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Chandasana H, Hayes S, Buchanan AM, Brothers C, Wiznia A, Bartlett M, Popson S, Townley E, George K, Vavro C, Ruel T, Acosta EP, Singh R. Bridging dolutegravir clinical viral response across doses and formulations using model-based exposure-response analysis in pediatrics. AIDS 2024; 38:F11-F18. [PMID: 38768443 DOI: 10.1097/qad.0000000000003929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
OBJECTIVE Dolutegravir (DTG) is a once-daily HIV-1 integrase inhibitor approved for the treatment of HIV-1 infection in adults and children from 4 weeks of age. The posology of DTG in children has been driven by exposure-matching relative to the adult dose for efficacy and safety. However, higher variability in pediatric exposures raises concern that efficacy may not be reliably extrapolated from adult trials. Therefore, we evaluated the relationship between DTG exposure and virologic response in children. DESIGN/METHODS A population exposure-response analysis using logistic regression for virologic response was undertaken based on DTG exposure and covariate data from 146 pediatric participants with HIV-1 from age at least 4 weeks to less than 18 years treated for up to 48 weeks with DTG in IMPAACT P1093 study. RESULTS None of the DTG exposure metrics were predictive of virologic response over the range of exposures in this analysis. Of the covariates tested, viral load at least 100 000 copies/ml at enrolment was a significant predictor of virologic response showing a lower probability of achieving a virologic response of HIV-1 RNA less than 50 copies/ml compared with participants with viral load less than 100 000 copies/ml at enrolment. Baseline viral load was also a significant predictor at week 48 whereby the probability of achieving a virologic response at week 48 decreased with increasing baseline viral load. CONCLUSION This exposure-response analysis suggests that DTG exposures in children are all above the plateau of the exposure-response relationship. These results suggest that matching pediatric pharmacokinetic exposure parameters to those in adults is a reasonable approach for dose determination of DTG-containing formulations in pediatrics.
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Affiliation(s)
- Hardik Chandasana
- Clinical Pharmacology Modeling & Simulation, GSK, Collegeville, Pennsylvania, USA
| | | | | | | | - Andrew Wiznia
- Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | | | | | - Ellen Townley
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | | | | | - Theodore Ruel
- University of California, San Francisco, San Francisco, CA
| | - Edward P Acosta
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rajendra Singh
- Clinical Pharmacology Modeling & Simulation, GSK, Collegeville, Pennsylvania, USA
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Weerdenburg H, Walker H, Curtis N, Duffull S, Haeusler G, Cole T, Gwee A. Posaconazole in paediatric malignancy and haematopoietic stem cell transplant: dosing to achieve therapeutic concentration. J Antimicrob Chemother 2024; 79:1493-1507. [PMID: 38637310 DOI: 10.1093/jac/dkae099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/05/2024] [Indexed: 04/20/2024] Open
Abstract
OBJECTIVES Posaconazole is increasingly used for the treatment and prophylaxis of invasive fungal infections in immunocompromised children. We aimed to review evidence for paediatric posaconazole dosing regimens focusing on attainment of target concentrations and frequency of adverse effects. METHODS In May 2023, the Cochrane, Embase, MEDLINE and PubMed databases were searched for articles reporting posaconazole dosing in children with malignancy or post-haematopoietic stem cell transplantation. Studies reporting the attainment of target serum concentrations were included. RESULTS Overall, 24 studies were included. Eighteen studies of the oral suspension consistently reported poor attainment of target concentrations for prophylaxis (≥0.7 µg/mL, 12%-78%) despite high daily doses of 14-23 mg/kg/day (max. 1200 mg/day). Target attainment was significantly affected by gastric pH and food intake. Six studies of the delayed-release tablet (DRT) reported 58%-94% achieved concentrations ≥0.7 µg/mL, with the majority using lower doses of 4-12 mg/kg/day (max. 300 mg/day). Similarly, one study of powder for oral suspension found 67%-100% achieved target concentrations with a dose of 6 mg/kg/day (max. 300 mg/day). As expected, the IV formulation had high attainment of prophylaxis targets (81%-90%) with 6-10 mg/kg/day (max. 400 mg/day). All formulations were well tolerated, and no relationship between adverse effects and posaconazole concentrations was identified. CONCLUSIONS The required posaconazole dose in immunocompromised children varies depending on the formulation. The IV infusion had the highest attainment of therapeutic concentration followed by the DRT and powder for suspension. By contrast, the oral suspension had low attainment of target concentrations despite higher daily doses.
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Affiliation(s)
- Heather Weerdenburg
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Hannah Walker
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nigel Curtis
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Gabrielle Haeusler
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- The Victorian Paediatric Integrated Cancer Service, Victoria State Government, Melbourne, Victoria, Australia
| | - Theresa Cole
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Amanda Gwee
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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Portillo V, Neofytos D. An Update on Breakthrough Invasive Mold Infections. Mycopathologia 2024; 189:56. [PMID: 38869662 PMCID: PMC11176211 DOI: 10.1007/s11046-024-00864-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 05/21/2024] [Indexed: 06/14/2024]
Abstract
The incidence of breakthrough mold infections (bIMI) has been increasing, due to routine administration of broad-spectrum antifungal prophylaxis and an increasing pool of high-risk patient populations, with fungi more challenging to treat, resulting in a sustained high mortality, despite progress in diagnostic and therapeutic options. Pharmacokinetics of antifungal drugs, fungal, and host, including genetic, factors play a role in the emergence of bIMI. Suggested therapeutic approaches have included change of antifungal class treatment, with amphotericin-B products predominating as first-line empirical treatment and switching from one broad-spectrum azole to another remaining the most frequently used treatment modalities. Future perspectives include determining individual susceptibility to IMI to tailor prophylaxis and treatment strategies, improved diagnostic tests, and the introduction of new antifungal agents that may reduce morbidity and mortality caused by bIMI.
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Affiliation(s)
- Vera Portillo
- Division of Infectious Diseases, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland.
- Internal Medecine, Ensemble Hospitalier de la Côte, Hôpital de Moges, Chemin de la Crêt 2, Morges, Vaud, Switzerland.
| | - Dionysios Neofytos
- Division of Infectious Diseases, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland.
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4
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Muehlberg L, Pabst T, Largiadèr C, Aebi Y, Hayoz M, Muehlethaler K, Zimmerli S, Hirzel C. Evaluation of Posaconazole Serum Concentrations Achieved With Delayed-release Tablets and Oral Suspension in Patients Undergoing Intensive Chemotherapy for Acute Myeloid Leukemia and Myelodysplastic Syndrome. Open Forum Infect Dis 2024; 11:ofae263. [PMID: 38798896 PMCID: PMC11127630 DOI: 10.1093/ofid/ofae263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/03/2024] [Indexed: 05/29/2024] Open
Abstract
Data on posaconazole serum levels of patients on prophylaxis with delayed-release tablets or oral suspension during intensive chemotherapy for acute myeloid leukemia and myelodysplastic syndrome are scarce. In this analysis, the proportion of patients with acute myeloid leukemia/myelodysplastic syndrome achieving posaconazole target concentrations with delayed-release tablets was higher than with oral suspension.
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Affiliation(s)
- Leonora Muehlberg
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Carlo Largiadèr
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Yolanda Aebi
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Michael Hayoz
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Konrad Muehlethaler
- Department of Clinical Microbiology, Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Stefan Zimmerli
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Cédric Hirzel
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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5
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Jansen AME, Snijdelaar K, Keizer RJ, Spriet I, Dreesen E, Brüggemann RJM, Ter Heine R. Personalized Antifungal Therapy Through Model-Informed Precision Dosing of Posaconazole. Clin Pharmacokinet 2024; 63:645-656. [PMID: 38532053 PMCID: PMC11106146 DOI: 10.1007/s40262-024-01361-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND AND OBJECTIVE Posaconazole is a pharmacotherapeutic pillar for prophylaxis and treatment of invasive fungal diseases. Dose individualization is of utmost importance as achieving adequate antifungal exposure is associated with improved outcome. This study aimed to select and evaluate a model-informed precision dosing strategy for posaconazole. METHODS Available population pharmacokinetic models for posaconazole administered as a solid oral tablet were extracted from the literature and evaluated using data from a previously published prospective study combined with data collected during routine clinical practice. External evaluation and selection of the most accurate and precise model was based on graphical goodness-of-fit and predictive performance. Measures for bias and imprecision included mean percentage error (MPE) and normalized relative root mean squared error (NRMSE), respectively. Subsequently, the best-performing model was evaluated for its a posteriori fit-for-purpose and its suitability in a limited sampling strategy. RESULTS Seven posaconazole models were evaluated using 764 posaconazole plasma concentrations from 143 patients. Multiple models showed adequate predictive performance illustrated by acceptable goodness-of-fit and MPE and NRMSE below ± 10% and ± 25%, respectively. In the fit-for-purpose analysis, the selected model showed adequate a posteriori predictive performance. Bias and imprecision were lowest in the presence of two prior measurements. Additionally, this model showed to be useful in a limited sampling strategy as it adequately predicted total posaconazole exposure from one (non-)trough concentration. CONCLUSION We validated an MIPD strategy for posaconazole for its fit-for-purpose. Thereby, this study is an important first step towards MIPD-supported posaconazole dosage optimization with the goal to improve antifungal treatment in clinical practice.
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Affiliation(s)
- Anouk M E Jansen
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Medical Innovation, Nijmegen, The Netherlands.
- Center of Expertise in Mycology, Radboud University Medical Center/Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands.
| | - Kim Snijdelaar
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Medical Innovation, Nijmegen, The Netherlands
| | | | - Isabel Spriet
- Department of Pharmacy, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Erwin Dreesen
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Roger J M Brüggemann
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Medical Innovation, Nijmegen, The Netherlands
- Center of Expertise in Mycology, Radboud University Medical Center/Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Medical Innovation, Nijmegen, The Netherlands
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Sugimoto M, Yonezawa A, Kanda J, Itohara K, Hira D, Yamagiwa T, Taniguchi R, Hanyu Y, Watanabe M, Arai Y, Mizumoto C, Kitawaki T, Kondo T, Yamashita K, Takaori-Kondo A, Terada T. Population Pharmacokinetic Modeling of Posaconazole in Japanese Patients Receiving Fungal Prophylaxis. Ther Drug Monit 2024:00007691-990000000-00207. [PMID: 38648638 DOI: 10.1097/ftd.0000000000001198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 01/26/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Posaconazole is a vital drug to treat and prevent invasive fungal infections. Several factors, such as sex, body weight, total serum proteins, dietary intake, and severe mucositis, affect posaconazole pharmacokinetics (PKs). However, the relevance of other factors that affect the PKs of posaconazole in hematopoietic stem cell transplantation (HSCT) is unknown. This study explored factors influencing the PKs of posaconazole in HSCT recipients and nontransplant patients with hematological diseases. METHODS The authors conducted a single-institution, retrospective study. Forty-two Japanese inpatients receiving oral posaconazole tablets as prophylaxis for fungal infections were enrolled in this study. A one-compartment model with first-order absorption was used as the structural pharmacokinetic model. A population PK (PopPK) analysis was performed using a nonlinear mixed-effects modeling program, using a first-order conditional estimation method with interactions. Perl-speaks-NONMEM and R were used to evaluate the goodness of fit and visualize the output. RESULTS In 29% of the enrolled patients, the serum concentration of posaconazole was <0.5 mcg/mL, considered the effective range. PopPK analysis revealed that the patient had undergone HSCT within 1 year, diarrhea occurred more than 5 times a day, and aspartate aminotransferase were covariates that influenced apparent clearance (CL/F). The CL/F of posaconazole was 1.43-fold higher after HSCT and 1.26-fold higher during diarrhea. CONCLUSIONS PopPK analysis revealed that HSCT, diarrhea, and aspartate aminotransferase were factors associated with the CL/F of posaconazole. The trough concentration of posaconazole may be below the therapeutic range in a few patients with diarrhea and/or after HSCT. As invasive fungal infections in patients with hematologic diseases can be life-threatening, therapeutic drug monitoring of posaconazole is strongly recommended, and patients should be carefully monitored.
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Affiliation(s)
- Mitsuhiro Sugimoto
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
- Division of Integrative Clinical Pharmacology, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Kotaro Itohara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Daiki Hira
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Takeo Yamagiwa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Risa Taniguchi
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Yuta Hanyu
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Mizuki Watanabe
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Chisaki Mizumoto
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Toshio Kitawaki
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kouhei Yamashita
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Tomohiro Terada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
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7
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Yamada T, Belabbas T, Suetsugu K, Hirota T, Mori Y, Kato K, Akashi K, Egashira N, Ieiri I. Factors Influencing Serum Posaconazole Concentrations in Patients with Hematologic Malignancies Receiving Delayed-Release Tablets. Ther Drug Monit 2024:00007691-990000000-00205. [PMID: 38648660 DOI: 10.1097/ftd.0000000000001196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/30/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Posaconazole (PCZ) plays a crucial role in the prophylaxis and treatment of invasive fungal infections in hematologic malignancies. PCZ concentrations reportedly vary among patients receiving delayed-release tablets (DRT). However, the factors influencing these concentrations remain insufficiently elucidated. Therefore, this study aimed to evaluate the factors influencing PCZ concentrations and their effect on the probability of target attainment (PTA) using a population pharmacokinetic (PPK) approach. We also explored the relationship between PCZ exposure and hepatotoxicity. METHODS This retrospective study included adult patients with hematologic malignancies who received PCZ DRT. A PPK model was developed based on observational data for 130 concentrations in 28 patients. Simulation analyses were performed to assess the PTA at standard doses of 0.7 and 1.0 mg/L for prophylaxis and treatment, respectively. Estimated concentrations were used to evaluate the correlation between PCZ exposure and hepatotoxicity. RESULTS Significant factors influencing PCZ concentrations included body weight, serum total protein levels, and diarrhea. Diarrhea correlated with decreased PCZ concentrations resulting in up to 26% lower PTA compared with that without diarrhea. Moreover, PTA declined markedly as the total protein levels decreased from 6.6 g/dL to 4.4 g/dL. The incidence of hepatotoxicity was 17.4% (4/23); no significant relationship could be established between the PCZ concentrations and hepatotoxicity (P = 0.188). CONCLUSIONS We identified the factors affecting PCZ exposure, which could not be detected by PPK analysis using data from clinical trials. Our results suggest that the generally recommended dose of PCZ causes underexposure in patients with hematologic malignancies characterized by high body weight, hypoproteinemia, or concurrent diarrhea. Therapeutic drug monitoring for DRT may be recommended, especially in patients with these risk factors.
