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 09/24/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE This study investigated the effects of clotrimazole troche on the risk of transplant rejection and the pharmacokinetics of tacrolimus. METHODS The data mining approach was used to investigate whether the use of clotrimazole increased the risk of transplant rejection in patients receiving tacrolimus therapy. Patient data were acquired from the US Food and Drug Administration's Adverse Event Reporting System (FAERS) from the first quarter of 2004 to the end of 2017. Next, we retrospectively investigated the effect of clotrimazole troche on tacrolimus pharmacokinetics in seven patients who underwent heart transplantation between March and December 2017. RESULTS The FAERS subset data indicated a significant association between transplant rejection and tacrolimus with clotrimazole [reporting odds ratio 1.92, 95% two-sided confidence interval (95% CI) 1.43-2.58, information component 0.81, 95% CI 0.40-1.23]. The pharmacokinetic study demonstrated a significant correlation between trough concentration (C0) and area under the concentration-time curve of tacrolimus after discontinuation of clotrimazole (R2 = 0.60, P < 0.05) but not before its discontinuation. Furthermore, the median clearance/bioavailability of tacrolimus after discontinuation of clotrimazole was 2.2-fold greater than that before its discontinuation (0.27 vs. 0.59 L/h/kg, P < 0.05). The median C0 decreased from 10.7 ng/mL on the day after discontinuation of clotrimazole to 6.5 ng/mL at 1 day and 5.3 ng/mL at 2 days after its discontinuation. CONCLUSION Immediate dose adjustments of tacrolimus may be beneficial to avoid transplant rejection when clotrimazole troche is added or discontinued.
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Affiliation(s)
- Takaya Uno
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, Higashi-osaka, Japan
- Division of Cardiovascular Drugs, Therapy, Kindai University Graduate School of Pharmacy, Higashi-osaka, Japan
| | - Kyoichi Wada
- Education and Research Center for Clinical Pharmacy, Osaka University of Pharmaceutical Sciences, Takatsuki, Japan
| | - Kouichi Hosomi
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, Higashi-osaka, Japan
- Division of Cardiovascular Drugs, Therapy, Kindai University Graduate School of Pharmacy, Higashi-osaka, Japan
| | - Sachi Matsuda
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Megumi Morii Ikura
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiromi Takenaka
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nobue Terakawa
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akira Oita
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Yokoyama
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, Higashi-osaka, Japan
- Division of Cardiovascular Drugs, Therapy, Kindai University Graduate School of Pharmacy, Higashi-osaka, Japan
| | - Atsushi Kawase
- Department of Pharmacy, Faculty of Pharmacy, Kindai University, Higashi-osaka, Japan
| | - Mitsutaka Takada
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, Higashi-osaka, Japan.
- Division of Cardiovascular Drugs, Therapy, Kindai University Graduate School of Pharmacy, Higashi-osaka, Japan.
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Sparkes T, Lemonovich TL. Interactions between anti-infective agents and immunosuppressants-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13510. [PMID: 30817021 DOI: 10.1111/ctr.13510] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/12/2019] [Indexed: 01/14/2023]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation provide an update on potential drug-drug interactions between anti-infectives and immunosuppressants, which are most notable with calcineurin and mTOR inhibitors. Drug-drug interactions may occur through pharmacokinetic mechanisms leading to altered drug concentrations of either the anti-infective or immunosuppressive drug, or by pharmacodynamic interactions increasing or decreasing the efficacy or toxicity of the medications. Many of the significant pharmacokinetic interactions occur through inhibition or induction of the cytochrome 3A4 system by anti-infective agents leading to increased or decreased immunosuppressive agent levels, respectively. The membrane transporter P-glycoprotein is also often involved in drug interactions. Since the last iteration of these guidelines, multiple new hepatitis C virus direct-acting antivirals have become available for use in SOT recipients. Of these agents, some are substrates of cytochrome and drug transporter systems, while others inhibit these systems and may affect immunosuppressive agents. Due to the high risk for drug-drug interactions in the solid organ transplant population, practitioners must be aware of potential interactions and be vigilant in monitoring and adjusting drug dosing when appropriate.
