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Kably B, Launay M, Derobertmasure A, Lefeuvre S, Dannaoui E, Billaud EM. Antifungal Drugs TDM: Trends and Update. Ther Drug Monit 2022; 44:166-197. [PMID: 34923544 DOI: 10.1097/ftd.0000000000000952] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/09/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The increasing burden of invasive fungal infections results in growing challenges to antifungal (AF) therapeutic drug monitoring (TDM). This review aims to provide an overview of recent advances in AF TDM. METHODS We conducted a PubMed search for articles during 2016-2020 using "TDM" or "pharmacokinetics" or "drug-drug-interaction" with "antifungal," consolidated for each AF. Selection was limited to English language articles with human data on drug exposure. RESULTS More than 1000 articles matched the search terms. We selected 566 publications. The latest findings tend to confirm previous observations in real-life clinical settings. The pharmacokinetic variability related to special populations is not specific but must be considered. AF benefit-to-risk ratio, drug-drug interaction (DDI) profiles, and minimal inhibitory concentrations for pathogens must be known to manage at-risk situations and patients. Itraconazole has replaced ketoconazole in healthy volunteers DDI studies. Physiologically based pharmacokinetic modeling is widely used to assess metabolic azole DDI. AF prophylactic use was studied more for Aspergillus spp. and Mucorales in oncohematology and solid organ transplantation than for Candida (already studied). Emergence of central nervous system infection and severe infections in immunocompetent individuals both merit special attention. TDM is more challenging for azoles than amphotericin B and echinocandins. Fewer TDM requirements exist for fluconazole and isavuconazole (ISZ); however, ISZ is frequently used in clinical situations in which TDM is recommended. Voriconazole remains the most challenging of the AF, with toxicity limiting high-dose treatments. Moreover, alternative treatments (posaconazole tablets, ISZ) are now available. CONCLUSIONS TDM seems to be crucial for curative and/or long-term maintenance treatment in highly variable patients. TDM poses fewer cost issues than the drugs themselves or subsequent treatment issues. The integration of clinical pharmacology into multidisciplinary management is now increasingly seen as a part of patient care.
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Affiliation(s)
- Benjamin Kably
- Laboratoire de Pharmacologie-Toxicologie, Hôpital Européen Georges Pompidou, AP-HP Centre
- Faculté de Médecine, Université de Paris, Paris, France
| | - Manon Launay
- Laboratoire de Pharmacologie-Toxicologie-Gaz du sang, Hôpital Nord-CHU Saint Etienne, Saint-Etienne
| | - Audrey Derobertmasure
- Laboratoire de Pharmacologie-Toxicologie, Hôpital Européen Georges Pompidou, AP-HP Centre
| | - Sandrine Lefeuvre
- Laboratoire de Toxicologie et Pharmacocinétique, CHU de Poitiers, Poitiers; and
| | - Eric Dannaoui
- Faculté de Médecine, Université de Paris, Paris, France
- Unité de Parasitologie-Mycologie, Laboratoire de Microbiologie, Hôpital Européen Georges Pompidou, Paris, France
| | - Eliane M Billaud
- Laboratoire de Pharmacologie-Toxicologie, Hôpital Européen Georges Pompidou, AP-HP Centre
- Faculté de Médecine, Université de Paris, Paris, France
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Liao J, Pan B, Zhuo X, Liao G, Gao Y, Yao Z, Wang L, Wu Q, Pan W, Jiao B, Zhao Q. β-1,2-Mannan-based glycoconjugates as potential antifungal vaccines. CHINESE CHEM LETT 2021. [DOI: 10.1016/j.cclet.2021.12.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Czyrski A, Resztak M, Świderski P, Brylak J, Główka FK. The Overview on the Pharmacokinetic and Pharmacodynamic Interactions of Triazoles. Pharmaceutics 2021; 13:pharmaceutics13111961. [PMID: 34834376 PMCID: PMC8620887 DOI: 10.3390/pharmaceutics13111961] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/09/2021] [Accepted: 11/15/2021] [Indexed: 12/24/2022] Open
Abstract
Second generation triazoles are widely used as first-line drugs for the treatment of invasive fungal infections, including aspergillosis and candidiasis. This class, along with itraconazole, voriconazole, posaconazole, and isavuconazole, is characterized by a broad range of activity, however, individual drugs vary considerably in safety, tolerability, pharmacokinetics profiles, and interactions with concomitant medications. The interaction may be encountered on the absorption, distribution, metabolism, and elimination (ADME) step. All triazoles as inhibitors or substrates of CYP isoenzymes can often interact with many drugs, which may result in the change of the activity of the drug and cause serious side effects. Drugs of this class should be used with caution with other agents, and an understanding of their pharmacokinetic profile, safety, and drug-drug interaction profiles is important to provide effective antifungal therapy. The manuscript reviews significant drug interactions of azoles with other medications, as well as with food. The PubMed and Google Scholar bases were searched to collect the literature data. The interactions with anticonvulsants, antibiotics, statins, kinase inhibitors, proton pump inhibitors, non-nucleoside reverse transcriptase inhibitors, opioid analgesics, benzodiazepines, cardiac glycosides, nonsteroidal anti-inflammatory drugs, immunosuppressants, antipsychotics, corticosteroids, biguanides, and anticoagulants are presented. We also paid attention to possible interactions with drugs during experimental therapies for the treatment of COVID-19.
