Efficacy and safety of itraconazole use in children

Antifungal Selection for the Treatment of Onychomycosis: Patient Considerations and Outcomes

Onychomycosis, a common fungal nail infection, affects >20% of adults over age 60 and >50% of people over age 70. Onychomycosis may cause pain, psychosocial problems, and secondary infections, therefore meriting treatment. This review describes the range of treatment modalities, including FDA-approved systemic drugs and topical therapies. Additionally, new and emerging oral and topical therapies are discussed. We emphasize the importance of tailoring onychomycosis therapy to individual patient characteristics, comorbidities, preferences, extent of nail involvement, and fungal species, such that physicians may optimize treatment outcomes, patient satisfaction, and safety.

Oral drug delivery strategies for development of poorly water soluble drugs in paediatric patient population

Selecting the appropriate formulation and solubility-enabling technology for poorly water soluble drugs is an essential element in the development of formulations for paediatric patients. Different methodologies and structured strategies are available to select a suitable approach and guide formulation scientists for development of adult formulations. However, there is paucity of available literature for selection of technology and overcoming the challenges in paediatric formulation development. The need for flexible dosing, and the limited knowledge of the safety of many formulation excipients in paediatric subjects, impose significant constraints and in some instances require adaptation of the approaches taken to formulating these drugs for the adult population. Selection of the best drug delivery system for paediatrics requires an efficient, systematic approach that considers a drug's physical and chemical properties and the targeted patient population's requirements. This review is a step towards development of a strategy for the design of solubility enhancing paediatric formulations of highly insoluble drugs. The aim of this review is to provide an overview of different approaches and strategies to consider in order to assist development of paediatric formulation for poorly water-soluble drugs with the provision of examples of some marketed products. In addition, it provides recommendations to overcome the range of challenges posed by these strategies and adaptations of the adult approach/product presentation required to enable paediatric drug development and administration.

Onychomycosis in children - review on treatment and management strategies

BACKGROUND

Onychomycosis is an uncommon condition in children with increasing global prevalence. Health practitioners should confirm the diagnosis through mycology examination and examine family members of affected individuals for onychomycosis and tinea pedis.

OBJECTIVE

To comprehensively summarize the treatment and management strategies for pediatric onychomycosis.

METHODS

We performed a comprehensive literature search in the PubMed database to identify clinical studies on treatment for mycologically-confirmed dermatophyte onychomycosis in children <18 years. The exclusion criteria were combination therapy, case reports, reviews, systematic reviews and duplicate studies.

RESULTS

Per-weight dosing regimens of systemic antifungal agents such as terbinafine, itraconazole, and fluconazole are found to be safe in children and are used off-label for the treatment of pediatric onychomycosis with high efficacy. Topical antifungal agents such as ciclopirox, efinaconazole, and tavaborole have established safety and efficacy in children. Children respond better than adults to topical therapy due to their thinner, faster growing nails. There is no data on the efficacy of medical devices for onychomycosis in children.

CONCLUSION

Efinaconazole topical solution 10% and tavaborole topical solution 5% are FDA approved for the treatment of onychomycosis in children ≥6 years; ciclopirox topical solution 8% nail lacquer is approved in children ≥12 years.

Formulation and evaluation of itraconazole liposomes for Hedgehog pathway inhibition

Itraconazole (ITZ) is an FDA-approved antifungal agent that has recently been explored for novel biological properties. In particular, ITZ was identified as a potent inhibitor of the hedgehog (Hh) pathway, a cell signalling pathway that has been linked to a variety of cancers and accounts for ∼25% of paediatric medulloblastoma (MB) cases. To date, there is not a targeted therapeutic option for paediatric MB, resulting in long-term side effects such as hormone deficiency, organ damage and secondary cancers. A primary obstacle for developing targeted therapy for brain ailments is the presence of the blood-brain barrier (BBB), which protects the brain from potentially harmful substances. Due to its size and hydrophobicity, ITZ does not penetrate the BBB. Alternatively, liposomes are being increasingly used within the clinic to increase drug bioavailability, target specificity and BBB permeability. With this in mind, we have successfully developed ITZ-containing liposomes with an optimal size for BBB penetration (<100 nm) and encapsulation efficiency (∼95%) by utilizing a continuous manufacturing approach-turbulent coaxial jet in co-flow. Our preliminary in vitro data demonstrate that these liposomes inhibit the Hh pathway, albeit at a reduced level in comparison to free ITZ. (196/250 words).