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Affiliation(s)
- Tracy Sparkes
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland
| | - Tracy L Lemonovich
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
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5
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Liu L, Bello A, Dresser MJ, Heald D, Komjathy SF, O'Mara E, Rogge M, Stoch SA, Robertson SM. Best practices for the use of itraconazole as a replacement for ketoconazole in drug-drug interaction studies. J Clin Pharmacol 2015; 56:143-51. [PMID: 26044116 DOI: 10.1002/jcph.562] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 05/31/2015] [Indexed: 01/10/2023]
Abstract
Ketoconazole has been widely used as a strong cytochrome P450 (CYP) 3A (CYP3A) inhibitor in drug-drug interaction (DDI) studies. However, the US Food and Drug Administration has recommended limiting the use of ketoconazole to cases in which no alternative therapies exist, and the European Medicines Agency has recommended the suspension of its marketing authorizations because of the potential for serious safety concerns. In this review, the Innovation and Quality in Pharmaceutical Development's Clinical Pharmacology Leadership Group (CPLG) provides a compelling rationale for the use of itraconazole as a replacement for ketoconazole in clinical DDI studies and provides recommendations on the best practices for the use of itraconazole in such studies. Various factors considered in the recommendations include the choice of itraconazole dosage form, administration in the fasted or fed state, the dose and duration of itraconazole administration, the timing of substrate and itraconazole coadministration, and measurement of itraconazole and metabolite plasma concentrations, among others. The CPLG's recommendations are based on careful review of available literature and internal industry experiences.
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Affiliation(s)
- Lichuan Liu
- Genentech Inc., South San Francisco, CA, USA
| | | | | | - Donald Heald
- Janssen Research and Development, Spring House, PA, USA
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6
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Therapeutic drug monitoring for triazoles: A needs assessment review and recommendations from a Canadian perspective. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2015; 25:327-43. [PMID: 25587296 PMCID: PMC4277162 DOI: 10.1155/2014/340586] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Invasive fungal infections cause significant morbidity and mortality in patients with concomitant underlying immunosuppressive diseases. The recent addition of new triazoles to the antifungal armamentarium has allowed for extended-spectrum activity and flexibility of administration. Over the years, clinical use has raised concerns about the degree of drug exposure following standard approved drug dosing, questioning the need for therapeutic drug monitoring (TDM). Accordingly, the present guidelines focus on TDM of triazole antifungal agents. A review of the rationale for triazole TDM, the targeted patient populations and available laboratory methods, as well as practical recommendations based on current evidence from an extended literature review are provided in the present document.
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7
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Enderby CY, Heckman MG, Thomas CS, Keller CA. Tacrolimus dosage requirements in lung transplant recipients receiving antifungal prophylaxis with voriconazole followed by itraconazole: a preliminary prospective study. Clin Transplant 2014; 28:911-5. [DOI: 10.1111/ctr.12403] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2014] [Indexed: 12/01/2022]
Affiliation(s)
| | | | | | - Cesar A. Keller
- Department of Transplantation; Mayo Clinic; Jacksonville FL USA
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8
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Dodds-Ashley E. Management of drug and food interactions with azole antifungal agents in transplant recipients. Pharmacotherapy 2011; 30:842-54. [PMID: 20653361 DOI: 10.1592/phco.30.8.842] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Azole antifungal agents are frequently used in hematopoietic stem cell and solid organ transplant recipients for prevention or treatment of invasive fungal infections. However, because of metabolism by or substrate activity for various isoenzymes of the cytochrome P450 system and/or P-glycoprotein, azole antifungals have the potential to interact with many of the drugs commonly used in these patient populations. Thus, to identify drug interactions that may result between azole antifungals and other drugs, we conducted a literature search of the MEDLINE database (1966-December 2009) for English-language articles on drug interaction studies involving the azole antifungal agents fluconazole, itraconazole, voriconazole, and posaconazole. Another literature search between each of the azoles and the immunosuppressants cyclosporine, tacrolimus, and sirolimus, as well as the corticosteroids methylprednisolone, dexamethasone, prednisolone, and prednisone, was also conducted. Concomitant administration of azoles and immunosuppressive agents may cause clinically significant drug interactions resulting in extreme immunosuppression or toxicity. The magnitude and duration of an interaction between azoles and immunosuppressants are not class effects of the azoles, but differ between drug combinations and are subject to interpatient variability. Drug interactions in the transplant recipient receiving azole therapy may also occur with antibiotics, chemotherapeutic agents, and acid-suppressive therapies, among other drugs. Initiation of an azole antifungal in transplant recipients nearly ensures a drug-drug interaction, but often these drugs are required. Management of these interactions first involves knowledge of the potential drug interaction, appropriate dosage adjustments when necessary, and therapeutic or clinical monitoring at an appropriate point in therapy to assess the drug-drug interaction (e.g., immunosuppressive drug concentrations, signs and symptoms of toxicity). These aspects of drug interaction management are essential not only at the initiation of azole antifungal therapy, but also when these agents are removed from the regimen.