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Affiliation(s)
- Andrzej Czyrski
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland; (M.R.); (F.K.G.)
- Correspondence: ; Tel.: +48-61-854-64-33
| | - Matylda Resztak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland; (M.R.); (F.K.G.)
| | - Paweł Świderski
- Department of Forensic Medicine, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland;
| | - Jan Brylak
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, 27/33 Szpitalna Street, 60-572 Poznań, Poland;
| | - Franciszek K. Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland; (M.R.); (F.K.G.)
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Zhao Y, Hou J, Xiao Y, Wang F, Zhang B, Zhang M, Jiang Y, Li J, Gong G, Xiang D, Yan M. Predictors of Voriconazole Trough Concentrations in Patients with Child-Pugh Class C Cirrhosis: A Prospective Study. Antibiotics (Basel) 2021; 10:antibiotics10091130. [PMID: 34572712 PMCID: PMC8470058 DOI: 10.3390/antibiotics10091130] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/12/2021] [Accepted: 09/14/2021] [Indexed: 12/13/2022] Open
Abstract
This prospective observational study aimed to clinically describe voriconazole administrations and trough concentrations in patients with Child–Pugh class C and to investigate the variability of trough concentration. A total of 144 voriconazole trough concentrations from 43 Child–Pugh class C patients were analyzed. The majority of patients (62.8%) received adjustments. The repeated measured trough concentration was higher than the first and final ones generally (median, 4.33 vs. 2.99, 3.90 mg/L). Eight patients with ideal initial concentrations later got supratherapeutic with no adjusted daily dose, implying accumulation. There was a significant difference in concentrations among the six groups by daily dose (p = 0.006). The bivariate correlation analysis showed that sex, CYP2C19 genotyping, daily dose, prothrombin time activity, international normalized ratio, platelet, and Model for end-stage liver disease score were significant factors for concentration. Subsequently, the first four factors mentioned above entered into a stepwise multiple linear regression model (variance inflation factor <5), implying that CYP2C19 testing makes sense for precision medicine of Child–Pugh class C cirrhosis patients. The equation fits well and explains the 34.8% variety of concentrations (R2 = 0.348). In conclusion, it needs more cautious administration clinically due to no recommendation for Child–Pugh class C patients in the medication label. The adjustment of the administration regimen should be mainly based on the results of repeated therapeutic drug monitoring.
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Affiliation(s)
- Yichang Zhao
- The Second Xiangya Hospital, Central South University, Changsha 410011, China; (Y.Z.); (J.H.); (Y.X.); (F.W.); (B.Z.); (M.Z.); (Y.J.); (J.L.); (G.G.); (D.X.)
- Institute of Clinical Pharmacy, Central South University, Changsha 410011, China
| | - Jingjing Hou
- The Second Xiangya Hospital, Central South University, Changsha 410011, China; (Y.Z.); (J.H.); (Y.X.); (F.W.); (B.Z.); (M.Z.); (Y.J.); (J.L.); (G.G.); (D.X.)
