1
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Zhou JX, Xiong CL, Chang ZS, Yin YC, Su KP, Zhang JH, Wu JC, Sun B. Association of procalcitonin with voriconazole concentrations: a retrospective cohort study. BMC Infect Dis 2024; 24:952. [PMID: 39256640 PMCID: PMC11389108 DOI: 10.1186/s12879-024-09862-4] [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: 05/30/2024] [Accepted: 09/02/2024] [Indexed: 09/12/2024] Open
Abstract
Inflammation is a potential risk factor of voriconazole (VCZ) overdose, procalcitonin (PCT) is reported to act as a diagnostic marker for bacterial infections. However, the association of PCT with VCZ trough serum concentrations (VCZ-Cmin) is not fully clear. Our study aims to investigate the associations between PCT and VCZ-Cmin. In this retrospective cohort study, we collected the clinical data of 147 patients who received VCZ and monitored the VCZ concentration of them in our hospital from August 2017 to August 2021. All patients underwent routine clinical examinations on the day or the day before VCZ administration. General information and clinical symptoms of these patients were recorded. Multivariate liner analysis showed that PCT was significantly associated with VCZ-Cmin (p < 0.001). Overall, it was shown that VCZ-Cmin was significantly increased by 0.32 µg/mL for each fold increment in PCT in crude model. In the minor adjusted model (Model 1, adjustment for sex, age, albumin, direct bi1irubin, WBC) and fully adjusted model (Model 2, adjustment for sex, age, albumin, direct bilirubin, WBC, AST and ALT), VCZ-Cmin was significantly increased by 0.23 µg/mL and 0.21 µg/mL, respectively, for each fold increment in PCT. In conclusion, this research reveals the correlation between PCT and VCZ-Cmin, indicating that PCT has the potential to serve as a valuable biomarker for drug monitoring in the treatment of VCZ.
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Affiliation(s)
- Ju-Xiang Zhou
- Department of Pharmacy, The Central Hospital of Shaoyang, Shaoyang, 422000, Hunan, China
| | - Chun-Lin Xiong
- Department of Pharmacy, The Central Hospital of Shaoyang, Shaoyang, 422000, Hunan, China
| | - Zao-Shang Chang
- Department of Physiology, Pu Ai Medical School, Shaoyang University, Shaoyang, 422000, Hunan, China
| | - You-Cong Yin
- Department of Pharmacy, The Central Hospital of Shaoyang, Shaoyang, 422000, Hunan, China
| | - Kai-Peng Su
- Department of Physiology, Pu Ai Medical School, Shaoyang University, Shaoyang, 422000, Hunan, China
| | - Ji-Hong Zhang
- Department of Pharmacy, The Central Hospital of Shaoyang, Shaoyang, 422000, Hunan, China.
| | - Ji-Chu Wu
- Department of gerontology, Shaoyang Central Hospital, Shaoyang, 422000, Hunan, China.
| | - Bao Sun
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, No. 139, People's Middle Street, Changsha, 410011, China.
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2
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Klomp SD, Veringa A, Alffenaar JC, de Boer MGJ, Span LFR, Guchelaar H, Swen JJ. Inflammation altered correlation between CYP2C19 genotype and CYP2C19 activity in patients receiving voriconazole. Clin Transl Sci 2024; 17:e13887. [PMID: 39010708 PMCID: PMC11250525 DOI: 10.1111/cts.13887] [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: 05/08/2024] [Revised: 06/24/2024] [Accepted: 06/27/2024] [Indexed: 07/17/2024] Open
Abstract
Voriconazole is the cornerstone of the treatment and prevention of fungal infections. While there is a good correlation between CYP2C19 genotype and voriconazole exposure during prophylactic treatment, no correlation was found in patients with invasive aspergillosis. Proinflammatory cytokines result in inhibition of CYP2C19 enzyme activity (and may result in phenoconversion). Here we investigated the relationship between inflammation, CYP2C19 genotype-predicted-phenotype, and CYP2C19 activity in patients receiving voriconazole. Data were obtained from two prospective studies investigating voriconazole treatment (NCT02074462 and NCT00893555). Dose-corrected voriconazole plasma concentration and C-reactive protein (CRP) were used as proxies for CYP2C19 activity and inflammation, respectively. After data extraction and synthesis, data from 39 patients with paired voriconazole and CRP measurements were available. The distribution of CYP2C19 genotype-predicted metabolizer phenotypes was 31% intermediate (IM), 41% normal (NM), and 28% rapid metabolizer (RM). During inflammation, dose-corrected voriconazole levels were increased by 245%, 278%, and 486% for CYP2C19 NMs IMs and RMs, respectively. Patients with moderate or high CRP levels (>50 mg/L) were phenoconverted to a lower metabolizer phenotype irrespective of their CYP2C19 genotype. In a subgroup analysis of eight patients with longitudinal data available with and without inflammation, the pattern of the dose-corrected voriconazole and CRP measurements were similar, with CYP2C19 activity following decreasing or increasing CRP levels. In conclusion, voriconazole plasma concentrations increase during inflammation due to downregulation of CYP2C19 activity. While this effect appears largest for CYP2C19 RMs, no clinically relevant differences were observed between the CYP2C19 genotypes.