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Affiliation(s)
- Elizabeth Dodds-Ashley
- Department of Pharmacy, University of Rochester Medical Center, Rochester, New York 14642, USA.
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9
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Preparation, characterization of hydrophilic and hydrophobic drug in combine loaded chitosan/cyclodextrin nanoparticles and in vitro release study. Colloids Surf B Biointerfaces 2011; 83:103-7. [DOI: 10.1016/j.colsurfb.2010.11.005] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Revised: 10/30/2010] [Accepted: 11/01/2010] [Indexed: 11/20/2022]
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10
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Mori T, Aisa Y, Kato J, Nakamura Y, Ikeda Y, Okamoto S. Drug interaction between oral solution itraconazole and calcineurin inhibitors in allogeneic hematopoietic stem cell transplantation recipients: an association with bioavailability of oral solution itraconazole. Int J Hematol 2009; 90:103-107. [DOI: 10.1007/s12185-009-0344-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Revised: 03/02/2009] [Accepted: 05/06/2009] [Indexed: 11/28/2022]
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11
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Templeton I, Thummel KE, Kharasch ED, Kunze KL, Hoffer C, Nelson WL, Isoherranen N. Contribution of itraconazole metabolites to inhibition of CYP3A4 in vivo. Clin Pharmacol Ther 2007; 83:77-85. [PMID: 17495874 PMCID: PMC3488349 DOI: 10.1038/sj.clpt.6100230] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Itraconazole (ITZ) is metabolized in vitro to three inhibitory metabolites: hydroxy-itraconazole (OH-ITZ), keto-itraconazole (keto-ITZ), and N-desalkyl-itraconazole (ND-ITZ). The goal of this study was to determine the contribution of these metabolites to drug-drug interactions caused by ITZ. Six healthy volunteers received 100 mg ITZ orally for 7 days, and pharmacokinetic analysis was conducted at days 1 and 7 of the study. The extent of CYP3A4 inhibition by ITZ and its metabolites was predicted using this data. ITZ, OH-ITZ, keto-ITZ, and ND-ITZ were detected in plasma samples of all volunteers. A 3.9-fold decrease in the hepatic intrinsic clearance of a CYP3A4 substrate was predicted using the average unbound steady-state concentrations (C(ss,ave,u)) and liver microsomal inhibition constants for ITZ, OH-ITZ, keto-ITZ, and ND-ITZ. Accounting for circulating metabolites of ITZ significantly improved the in vitro to in vivo extrapolation of CYP3A4 inhibition compared to a consideration of ITZ exposure alone.