- Institute of Clinical Pharmacy, Central South University, Changsha 410011, China
| | - Yiwen Xiao
- The Second Xiangya Hospital, Central South University, Changsha 410011, China; (Y.Z.); (J.H.); (Y.X.); (F.W.); (B.Z.); (M.Z.); (Y.J.); (J.L.); (G.G.); (D.X.)
- Institute of Clinical Pharmacy, Central South University, Changsha 410011, China
| | - Feng Wang
- The Second Xiangya Hospital, Central South University, Changsha 410011, China; (Y.Z.); (J.H.); (Y.X.); (F.W.); (B.Z.); (M.Z.); (Y.J.); (J.L.); (G.G.); (D.X.)
- Institute of Clinical Pharmacy, Central South University, Changsha 410011, China
| | - Bikui Zhang
- The Second Xiangya Hospital, Central South University, Changsha 410011, China; (Y.Z.); (J.H.); (Y.X.); (F.W.); (B.Z.); (M.Z.); (Y.J.); (J.L.); (G.G.); (D.X.)
- Institute of Clinical Pharmacy, Central South University, Changsha 410011, China
| | - Min Zhang
- The Second Xiangya Hospital, Central South University, Changsha 410011, China; (Y.Z.); (J.H.); (Y.X.); (F.W.); (B.Z.); (M.Z.); (Y.J.); (J.L.); (G.G.); (D.X.)
- Department of Infection, Central South University, Changsha 410011, China
| | - Yongfang Jiang
- The Second Xiangya Hospital, Central South University, Changsha 410011, China; (Y.Z.); (J.H.); (Y.X.); (F.W.); (B.Z.); (M.Z.); (Y.J.); (J.L.); (G.G.); (D.X.)
- Department of Infection, Central South University, Changsha 410011, China
| | - Jiakai Li
- The Second Xiangya Hospital, Central South University, Changsha 410011, China; (Y.Z.); (J.H.); (Y.X.); (F.W.); (B.Z.); (M.Z.); (Y.J.); (J.L.); (G.G.); (D.X.)
- Institute of Clinical Pharmacy, Central South University, Changsha 410011, China
| | - Guozhong Gong
- The Second Xiangya Hospital, Central South University, Changsha 410011, China; (Y.Z.); (J.H.); (Y.X.); (F.W.); (B.Z.); (M.Z.); (Y.J.); (J.L.); (G.G.); (D.X.)
- Department of Infection, Central South University, Changsha 410011, China
| | - Daxiong Xiang
- The Second Xiangya Hospital, Central South University, Changsha 410011, China; (Y.Z.); (J.H.); (Y.X.); (F.W.); (B.Z.); (M.Z.); (Y.J.); (J.L.); (G.G.); (D.X.)
- Institute of Clinical Pharmacy, Central South University, Changsha 410011, China
| | - Miao Yan
- The Second Xiangya Hospital, Central South University, Changsha 410011, China; (Y.Z.); (J.H.); (Y.X.); (F.W.); (B.Z.); (M.Z.); (Y.J.); (J.L.); (G.G.); (D.X.)
- Institute of Clinical Pharmacy, Central South University, Changsha 410011, China
- Correspondence: ; Tel.: +86-0731-8529-2098; Fax: +86-0731-8443-6720
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Study of dissolution and transfer processes of new bioactive thiazolo[4,5-d]pyrimidine derivatives in modeling biological systems. J Mol Liq 2021. [DOI: 10.1016/j.molliq.2021.116395] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Synthesis and antifungal activity of new hybrids thiazolo[4,5-d]pyrimidines with (1H-1,2,4)triazole. Bioorg Med Chem Lett 2021; 40:127944. [PMID: 33713781 DOI: 10.1016/j.bmcl.2021.127944] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 11/22/2022]
Abstract
Synthesis and antifungal activity of hybrids of thiazolo[4,5-d]pyrimidines with (1H-1,2,4)triazoles are presented. The solubility and lipophilicity of compounds was assessed and it was discovered that compounds with piperazine linker exhibited significant antifungal activity against filamentous and yeast fungi.