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Affiliation(s)
- Takaaki Yamada
- Department of Pharmacy, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
- Department of Clinical Pharmacology and Therapeutics, School of Pharmaceutical Sciences, Wakayama Medical University, Wakayama-shi, Wakayama, Japan
| | - Tassadit Belabbas
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan; and
| | - Kimitaka Suetsugu
- Department of Pharmacy, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
| | - Takeshi Hirota
- Department of Pharmacy, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan; and
| | - Yasuo Mori
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Koji Kato
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Nobuaki Egashira
- Department of Pharmacy, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
- Department of Clinical Pharmacology and Therapeutics, School of Pharmaceutical Sciences, Wakayama Medical University, Wakayama-shi, Wakayama, Japan
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan; and
| | - Ichiro Ieiri
- Department of Pharmacy, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan; and
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8
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Winchell G, de Greef R, Ouerdani A, Fauchet F, Wrishko RE, Mangin E, Bruno C, Waskin H. A population pharmacokinetic model for posaconazole intravenous solution and oral powder for suspension formulations in pediatric patients with neutropenia. Antimicrob Agents Chemother 2024; 68:e0119723. [PMID: 38376229 PMCID: PMC10994819 DOI: 10.1128/aac.01197-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/15/2023] [Indexed: 02/21/2024] Open
Abstract
The objective of this study was to support posaconazole dose regimens in pediatric patients aged ≥2 years, using a population pharmacokinetic (PK) approach with data from a phase 1b study (NCT02452034). A one-compartment model with first-order absorption was fit to pharmacokinetic data from 144 participants aged 2 to 17 years, who were administered posaconazole as intravenous (IV) and powder for oral suspension (PFS) formulations, or IV only, at dosing regimens of 3.5, 4.5, and 6 mg/kg. The influence of demographic and clinical factors on pharmacokinetic parameters was evaluated using a stepwise forward inclusion/backward exclusion procedure. The final model simulated posaconazole exposure in patients aged 2 to <7 and 7 to 17 years at dosing regimens of 4.5, 6, and 7.5 mg/kg. Plasma concentration data following IV and PFS administration were well-described by a one-compartment model with first-order absorption and estimated bioavailability, where clearance and volume were subject to allometric scaling by body weight. The 6-mg/kg dosing regimen achieved the pharmacokinetic target (90% of the pediatric population having an average steady-state plasma concentration of ≥500 and <2,000 ng/mL) for both age groups, regardless of whether patients received IV and PFS or IV only. In a virtual adolescent population (body weight >40 kg), the 300 mg/day posaconazole tablet was also predicted to achieve the pharmacokinetic target and remain within a safe range of exposure. These data informed a weight-based nomogram for PFS dosing to maximize the number of pediatric patients achieving the pharmacokinetic target across weight bands, while also maintaining a favorable benefit/risk profile.
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9
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Boppana M, Sengar M, Jain H, Gurjar M, Ambotkar M, Gota V, Bonda A, Bagal B, Thorat J, Gokarn A, Nayak L, Shetty N, Baheti A, Mokal S, Kannan S, Shetty A, Eipe T. A Prospective Study to Evaluate the Effect of Therapeutic Drug Monitoring-Based Posaconazole Prophylaxis on Invasive Fungal Infection Rate During Acute Myeloid Leukemia Induction Therapy. Indian J Hematol Blood Transfus 2024; 40:204-212. [PMID: 38708158 PMCID: PMC11065854 DOI: 10.1007/s12288-023-01709-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 10/04/2023] [Indexed: 05/07/2024] Open
Abstract
Invasive fungal infections (IFIs) are a significant cause of morbidity and mortality in de-novo acute myeloid leukemia patients receiving induction chemotherapy. Despite using posaconazole, a broad-spectrum antifungal, for IFI prophylaxis, the breakthrough IFI rate is high in the real-world setting. One of the reasons could be frequent suboptimal plasma posaconazole levels. In the present study, we evaluated if therapeutic drug monitoring (TDM) guided posaconazole prophylaxis can reduce the IFI rates in comparison to a historical cohort. We enrolled 90 patients, > / = 16 years of age, without baseline IFIs, planned for remission induction therapy. All patients were started on posaconazole suspension 200 mg TDS and the dose was increased in a stepwise manner if trough levels were found to be suboptimal (< 350 ng/ml for day 2 or < 700 ng/ml subsequently). The TDM based approach resulted in a significant decline in breakthrough IFI rates (18% versus 52%, P < 0.0001) A total of 69 patients (78%) required dose escalation. Thirty-one patients required change in antifungals due to either suboptimal levels, persistent fever, diarrhoea or vomiting. We could not demonstrate an exposure-response relationship but the difference in IFI rates in patients with a median posaconazole level > / = 700 ng/ml (0%) and < 700 ng/ml (21.6%) was clinically meaningful. Posaconazole levels were found to be significantly lower in patients on antacids and prokinetics. The incidence of posaconazole-related grade 3 toxicity was low (2.3%). Thus TDM-based dosing of posaconazole helps reduce breakthrough IFI rate and should be a part of posaconazole prophylaxis. Supplementary Information The online version contains supplementary material available at 10.1007/s12288-023-01709-3.
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Affiliation(s)
- Mounika Boppana
- Department of Medical Oncology, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
- Present Address: Department of Medical Oncology, Krishna Institute of Medical Sciences, Minister Road, Secunderabad, Telangana 500003, India
| | - Manju Sengar
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National University, Earnest Borges Road, Parel, Mumbai 400012 India
| | - Hasmukh Jain
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Murari Gurjar
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Madhavi Ambotkar
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Vikram Gota
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Avinash Bonda
- Department of Medical Oncology, Asian Institute of Gastroenterology (AIG) Hospitals, Mindspace Road, P Janardhan Reddy Nagar, Gachibowli, Hyderabad, Telangana 500032, India
| | - Bhausaheb Bagal
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Jayashree Thorat
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Anant Gokarn
- Adult Hematolymphoid Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Lingaraj Nayak
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Nitin Shetty
- Department of Radiodiagnosis, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Akshay Baheti
- Department of Radiodiagnosis, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Smruti Mokal
- Clinical Research Secretariat, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Sadhana Kannan
- Clinical Research Secretariat, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Alok Shetty
- Department of Medical Oncology, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Thomas Eipe
- Department of Medical Oncology, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
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10
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Fumarola B, Signorini L, Lorenzotti S, Lanza P, Saccani B, Van Hauwermeiren E, Mulè A, Piva S, Rota M, Zuccalà F, Rasulo FA, Filippini M, Bertazzoli A, Del Fabro G, Matteelli A. Use of nebulized liposomal amphotericin B and posaconazole as antifungal prophylaxis in patients with severe SARS-CoV2 infection in intensive care unit. Infection 2024:10.1007/s15010-024-02234-9. [PMID: 38530518 DOI: 10.1007/s15010-024-02234-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/12/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE COVID-19 associated pulmonary aspergillosis (CAPA) is common and linked with high fatality rates. To assess the impact on the incidence and outcome of CAPA of an antifungal prophylaxis (AFP) we compared two cohorts of COVID-19 patients admitted to intensive care units (ICU) in Brescia, Italy, from January to August 2021. METHODS The study cohort included all mechanically ventilated patients observed between April 2021 and August 2021 with SARS-CoV-2-pneumonia, who received AFP with oral posaconazole (200 mg every 6 h) and nebulized liposomal amphotericin B (50 mg every 2 weeks) from ICU admission to 7 days after discharge or, if applicable, until tracheostomy removal. The control cohort included COVID-19 patients admitted to the same ICU between January and March 2021 who did not receive any AFP. Subjects with CAPA at ICU admission were excluded. RESULTS We included 270 patients, of whom 64 (23.7%) received AFP. In patients in the study group, CAPA-related mortality was significantly reduced (29% vs. 48% p = 0.04), as well as the incidence of CAPA (3.1% vs 12.1%, p = 0.03). Patients who developed CAPA were older (mean of 70-y-old vs 63-y-old, p < 0.001). One subject discontinued posaconazole due to an adverse reaction. Among the 46 patients who received it, only one patient reached an effective plasma concentration of posaconazole. CONCLUSION AFP was associated with reduced incidence and mortality from CAPA and was well tolerated in patients with severe COVID-19. Posaconazole concentrations below the efficacy threshold in almost all patients may be attributable to drug interactions and prompt further studies to define its clinical significance.
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Affiliation(s)
| | - Liana Signorini
- Clinic of Infectious Diseases, ASST Spedali Civili, Brescia, Italy
| | | | - Paola Lanza
- Clinic of Infectious Diseases, ASST Spedali Civili, Brescia, Italy
| | - Barbara Saccani
- Clinic of Infectious Diseases, ASST Spedali Civili, Brescia, Italy
| | | | - Alice Mulè
- Clinic of Infectious Diseases, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Medicine, University of Brescia, Brescia, Italy
| | - Simone Piva
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Matteo Rota
- Department of Molecular and Translational Medicine, Università degli Studi di Brescia, Brescia, Italy
| | - Francesco Zuccalà
- Department of Anesthesia and Intensive Care, Spedali Civili Hospital, Brescia, Italy
| | - Francesco Antonio Rasulo
- Intensive Care and Anesthesiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia and Spedali Civili Hospital, Brescia, Italy
| | - Matteo Filippini
- Intensive Care and Anesthesiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia and Spedali Civili Hospital, Brescia, Italy
| | - Alberto Bertazzoli
- Department of Anesthesia and Intensive Care, Spedali Civili Hospital, Brescia, Italy
| | - Giovanni Del Fabro
- Department of Infectious Diseases, ASFO "Santa Maria Degli Angeli" Hospital of Pordenone, Pordenone, Italy
| | - Alberto Matteelli
- Clinic of Infectious Diseases, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Medicine, University of Brescia, Brescia, Italy
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11
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Wang L, Gao L, Liang Z, Cen X, Ren H, Dong Y. Efficacy and safety of coadministration of venetoclax and anti-fungal agents under therapeutic drug monitor in unfit acute myeloid leukemia and high-risk myelodysplastic syndrome with neutropenia: a single-center retrospective study. Leuk Lymphoma 2024; 65:353-362. [PMID: 38069781 DOI: 10.1080/10428194.2023.2290465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/28/2023] [Indexed: 02/15/2024]
Abstract
Unfit acute myeloid leukemia and high-risk myelodysplastic syndrome patients with prolonged neutropenia demand coadministration of venetoclax and azoles. However, venetoclax dosing under drug-drug interaction with azoles remains controversial. Therapeutic drug monitoring (TDM) is expected to guide drug dosage adjustments. We retrospectively enrolled 17 patients under this coadministration and TDM. Venetoclax dosages were interfered when inappropriate drug concentrations appeared. The primary endpoints were objective response and adverse events. Venetoclax concentration outliers were more frequently evaluated before than after dose adjustment (Cmax 60.87% vs. 0.00%, p < .0001). MRD negativity rate was higher in patients staying within reference range than those having outliers (90.91% vs. 33.33%, p = .028). Objective response rate was 100%. Hematologic adverse events included neutropenia (93.3%), febrile neutropenia (53.3%), and thrombocytopenia (81.3%). Median time to neutropenia and thrombocytopenia recovery was 20 (14-32) and 16.5 (6-34) days, respectively. No invasive fungal and other life-threatening infections were observed.
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Affiliation(s)
- Lihong Wang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Liang Gao
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Zeyin Liang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Xinan Cen
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Hanyun Ren
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Yujun Dong
- Department of Hematology, Peking University First Hospital, Beijing, China
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12
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Selby PR, Heffernan AJ, Yeung D, Warner MS, Peake SL, Hahn U, Westley I, Shakib S, Roberts JA. Population pharmacokinetics of posaconazole in allogeneic haematopoietic stem cell transplant patients. J Antimicrob Chemother 2024; 79:567-577. [PMID: 38217845 DOI: 10.1093/jac/dkae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/02/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Invasive fungal disease (IFD) in the early post-allogeneic HSCT (alloHCT) period is associated with increased likelihood of catastrophic outcomes. The utility of oral modified release (MR) posaconazole tablets is limited by reduced drug absorption from gastrointestinal toxicity induced by cytotoxic chemotherapy, necessitating a switch to the IV posaconazole formulation. OBJECTIVES To describe the population pharmacokinetics of posaconazole for oral MR and IV formulations in alloHCT patients and determine dosing regimens likely to achieve therapeutic exposures. METHODS We performed a prospective observational pharmacokinetic study in adult patients in the early post-alloHCT period requiring a change in posaconazole formulation (oral to IV). Samples were analysed using a validated LC-MS/MS method. Population pharmacokinetic analysis and Monte Carlo simulations (n = 1000) were performed using Pmetrics for R. RESULTS Twenty patients aged between 21 and 70 years were included in the study. A two-compartment model, incorporating mucositis/diarrhoea to modify the bioavailability for oral administration best described the data. To achieve ≥90% PTA, simulations showed that higher than currently recommended doses of oral MR posaconazole were required for prophylaxis Cmin targets (≥0.5 and ≥0.7 mg/L), while increased doses of both formulations were required for IFD treatment PK/PD targets, with patients experiencing oral mucositis/diarrhoea unlikely to achieve these. CONCLUSIONS Increased doses of posaconazole should be considered for both prophylaxis and treatment of IFD to increase the proportion of alloHCT patients achieving therapeutic exposures, particularly the oral formulation in patients with mucositis and/or diarrhoea. Posaconazole therapeutic drug monitoring should be considered for all formulations in this setting.