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Affiliation(s)
- Ian Templeton
- Department of Pharmaceutics, Schools of Pharmacy and Medicine, University of Washington
| | - Kenneth E Thummel
- Department of Pharmaceutics, Schools of Pharmacy and Medicine, University of Washington
| | - Evan D Kharasch
- Department of Medicinal Chemistry, Schools of Pharmacy and Medicine, University of Washington
- Department of Anesthesiology, Schools of Pharmacy and Medicine, University of Washington
| | - Kent L Kunze
- Department of Medicinal Chemistry, Schools of Pharmacy and Medicine, University of Washington
| | - Christine Hoffer
- Department of Anesthesiology, Schools of Pharmacy and Medicine, University of Washington
| | - Wendel L Nelson
- Department of Medicinal Chemistry, Schools of Pharmacy and Medicine, University of Washington
| | - Nina Isoherranen
- Department of Pharmaceutics, Schools of Pharmacy and Medicine, University of Washington
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12
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Saad AH, DePestel DD, Carver PL. Factors Influencing the Magnitude and Clinical Significance of Drug Interactions Between Azole Antifungals and Select Immunosuppressants. Pharmacotherapy 2006; 26:1730-44. [PMID: 17125435 DOI: 10.1592/phco.26.12.1730] [Citation(s) in RCA: 212] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The magnitude of drug interactions between azole antifungals and immunosuppressants is drug and patient specific and depends on the potency of the azole inhibitor involved, the resulting plasma concentrations of each drug, the drug formulation, and interpatient variability. Many factors contribute to variability in the magnitude and clinical significance of drug interactions between an immunosuppressant such as cyclosporine, tacrolimus, or sirolimus and an antifungal agent such as ketoconazole, fluconazole, itraconazole, voriconazole, or posaconazole. By bringing similarities and differences among these agents and their potential interactions to clinicians' attention, they can appreciate and apply these findings in a individualized patient approach rather than follow only the one-size-fits-all dosing recommendations suggested in many tertiary references. Differences in metabolism and in the inhibitory potency of cytochrome P450 3A4 and P-glycoprotein influence the onset, magnitude, and resolution of drug interactions and their potential effect on clinical outcomes. Important issues are the route of administration and the decision to preemptively adjust dosages versus intensive monitoring with subsequent dosage adjustments. We provide recommendations for the concomitant use of these agents, including suggestions regarding contraindicated combinations, those best avoided, and those requiring close monitoring of drug dosages and plasma concentrations.
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Affiliation(s)
- Aline H Saad
- Department of Pharmacy Services, University of Michigan Health System, Ann Arbor, Michigan 48109-1065, USA
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Leather H, Boyette RM, Tian L, Wingard JR. Pharmacokinetic Evaluation of the Drug Interaction between Intravenous Itraconazole and Intravenous Tacrolimus or Intravenous Cyclosporin A in Allogeneic Hematopoietic Stem Cell Transplant Recipients. Biol Blood Marrow Transplant 2006; 12:325-34. [PMID: 16503502 DOI: 10.1016/j.bbmt.2005.10.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2005] [Accepted: 10/28/2005] [Indexed: 01/13/2023]
Abstract
A single-institution, open-label prospective pharmacokinetic evaluation of the interaction between intravenous itraconazole and intravenous cyclosporin A and tacrolimus was conducted in allogeneic hematopoietic stem cell transplant recipients. The study was conducted in 2 phases, with patients acting as their own controls. In phase 1, steady-state concentrations and clearance of cyclosporin A and tacrolimus administered alone were evaluated. Phase 2 evaluated serum concentrations and clearance of cyclosporin A and tacrolimus under the influence of itraconazole therapy. Among 17 patients who completed both phases of the study, the mean increase in the serum tacrolimus concentration was 83% (P<.0001), and the mean increase in the serum cyclosporin A concentration was 80% (P=.0001). There was no correlation between serum itraconazole concentrations and the serum concentrations of tacrolimus or cyclosporin A. The drug interaction between itraconazole and calcineurin inhibitors is predictable and occurs within 48 hours of concomitant drug administration. The data suggest that dose reductions of tacrolimus and cyclosporin A in the range of 50% to 100% are necessary when itraconazole therapy is initiated and that subsequent close monitoring of serum concentrations is necessary to guide further dose modifications.
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Affiliation(s)
- Helen Leather
- Shands at the University of Florida, Gainesville, Florida 32610-0316, USA.