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Zurl C, Waller M, Schwameis F, Muhr T, Bauer N, Zollner-Schwetz I, Valentin T, Meinitzer A, Ullrich E, Wunsch S, Hoenigl M, Grinschgl Y, Prattes J, Oulhaj A, Krause R. Isavuconazole Treatment in a Mixed Patient Cohort with Invasive Fungal Infections: Outcome, Tolerability and Clinical Implications of Isavuconazole Plasma Concentrations. J Fungi (Basel) 2020; 6:jof6020090. [PMID: 32580296 PMCID: PMC7344482 DOI: 10.3390/jof6020090] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 12/18/2022] Open
Abstract
Isavuconazole (ISA) is a triazole antifungal agent recommended for treatment of invasive aspergillosis or mucormycosis. The objective of this study was to evaluate ISA levels in a real world setting in a mixed patient cohort including patients with non-malignant diseases and extracorporeal treatments, and to correlate findings with efficacy and safety outcomes. We investigated 33 ISA treatment courses in 32 adult patients with hematological and other underlying diseases and assessed the clinical response, side effects and ISA trough plasma concentrations. ISA treatment led to complete and partial response in 87% of patients and was well tolerated. The median ISA plasma concentration was 3.05 µg/mL (range 1.38–9.1, IQR 1.93–4.35) in patients without renal replacement therapy (RRT) or extracorporeal membrane oxygenation (ECMO) and significantly lower in patients with RRT including cases with additional ECMO or Cytosorb® adsorber therapy (0.88 µg/mL, range 0.57–2.44, IQR 0.71–1.21). After exclusion of values obtained from four patients with ECMO or Cytosorb® adsorber the median concentration was 0.91 µg/mL (range 0.75–2.44, IQR 0.90–1.36) in the RRT group. In addition to previous recommendations we propose to monitor ISA trough plasma concentrations in certain circumstances including RRT, other extracorporeal treatments and obesity.
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Affiliation(s)
- Christoph Zurl
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (C.Z.); (M.W.); (I.Z.-S.); (T.V.); (E.U.); (S.W.); (M.H.); (J.P.)
- Division of General Paediatrics, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
- BioTechMed-Graz, 8010 Graz, Austria
| | - Maximilian Waller
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (C.Z.); (M.W.); (I.Z.-S.); (T.V.); (E.U.); (S.W.); (M.H.); (J.P.)
| | - Franz Schwameis
- Department for Anaesthesiology and Intensive Care Medicine, Landesklinikum Baden, 2500 Baden, Austria;
| | - Tina Muhr
- Department of Internal Medicine, Landeskrankenhaus Graz 2, 8020 Graz, Austria;
| | - Norbert Bauer
- Department of Internal Medicine, Landeskrankenhaus Hartberg, 8230 Hartberg, Austria;
| | - Ines Zollner-Schwetz
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (C.Z.); (M.W.); (I.Z.-S.); (T.V.); (E.U.); (S.W.); (M.H.); (J.P.)
| | - Thomas Valentin
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (C.Z.); (M.W.); (I.Z.-S.); (T.V.); (E.U.); (S.W.); (M.H.); (J.P.)
| | - Andreas Meinitzer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, 8036 Graz, Austria;
| | - Elisabeth Ullrich
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (C.Z.); (M.W.); (I.Z.-S.); (T.V.); (E.U.); (S.W.); (M.H.); (J.P.)
- Institute of Hygiene, Microbiology and Environmental Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Stefanie Wunsch
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (C.Z.); (M.W.); (I.Z.-S.); (T.V.); (E.U.); (S.W.); (M.H.); (J.P.)
| | - Martin Hoenigl
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (C.Z.); (M.W.); (I.Z.-S.); (T.V.); (E.U.); (S.W.); (M.H.); (J.P.)
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, San Diego, CA 92093, USA
| | - Yvonne Grinschgl
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, 8036 Graz, Austria;
| | - Juergen Prattes
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (C.Z.); (M.W.); (I.Z.-S.); (T.V.); (E.U.); (S.W.); (M.H.); (J.P.)