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Affiliation(s)
- Philip R Selby
- School of Medicine, Discipline of Pharmacology, University of Adelaide, Adelaide, Australia
- Pharmacy Department, Royal Adelaide Hospital, Port Road, Adelaide, Australia
| | - Aaron J Heffernan
- School of Medicine and Dentistry, Griffith University, Gold Coast, Australia
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - David Yeung
- School of Medicine, Discipline of Pharmacology, University of Adelaide, Adelaide, Australia
- SA Pathology, Adelaide, Australia
- Haematology Unit, Royal Adelaide Hospital, Adelaide, Australia
- Cancer Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Morgyn S Warner
- School of Medicine, Discipline of Pharmacology, University of Adelaide, Adelaide, Australia
- SA Pathology, Adelaide, Australia
- Infectious Diseases Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Sandra L Peake
- School of Medicine, Discipline of Pharmacology, University of Adelaide, Adelaide, Australia
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Uwe Hahn
- School of Medicine, Discipline of Pharmacology, University of Adelaide, Adelaide, Australia
- SA Pathology, Adelaide, Australia
- Haematology Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Ian Westley
- SA Pathology, Adelaide, Australia
- School of Pharmacy and Biomedical Sciences, University of South Australia, Adelaide, Australia
| | - Sepehr Shakib
- School of Medicine, Discipline of Pharmacology, University of Adelaide, Adelaide, Australia
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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13
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Körholz K, Holterhus M, Gordon K, Müller-Ohrem C, Müller C, Groll AH. Cerebrospinal fluid concentrations of posaconazole in paediatric leukaemia patients. J Antimicrob Chemother 2024; 79:564-566. [PMID: 38198576 DOI: 10.1093/jac/dkae005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/02/2024] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Little is known about the distribution of posaconazole in brain tissue and CSF. We therefore analysed trough concentrations of posaconazole in paediatric leukaemia patients in non-inflamed CSF. PATIENTS AND METHODS The study included paediatric patients <18 years of age with acute leukaemia in remission who underwent repeat therapeutic lumbar punctures as part of their anti-leukaemia treatment. CSF and blood were obtained 20-24 h after dosing, and posaconazole was measured by LC-MS/MS. RESULTS Six patients (median age: 10 years; range, 6-14) with acute lymphatic (three) or acute myeloid (three) leukaemia were included who received posaconazole gastroresistant tablets at weight-banded doses (five) or the oral solution (one). In contrast to 14 control samples, posaconazole was detectable in all 11 samples of treated patients. CSF concentrations ranged from 8.3 to 42 ng/mL with a median CSF concentration of 13.6 ng/mL. Concurrent serum concentrations were between 965 and 5177 ng/mL with a median of 1716 ng/mL. CONCLUSIONS Trough concentrations of posaconazole in the CSF after systemic administration were low but detectable in all subjects. Concurrent serum concentrations were in the target range for prophylaxis and treatment in 100% and 90%, respectively.
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Affiliation(s)
- Katharina Körholz
- Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, Infectious Disease Research Program, University Children´s Hospital Münster, Münster, Germany
| | - Malcolm Holterhus
- Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, Infectious Disease Research Program, University Children´s Hospital Münster, Münster, Germany
| | - Kathrin Gordon
- Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, Infectious Disease Research Program, University Children´s Hospital Münster, Münster, Germany
| | - Charlotte Müller-Ohrem
- TDM-Laboratory, Pharmacology at the Laboratory Diagnostic Center, University Hospital of Cologne, Cologne, Germany
| | - Carsten Müller
- TDM-Laboratory, Pharmacology at the Laboratory Diagnostic Center, University Hospital of Cologne, Cologne, Germany
| | - Andreas H Groll
- Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, Infectious Disease Research Program, University Children´s Hospital Münster, Münster, Germany
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14
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Mori G, Diotallevi S, Farina F, Lolatto R, Galli L, Chiurlo M, Acerbis A, Xue E, Clerici D, Mastaglio S, Lupo Stanghellini MT, Ripa M, Corti C, Peccatori J, Puoti M, Bernardi M, Castagna A, Ciceri F, Greco R, Oltolini C. High-Risk Neutropenic Fever and Invasive Fungal Diseases in Patients with Hematological Malignancies. Microorganisms 2024; 12:117. [PMID: 38257945 PMCID: PMC10818361 DOI: 10.3390/microorganisms12010117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 12/30/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
Invasive fungal diseases (IFDs) still represent a relevant cause of mortality in patients affected by hematological malignancies, especially acute myeloid leukaemia (AML) and myelodysplastic syndrome (MDS) undergoing remission induction chemotherapy, and in allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients. Mold-active antifungal prophylaxis (MAP) has been established as a standard of care. However, breakthrough IFDs (b-IFDs) have emerged as a significant issue, particularly invasive aspergillosis and non-Aspergillus invasive mold diseases. Here, we perform a narrative review, discussing the major advances of the last decade on prophylaxis, the diagnosis of and the treatment of IFDs in patients with high-risk neutropenic fever undergoing remission induction chemotherapy for AML/MDS and allo-HSCT. Then, we present our single-center retrospective experience on b-IFDs in 184 AML/MDS patients undergoing high-dose chemotherapy while receiving posaconazole (n = 153 induction treatments, n = 126 consolidation treatments, n = 60 salvage treatments). Six cases of probable/proven b-IFDs were recorded in six patients, with an overall incidence rate of 1.7% (6/339), which is in line with the literature focused on MAP with azoles. The incidence rates (IRs) of b-IFDs (95% confidence interval (95% CI), per 100 person years follow-up (PYFU)) were 5.04 (0.47, 14.45) in induction (n = 2), 3.25 (0.0013, 12.76) in consolidation (n = 1) and 18.38 (3.46, 45.06) in salvage chemotherapy (n = 3). Finally, we highlight the current challenges in the field of b-IFDs; these include the improvement of diagnoses, the expanding treatment landscape of AML with molecular targeted drugs (and related drug-drug interactions with azoles), evolving transplantation techniques (and their related impacts on IFDs' risk stratification), and new antifungals and their features (rezafungin and olorofim).
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Affiliation(s)
- Giovanni Mori
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Infectious Diseases Unit, Ospedale Santa Chiara, 38122 Trento, Italy
| | - Sara Diotallevi
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Francesca Farina
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Riccardo Lolatto
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Laura Galli
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Matteo Chiurlo
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Andrea Acerbis
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Elisabetta Xue
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Centre for Immuno-Oncology, National Cancer Institute, Eliminate NIH, Bethesda, MD 20850, USA
| | - Daniela Clerici
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Sara Mastaglio
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | | | - Marco Ripa
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Consuelo Corti
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Jacopo Peccatori
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Massimo Puoti
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, 20161 Milan, Italy
- Faculty of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Massimo Bernardi
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Antonella Castagna
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Fabio Ciceri
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Raffaella Greco
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Chiara Oltolini
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, 20161 Milan, Italy
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15
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Maertens JA, Rahav G, Lee DG, Haider S, Ramirez-Sanchez IC, Klimko N, Ponce-de-León A, Han S, Wrishko R, Winchell GA, Grandhi A, Waskin H. Pharmacokinetic and Exposure Response Analysis of the Double-Blind Randomized Study of Posaconazole and Voriconazole for Treatment of Invasive Aspergillosis. Clin Drug Investig 2023; 43:681-690. [PMID: 37676612 PMCID: PMC10514181 DOI: 10.1007/s40261-023-01282-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND AND OBJECTIVE A double-blind phase 3 study was conducted to compare posaconazole 300 mg intravenously (IV)/300 mg orally once daily (twice daily day 1) with voriconazole 4 mg/kg IV twice daily/200 mg orally twice daily (6 mg/kg day 1) for treatment of invasive aspergillosis. This analysis was conducted to summarize the pharmacokinetics and exposure-response relationships of posaconazole and voriconazole using plasma trough concentration (Ctrough) as a surrogate for exposure from the double-blind phase 3 study. METHODS The pharmacokinetic evaluable population included all intention-to-treat (ITT) participants with at least one plasma concentration during the treatment period. Treatment blinding was maintained without therapeutic drug monitoring. Ctrough sampling occurred throughout treatment; efficacy and safety were evaluated using quartiles determined by mean Ctrough concentrations. Exposure efficacy variables included day 42 all-cause mortality (primary study endpoint) and global clinical response. Exposure safety variables included all adverse events and treatment-related adverse events. RESULTS The pharmacokinetic analysis population included 506 of 575 ITT participants (437 with Ctrough concentrations: 228 posaconazole, 209 voriconazole). No trend was seen across quartiles of posaconazole Ctrough for the key efficacy endpoint of all-cause mortality through day 42. Participants in the highest quartile of voriconazole Ctrough had higher all-cause mortality through day 42 than participants in the lower three quartiles of voriconazole Ctrough. Similar findings were observed for global clinical response and Ctrough. No clear exposure safety trend by quartile was seen for posaconazole or voriconazole. CONCLUSIONS A strong exposure-response relationship was not observed across the range of exposure from the administered doses and formulations for posaconazole or voriconazole. TRIAL REGISTRATION NCT01782131; registered January 30, 2013.
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Affiliation(s)
- Johan A Maertens
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Herestraat 49 Campus, 3000, Leuven, Belgium.
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium.
| | - Galia Rahav
- Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Shariq Haider
- Juravinski Hospital and Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | - Nikolai Klimko
- North-Western State Medical University, St. Petersburg, Russia
| | - Alfredo Ponce-de-León
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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16
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Yasinskaya Y, Bala S, Waack U, Dixon C, Higgins K, Moore JN, Jjingo CJ, O'Shaughnessy E, Colangelo P, Botgros R, Nambiar S, Angulo D, Dane A, Chiller T, Hodges MR, Sandison T, Hope W, Walsh TJ, Pappas P, Katragkou A, Kovanda L, Rex JH, Marr KA, Ostrosky-Zeichner L, Sekine S, Deshpande M, Shukla SJ, Farley J. Food and Drug Administration Public Workshop Summary-Development Considerations of Antifungal Drugs to Address Unmet Medical Need. Clin Infect Dis 2023; 77:380-387. [PMID: 37021650 DOI: 10.1093/cid/ciad195] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/20/2023] [Accepted: 03/30/2023] [Indexed: 04/07/2023] Open
Abstract
Pressing challenges in the treatment of invasive fungal infections (IFIs) include emerging and rare pathogens, resistant/refractory infections, and antifungal armamentarium limited by toxicity, drug-drug interactions, and lack of oral formulations. Development of new antifungal drugs is hampered by the limitations of the available diagnostics, clinical trial endpoints, prolonged trial duration, difficulties in patient recruitment, including subpopulations (eg, pediatrics), and heterogeneity of the IFIs. On 4 August 2020, the US Food and Drug Administration convened a workshop that included IFI experts from academia, industry, and other government agencies to discuss the IFI landscape, unmet need, and potential strategies to facilitate the development of antifungal drugs for treatment and prophylaxis. This article summarizes the key topics presented and discussed during the workshop, such as incentives and research support for drug developers, nonclinical development, clinical trial design challenges, lessons learned from industry, and potential collaborations to facilitate antifungal drug development.
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Affiliation(s)
- Yuliya Yasinskaya
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Shukal Bala
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Ursula Waack
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Cheryl Dixon
- Division of Biometrics IV, Office of Biostatistics, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration ; Silver Spring, Maryland, USA
| | - Karen Higgins
- Division of Biometrics IV, Office of Biostatistics, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration ; Silver Spring, Maryland, USA
| | - Jason N Moore
- Division of Infectious Disease Pharmacology, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Food and Drug Administration ; Silver Spring, Maryland, USA
| | - Caroline J Jjingo
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Elizabeth O'Shaughnessy
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Philip Colangelo
- Division of Infectious Disease Pharmacology, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Food and Drug Administration ; Silver Spring, Maryland, USA
| | - Radu Botgros
- Health Threats and Vaccines Strategy, European Medicines Agency, Amsterdam, the Netherlands
| | - Sumathi Nambiar
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Aaron Dane
- DaneStat Consulting, Macclesfield, United Kingdom
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | - William Hope
- Centre for Excellence in Infectious Diseases Research, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York, New York, USA
| | - Peter Pappas
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Aspasia Katragkou
- Transplantation-Oncology Infectious Disease Program, Weill Cornell Medicine, New York, New York, USA
| | - Laura Kovanda
- Astellas Pharma Global Development, Northbrook, Illinois, USA
| | | | - Kieren A Marr
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Luis Ostrosky-Zeichner
- Director of the Laboratory of Mycology Research, McGovern Medical School, Houston, Texas, USA
| | - Shohko Sekine
- Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | | | - Sunita J Shukla
- Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - John Farley
- Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
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17
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Kane Z, Cheng I, McGarrity O, Chiesa R, Klein N, Cortina-Borja M, Standing JF, Gastine S. Model Based Estimation of Posaconazole Tablet and Suspension Bioavailability in Hospitalized Children Using Real-World Therapeutic Drug Monitoring Data in Patients Receiving Intravenous and Oral Dosing. Antimicrob Agents Chemother 2023; 67:e0007723. [PMID: 37260401 PMCID: PMC10353366 DOI: 10.1128/aac.00077-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/18/2023] [Indexed: 06/02/2023] Open
Abstract
Invasive fungal infections are a major cause of morbidity and mortality for immunocompromised patients. Posaconazole is approved for treatment and prophylaxis of invasive fungal infection in adult patients, with intravenous, oral suspension, and gastroresistant/delayed-released tablet formulations available. In Europe, until very recently, posaconazole was used off-label in children, although a new delayed-release suspension approved for pediatric use is expected to become available soon. A population pharmacokinetic model was developed which uses posaconazole therapeutic drug monitoring data following intravenous and oral dosing in hospitalized children, thus enabling estimation of pediatric suspension and tablet oral bioavailability. In total, 297 therapeutic drug monitoring plasma levels from 104 children were included in this analysis. The final model was a one-compartment model with first-order absorption and nonlinear elimination. Allometric scaling on clearance and volume of distribution was included a priori. Tablet bioavailability was estimated to be 66%. Suspension bioavailability was estimated to decrease with increasing doses, ranging from 3.8% to 32.2% in this study population. Additionally, concomitant use of proton pump-inhibitors was detected as a significant covariate, reducing suspension bioavailability by 41.0%. This is the first population pharmacokinetic study to model posaconazole data from hospitalized children following intravenous, tablet, and suspension dosing simultaneously. The incorporation of saturable posaconazole clearance into the model has been key to the credible joint estimation of tablet and suspension bioavailability. To aid rational posaconazole dosing in children, this model was used alongside published pharmacodynamic targets to predict the probability of target attainment using typical pediatric dosing regimen.