Itraconazole Dosing and Drug Monitoring at a Tertiary Children's Hospital

BACKGROUND

Itraconazole is a broad-spectrum antifungal agent used for prophylaxis and treatment of fungal infections in immunocompromised children. Achieving the recommended target serum itraconazole trough concentration of ≥0.5 mg/L is challenging in children because of variation in itraconazole pharmacokinetics with age. We studied itraconazole use and treatment outcomes in a tertiary children's hospital.

METHODS

We did a 10-year retrospective review of medical records of children at the Royal Children's Hospital Melbourne who received oral itraconazole and had therapeutic drug monitoring (TDM).

RESULTS

Overall, 81 children received 92 courses of oral itraconazole and had TDM. Of 222 TDM samples, 183 (82.4%) were taken at the appropriate time (trough level at steady state). Patients ≤12 and >12 years of age required median doses of 6.2 and 3.9 mg/kg/d, respectively, to attain target trough levels (P < 0.001). Of children ≤12 years of age, 71.4% required doses above the recommended dose of 5 mg/kg/d to achieve therapeutic levels, compared with 17.4% of those >12 years of age. At least 1 subtherapeutic trough concentration was reported in 63 (76.8%) courses; in only 18 (28.6%) of these was the dose adjusted. Gastrointestinal symptoms [14/92 (15.2%) courses] and hepatotoxicity [6/92 (6.5%)] were the most frequent adverse events. Neither was associated with elevated trough levels.

CONCLUSIONS

The poor attainment of target levels with current recommended dosing in children <12 years of age suggests that higher empiric doses are needed in this age group. The poor compliance with TDM guidelines highlights the need for better education about appropriate timing of sampling and dose adjustment.

Efficacy and safety of itraconazole use in infants

BACKGROUND

Itraconazole has been used to treat fungal infections, in particular invasive fungal infections in infants or neonates in many countries.

DATA SOURCES

Literature search was conducted through Ovid EMBASE, PubMed, ISI Web of Science, CNKI and Google scholarship using the following key words: "pediatric" or "infant" or "neonate" and "fungal infection" in combination with "itraconazole". Based on the literature and our clinical experience, we outline the administration of itraconazole in infants in order to develop evidence-based pharmacotherapy.

RESULTS

Of 45 articles on the use of itraconazole in infancy, 13 are related to superficial fungal infections including tinea capitis, sporotrichosis, mucosal fungal infections and opportunistic infections. The other 32 articles are related to systemic fungal infections including candidiasis, aspergillosis, histoplasmosis, zygomycosis, trichosporonosis and opportunistic infections as caused by Myceliophthora thermophila.

CONCLUSION

Itraconazole is safe and effective at a dose of 5 mg/kg per day in a short duration of therapy for superficial fungal infections and 10 mg/kg per day for systemic fungal infections in infants. With a good compliance, it is cost-effective in treating infantile fungal infections. The profiles of adverse events induced by itraconazole in infants are similar to those in adults and children.

Repurposing Drugs in Oncology (ReDO)-itraconazole as an anti-cancer agent

Itraconazole, a common triazole anti-fungal drug in widespread clinical use, has evidence of clinical activity that is of interest in oncology. There is evidence that at the clinically relevant doses, itraconazole has potent anti-angiogenic activity, and that it can inhibit the Hedgehog signalling pathway and may also induce autophagic growth arrest. The evidence for these anticancer effects, in vitro, in vivo, and clinical are summarised, and the putative mechanisms of their action outlined. Clinical trials have shown that patients with prostate, lung, and basal cell carcinoma have benefited from treatment with itraconazole, and there are additional reports of activity in leukaemia, ovarian, breast, and pancreatic cancers. Given the evidence presented, a case is made that itraconazole warrants further clinical investigation as an anti- cancer agent. Additionally, based on the properties summarised previously, it is proposed that itraconazole may synergise with a range of other drugs to enhance the anti-cancer effect, and some of these possible combinations are presented in the supplementary materials accompanying this paper.