- BioTechMed-Graz, 8010 Graz, Austria
| | - Abderrahim Oulhaj
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, UAE;
| | - Robert Krause
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (C.Z.); (M.W.); (I.Z.-S.); (T.V.); (E.U.); (S.W.); (M.H.); (J.P.)
- BioTechMed-Graz, 8010 Graz, Austria
- Correspondence: ; Tel.: +43-316-385-81796
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Chatelon J, Cortegiani A, Hammad E, Cassir N, Leone M. Choosing the Right Antifungal Agent in ICU Patients. Adv Ther 2019; 36:3308-3320. [PMID: 31617055 PMCID: PMC6860507 DOI: 10.1007/s12325-019-01115-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Indexed: 12/12/2022]
Abstract
Fungi are responsible for around 20% of microbiologically documented infections in intensive care units (ICU). In the last decade, the incidence of invasive fungal infections (IFI), including candidemia, has increased steadily because of increased numbers of both immunocompromised and ICU patients. To improve the outcomes of patients with IFI, intensivists need to be aware of the inherent challenges. This narrative review summarizes the features of routinely used treatments directed against IFI in non-neutropenic ICU patients, which include three classes of antifungals: polyenes, azoles, and echinocandins. ICU patients’ pathophysiological changes are responsible for deep changes in the pharmacokinetics of antifungals. Moreover, drug interactions affect the response to antifungal treatments. Consequently, appropriate antifungal dosage is a challenge under these special conditions. Dosages should be based on renal and liver function, and serum concentrations should be monitored. This review summarizes recent guidelines, focusing on bedside management.
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Affiliation(s)
- Jeanne Chatelon
- Service d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Emmanuelle Hammad
- Service d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Nadim Cassir
- MEPHI, IHU Méditerranée Infection, Aix Marseille Université, Marseille, France
| | - Marc Leone
- Service d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France.
- MEPHI, IHU Méditerranée Infection, Aix Marseille Université, Marseille, France.
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Bongomin F, Rodriguez-Goncer I, Lorden C, Otu A, Bazaz R. Late-onset isavuconazole-induced liver injury. Med Mycol Case Rep 2018; 22:11-13. [PMID: 30094131 PMCID: PMC6076222 DOI: 10.1016/j.mmcr.2018.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 07/11/2018] [Indexed: 11/19/2022] Open
Abstract
Antifungal agents account for approximately 3% of Drug-Induced Liver Injury (DILI) cases. Isavuconazole is a novel triazole, and experience with long-term use of it is lacking. We report a case of late-onset DILI occurring after 11 months of isavuconazole therapy in a 55-year old man of Angolan descent on long-term antifungal therapy for the management of chronic pulmonary aspergillosis complicating previously treated pulmonary tuberculosis. The DILI could be described as idiosyncratic as it was not associated with high isavuconazole serum levels and his liver function tests returned to normal following treatment discontinuation.
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Affiliation(s)
- Felix Bongomin
- The National Aspergillosis Centre, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9PL, UK
| | - Isabel Rodriguez-Goncer
- The National Aspergillosis Centre, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK
| | - Carol Lorden
- The National Aspergillosis Centre, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK
| | - Akaninyene Otu
- The National Aspergillosis Centre, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK
| | - Rohit Bazaz
- The National Aspergillosis Centre, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK
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Boddu P, Chen PL, Nagarajan P, Prieto VG, Won A, Chambers M, Kornblau S. Necrotizing fungal gingivitis in a patient with Acute Myelogenous Leukemia: visible yet obscure. JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY, MEDICINE, AND PATHOLOGY 2018; 30:50-54. [PMID: 29404266 PMCID: PMC5796543 DOI: 10.1016/j.ajoms.2017.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Oral fungal infections present with atypical and varied manifestations, and distinguishing them from other entities including leukemic infiltration can be diagnostically challenging. In this report, we describe a 62 year old female with acute myeloid leukemia who presented, towards the end of her second treatment cycle of decitabine in a prolonged neutropenic state, with a month of painful, necrotic-appearing marginal gingival lesions. She was duly initiated on empiric broad spectrum antifungal treatment but did not show a clinical response with the appearance of new skin lesions concerning for progressive fungemia. Concurrent gingival and cutaneous biopsy showed fungal invasion with Fusarium. Despite changing antifungal treatment the lesions progressed, and white blood cell (WBC) transfusions were instituted. The patient had an impressive response with gradual resolution of the skin lesions and regression in gingival lesions over a week of therapy. This case illustrates the highly atypical, confounding appearance of oral fungal infections in immunocompromised hematological malignancy patients. Maxillary and mandibular marginal gingival involvement, although extremely rare, should be recognized as potential sites of fungal involvement. Accurate diagnosis entails a biopsy especially in ambiguous clinical scenarios, as presented here. The role of WBC transfusions in the management of these rare fungal pathogenic infections needs to re-established.