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Affiliation(s)
- Zoe Kane
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Iek Cheng
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Department of Pharmacy, Great Ormond Street Hospital, London, United Kingdom
| | - Orlagh McGarrity
- Department of Pharmacy, Great Ormond Street Hospital, London, United Kingdom
| | - Robert Chiesa
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital, London, United Kingdom
| | - Nigel Klein
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Mario Cortina-Borja
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Joseph F. Standing
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Department of Pharmacy, Great Ormond Street Hospital, London, United Kingdom
| | - Silke Gastine
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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18
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Bunn HT, Gobburu JVS, Floryance LM. Bayesian model-guided antimicrobial therapy in pediatrics. Front Pharmacol 2023; 14:1118771. [PMID: 37426816 PMCID: PMC10323137 DOI: 10.3389/fphar.2023.1118771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 06/12/2023] [Indexed: 07/11/2023] Open
Abstract
Antimicrobials have transformed the practice of medicine, making life-threatening infections treatable, but determining optimal dosing, particularly in pediatric patients, remains a challenge. The lack of pediatric data can largely be traced back to pharmaceutical companies, which, until recently, were not required to perform clinical testing in pediatrics. As a result, most antimicrobial use in pediatrics is off-label. In recent years, a concerted effort (e.g., Pediatric Research Equality Act) has been made to fill these knowledge gaps, but progress is slow and better strategies are needed. Model-based techniques have been used by pharmaceutical companies and regulatory agencies for decades to derive rational individualized dosing guidelines. Historically, these techniques have been unavailable in a clinical setting, but the advent of Bayesian-model-driven, integrated clinical decision support platforms has made model-informed precision dosing more accessible. Unfortunately, the rollout of these systems remains slow despite their increasingly well documented contributions to patient-centered care. The primary goals of this work are to 1) provide a succinct, easy-to-follow description of the challenges associated with designing and implementing dose-optimization strategies; and 2) provide supporting evidence that Bayesian-model informed precision dosing can meet those challenges. There are numerous stakeholders in a hospital setting, and our intention is for this work to serve as a starting point for clinicians who recognize that these techniques are the future of modern pharmacotherapy and wish to become champions of that movement.
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Affiliation(s)
| | - Jogarao V. S. Gobburu
- Pumas-AI, Inc., Centreville, VA, United States
- School of Pharmacy, University of Maryland, Baltimore, MD, United States
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19
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Stemler J, Mellinghoff SC, Khodamoradi Y, Sprute R, Classen AY, Zapke SE, Hoenigl M, Krause R, Schmidt-Hieber M, Heinz WJ, Klein M, Koehler P, Liss B, Koldehoff M, Buhl C, Penack O, Maschmeyer G, Schalk E, Lass-Flörl C, Karthaus M, Ruhnke M, Cornely OA, Teschner D. Primary prophylaxis of invasive fungal diseases in patients with haematological malignancies: 2022 update of the recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society for Haematology and Medical Oncology (DGHO). J Antimicrob Chemother 2023:dkad143. [PMID: 37311136 PMCID: PMC10393896 DOI: 10.1093/jac/dkad143] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Abstract
Patients with haematological malignancies (HM) are at high risk of developing invasive fungal disease (IFD) with high morbidity and attributable mortality. We reviewed data published until September 2021 to update the 2017 antifungal prophylaxis recommendations of the German Society of Haematology and Medical Oncology (DGHO). The strong recommendation to administer antifungal prophylaxis in patients with HM with long-lasting neutropenia, i.e. <500 cells/μL for >7 days remains unchanged. Posaconazole remains the drug of choice for mould-active prophylaxis in these patients. Novel treatment options in HM, such as CAR-T-cell treatment or novel targeted therapies for acute myeloid leukaemia (AML) were considered, however, data are insufficient to give general recommendations for routine antifungal prophylaxis in these patients. Major changes regarding specific recommendations compared to the 2017 edition are the now moderate instead of mild support for the recommendations of isavuconazole and voriconazole. Furthermore, published evidence on micafungin allows recommending it at moderate strength for its use in HM. For the first time we included recommendations for non-pharmaceutical measures regarding IFD, comprising the use of high-efficiency particulate air (HEPA) filters, smoking, measures during construction work and neutropenic diets. We reviewed the impact of antifungal prophylaxis with triazoles on drug-drug interactions with novel targeted therapies that are metabolized via cytochrome p450 where triazoles inhibit CYP3A4/5. The working group recommends reducing the dose of venetoclax when used concomitantly with strong CYP3A4 inhibiting antifungals. Furthermore, we reviewed data on the prophylactic use of novel antifungal agents. Currently there is no evidence to support their use in a prophylactic setting in clinical practice.
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Affiliation(s)
- Jannik Stemler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Cologne, Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Sibylle C Mellinghoff
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Cologne, Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Yascha Khodamoradi
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Rosanne Sprute
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Cologne, Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Annika Y Classen
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Sonja E Zapke
- Department Hematology, Oncology, Infectious disease and Palliatve Care, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Medical University of Graz, Graz, Austria and BioTechMed, Graz, Austria
| | - Robert Krause
- Division of Infectious Diseases, Department of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Medical University of Graz, Graz, Austria and BioTechMed, Graz, Austria
| | - Martin Schmidt-Hieber
- 2nd Medical Clinic (Hematology, Oncology, Pneumology, Nephrology), Carl-Thiem Clinic Cottbus, Cottbus, Germany
| | - Werner J Heinz
- Medical Clinic II, Caritas Hospital, Bad Mergentheim, Germany
| | - Michael Klein
- Department of Hematology and Medical Oncology, Klinikum Vest, Knappschaftskrankenhaus, Recklinghausen, Germany
| | - Philipp Koehler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Cologne, Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Blasius Liss
- Department Hematology, Oncology, Infectious disease and Palliatve Care, Helios University Hospital Wuppertal, Wuppertal, Germany
- School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Michael Koldehoff
- Department of Bone Marrow Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Department of Hygiene and Environmental Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | | | - Olaf Penack
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin, Germany
- Humboldt-Universität zu Berlin, Department of Hematology, Oncology and Tumorimmunology, Berlin, Germany
| | - Georg Maschmeyer
- Formerly Department of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Enrico Schalk
- Department of Haematology and Oncology, Medical Centre, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, ECMM Excellence Centre, Medical University of Innsbruck, Innsbruck, Austria
| | - Meinolf Karthaus
- Department of Hematology, Oncology and Palliative Care, Klinikum Neuperlach, Munich, Germany
| | - Markus Ruhnke
- Helios Klinikum Aue, Klinik für Hämatologie/Onkologie & Palliativmedizin, Aue, Germany
| | - Oliver A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Chair Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, NRW, Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany
| | - Daniel Teschner
- Department of Hematology, and Medical Oncology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
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20
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Neofytos D, Steinbach WJ, Hanson K, Carpenter PA, Papanicolaou GA, Slavin MA. American Society for Transplantation and Cellular Therapy Series, #6: Management of Invasive Candidiasis in Hematopoietic Cell Transplantation Recipients. Transplant Cell Ther 2023; 29:222-227. [PMID: 36649748 DOI: 10.1016/j.jtct.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
The Practice Guidelines Committee of the American Society of Transplantation and Cellular Therapy (ASTCT) partnered with its Transplant Infectious Disease Special Interest Group (TID-SIG) to update its 2009 compendium-style infectious disease guidelines for hematopoietic cell transplantation (HCT). A completely new approach was taken with the goal of better serving clinical providers by publishing each standalone topic in the infectious disease series as a concise format of frequently asked questions (FAQ), tables, and figures. Adult and pediatric infectious disease and HCT content experts developed and then answered FAQs and finalized topics with harmonized recommendations made by assigning an A through E strength of recommendation paired with a level of supporting evidence graded I through III. This sixth guideline in the series focuses on invasive candidiasis (IC) with FAQs to address epidemiology, clinical diagnosis, prophylaxis, and treatment of IC, plus special considerations for pediatric, cord blood, haploidentical, and T cell-depleted HCT recipients and chimeric antigen receptor T cell recipients, as well as future research directions.
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Affiliation(s)
- Dionysios Neofytos
- Division of Infectious Diseases, Transplant Infectious Disease Service, University Hospital of Geneva, Geneva, Switzerland.
| | - William J Steinbach
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Kimberly Hanson
- Transplant Infectious Diseases and Immunocompromised Host Service, Clinical Microbiology, University of Utah, Salt Lake City, Utah
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Genovefa A Papanicolaou
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Monica A Slavin
- Department of Infectious Disease Peter MacCallum Cancer Centre, Melbourne, Australia
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21
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Iwasa T, de Almeida C, Fauchet F, Winchell GA, de Greef R, Hasegawa C, Yoshitsugu H, Wrishko RE. Model-Informed Dose Justifications of Posaconazole in Japanese Patients for Prophylaxis and Treatment Against Fungal Infection. J Clin Pharmacol 2023; 63:421-434. [PMID: 36374235 DOI: 10.1002/jcph.2180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022]
Abstract
Posaconazole is a globally approved broad-spectrum triazole antifungal compound. In Japanese patients, posaconazole has identical dosing regimens as those approved globally for both tablet and intravenous formulations. This article aims to describe a model-informed approach for dose justification of posaconazole in the Japanese population as either high-risk patients with fungal infections (prophylaxis patients) or patients with fungal infections (treatment patients). A simultaneous population pharmacokinetic (PK) model for tablet and intravenous formulation was developed on the basis of a data set including Japanese data from healthy participants and treatment patients. The PK profiles and exposure distributions in Japanese patients were predicted and compared against foreign patients, that is, patients outside of Japan. Relationships between the post hoc posaconazole exposures and frequently observed clinical adverse events were evaluated. Although clinical trials for Japanese prophylaxis patients were not conducted, PK profiles in Japanese prophylaxis patients were predicted using the population PK model and demographic covariate information obtained from the published literature. Based upon the globally approved dosing regimen, posaconazole exposure distribution was predicted to be the highest in Japanese treatment patients, and generally similar between Japanese and foreign prophylaxis patients. Exposures in Japanese patients exceeded the efficacy target level (500 ng/mL). Safety profiles in Japanese treatment patients with the highest exposures were clinically acceptable without specific concerns to Japanese patients and appeared to have no relationship with posaconazole exposures. From PK, safety, and efficacy perspectives, the use of the same dosing regimen as in foreign patients was justified in Japanese prophylaxis and treatment patients.
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Affiliation(s)
- Takashi Iwasa
- Clinical Pharmacology Development, MSD K.K, Tokyo, Japan
| | | | | | | | | | | | | | - Rebecca Ellen Wrishko
- Quantitative Pharmacology and Pharmacometrics, Merck & Co., Inc., Rahway, New Jersey, USA
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22
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An Integrated Population Pharmacokinetic Analysis for Posaconazole Oral Suspension, Delayed-Release Tablet, and Intravenous Infusion in Healthy Volunteers. Drugs 2023; 83:75-86. [PMID: 36607589 DOI: 10.1007/s40265-022-01819-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Posaconazole is widely used for the prophylaxis and treatment of invasive fungal diseases. Because of the limited and variable absorption of the initially available oral suspension, a delayed-release tablet and intravenous formulation were developed. OBJECTIVE This study aimed to characterize the pharmacokinetics, including the absolute oral bioavailability, of all posaconazole formulations in healthy volunteers. METHODS Data from 182 healthy volunteers with 3898 densely sampled posaconazole concentrations were pooled from eight phase I clinical studies on the three formulations of various single and multiple dosage regimens between 50 and 400 mg. Analysis and simulations were performed using NONMEM 7.5.0. In the covariate analysis, the influence of food (fed vs fasted), nonlinearity, and for the delayed-release tablet, comedication (antacid, ranitidine, esomeprazole, and metoclopramide) were tested. RESULTS A two-compartment model with respectively, four and eight absorption transit compartments, best described the profiles of the oral suspension and delayed-release tablet. For the suspension, both a food effect and a dose-dependent nonlinear bioavailability were quantified, resulting in lower bioavailability when fasted or at a higher dose. The typical bioavailability of the suspension at 100 mg and 400 mg was derived to be respectively, 17.1% and 10.1% under fasted conditions and 59.1% and 49.2% under fed conditions. The absolute bioavailability of the delayed-release tablet was 58.8% (95% confidence interval 33.2-80.4) under fasted conditions and approached complete absorption under fed conditions for dosages up to 300 mg. Food intake reduced the absorption rate constant of the suspension by 52.2% (confidence interval 45.2-59.2). The impact of comedication on the absorption of the delayed-release tablet was not statistically significant. Model-based simulations indicate that under fed conditions, the licensed dosages of the three formulations yield a steady-state trough concentration ≥ 0.7 mg/L in over 90% of healthy volunteers. About 35% of healthy volunteers who receive the licensed 300-mg delayed-release tablet under fasted conditions do not achieve this target, while for the suspension this percentage varies between 55 and 85%, depending on the dose. CONCLUSIONS For both oral posaconazole formulations, we quantified bioavailability and absorption rate, including food effects, in healthy volunteers. The pharmacokinetic superiority of the delayed-release tablet was demonstrated under both fed and fasted conditions, compared with the oral suspension. The impact of food on the bioavailability of the delayed-release tablet was larger than anticipated, suggesting that administering the delayed-release tablet with food enhances absorption.