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Affiliation(s)
- Sylvia D. Klomp
- Department of Clinical Pharmacy & ToxicologyLeiden University Medical CenterLeidenThe Netherlands
| | - Anette Veringa
- Department of Clinical Pharmacy and PharmacologyUniversity Medical Center GroningenGroningenThe Netherlands
- Apotheek, OLVGAmsterdamThe Netherlands
| | - Jan‐Willem C. Alffenaar
- Department of Clinical Pharmacy and PharmacologyUniversity Medical Center GroningenGroningenThe Netherlands
- Faculty of Medicine and HealthSydney School of PharmacySydneyNew South WalesAustralia
- The University of Sydney Institute for Infectious DiseasesSydneyNew South WalesAustralia
- Westmead HospitalSydneyNew South WalesAustralia
| | - Mark G. J. de Boer
- Department of Infectious DiseasesLeiden University Medical CenterLeidenThe Netherlands
| | - Lambert F. R. Span
- Department of HematologyUniversity Medical Center GroningenGroningenThe Netherlands
| | - Henk‐Jan Guchelaar
- Department of Clinical Pharmacy & ToxicologyLeiden University Medical CenterLeidenThe Netherlands
| | - Jesse J. Swen
- Department of Clinical Pharmacy & ToxicologyLeiden University Medical CenterLeidenThe Netherlands
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3
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Liu XI, Leong R, Burckart GJ, Dallmann A. Physiologically Based Pharmacokinetic Modeling of Nilotinib for Drug-Drug Interactions, Pediatric Patients, and Pregnancy and Lactation. J Clin Pharmacol 2024; 64:323-333. [PMID: 37909674 DOI: 10.1002/jcph.2379] [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: 07/09/2023] [Accepted: 10/23/2023] [Indexed: 11/03/2023]
Abstract
Nilotinib is a second-generation BCR-ABL tyrosine kinase inhibitor for the treatment of Philadelphia chromosome-positive chronic myeloid leukemia in both adult and pediatric patients. The pharmacokinetics (PK) of nilotinib in specific populations such as pregnant and lactating people remain poorly understood. Therefore, the objectives of the current study were to develop a physiologically based pharmacokinetic (PBPK) model to predict nilotinib PK in virtual drug-drug interaction (DDI) studies, as well as in pediatric, pregnant, and lactating populations. The nilotinib PBPK model was built in PK-Sim, which is part of the free and open-source software Open Systems Pharmacology. The observed clinical data for the validation of the nilotinib models were obtained from the literature. The model reasonably predicted nilotinib concentrations in the adult population; the DDIs between nilotinib and rifampin or ketoconazole in the adult population; and the PK in the pediatric, pregnant, and lactating populations, although in the latter 2 populations plasma concentrations were slightly underestimated. The ratio of predicted versus observed PK parameters for the adult model ranged from 0.71 to 1.11 for area under the concentration-time curve and 0.55 to 0.95 for maximum concentration. For the DDI, the predicted area under the concentration-time curve ratio and maximum concentration ratio fell within the Guest criterion. The current study demonstrated the utility of using PBPK modeling to understand the mechanistic basis of PK differences between adults and specific populations, such as pediatrics, and pregnant and lactating individuals, indicating that this technology can potentially inform or optimize dosing conditions in specific populations.