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Affiliation(s)
- Prajwal Boddu
- Department of Leukemia, The University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Pei-Ling Chen
- Department of Pathology, The University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Priyadharsini Nagarajan
- Department of Pathology, The University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Victor G. Prieto
- Department of Pathology, The University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Alex Won
- Department of Oncologic Dentistry Prosthodontics, The University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Mark Chambers
- Department of Oncologic Dentistry Prosthodontics, The University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Steven Kornblau
- Department of Leukemia, The University of Texas, M. D. Anderson Cancer Center, Houston, Texas
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Natesan SK, Chandrasekar PH. Isavuconazole for the treatment of invasive aspergillosis and mucormycosis: current evidence, safety, efficacy, and clinical recommendations. Infect Drug Resist 2016; 9:291-300. [PMID: 27994475 PMCID: PMC5153275 DOI: 10.2147/idr.s102207] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The majority of invasive mold infections diagnosed in immunocompromised cancer patients include invasive aspergillosis (IA) and mucormycosis. Despite timely and effective therapy, mortality remains considerable. Antifungal agents currently available for the management of these serious infections include triazoles, polyenes, and echinocandins. Until recently, posaconazole has been the only triazole with a broad spectrum of anti-mold activity against both Aspergillus sp. and mucorales. Other clinically available triazoles voriconazole and itraconazole, with poor activity against mucorales, have significant drug interactions in addition to a side effect profile inherent for all triazoles. Polyenes including lipid formulations pose a problem with infusion-related side effects, electrolyte imbalance, and nephrotoxicity. Echinocandins are ineffective against mucorales and are approved as salvage therapy for refractory IA. Given that all available antifungal agents have limitations, there has been an unmet need for a broad-spectrum anti-mold agent with a favorable profile. Following phase III clinical trials that started in 2006, isavuconazole (ISZ) seems to fit this profile. It is the first novel triazole agent recently approved by the United States Food and Drug Administration (FDA) for the treatment of both IA and mucormycosis. This review provides a brief overview of the salient features of ISZ, its favorable profile with regard to spectrum of antifungal activity, pharmacokinetic and pharmacodynamic parameters, drug interactions and tolerability, clinical efficacy, and side effects.
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Affiliation(s)
- Suganthini Krishnan Natesan
- Division of Infectious Diseases, Department of Internal Medicine, Wayne State University
- John D Dingell VA Medical Center, Detroit, MI, USA
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Shirley M, Scott LJ. Isavuconazole: A Review in Invasive Aspergillosis and Mucormycosis. Drugs 2016; 76:1647-1657. [DOI: 10.1007/s40265-016-0652-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
ABSTRACT
Invasive fungal infections are becoming an increasingly important cause of human mortality and morbidity, particularly for immunocompromised populations. The fungal pathogens
Candida albicans
,
Cryptococcus neoformans
, and
Aspergillus fumigatus
collectively contribute to over 1 million human deaths annually. Hence, the importance of safe and effective antifungal therapeutics for the practice of modern medicine has never been greater. Given that fungi are eukaryotes like their human host, the number of unique molecular targets that can be exploited for drug development remains limited. Only three classes of molecules are currently approved for the treatment of invasive mycoses. The efficacy of these agents is compromised by host toxicity, fungistatic activity, or the emergence of drug resistance in pathogen populations. Here we describe our current arsenal of antifungals and highlight current strategies that are being employed to improve the therapeutic safety and efficacy of these drugs. We discuss state-of-the-art approaches to discover novel chemical matter with antifungal activity and highlight some of the most promising new targets for antifungal drug development. We feature the benefits of combination therapy as a strategy to expand our current repertoire of antifungals and discuss the antifungal combinations that have shown the greatest potential for clinical development. Despite the paucity of new classes of antifungals that have come to market in recent years, it is clear that by leveraging innovative approaches to drug discovery and cultivating collaborations between academia and industry, there is great potential to bolster the antifungal armamentarium.