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Leather HL. Drug interactions in the hematopoietic stem cell transplant (HSCT) recipient: what every transplanter needs to know. Bone Marrow Transplant 2004; 33:137-52. [PMID: 14676788 DOI: 10.1038/sj.bmt.1704316] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Pharmacokinetic drug interactions among hematopoietic stem cell transplant recipients can result in either increases in serum concentrations of medications, which may lead to enhanced toxicity; or reduced serum concentrations, which can lead to treatment failure and the emergence of post transplant complications. The use of drugs that have a narrow therapeutic index, such as cyclosporine/tacrolimus (calcineurin inhibitors), increases the significance of these interactions when they occur. This report will review the clinical data evaluating the drug interactions of relevance to HSCT clinical practice, focusing on the pharmacokinetic interactions, and provides recommendations for managing these interactions to avoid both toxicity and treatment failure.
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Affiliation(s)
- H L Leather
- University of Florida, 1600 SW Archer Road, Box 100316, Gainesville, FL 32610, USA.
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15
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Isoherranen N, Kunze KL, Allen KE, Nelson WL, Thummel KE. ROLE OF ITRACONAZOLE METABOLITES IN CYP3A4 INHIBITION. Drug Metab Dispos 2004; 32:1121-31. [PMID: 15242978 DOI: 10.1124/dmd.104.000315] [Citation(s) in RCA: 193] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Itraconazole (ITZ) is a potent inhibitor of CYP3A in vivo. However, unbound plasma concentrations of ITZ are much lower than its reported in vitro Ki, and no clinically significant interactions would be expected based on a reversible mechanism of inhibition. The purpose of this study was to evaluate the reasons for the in vitro-in vivo discrepancy. The metabolism of ITZ by CYP3A4 was studied. Three metabolites were detected: hydroxy-itraconazole (OH-ITZ), a known in vivo metabolite of ITZ, and two new metabolites: keto-itraconazole (keto-ITZ) and N-desalkyl-itraconazole (ND-ITZ). OHITZ and keto-ITZ were also substrates of CYP3A4. Using a substrate depletion kinetic approach for parameter determination, ITZ exhibited an unbound K(m) of 3.9 nM and an intrinsic clearance (CLint) of 69.3 ml.min(-1).nmol CYP3A4(-1). The respective unbound Km values for OH-ITZ and keto-ITZ were 27 nM and 1.4 nM and the CLint values were 19.8 and 62.5 ml.min(-1).nmol CYP3A4(-1). Inhibition of CYP3A4 by ITZ, OH-ITZ, keto-ITZ, and ND-ITZ was evaluated using hydroxylation of midazolam as a probe reaction. Both ITZ and OH-ITZ were competitive inhibitors of CYP3A4, with unbound Ki (1.3 nM for ITZ and 14.4 nM for OH-ITZ) close to their respective Km. ITZ, OH-ITZ, keto-ITZ and ND-ITZ exhibited unbound IC50 values of 6.1 nM, 4.6 nM, 7.0 nM, and 0.4 nM, respectively, when coincubated with human liver microsomes and midazolam (substrate concentration < Km). These findings demonstrate that ITZ metabolites are as potent as or more potent CYP3A4 inhibitors than ITZ itself, and thus may contribute to the inhibition of CYP3A4 observed in vivo after ITZ dosing.
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Affiliation(s)
- Nina Isoherranen
- University of Washington, Department of Pharmaceutics, H272 Health Sciences Building, Box 357610, Seattle, WA 98195-7610, USA
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Mahnke CB, Sutton RM, Venkataramanan R, Michaels M, Kurland G, Boyle GJ, Law YM, Miller SA, Pigula FA, Gandhi S, Webber SA. Tacrolimus dosage requirements after initiation of azole antifungal therapy in pediatric thoracic organ transplantation. Pediatr Transplant 2003; 7:474-8. [PMID: 14870897 DOI: 10.1046/j.1397-3142.2003.00103.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Azole antifungals inhibit the metabolism of tacrolimus mediated by CYP3A4. Upon initiation of azole therapy, the required dose reduction of tacrolimus is unknown. We reviewed our experience with azole antifungals in our pediatric thoracic transplant population receiving tacrolimus. Tacrolimus levels and dosage requirements were compared before and during azole therapy. Thirty-one patients received both tacrolimus and an azole antifungal (fluconazole = 9, itraconazole = 22). The tacrolimus dose was empirically reduced by approximately one-third when azole therapy was initiated. Mean tacrolimus dose requirements decreased by 68% within the first month of therapy (pre-azole: 0.27 +/- 0.14 mg/kg/day; 30 day post-azole: 0.087 +/- 0.069 mg/kg/day; p < 0.001). Despite a mean decrease in tacrolimus dose from baseline of 33, 42, and 55% on day 1, 2, and 4 of azole therapy, respectively, there was still an unintended 38% increase in tacrolimus levels during the first month of azole therapy. A calculated dose-reduction protocol of 50% on day of azole initiation, 70% on day 3, and 75% on day 14 should result in minimal mean changes in the tacrolimus levels. There was no difference in tacrolimus dose reduction between fluconazole and itraconazole groups. Azole antifungals markedly decrease tacrolimus requirements within the first few days of therapy. An initial reduction in tacrolimus dose by one-third is insufficient, and dose reduction of at least 50% upon azole initiation seems warranted. Once azole antifungal therapy is initiated, frequent therapeutic drug monitoring is required.