Antifungal therapy for onychomycosis in children

Onychomycosis is a chronic infection of the nail unit, and its prevalence increases with age. Treatment options for children are similar to those for adults and include both oral and topical therapies. Oral agents, such as terbinafine, itraconazole, and fluconazole have been reported to have good efficacy and a low rate of side effects in children. Topical therapies, such as amorolfine and ciclopirox, can also be used as monotherapy or combined with oral agents to treat onychomycosis. Due to their thinner, faster-growing nails, children are more likely to respond to topical monotherapy than adults. There is currently insufficient data comparing emerging medical devices, such as laser therapy, with standard therapeutic options to recommend their use in children.

Diagnosis and management of nail disorders in children

The authors herein describe several nail conditions, which the general pediatrician is likely to encounter in the course of routine practice. Because pediatric nail disorders represent a limited component of a general pediatric practice, it can be challenging for practitioners to establish expertise in the diagnosis and treatment of these conditions and to recognize when reassurance is appropriate or when referral to a specialist is necessary. This article summarizes the anatomy of the normal nail unit, as well as the evaluation and management of onychomycosis, melanonychia, trachyonychia, onychomadesis, and nail pitting.

Antifungal therapy in children: an update

Invasive fungal infections are a common problem in children affected by primary or secondary immunodeficiencies. Thanks to an increased knowledge about their mechanisms of action and their pharmacokinetic and toxicity profiles, the use of these drugs in common and uncommon invasive infections in immunocompromised children has improved over the last decades. Choosing the most appropriate antifungal drug is a serious challenge for any clinician, also considering that, in most cases, therapy has to be started before cultures are available, the choice being driven by clinical symptoms and statistical criteria only. In this study, we performed a systematic review of literature, providing antifungal treatment recommendations for paediatric patients which can help clinicians find the most suitable treatment for each specific case. Principal antifungal drugs-ranging from first-generation antimycotics to the latest molecules-are classified according to their targets, and of each group, the pharmacokinetic profile, clinical indications and side effects are extensively described.

Itraconazole treatment of nonmeningeal coccidioidomycosis in children: two case reports and review of the literature

Coccidioides immitis causes a wide range of disease in humans. Fluconazole and itraconazole are effective treatments. Clinical evidence suggests that itraconazole is equivalent or superior to fluconazole in treating osteoarticular infections in rates of cure and recurrence. We report 2 cases of coccidioidomycosis involving bone in children successfully treated with itraconazole oral solution. Itraconazole oral solution is effective in treating nonmeningeal coccidioidomycosis in children, particularly skeletal disease, and infections that are refractory to fluconazole.

Tinea capitis in early infancy treated with itraconazole: a pilot study

BACKGROUND

Tinea capitis is the most common fungal infection of the scalp in childhood, but a very rare disorder in the first year of life.

OBJECTIVE

To evaluate the efficacy, tolerability and safety of itraconazole in 7 children aged between 3 and 46 weeks (median: 36 weeks) suffering from tinea capitis caused by Microsporum canis.

METHODS

Prospective case note study. In all patients KOH testing and fungal cultivation on Sabouraud dextrose agar were performed.

RESULTS

7 patients (5 girls and 2 boys) were included in the period between 2001 and 2008. The causative etiologic agent was Microsporum canis in all children. The patients received itraconazole 5mg/kg bodyweight daily for 3 to 6 weeks with no clinically side effects being noted. In all patients clinical and mycological cure could be achieved.

CONCLUSION

Itraconazole proved to be a safe and effective treatment option for Microsporum canis induced tinea capitis in children in their first year of life.