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23
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Bui J, Gellatly R, Othman J, Lindsay J. Subtherapeutic concentrations of posaconazole tablet: determining risk factors and effectiveness of a standardized dose adjustment in hematology inpatients. Leuk Lymphoma 2022; 63:3418-3425. [PMID: 36175159 DOI: 10.1080/10428194.2022.2126282] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Posaconazole is indicated for antifungal prophylaxis in hematology patients at high-risk of invasive fungal infections (IFI). Consensus guidelines recommend maintaining steady-state trough concentrations above 0.7 mg/L; however, upto one-third of patients return subtherapeutic concentrations which is associated with breakthrough IFI. This retrospective observational study of 496 concentrations from 90 hematology inpatients prescribed posaconazole tablet (PCZ-tab) between May 2017 and May 2019 identified 24% (n = 121) of posaconazole concentrations were subtherapeutic after the dosage of 300 mg daily. On multivariable analyses, diarrhea (p = 0.002), male gender (p = 0.018), and concurrent regular metoclopramide (p = 0.002) were significantly associated with subtherapeutic posaconazole concentrations. Eighty-nine percent of patients (n = 16) who underwent dose adjustment to 200 mg twice daily successfully achieved target posaconazole concentrations at first steady-state measurement. This study confirms that therapeutic drug monitoring of posaconazole remains necessary as subtherapeutic posaconazole concentrations are relatively common, and that dose adjustment of 200 mg twice daily, safely enabled achievement of therapeutic concentrations.
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Affiliation(s)
- Jessica Bui
- Clinical Pharmacy Department, Royal North Shore Hospital, Sydney, Australia.,Department of Infectious Diseases, Royal North Shore Hospital, Sydney, Australia
| | - Rochelle Gellatly
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia.,Pharmacy Department, Surrey Memorial Hospital, Surrey, Canada
| | - Jad Othman
- Haematology Department, Royal North Shore Hospital, Sydney, Australia
| | - Julian Lindsay
- Haematology Department, Royal North Shore Hospital, Sydney, Australia.,National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia.,Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Research Center, SE, USA
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24
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Challenges in the Treatment of Invasive Aspergillosis in Immunocompromised Children. Antimicrob Agents Chemother 2022; 66:e0215621. [PMID: 35766509 PMCID: PMC9295552 DOI: 10.1128/aac.02156-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Invasive aspergillosis (IA) is associated with significant morbidity and mortality. Voriconazole remains the drug of choice for the treatment of IA in children; however, the complex kinetics of voriconazole in children make dosing challenging and therapeutic drug monitoring (TDM) essential for treatment success. The overarching goal of this review is to discuss the role of voriconazole, posaconazole, isavuconazole, liposomal amphotericin B, echinocandins, and combination antifungal therapy for the treatment of IA in children. We also provide a detailed discussion of antifungal TDM in children.
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25
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Jia M, Zhang Q, Qin Z, Wang D, Liu P, Yang J, Zhang X. Dose Optimisation of Posaconazole and Therapeutic Drug Monitoring in Pediatric Patients. Front Pharmacol 2022; 13:833303. [PMID: 35517786 PMCID: PMC9061949 DOI: 10.3389/fphar.2022.833303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Experience in the clinical use of posaconazole (PCZ) in pediatric patients is limited, and no specific dose recommendations exist. This study aimed to investigate an appropriate dosing regimen, and assess the exposure-response relationships of PCZ in children. We reviewed the medical records of inpatients aged <18 years who subjected to PCZ concentrations monitoring. Clinical data, PCZ dosing and monitoring data were collected. A total of 375 PCZ trough concentrations (C min) from 105 pediatric patients were included. For children receiving PCZ for prophylaxis, the median doses required to achieve the therapeutic range at the ages of <6, 6-12 and >12 years were 14.80, 14.52 and 12.90 mg/kg/day, respectively (p = 0.001); and for those receiving PCZ for treatment, the median doses were 23.50, 20.96 and 15.38 mg/kg/day, respectively (p = 0.001). Among children taking PCZ for prophylaxis, 12% developed a proven or probable breakthrough IFIs; the median PCZ concentrations were significantly lower than those children with successful treatment response (0.43 versus 1.20 μg mL-1; p < 0.001). 79.2% patients taking PCZ for treatment had a positive clinical response, and the median PCZ concentrations were significantly higher than those children with disease progression (1.06 versus 0.53 μg mL-1; p = 0.024). No association between C min values and hepatotoxicity was observed. Factors such as age, CRP, ALT and co-administration with proton pump inhibitors exhibited significant effects on PCZ C min. It is necessary to adjust the dosing regimens based on PCZ C min to individualize antifungal therapy and provide guidelines for dose adjustment in children.
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Affiliation(s)
- Mengmeng Jia
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Qiwen Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Zifei Qin
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Dao Wang
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peng Liu
- Pediatric Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Yang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Xiaojian Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
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26
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Roth RS, Masouridi-Levrat S, Chalandon Y, Mamez AC, Giannotti F, Riat A, Fischer A, Poncet A, Glampedakis E, Van Delden C, Kaiser L, Neofytos D. Invasive Mold Infections in Allogeneic Hematopoietic Cell Transplant Recipients in 2020: Have We Made Enough Progress? Open Forum Infect Dis 2022; 9:ofab596. [PMID: 34993259 PMCID: PMC8719608 DOI: 10.1093/ofid/ofab596] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 11/26/2021] [Indexed: 11/21/2022] Open
Abstract
Background Despite progress in diagnostic, prevention, and treatment strategies, invasive mold infections (IMIs) remain the leading cause of mortality in allogeneic hematopoietic cell transplant (allo-HCT) recipients. Methods We describe the incidence, risk factors, and mortality of allo-HCT recipients with proven/probable IMI in a retrospective single-center 10-year (01/01/2010–01/01/2020) cohort study. Results Among 515 allo-HCT recipients, 48 (9.3%) patients developed 51 proven/probable IMI: invasive aspergillosis (IA; 34/51, 67%), mucormycosis (9/51, 18%), and other molds (8/51, 15%). Overall, 35/51 (68.6%) breakthrough IMIs (bIMIs) were identified: 22/35 (62.8%) IA and 13/35 (37.1%) non-IA IMI. One-year IMI cumulative incidence was 7%: 4.9% and 2.1% for IA and non-IA IMI, respectively. Fourteen (29.2 %), 10 (20.8%), and 24 (50.0%) patients were diagnosed during the first 30, 31–180, and >180 days post-HCT, respectively. Risk factors for IMI included prior allo-HCT (sub hazard ratio [SHR], 4.06; P = .004) and grade ≥2 acute graft-vs-host disease (aGvHD; SHR, 3.52; P < .001). All-cause 1-year mortality was 33% (170/515): 48% (23/48) and 31.5% (147/467) for patients with and without IMI (P = .02). Mortality predictors included disease relapse (hazard ratio [HR], 7.47; P < .001), aGvHD (HR, 1.51; P = .001), CMV serology–positive recipients (HR, 1.47; P = .03), and IMI (HR, 3.94; P < .001). All-cause 12-week mortality for patients with IMI was 35.4% (17/48): 31.3% (10/32) for IA and 43.8% (7/16) for non-IA IMI (log-rank P = .47). At 1 year post–IMI diagnosis, 70.8% (34/48) of the patients were dead. Conclusions IA mortality has remained relatively unchanged during the last 2 decades. More than two-thirds of allo-HCT recipients with IMI die by 1 year post–IMI diagnosis. Dedicated intensified research efforts are required to further improve clinical outcomes.
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Affiliation(s)
- Romain Samuel Roth
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
| | - Stavroula Masouridi-Levrat
- Bone Marrow Transplant Unit, Division of Hematology, University Hospital of Geneva, and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Yves Chalandon
- Bone Marrow Transplant Unit, Division of Hematology, University Hospital of Geneva, and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Anne-Claire Mamez
- Bone Marrow Transplant Unit, Division of Hematology, University Hospital of Geneva, and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Federica Giannotti
- Bone Marrow Transplant Unit, Division of Hematology, University Hospital of Geneva, and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Arnaud Riat
- Laboratory of Bacteriology, Diagnostic Department, University Hospital of Geneva, Geneva, Switzerland
| | - Adrien Fischer
- Laboratory of Bacteriology, Diagnostic Department, University Hospital of Geneva, Geneva, Switzerland
| | - Antoine Poncet
- Clinical Research Center, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of Clinical Epidemiology, Department of Health and Community Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Emmanouil Glampedakis
- Division of Infectious Diseases, University Hospital of Lausanne, Lausanne, Switzerland
| | - Christian Van Delden
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
| | - Laurent Kaiser
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
| | - Dionysios Neofytos
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
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Chau MM, Daveson K, Alffenaar JWC, Gwee A, Ho SA, Marriott DJE, Trubiano JA, Zhao J, Roberts JA. Consensus guidelines for optimising antifungal drug delivery and monitoring to avoid toxicity and improve outcomes in patients with haematological malignancy and haemopoietic stem cell transplant recipients, 2021. Intern Med J 2021; 51 Suppl 7:37-66. [PMID: 34937141 DOI: 10.1111/imj.15587] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Antifungal agents can have complex dosing and the potential for drug interaction, both of which can lead to subtherapeutic antifungal drug concentrations and poorer clinical outcomes for patients with haematological malignancy and haemopoietic stem cell transplant recipients. Antifungal agents can also be associated with significant toxicities when drug concentrations are too high. Suboptimal dosing can be minimised by clinical assessment, laboratory monitoring, avoidance of interacting drugs, and dose modification. Therapeutic drug monitoring (TDM) plays an increasingly important role in antifungal therapy, particularly for antifungal agents that have an established exposure-response relationship with either a narrow therapeutic window, large dose-exposure variability, cytochrome P450 gene polymorphism affecting drug metabolism, the presence of antifungal drug interactions or unexpected toxicity, and/or concerns for non-compliance or inadequate absorption of oral antifungals. These guidelines provide recommendations on antifungal drug monitoring and TDM-guided dosing adjustment for selected antifungal agents, and include suggested resources for identifying and analysing antifungal drug interactions. Recommended competencies for optimal interpretation of antifungal TDM and dose recommendations are also provided.
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Affiliation(s)
- Maggie M Chau
- Pharmacy Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Kathryn Daveson
- Department of Infectious Diseases and Microbiology, The Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - Jan-Willem C Alffenaar
- Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Camperdown, New South Wales, Australia.,Pharmacy Department, Westmead Hospital, Westmead, New South Wales, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Camperdown, New South Wales, Australia
| | - Amanda Gwee
- Infectious Diseases Unit, The Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Infectious Diseases Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Su Ann Ho
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Deborah J E Marriott
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Darlinghurst, New South Wales, Australia.,Faculty of Science, University of Technology, Ultimo, New South Wales, Australia.,Faculty of Medicine, The University of New South Wales, Kensington, New South Wales, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Jessie Zhao
- Department of Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason A Roberts
- The University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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Panagopoulou P, Roilides E. Evaluating posaconazole, its pharmacology, efficacy and safety for the prophylaxis and treatment of fungal infections. Expert Opin Pharmacother 2021; 23:175-199. [PMID: 34758695 DOI: 10.1080/14656566.2021.1996562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Invasive fungal diseases (IFDs) are a significant cause of morbidity and mortality among immunocompromised patients. Safe and effective antifungal medications used for prophylaxis and treatment are pivotal in their management. Posaconazole is a promising triazole antifungal agent. AREAS COVERED The authors discuss the pharmacological properties of posaconazole, including pharmacokinetics/pharmacodynamics, safety and tolerability profile, together with efficacy data for prophylaxis and treatment as well as its use in special populations based on current literature. EXPERT OPINION Posaconazole has a favorable safety and tolerability profile; however, caution is advised when co-administered with agents that are CYP3A4 inhibitors, because their concentration may significantly increase, and their levels should be closely monitored. It has an extended spectrum of activity against yeasts and filamentous fungi. It is successfully used as prophylaxis for patients with acute myeloid leukemia (AML)/myelodysplastic syndrome (MDS) and post-hematopoietic cell transplantation (HCT) with graft-versus-host disease (GVHD). It is the first line treatment for oropharyngeal candidiasis and is also used as a salvage treatment for refractory IFDs. Currently available formulations include the oral suspension, delayed-release tablets and solution for intravenous infusion, all with different PK/PD properties and indications. Its use in children and adolescents is currently being examined in Phase-II clinical trials.
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Affiliation(s)
- Paraskevi Panagopoulou
- 4th Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Papageorgiou General Hospital, Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Hippokration General Hospital, Thessaloniki, Greece.,Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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29
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Population pharmacokinetics of a posaconazole tablet formulation in transplant adult allogeneic stem cell recipients. Eur J Pharm Sci 2021; 168:106049. [PMID: 34699939 DOI: 10.1016/j.ejps.2021.106049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/05/2021] [Accepted: 10/21/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Posaconazole is an antifungal agent extensively used as a prophylaxis for invasive fungal infections (IFIs) in allogeneic stem cell transplant (SCT) recipients. Low posaconazole concentrations have been associated with reduced clinical response. The aim of this study was to develop a population pharmacokinetic (popPK) model of a posaconazole tablet formulation in allogeneic SCT adult recipients for supporting model-informed precision dosing (MIPD). MATERIALS AND METHOD Prospective observational study performed in adult allogeneic SCT recipients receiving posaconazole as prophylaxis for IFIs and followed up by a therapeutic drug monitoring (TDM) program. Posaconazole plasma concentrations were quantified using an ultra-high-performance liquid chromatography (UPLC) with UV detector. A popPK model was developed using NONMEM v.7.4.0. Deterministic and stochastic simulations were carried out with the final model to evaluate the differences across physiological variables with impact on drug exposure. RESULTS A one-compartment model with sequential absorption (zero and first order) and first order elimination described adequately 55 posaconazole concentrations from 36 patients. Higher doses of posaconazole were found to be required by males and patients with lower values of total serum proteins. A nomogram to estimate the posaconazole daily dose based on pharmacokinetic/pharmacodynamic (PKPD) criterion for males and females for different values of total proteins was developed. CONCLUSIONS Gender and total serum proteins have been identified as covariates influencing posaconazole CL/F in adult allogeneic SCT recipients receiving the delay-released tablet formulation. Additional studies are required to better characterize the absorption of posaconazole and implications on dosage recommendations together with potential safety concerns.