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Affiliation(s)
- C Becket Mahnke
- Division of Cardiology, Children's Hospital of Pittsburgh, PA 15213, USA
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Scott LJ, McKeage K, Keam SJ, Plosker GL. Tacrolimus: a further update of its use in the management of organ transplantation. Drugs 2003; 63:1247-97. [PMID: 12790696 DOI: 10.2165/00003495-200363120-00006] [Citation(s) in RCA: 309] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
UNLABELLED Extensive clinical use has confirmed that tacrolimus (Prograf) is a key option for immunosuppression after transplantation. In large, prospective, randomised, multicentre trials in adults and children receiving solid organ transplants, tacrolimus was at least as effective or provided better efficacy than cyclosporin microemulsion in terms of patient and graft survival, treatment failure rates and the incidence of biopsy-proven acute and corticosteroid-resistant rejection episodes. Notably, the lower incidence of rejection episodes after renal transplantation in tacrolimus recipients was reflected in improved cost effectiveness. In bone marrow transplant (BMT) recipients, the incidence of tacrolimus grade II-IV graft-versus-host disease was significantly lower with tacrolimus than cyclosporin treatment. Efficacy was maintained in renal and liver transplant recipients after total withdrawal of corticosteroid therapy from tacrolimus-based immunosuppression, with the incidence of acute rejection episodes at up to 2 years' follow-up being similar with or without corticosteroids. Tacrolimus provided effective rescue therapy in transplant recipients with persistent acute or chronic allograft rejection or drug-related toxicity associated with cyclosporin treatment. Typically, conversion to tacrolimus reversed rejection episodes and/or improved the tolerability profile, particularly in terms of reduced hyperlipidaemia. In lung transplant recipients with obliterative bronchiolitis, conversion to tacrolimus reduced the decline in and/or improved lung function in terms of forced expiratory volume in 1 second. Tolerability issues may be a factor when choosing a calcineurin inhibitor. Cyclosporin tends to be associated with a higher incidence of significant hypertension, hyperlipidaemia, hirsutism, gingivitis and gum hyperplasia, whereas the incidence of some types of neurotoxicity, disturbances in glucose metabolism, diarrhoea, pruritus and alopecia may be higher with tacrolimus treatment. Renal function, as assessed by serum creatinine levels and glomerular filtration rates, was better in tacrolimus than cyclosporin recipients at up to 5 years' follow-up. CONCLUSION Recent well designed trials have consolidated the place of tacrolimus as an important choice for primary immunosuppression in solid organ transplantation and in BMT. Notably, in adults and children receiving transplants, tacrolimus-based primary immunosuppression was at least as effective or provided better efficacy than cyclosporin microemulsion treatment in terms of patient and graft survival, treatment failure and the incidence of acute and corticosteroid-resistant rejection episodes. The reduced incidence of rejection episodes in renal transplant recipients receiving tacrolimus translated into a better cost effectiveness relative to cyclosporin microemulsion treatment. The optimal immunosuppression regimen is ultimately dependent on balancing such factors as the efficacy of the individual drugs, their tolerability, potential for drug interactions and pharmacoeconomic issues.
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