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Murrell D, Bossaer JB, Carico R, Harirforoosh S, Cluck D. Isavuconazonium sulfate: a triazole prodrug for invasive fungal infections. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2016; 25:18-30. [DOI: 10.1111/ijpp.12302] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 07/27/2016] [Indexed: 01/03/2023]
Affiliation(s)
- Derek Murrell
- Department of Pharmaceutical Sciences; Gatton College of Pharmacy; East Tennessee State University; Johnson City TN
| | - John B. Bossaer
- Department of Pharmacy Practice; Gatton College of Pharmacy; East Tennessee State University; Johnson City TN
| | - Ronald Carico
- Department of Pharmacy Practice; Gatton College of Pharmacy; East Tennessee State University; Johnson City TN
| | - Sam Harirforoosh
- Department of Pharmaceutical Sciences; Gatton College of Pharmacy; East Tennessee State University; Johnson City TN
| | - David Cluck
- Department of Pharmacy Practice; Gatton College of Pharmacy; East Tennessee State University; Johnson City TN
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Wilson DT, Dimondi VP, Johnson SW, Jones TM, Drew RH. Role of isavuconazole in the treatment of invasive fungal infections. Ther Clin Risk Manag 2016; 12:1197-206. [PMID: 27536124 PMCID: PMC4977098 DOI: 10.2147/tcrm.s90335] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Despite recent advances in both diagnosis and prevention, the incidence of invasive fungal infections continues to rise. Available antifungal agents to treat invasive fungal infections include polyenes, triazoles, and echinocandins. Unfortunately, individual agents within each class may be limited by spectrum of activity, resistance, lack of oral formulations, significant adverse event profiles, substantial drug–drug interactions, and/or variable pharmacokinetic profiles. Isavuconazole, a second-generation triazole, was approved by the US Food and Drug Administration in March 2015 and the European Medicines Agency in July 2015 for the treatment of adults with invasive aspergillosis (IA) or mucormycosis. Similar to amphotericin B and posaconazole, isavuconazole exhibits a broad spectrum of in vitro activity against yeasts, dimorphic fungi, and molds. Isavuconazole is available in both oral and intravenous formulations, exhibits a favorable safety profile (notably the absence of QTc prolongation), and reduced drug–drug interactions (relative to voriconazole). Phase 3 studies have evaluated the efficacy of isavuconazole in the management of IA, mucormycosis, and invasive candidiasis. Based on the results of these studies, isavuconazole appears to be a viable treatment option for patients with IA as well as those patients with mucormycosis who are not able to tolerate or fail amphotericin B or posaconazole therapy. In contrast, evidence of isavuconazole for invasive candidiasis (relative to comparator agents such as echinocandins) is not as robust. Therefore, isavuconazole use for invasive candidiasis may initially be reserved as a step-down oral option in those patients who cannot receive other azoles due to tolerability or spectrum of activity limitations. Post-marketing surveillance of isavuconazole will be important to better understand the safety and efficacy of this agent, as well as to better define the need for isavuconazole serum concentration monitoring.
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Affiliation(s)
- Dustin T Wilson
- Department of Pharmacy Practice, Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, USA; Department of Pharmacy, Duke University Hospital, Durham, NC, USA
| | - V Paul Dimondi
- Department of Pharmacy Practice, Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, USA; Department of Pharmacy, Durham VA Medical Center, Durham, NC, USA
| | - Steven W Johnson
- Department of Pharmacy Practice, Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, USA; Department of Pharmacy, Forsyth Medical Center, Winston-Salem, NC, USA
| | - Travis M Jones
- Department of Pharmacy Practice, Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, USA
| | - Richard H Drew
- Department of Pharmacy Practice, Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, USA; Division of Infectious Diseases, Duke University Hospital, Durham, NC, USA
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