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Vu CA, Riollano-Cruz M, Kowalsky SR. Supratherapeutic Posaconazole Concentration in a Pediatric Transplant Patient With Confirmed Rhizopus Infection. J Pediatr Pharmacol Ther 2021; 26:753-757. [PMID: 34588941 PMCID: PMC8475801 DOI: 10.5863/1551-6776-26.7.753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 01/19/2021] [Indexed: 11/11/2022]
Abstract
There are a limited number of studies that guide dosing of posaconazole delayed-release (DR) tablets for the pediatric population. Current FDA-approved doses are only recommended for patients 13 years and older. For younger patients, providers are faced with the challenge of recommending posaconazole doses extrapolated from adult studies or choosing an alternative agent. We report on a case of a 10-year-old patient who experienced a supratherapeutic trough serum concentration and transaminitis after receiving the extrapolated adult dosage of posaconazole DR tablets (300 mg twice daily for the first day, followed by 300 mg daily) for 7 days. In the end, the patient required a smaller dose of 200 mg daily to achieve the desired trough target concentration for the treatment of a Rhizopus neck infection. Our findings highlight the need for additional studies to determine the optimal dosing of posaconazole DR tablets for children.
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31
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Lewis RE, Andes DR. Managing uncertainty in antifungal dosing: antibiograms, therapeutic drug monitoring and drug-drug interactions. Curr Opin Infect Dis 2021; 34:288-296. [PMID: 34010233 PMCID: PMC9914162 DOI: 10.1097/qco.0000000000000740] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE OF REVIEW A number of pharmacokinetic and pharmacodynamic factors in critically ill or severely immunosuppressed patients influence the effectiveness of antifungal therapy making dosing less certain. Recent position papers from infectious diseases societies and working groups have proposed methods for dosage individualization of antibiotics in critically ill patients using a combination of population pharmacokinetic models, Monte-Carlo simulation and therapeutic drug monitoring (TDM) to guide dosing. In this review, we examine the current limitations and practical issues of adapting a pharmacometrics-guided dosing approaches to dosing of antifungals in critically ill or severely immunosuppressed populations. RECENT FINDINGS We review the current status of antifungal susceptibility testing and challenges in incorporating TDM into Bayesian dose prediction models. We also discuss issues facing pharmacometrics dosage adjustment of newer targeted chemotherapies that exhibit severe pharmacokinetic drug-drug interactions with triazole antifungals. SUMMARY Although knowledge of antifungal pharmacokinetic/pharmacodynamic is maturing, the practical application of these concepts towards point-of-care dosage individualization is still limited. User-friendly pharmacometric models are needed to improve the utility of TDM and management of a growing number of severe pharmacokinetic antifungal drug-drug interactions with targeted chemotherapies.
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Affiliation(s)
- Russell E. Lewis
- Department of Medical and Surgical Sciences, University of Bologna. Infectious Diseases, IRCCS S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - David R. Andes
- Departments of Medicine and Medical Microbiology & Immunology, University of Wisconsin-Madison, Madison, Wisconsin, USA
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32
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Wasmann RE, Smit C, van Donselaar MH, van Dongen EPA, Wiezer RMJ, Verweij PE, Burger DM, Knibbe CAJ, Brüggemann RJM. Implications for IV posaconazole dosing in the era of obesity. J Antimicrob Chemother 2021; 75:1006-1013. [PMID: 31971567 PMCID: PMC7069473 DOI: 10.1093/jac/dkz546] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/04/2019] [Accepted: 12/06/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The prevalence of obesity has shown a dramatic increase over recent decades. Obesity is associated with underdosing of antimicrobial drugs for prophylaxis and treatment. Posaconazole is a broad-spectrum triazole antifungal drug licensed for prophylaxis and treatment of invasive fungal infections. It is unclear how posaconazole should be dosed in obese patients. METHODS We performed a prospective study investigating the pharmacokinetics of posaconazole in morbidly obese (n = 16) and normal-weight (n = 8) subjects, with a weight ranging between 61.4 and 190 kg, after a 300 or 400 mg IV dose. Population pharmacokinetic modelling was used to assess the effect of body size on posaconazole pharmacokinetics. ClinicalTrials.gov Identifier: NCT03246386. RESULTS Total body weight best predicted changes in CL and V. Model-based simulations demonstrated that, for treatment of fungal infections, a daily IV dose of 300 mg will result in a PTA of ≥90% in individuals up to 140 kg, after which both twice daily loading and the daily maintenance dose should be increased to 400 mg. For prophylaxis, a 300 mg IV dose is adequate in patients up to 190 kg. CONCLUSIONS Body size has a significant impact on posaconazole CL and V, resulting in a lower exposure in obese subjects compared with normal-weight subjects. For therapeutic use of posaconazole, a dose increase is required in patients above 140 kg. For prophylaxis, a 300 mg IV dose is adequate. For oral treatment, these recommendations can act as a starting point followed by therapeutic drug monitoring.
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Affiliation(s)
- Roeland E Wasmann
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
- Corresponding author. E-mail:
| | - Cornelis Smit
- Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Marieke H van Donselaar
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eric P A van Dongen
- Department of Anaesthesiology, Intensive Care and Pain Management, St Antonius Hospital, Nieuwegein, The Netherlands
| | - René M J Wiezer
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Paul E Verweij
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Roger J M Brüggemann
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
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Lambrix AA, Swanson HD, Pauley JL, Bragg AW, Carias DC, Bourque MS, Zhou Y, Cheng C, Greene WL, Maron G. Experience using intravenous posaconazole in paediatric and young adult oncology patients. J Antimicrob Chemother 2021; 75:3682-3687. [PMID: 32929484 DOI: 10.1093/jac/dkaa377] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/04/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Posaconazole exhibits broad-spectrum antifungal activity. An IV formulation became available in 2014. Few studies describing the use of this formulation exist in patients under the age of 18 years. This study describes our experience using IV posaconazole in paediatric and young adult cancer patients. METHODS This single-centre retrospective chart review evaluated patients who received IV posaconazole and had at least one posaconazole plasma concentration obtained after five or more days with a consistent dosage. Relationships between doses required to achieve a plasma concentration of ≥1 µg/mL and patient age, weight and body surface area (BSA) were evaluated. The clinical record was reviewed to identify descriptions of any adverse events. RESULTS Twenty-five patients were analysed, with a median age of 10.5 years (range 1.9-22.9 years; 92% were <18 years). All patients were able to achieve a posaconazole plasma concentration ≥1 µg/mL during their treatment course. The daily mg/kg/day dose required to achieve the target concentration decreased significantly with increasing age of the patient (P = 0.018). Assessment of dosage based on BSA suggested a requirement of 225 mg/m2/day across all age groups <18 years. Adverse events documented in the clinical record were consistent with those described with the oral formulations. No CNS toxicities were observed with use of IV posaconazole. CONCLUSIONS Concentrations ≥1 µg/mL are achievable and a BSA-based dosing approach may allow a consistent empirical dose for patients <18 years of age. Therapeutic drug monitoring is recommended to ensure patients achieve therapeutic concentrations.
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Affiliation(s)
- Arathi A Lambrix
- Department of Pharmacy, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Hope D Swanson
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jennifer L Pauley
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Allison W Bragg
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Delia C Carias
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Melissa S Bourque
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yinmei Zhou
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Cheng Cheng
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - William L Greene
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Gabriela Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
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Downes KJ, Goldman JL. Too Much of a Good Thing: Defining Antimicrobial Therapeutic Targets to Minimize Toxicity. Clin Pharmacol Ther 2021; 109:905-917. [PMID: 33539569 DOI: 10.1002/cpt.2190] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/27/2021] [Indexed: 12/19/2022]
Abstract
Antimicrobials are a common cause of drug toxicity. Understanding the relationship between systemic antimicrobial exposure and toxicity is necessary to enable providers to take a proactive approach to prevent undesired drug effects. When an exposure threshold has been defined that predicts drug toxicity, therapeutic drug monitoring (TDM) can be performed to assure drug exposure does not exceed the defined threshold. Although some antimicrobials have well-defined dose-dependent toxicities, many other exposure-toxicity relationships have either not been well-defined or, in some cases, not been evaluated at all. In this review, we examine the relationship between exposures and toxicities for antibiotic, antifungal, and antiviral agents. Furthermore, we classify these relationships into four categories: known association between drug exposure and toxicity such that clinical implementation of a specific exposure threshold associated with toxicity for TDM is supported (category 1), known association between drug exposure and toxicity but the specific exposure threshold associated with toxicity is undefined (category 2), association between drug exposure and toxicity has been suggested but relationship is poorly defined (category 3), and no known association between drug exposure and toxicity (category 4). Further work to define exposure-toxicity thresholds and integrate effective TDM strategies has the potential to minimize many of the observed antimicrobial toxicities.
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Affiliation(s)
- Kevin J Downes
- The Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,The Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer L Goldman
- Divisions of Clinical Pharmacology, Toxicology and Therapeutic Innovation and Infectious Diseases, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, University of Missouri - Kansas City, Kansas City, Missouri, USA
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Review of Pharmacologic Considerations in the Use of Azole Antifungals in Lung Transplant Recipients. J Fungi (Basel) 2021; 7:jof7020076. [PMID: 33499209 PMCID: PMC7911495 DOI: 10.3390/jof7020076] [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: 12/20/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 12/15/2022] Open
Abstract
Mold-active azole antifungals are commonly prescribed for the prevention of invasive fungal infections in lung transplant recipients. Each agent exhibits a unique pharmacologic profile, an understanding of which is crucial for therapy selection and optimization. This article reviews pharmacologic considerations for three frequently-used azole antifungals in lung transplant recipients: voriconazole, posaconazole, and isavuconazole. Focus is drawn to analysis of drug-interactions, adverse drug reactions, pharmacokinetic considerations, and the role of therapeutic drug monitoring with special emphasis on data from the post-lung transplant population.
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36
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Pharmacodynamics of Posaconazole in Experimental Invasive Pulmonary Aspergillosis: Utility of Serum Galactomannan as a Dynamic Endpoint of Antifungal Efficacy. Antimicrob Agents Chemother 2021; 65:AAC.01574-20. [PMID: 33168606 DOI: 10.1128/aac.01574-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/28/2020] [Indexed: 12/25/2022] Open
Abstract
Aspergillus galactomannan antigenemia is an accepted tool for the diagnosis of invasive pulmonary aspergillosis (IPA) in neutropenic patients. Little is known, however, about the utility of this biomarker to assess the efficacy of antifungal therapies. The pharmacokinetics (PK) and pharmacodynamics (PD) of posaconazole in treatment and prophylaxis were investigated in the persistently neutropenic rabbit model of Aspergillus fumigatus IPA at doses between 2 and 20 mg/kg per day. Sparse plasma sampling was used to obtain PK data at steady state, and the serum galactomannan index (GMI), as a dynamic endpoint of antifungal response, was obtained every other day, in addition to conventional outcome parameters including survival and fungal tissue burden. Nonparametric PK/PD model building was performed using the Pmetrics package in R. A one-compartment model with linear elimination best described the PK of posaconazole. The PD effect of posaconazole exposure in plasma on the GMI in serum was best described by dynamic Hill functions reflecting growth and killing of the fungus. Through calculations of the area under the concentration-time curve from 0 to 24 h (AUC0-24) at steady state, the exposure-response relationship between posaconazole and the GMI for treatment followed a sigmoidal function with an asymptote forming above an AUC0-24 of 30 mg · h/liter. All prophylactic doses were able to control the fungal burden. A nonparametric population PK/PD model adequately described the effect of posaconazole in prophylaxis and treatment of experimental IPA. An AUC0-24 greater than 30 mg · h/liter was associated with adequate resolution of the GMI, which well supports previously suggested exposure-response relationships in humans.
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Kraljevic M, Khanna N, Medinger M, Passweg J, Masouridi-Levrat S, Chalandon Y, Mueller NJ, Schanz U, Vernaz N, Van Delden C, Neofytos D. Clinical considerations on posaconazole administration and therapeutic drug monitoring in allogeneic hematopoietic cell transplant recipients. Med Mycol 2020; 59:701-711. [PMID: 33381803 DOI: 10.1093/mmy/myaa106] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/14/2020] [Accepted: 12/03/2020] [Indexed: 12/26/2022] Open
Abstract
There is a paucity of data on posaconazole (PCZ) dosing and therapeutic-drug-monitoring (TDM) in allogeneic hematopoietic cell transplant recipients (allogeneic-HCTr). This was a 3-year retrospective multicenter study (January 1, 2016 to December 31, 2018) in adult allogeneic-HCTr who received PCZ (intravenously, IV and/or as delayed-release tablet, DRT) as prophylaxis or treatment for ≥7 consecutive days (D) with at least 1-PCZ-level available using data of the Swiss Transplant Cohort Study. The primary objective was to describe the distribution of PCZ-level and identify predictors of therapeutic PCZ-level and associations between PCZ-dosing and PCZ-level. A total of 288 patients were included: 194 (67.4%) and 94 (32.6%) received PCZ as prophylaxis and treatment, respectively, for a median of 90 days (interquartile range, IQR: 42-188.5). There were 1944 PCZ-level measurements performed, with a median PCZ level of 1.3 mg/L (IQR: 0.8-1.96). PCZ-level was <0.7 mg/L in 383/1944 (19.7%) and <1.0 mg/L in 656/1944 (33.7%) samples. PCZ-level was <0.7 mg/L in 260/1317 (19.7%) and <1.0 mg/L in 197/627 (31.4%) in patients who received PCZ-prophylaxis versus treatment, respectively. There were no significant differences in liver function tests between baseline and end-of-treatment. There were nine (3.1%) breakthrough invasive fungal infections (bIFI), with no difference in PCZ levels between patients with or without bIFI. Despite a very intensive PCZ-TDM, PCZ-levels remain below target levels in up to one-third of allogeneic-HCTr. Considering the low incidence of bIFI observed among patients with PCZ levels in the targeted range, our data challenge the clinical utility of routine universal PCZ-TDM.