Dermatophytosis: the management of fungal infections

Dermatophytosis is an infection of the hair, skin, or nails caused by a dermatophyte, which is most commonly of the Trichophyton genus and less commonly of the Microsporum or Epidermophyton genera. Tinea capitis, tinea pedis, and onychomycosis are common dermatologic diseases that may result from such an infection. The treatment of fungal infections caused by a dermatophyte has been successful when treated with oral or topical antifungal agents. Terbinafine, itraconazole, and fluconazole are oral antimycotics that are effective in the treatment of superficial mycoses, although, depending on the severity of the infection, a topical antifungal may be sufficient.

[Epidemic of Trichophyton tonsurans tinea capitis in a nursery school in the Southern suburbs of Paris]

INTRODUCTION

In March 2001 a school and family survey was conducted in a nursery school in the Southern suburbs of Paris, during an epidemic of Trichophyton tondsurans tinea.

PATIENTS AND METHODS

One hundred twenty-nine children aged 3 to 6 were examined as well as 15 adults working in the school. A survey of the contaminated children or asymptomatic carriers was performed. All the children and adults concerned were treated at the same time, without eviction from school.

RESULTS

T. tonsurans was detected in 10 cases of tinea (7.7 p.cent of the persons examined), in 18 cases of cutaneous lesions (13.9 p.cent) and in 25 asymptomatic carriers on the scalp (19.4 p.cent). The majority of the positive cases came from the same school class as the original case: 23 of the 26 children (88 p.cent), with 6 tinea, 14 asymptomatic carriers and 13 cutaneous lesions. Only one of the 15 adults exhibited a T. tonsurans cutaneous lesion. Among the 13 families studied, 2 had several members involved, the first being that of the original case (3 tinea and 2 asymptomatic carriers).

DISCUSSION

Several important points are underlined by this study: 1) the high contagiousness of T. tonsurans; 2) the detection of 2 mechanisms of indirect contamination (rag doll mascot in the class and the family hair-clipper); 3) the one-year time lapse between the arrival of the contaminating child in the class and the survey, explaining the extent of the contamination; 4) the underestimation of the epidemic due to the lack of mycological examinations; 5) the identification of several dermatophytes in the same school:M. canis, T soudanense and T. tonsurans, and 7) the futility of eviction from school when all the children can be treated.

Optimal management of fungal infections of the skin, hair, and nails

Superficial fungal infections are chronic and recurring conditions. Tinea capitis is a scalp infection, primarily affecting prepubescent children. Ringworm infections, such as tinea corporis and tinea cruris, involve the glabrous skin. Tinea nigra is a rare mycotic infection that may be related to travel abroad. Piedra, black or white, is limited to the hair shaft without involvement of the adjacent skin. Pityriasis (tinea) versicolor and seborrheic dermatitis are dermatoses associated with yeasts of the genus Malassezia that affect the lipid-rich areas of the body. The taxonomy of the Malassezia yeasts has been revised to include nine species, eight of which have been recovered from humans. Tinea pedis, an infection of the feet and toes, is one of the most common forms of dermatophytosis. Onychomycosis is a fungal infection affecting the nail bed and nail plate; it may be chronic and can be difficult to treat. In instances where the superficial fungal infection is severe or chronic, an oral antifungal agent should be considered. Terbinafine, itraconazole, and fluconazole are oral antifungals that are effective in the treatment of superficial mycoses.

Superficial fungal infections: an update on pityriasis versicolor, seborrheic dermatitis, tinea capitis, and onychomycosis

The recent advances in pityriasis versicolor, seborrheic dermatitis, tinea capitis and onychomycosis are reviewed. Some highlighted points include the new classification of Malassezia species, and the association of Malassezia species with seborrheic dermatitis. The use of terbinafine, fluconazole, and itraconazole for the treatment of tinea capitis is discussed. The management of onychomycosis, highlighting the high efficacy rates obtained with terbinafine when used to treat dermatophyte toenail onychomycosis, is discussed. The use of combination therapies in some circumstances to maximize cure rates is reviewed.