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Affiliation(s)
- Mateja Kraljevic
- Division of Infectious Diseases, University Hospital of Basel, Basel, Switzerland
| | - Nina Khanna
- Division of Infectious Diseases, University Hospital of Basel, Basel, Switzerland
| | - Michael Medinger
- Department of Hematology, Bone Marrow Transplant Unit, University Hospital of Basel, Basel, Switzerland
| | - Jakob Passweg
- Department of Hematology, Bone Marrow Transplant Unit, University Hospital of Basel, Basel, Switzerland
| | - Stavroula Masouridi-Levrat
- Hematology Division, Oncology Department, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Yves Chalandon
- Hematology Division, Oncology Department, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nicolas J Mueller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, Switzerland
| | - Urs Schanz
- Department of Hematology, Bone Marrow Transplant Unit, University Hospital of Zurich, Zurich, Switzerland
| | - Nathalie Vernaz
- Medical Directorate, Finance Directorate Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Christian Van Delden
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Dionysios Neofytos
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
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Abstract
Posaconazole is typically used for preventing invasive yeast and mold infections such as invasive aspergillosis in high-risk immunocompromised patients. The oral suspension was the first released formulation and many pharmacokinetic and pharmacodynamic studies of this formulation have been published. Erratic absorption profiles associated with this formulation were widely reported. Posaconazole exposure was found to be significantly influenced by food and many gastrointestinal conditions, including pH and motility. As a result, low posaconazole plasma concentrations were obtained in large groups of patients. These issues of erratic absorption urged the development of the subsequently marketed delayed-release tablet, which proved to be associated with higher and more stable exposure profiles. Shortly thereafter, an intravenous formulation was released for patients who are not able to take oral formulations. Both new formulations require a loading dose on day 1 to achieve high posaconazole concentrations more quickly, which was not possible with the oral suspension. So far, there appears to be no evidence of increased toxicity correlated to the higher posaconazole exposure achieved with the regimen for these formulations. The higher systemic availability of posaconazole for the delayed-release tablet and intravenous formulation have resulted in these two formulations being preferable for both prophylaxis and treatment of invasive fungal disease. This review aimed to integrate the current knowledge on posaconazole pharmacokinetics, pharmacodynamics, major toxicity, existing resistance, clinical experience in special populations, and new therapeutic strategies in order to get a clear understanding of the clinical use of this drug.
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Arastehfar A, Gabaldón T, Garcia-Rubio R, Jenks JD, Hoenigl M, Salzer HJF, Ilkit M, Lass-Flörl C, Perlin DS. Drug-Resistant Fungi: An Emerging Challenge Threatening Our Limited Antifungal Armamentarium. Antibiotics (Basel) 2020; 9:antibiotics9120877. [PMID: 33302565 PMCID: PMC7764418 DOI: 10.3390/antibiotics9120877] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/02/2020] [Accepted: 12/03/2020] [Indexed: 12/14/2022] Open
Abstract
The high clinical mortality and economic burden posed by invasive fungal infections (IFIs), along with significant agricultural crop loss caused by various fungal species, has resulted in the widespread use of antifungal agents. Selective drug pressure, fungal attributes, and host- and drug-related factors have counteracted the efficacy of the limited systemic antifungal drugs and changed the epidemiological landscape of IFIs. Species belonging to Candida, Aspergillus, Cryptococcus, and Pneumocystis are among the fungal pathogens showing notable rates of antifungal resistance. Drug-resistant fungi from the environment are increasingly identified in clinical settings. Furthermore, we have a limited understanding of drug class-specific resistance mechanisms in emerging Candida species. The establishment of antifungal stewardship programs in both clinical and agricultural fields and the inclusion of species identification, antifungal susceptibility testing, and therapeutic drug monitoring practices in the clinic can minimize the emergence of drug-resistant fungi. New antifungal drugs featuring promising therapeutic profiles have great promise to treat drug-resistant fungi in the clinical setting. Mitigating antifungal tolerance, a prelude to the emergence of resistance, also requires the development of effective and fungal-specific adjuvants to be used in combination with systemic antifungals.
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Affiliation(s)
- Amir Arastehfar
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA; (A.A.); (R.G.-R.)
| | - Toni Gabaldón
- Life Sciences Programme, Supercomputing Center (BSC-CNS), Jordi Girona, 08034 Barcelona, Spain;
- Mechanisms of Disease Programme, Institute for Research in Biomedicine (IRB), 08024 Barcelona, Spain
- Catalan Institution for Research and Advanced Studies. Pg. Lluís Companys 23, 08010 Barcelona, Spain
| | - Rocio Garcia-Rubio
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA; (A.A.); (R.G.-R.)
| | - Jeffrey D. Jenks
- Department of Medicine, University of California San Diego, San Diego, CA 92103, USA;
- Clinical and Translational Fungal-Working Group, University of California San Diego, La Jolla, CA 92093, USA;
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
| | - Martin Hoenigl
- Clinical and Translational Fungal-Working Group, University of California San Diego, La Jolla, CA 92093, USA;
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
| | | | - Macit Ilkit
- Division of Mycology, University of Çukurova, 01330 Adana, Turkey
- Correspondence: (M.I.); (D.S.P.); Tel.: +90-532-286-0099 (M.I.); +1-201-880-3100 (D.S.P.)
| | - Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - David S. Perlin
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA; (A.A.); (R.G.-R.)
- Correspondence: (M.I.); (D.S.P.); Tel.: +90-532-286-0099 (M.I.); +1-201-880-3100 (D.S.P.)
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Jia MM, Zhang QW, Qin ZF, Lu RQ, Tian XK, Yang J, Zhang XJ. Deciphering the Relationship Between the Trough Concentration of Posaconazole and Its Efficacy and Safety in Chinese Patients With Hematological Disorders. Front Pharmacol 2020; 11:575463. [PMID: 33154724 PMCID: PMC7586309 DOI: 10.3389/fphar.2020.575463] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/15/2020] [Indexed: 01/24/2023] Open
Abstract
Posaconazole (PCZ) is effective in preventing and salvage treatment invasive fungal infections in patients with hematologic disorders. However, PCZ displays highly variable individual pharmacokinetics affecting its efficacy and safety. To investigate the correlation between PCZ concentration and efficacy and safety, the following key influencing factors were explored. A total of 285 trough plasma concentrations (Cmin) of 81 Chinese patients receiving PCZ oral suspension for prophylaxis or treatment of invasive fungal infections were collected in this study. The relationships between Cmin values and clinical response and hepatotoxicity were investigated as well as the incidence of clinical response under different Cmin values of PCZ with a logistic regression model. The concentration of PCZ showed remarkable differences among patients with haematologic disorders. PCZ Cmin values of 0.76 and 1.0 µg/mL were both associated with an over 80% probability of successful response to prophylaxis and treatment of fungal infections, respectively. No association between Cmin values and hepatotoxicity was noted (P > 0.05). Gender, albumin, and co-administration of proton pump inhibitor (PPI) were identified as independent factors influencing PCZ Cmin by multiple linear regression analysis. Furthermore, patients’ C-reactive protein (CRP), albumin, and co-administration of PPI exhibited significant effects on the therapeutic window of patients receiving PCZ for prophylaxis. The plasma concentration is closely associated with therapeutic efficacy of PCZ. It is necessary to adjust the dosing regimens based on PCZ Cmin to obtain an optimal therapeutic response.
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Affiliation(s)
- Meng-Meng Jia
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Qi-Wen Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Zi-Fei Qin
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Run-Qing Lu
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xue-Ke Tian
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Jing Yang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Xiao-Jian Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
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Tragiannidis A, Herbrüggen H, Ahlmann M, Vasileiou E, Gastine S, Thorer H, Fröhlich B, Müller C, Groll AH. Plasma exposures following posaconazole delayed-release tablets in immunocompromised children and adolescents. J Antimicrob Chemother 2020; 74:3573-3578. [PMID: 31504563 DOI: 10.1093/jac/dkz359] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 07/09/2019] [Accepted: 07/18/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Posaconazole is a recommended option for antifungal prophylaxis in paediatric patients >12 years of age. However, little is known about plasma exposures and safety following administration of the delayed-release tablets (DRTs) in children and adolescents. METHODS In a retrospective observational study, we analysed steady-state trough concentrations of posaconazole in all paediatric patients who had received the DRT formulation between May 2015 and December 2018 for antifungal prophylaxis. Dosing was guided by a published population pharmacokinetic model with weight-based dosing. Drug concentrations in plasma were measured by a validated tandem MS method. Liver function and drug discontinuations due to adverse effects were also assessed. RESULTS A total of 34 patients (21 male, 13 female; median age 12 years, range 5-17 years; median body weight 43.5 kg, range 16-84 kg) undergoing treatment for haemato-oncological disorders (n=23) or immunosuppression for polyarthritis (n=1) or post-allogeneic HSCT (n=11) received posaconazole DRTs for a median of 70 days (range 9-391 days). The median first steady-state trough plasma concentration following model-derived dosing was 1607 ng/mL (range 501-8485 ng/mL) with trough concentrations being above the dosing target of ≥700 ng/mL in 32/34 patients (94%). Considering all (first and subsequent) trough concentrations, target attainment was 90% (63/70 samples). Posaconazole was well tolerated without adverse event-related discontinuations or breakthrough infections. CONCLUSIONS Administration of posaconazole DRTs to paediatric patients guided by a population pharmacokinetic-derived dosing algorithm resulted in predictable and potentially effective exposures and was well tolerated over prolonged time periods.
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Affiliation(s)
- Athanasios Tragiannidis
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany.,Hematology Oncology Unit, 2nd Department of Pediatrics, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Heidrun Herbrüggen
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Martina Ahlmann
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Eleni Vasileiou
- Hematology Oncology Unit, 2nd Department of Pediatrics, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Silke Gastine
- Department of Pharmaceutical and Medical Chemistry, University of Münster, Münster, Germany
| | - Heike Thorer
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Birgit Fröhlich
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Carsten Müller
- Department of Pharmacology, University of Cologne, Cologne, Germany
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
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Bernardo V, Miles A, Fernandez AJ, Liverman R, Tippett A, Yildirim I. Initial posaconazole dosing to achieve therapeutic serum posaconazole concentrations among children, adolescents, and young adults receiving delayed-release tablet and intravenous posaconazole. Pediatr Transplant 2020; 24:e13777. [PMID: 32639095 DOI: 10.1111/petr.13777] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/20/2020] [Accepted: 05/29/2020] [Indexed: 02/06/2023]
Abstract
Posaconazole is a broad-spectrum antifungal used for prophylaxis and treatment of invasive fungal diseases. There are limited data on the optimal dosing, safety, and efficacy of the DRT and IV formulations in immunocompromised pediatric and adolescent patients. We describe our experience including dosing, plasma trough concentrations, safety, and tolerability. Plasma concentrations ≥.7 µg/mL were considered therapeutic for prophylaxis and ≥1.0 µg/mL for treatment. Fifty-four patients (median age of 16 years) received DRT or IV formulations of posaconazole. Thirty-one (57%) patients received posaconazole for treatment and 23 (43%) for prophylaxis. Overall, 36 (67%) patients achieved targeted initial plasma trough concentrations (median 1.3 µg/mL) (Figure 1). The median daily dose among patients <13 years of age who achieved the targeted initial concentrations was 7.3 mg/kg/day for the DRT formulation and 9.8 mg/kg/day for the IV formulation. The median daily dose among patients ≥13 years of age who achieved the targeted initial concentrations was 4.9 mg/kg/day for the DRT formulation and 5.6 mg/kg/day for the IV formulation. Thirty-six patients (67%) developed transaminitis, mostly grade 1. Our observations show that DRT and IV formulations are safe and effective in immunocompromised children, adolescents, and young adults. Higher dosing per body weight of DRT and IV posaconazole may be required in patients <13 years of age compared with patients 13 years of age and older to achieve therapeutic plasma concentrations. [Figure: see text].
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Affiliation(s)
| | - Alyssa Miles
- University of North Carolina Health Care, Chapel Hill, NC, USA
| | | | | | - Ashley Tippett
- Division of Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Inci Yildirim
- Children's Healthcare of Atlanta, Atlanta, GA, USA.,Division of Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
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De Paula DCC, Leite EA, Araujo CM, Branquinho RT, Guimarães HN, Grabe-Guimarães A. Caspofungin Effects on Electrocardiogram of Mice: An Evaluation of Cardiac Safety. Cardiovasc Toxicol 2020; 21:93-105. [PMID: 32845461 DOI: 10.1007/s12012-020-09599-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/11/2020] [Indexed: 01/02/2023]
Abstract
Caspofungin is an echinocandin, exhibiting efficacy against most Candida species invasive infection. Its cardiotoxicity was reported in isolated rat heart and ventricular myocytes, but in vivo and clinical studies are insufficient. Our objective was to evaluate caspofungin in vivo cardiac effects using an efficacious dose against Candida albicans. Female Swiss mice were infected with C. albicans, and treated with caspofungin, 5 or 10 mg/kg, intraperitoneal along 5 days. Survival rate and colony-forming units (CFU) into vital organs were determined. For cardiac effects study, mice were treated with caspofungin 10 mg/kg, and electrocardiogram (ECG) signal was obtained on C. albicans-infected mice, single dose-treated, and uninfected mice treated along 5 days, both groups to measure ECG intervals. Besides, ECG was also obtained by telemetry on uninfected mice to evaluate heart rate variability (HRV) parameters. The MIC for caspofungin on the wild-type C. albicans SC5314 strain was 0.3 μg/ml, indicating the susceptible. Survival rate increased significantly in infected mice treated with caspofungin compared to mice treated with vehicle. None of the survived infected mice presented positive CFU after treatment with 10 mg/kg. C. albicans infection induced prolongation of QRS, QT, and QTc intervals; caspofungin did not alter this effect. Caspofungin induced increase of PR and an additional increase of QRS after 24 h of a single dose in infected mice. No significant alterations occurred in ECG intervals and HRV parameters of uninfected mice, after caspofungin treatment. Caspofungin showed in vivo cardiac relative safety maintaining its antifungal efficacy against C. albicans.
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Affiliation(s)
- Danielle Cristiane Correa De Paula
- Pharmaceutical Science Program (CiPharma), School of Pharmacy, Federal University of Ouro Preto, Campus Morro do Cruzeiro, s/n, Ouro Preto, Minas Gerais, 35400-000, Brazil
| | - Elaine Amaral Leite
- Department of Pharmaceutical Products, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Carolina Morais Araujo
- Pharmaceutical Science Program (CiPharma), School of Pharmacy, Federal University of Ouro Preto, Campus Morro do Cruzeiro, s/n, Ouro Preto, Minas Gerais, 35400-000, Brazil
| | - Renata Tupinambá Branquinho
- Pharmaceutical Science Program (CiPharma), School of Pharmacy, Federal University of Ouro Preto, Campus Morro do Cruzeiro, s/n, Ouro Preto, Minas Gerais, 35400-000, Brazil
| | - Homero Nogueira Guimarães
- Department of Electrical Engineering, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Andrea Grabe-Guimarães
- Pharmaceutical Science Program (CiPharma), School of Pharmacy, Federal University of Ouro Preto, Campus Morro do Cruzeiro, s/n, Ouro Preto, Minas Gerais, 35400-000, Brazil.
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Lin S, Kuo C, Shen L, Chen Y, Hung C, Wu FL. Implementation and outcomes of a therapeutic drug monitoring program for antifungal and antiretroviral agents in a tertiary medical center in Taiwan. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Shu‐Wen Lin
- Graduate Institute of Clinical Pharmacy National Taiwan University College of Medicine Taipei Taiwan
- School of Pharmacy National Taiwan University College of Medicine Taipei Taiwan
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
| | - Ching‐Hua Kuo
- School of Pharmacy National Taiwan University College of Medicine Taipei Taiwan
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
| | - Li‐Jiuan Shen
- Graduate Institute of Clinical Pharmacy National Taiwan University College of Medicine Taipei Taiwan
- School of Pharmacy National Taiwan University College of Medicine Taipei Taiwan
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
| | - Yee‐Chun Chen
- Department of Internal Medicine National Taiwan University Hospital, National Taiwan University College of Medicine Taipei Taiwan
| | - Chien‐Ching Hung
- Department of Internal Medicine National Taiwan University Hospital, National Taiwan University College of Medicine Taipei Taiwan
- Department of Tropical Medicine and Parasitology National Taiwan University College of Medicine Taipei Taiwan
| | - Fe‐Lin Lin Wu
- Graduate Institute of Clinical Pharmacy National Taiwan University College of Medicine Taipei Taiwan
- School of Pharmacy National Taiwan University College of Medicine Taipei Taiwan
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
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Groll AH, Abdel-Azim H, Lehrnbecher T, Steinbach WJ, Paschke A, Mangin E, Winchell GA, Waskin H, Bruno CJ. Pharmacokinetics and safety of posaconazole intravenous solution and powder for oral suspension in children with neutropenia: an open-label, sequential dose-escalation trial. Int J Antimicrob Agents 2020; 56:106084. [PMID: 32682946 DOI: 10.1016/j.ijantimicag.2020.106084] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/18/2020] [Accepted: 07/05/2020] [Indexed: 12/24/2022]
Abstract
Posaconazole is approved for use in adults as an intravenous (IV) solution and two different oral formulations (a suspension and an improved bioavailability tablet). Data on the pharmacokinetics (PK), dosing and safety of posaconazole in children are limited. A novel powder for oral suspension (PFS) offers the bioavailability of the tablet formulated for weight-based dosing in children. A non-randomised, open-label, sequential dose-escalation, phase 1b trial evaluated the PK and safety of posaconazole IV and PFS in children aged 2 to 17 years with documented or expected neutropenia (ClinicalTrials.gov, NCT02452034; MSD protocol number, MK-5592-P097). Participants received posaconazole IV 3.5, 4.5 or 6.0 mg/kg/d for ≥10 days, with an option to switch to posaconazole PFS at the identical dose for ≤18 days. The target exposure was a mean within-dose cohort average steady-state plasma concentration (Cavg) of ~1200 ng/mL, with ~90% of participants achieving Cavg between 500 and 2500 ng/mL. Doses of 4.5 and 6.0 mg/kg/d achieved the PK target of ~90% of participants with a Cavg ≥500 ng/mL. PFS resulted in lower posaconazole exposures than IV across age groups at all doses. Posaconazole IV and PFS were well tolerated and had safety profiles similar to those reported for adults. Posaconazole PK following IV and PFS administration was well characterised by the data and enable selection of appropriate paediatric doses. Both formulations were well tolerated without dose-, exposure- or age-related differences in the safety profiles.
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Affiliation(s)
- Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany.
| | - Hisham Abdel-Azim
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Thomas Lehrnbecher
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University of Frankfurt, Frankfurt, Germany
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Kim HY, Märtson AG, Dreesen E, Spriet I, Wicha SG, McLachlan AJ, Alffenaar JW. Saliva for Precision Dosing of Antifungal Drugs: Saliva Population PK Model for Voriconazole Based on a Systematic Review. Front Pharmacol 2020; 11:894. [PMID: 32595511 PMCID: PMC7304296 DOI: 10.3389/fphar.2020.00894] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 06/01/2020] [Indexed: 12/16/2022] Open
Abstract
Precision dosing for many antifungal drugs is now recommended. Saliva sampling is considered as a non-invasive alternative to plasma sampling for therapeutic drug monitoring (TDM). However, there are currently no clinically validated saliva models available. The aim of this study is firstly, to conduct a systematic review to evaluate the evidence supporting saliva-based TDM for azoles, echinocandins, amphotericin B, and flucytosine. The second aim is to develop a saliva population pharmacokinetic (PK) model for eligible drugs, based on the evidence. Databases were searched up to July 2019 on PubMed® and Embase®, and 14 studies were included in the systematic review for fluconazole, voriconazole, itraconazole, and ketoconazole. No studies were identified for isavuconazole, posaconazole, flucytosine, amphotericin B, caspofungin, micafungin, or anidulafungin. Fluconazole and voriconazole demonstrated a good saliva penetration with an average S/P ratio of 1.21 (± 0.31) for fluconazole and 0.56 (± 0.18) for voriconazole, both with strong correlation (r = 0.89–0.98). Based on the evidence for TDM and available data, population PK analysis was performed on voriconazole using Nonlinear Mixed Effects Modeling (NONMEM 7.4). 137 voriconazole plasma and saliva concentrations from 11 patients (10 adults, 1 child) were obtained from the authors of the included study. Voriconazole pharmacokinetics was best described by one-compartment PK model with first-order absorption, parameterized by clearance of 4.56 L/h (36.9% CV), volume of distribution of 60.7 L, absorption rate constant of 0.858 (fixed), and bioavailability of 0.849. Kinetics of the voriconazole distribution from plasma to saliva was identical to the plasma kinetics, but the extent of distribution was lower, modeled by a scale factor of 0.5 (4% CV). A proportional error model best accounted for the residual variability. The visual and simulation-based model diagnostics confirmed a good predictive performance of the saliva model. The developed saliva model provides a promising framework to facilitate saliva-based precision dosing of voriconazole.
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Affiliation(s)
- Hannah Yejin Kim
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia.,Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia
| | - Anne-Grete Märtson
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, Netherlands
| | - Erwin Dreesen
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Jan-Willem Alffenaar
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia.,Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia
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47
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Van Daele R, Spriet I, Maertens J. Posaconazole in prophylaxis and treatment of invasive fungal infections: a pharmacokinetic, pharmacodynamic and clinical evaluation. Expert Opin Drug Metab Toxicol 2020; 16:539-550. [DOI: 10.1080/17425255.2020.1764939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Ruth Van Daele
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
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48
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Abdul-Aziz MH, Alffenaar JWC, Bassetti M, Bracht H, Dimopoulos G, Marriott D, Neely MN, Paiva JA, Pea F, Sjovall F, Timsit JF, Udy AA, Wicha SG, Zeitlinger M, De Waele JJ, Roberts JA. Antimicrobial therapeutic drug monitoring in critically ill adult patients: a Position Paper .. Intensive Care Med 2020; 46:1127-1153. [PMID: 32383061 PMCID: PMC7223855 DOI: 10.1007/s00134-020-06050-1] [Citation(s) in RCA: 483] [Impact Index Per Article: 120.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/10/2020] [Indexed: 12/12/2022]
Abstract
Purpose This Position Paper aims to review and discuss the available data on therapeutic drug monitoring (TDM) of antibacterials, antifungals and antivirals in critically ill adult patients in the intensive care unit (ICU). This Position Paper also provides a practical guide on how TDM can be applied in routine clinical practice to improve therapeutic outcomes in critically ill adult patients.
Methods Literature review and analysis were performed by Panel Members nominated by the endorsing organisations, European Society of Intensive Care Medicine (ESICM), Pharmacokinetic/Pharmacodynamic and Critically Ill Patient Study Groups of European Society of Clinical Microbiology and Infectious Diseases (ESCMID), International Association for Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT) and International Society of Antimicrobial Chemotherapy (ISAC). Panel members made recommendations for whether TDM should be applied clinically for different antimicrobials/classes. Results TDM-guided dosing has been shown to be clinically beneficial for aminoglycosides, voriconazole and ribavirin. For most common antibiotics and antifungals in the ICU, a clear therapeutic range has been established, and for these agents, routine TDM in critically ill patients appears meritorious. For the antivirals, research is needed to identify therapeutic targets and determine whether antiviral TDM is indeed meritorious in this patient population. The Panel Members recommend routine TDM to be performed for aminoglycosides, beta-lactam antibiotics, linezolid, teicoplanin, vancomycin and voriconazole in critically ill patients. Conclusion Although TDM should be the standard of care for most antimicrobials in every ICU, important barriers need to be addressed before routine TDM can be widely employed worldwide. Electronic supplementary material The online version of this article (10.1007/s00134-020-06050-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia
| | - Jan-Willem C Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Westmead Hospital, Westmead, NSW, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa, Genoa and Hospital Policlinico San Martino - IRCCS, Genoa, Italy
| | - Hendrik Bracht
- Department of Anaesthesiology, University Ulm, Ulm, Germany
| | - George Dimopoulos
- Department of Critical Care, University Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
| | - Deborah Marriott
- Department of Microbiology and Infectious Diseases, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Michael N Neely
- Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Division of Infectious Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jose-Artur Paiva
- Department of Medicine, Faculty of Medicine of Porto, Porto, Portugal.,Department of Emergency and Intensive Care Medicine, Centro Hospitalar Universitario de São João, Porto, Portugal
| | - Federico Pea
- Institute of Clinical Pharmacology, SM Misericordia University Hospital, ASUFC, Udine, Italy
| | - Fredrik Sjovall
- Department of Perioperative Medicine, Skåne University Hospital, Malmö, Sweden
| | - Jean F Timsit
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, Paris, France.,Infection, Antimicrobials, Modelling, Evolution (IAME), Paris Diderot University, Paris, France
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia. .,Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia. .,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia. .,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
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49
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Schauwvlieghe AFAD, Buil JB, Verweij PE, Hoek RAS, Cornelissen JJ, Blijlevens NMA, Henriet SSV, Rijnders BJA, Brüggemann RJM. High-dose posaconazole for azole-resistant aspergillosis and other difficult-to-treat mould infections. Mycoses 2019; 63:122-130. [PMID: 31660650 PMCID: PMC7003872 DOI: 10.1111/myc.13028] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/23/2019] [Accepted: 10/24/2019] [Indexed: 12/12/2022]
Abstract
Background Oral follow‐up therapy is problematic in moulds with reduced azole‐susceptibility, such as azole‐resistant Aspergillus fumigatus infection. Currently, only intravenous liposomal amphotericin B (L‐AmB) is advocated by guidelines for the treatment of azole‐resistant aspergillosis infections. Preclinical research indicates that high‐dose posaconazole (HD‐POS) might be a feasible option provided that high drug exposure (ie POS serum through levels >3 mg/L) can be achieved and is safe. Objectives To describe our experience with the use of oral HD‐POS as treatment strategies for patients infected with pathogens with a POS MIC close to the clinical breakpoint. Patients/Methods We review evidence supporting the use of HD‐POS and describe our experience on safety and efficacy in 16 patients. In addition, we describe the adverse events (AE) observed in 25 patients with POS concentrations at the higher end of the population distribution during treatment with the licensed dose. Results Sixteen patients were treated intentionally with HD‐POS for voriconazole‐resistant invasive aspergillosis (7/16), mucormycosis (4/16), salvage therapy for IA (4/16) and IA at a sanctuary site (spondylodiscitis) in 1. Grade 3‐4 AEs were observed in 6, and all of them were considered at least possibly related. Grade 3‐4 AEs were observed in 5 of the 25 patients with spontaneous high POS serum through levels considered at least possibly related using Naranjo scale. Conclusions High‐dose posaconazole is a treatment option if strict monitoring for both exposure and for AE is possible.
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Affiliation(s)
- Alexander F A D Schauwvlieghe
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands.,Department of Haematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jochem B Buil
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - Rogier A S Hoek
- Department of Pulmonary Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Jan J Cornelissen
- Department of Haematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Stefanie S V Henriet
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands.,Department of Paediatric Infectious Diseases and Immunology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Bart J A Rijnders
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Roger J M Brüggemann
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands.,Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
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50
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Oh J, Kang C, Kim S, Huh K, Cho SY, Chung DR, Lee S, Jung CW, Peck KR. Antifungal prophylaxis with posaconazole tablet and oral suspension in patients with haematologic malignancy: Therapeutic drug monitoring, efficacy and risk factors for the suboptimal level. Mycoses 2019; 63:89-94. [DOI: 10.1111/myc.13020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 02/03/2023]
Affiliation(s)
- Jihyu Oh
- Division of Infectious Disease Kangdong Sacred Heart HospitalHallym University college of Medicine Seoul Korea
- Division of Infectious Disease Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Cheol‐In Kang
- Division of Infectious Disease Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Si‐Ho Kim
- Division of Infectious Disease Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Kyungmin Huh
- Division of Infectious Disease Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Sun Young Cho
- Division of Infectious Disease Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Doo Ryeon Chung
- Division of Infectious Disease Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Soo‐Youn Lee
- Department of Laboratory Medicine and Genetics Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Chul Won Jung
- Division of Hematology‐Oncology Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Kyong Ran Peck
- Division of Infectious Disease Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
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