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Affiliation(s)
- Xiaomei I Liu
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
| | - Ruby Leong
- Office of Clinical Pharmacology, US Food and Drug Administration, Silver Spring, MD, USA
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, US Food and Drug Administration, Silver Spring, MD, USA
| | - André Dallmann
- Bayer HealthCare SAS, Loos, France, on behalf of: Pharmacometrics/Modeling and Simulation, Research and Development, Pharmaceuticals, Bayer AG, Leverkusen, Germany
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4
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Yasu T, Gando Y, Shirota M, Kosugi N, Kobayashi M. Association between plasma venetoclax trough levels and serum C-reactive protein levels in patients with acute myeloid leukemia treated with venetoclax plus azacitidine. Leuk Lymphoma 2024; 65:128-131. [PMID: 37797220 DOI: 10.1080/10428194.2023.2264427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/22/2023] [Indexed: 10/07/2023]
Affiliation(s)
- Takeo Yasu
- Department of Medicinal Therapy Research, Pharmaceutical Education and Research Center, Meiji Pharmaceutical University, Tokyo, Japan
- Bokutoh Hospital-Meiji Pharmaceutical University Joint Research Center, Tokyo, Japan
- Department of Pharmacy, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yoshito Gando
- Department of Medicinal Therapy Research, Pharmaceutical Education and Research Center, Meiji Pharmaceutical University, Tokyo, Japan
| | - Mikio Shirota
- Bokutoh Hospital-Meiji Pharmaceutical University Joint Research Center, Tokyo, Japan
- Department of Pharmacy, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Nobuharu Kosugi
- Department of Hematology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Masayuki Kobayashi
- Bokutoh Hospital-Meiji Pharmaceutical University Joint Research Center, Tokyo, Japan
- Department of Hematology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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5
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Boglione-Kerrien C, Zerrouki S, Le Bot A, Camus C, Marchand T, Bellissant E, Tron C, Verdier MC, Gangneux JP, Lemaitre F. Can we predict the influence of inflammation on voriconazole exposure? An overview. J Antimicrob Chemother 2023; 78:2630-2636. [PMID: 37796931 DOI: 10.1093/jac/dkad293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Voriconazole is a triazole antifungal indicated for invasive fungal infections that exhibits a high degree of inter-individual and intra-individual pharmacokinetic variability. Voriconazole pharmacokinetics is non-linear, making dosage adjustments more difficult. Therapeutic drug monitoring is recommended by measurement of minimum plasma concentrations. Several factors are responsible for the high pharmacokinetic variability of voriconazole: age, feeding (which decreases absorption), liver function, genetic polymorphism of the CYP2C19 gene, drug interactions and inflammation. Invasive fungal infections are indeed very frequently associated with inflammation, which engenders a risk of voriconazole overexposure. Many studies have reviewed this topic in both the adult and paediatric populations, but few studies have focused on the specific point of the prediction, to evaluate the influence of inflammation on voriconazole pharmacokinetics. Predicting the impact of inflammation on voriconazole pharmacokinetics could help optimize antifungal therapy and improve patient management. This review summarizes the existing data on the influence of inflammation on voriconazole pharmacokinetics in adult populations. We also evaluate the role of C-reactive protein, the impact of inflammation on patient metabolic phenotypes, and the tools that can be used to predict the effect of inflammation on voriconazole pharmacokinetics.
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Affiliation(s)
- Christelle Boglione-Kerrien
- Rennes University Hospital, Department of Biological Pharmacology, 2, rue Henri le Guilloux, F-35000 Rennes, France
| | - Selim Zerrouki
- Rennes University Hospital, Department of Biochemistry, Rennes, France
| | - Audrey Le Bot
- Rennes University Hospital, Department of Infectious Diseases, Rennes, France
| | - Christophe Camus
- Rennes University Hospital, Department of Intensive Care Medicine, Rennes, France
| | - Tony Marchand
- Rennes University Hospital, Department of Clinical Haematology, Rennes, France
| | - Eric Bellissant
- Rennes University Hospital, Department of Biological Pharmacology, 2, rue Henri le Guilloux, F-35000 Rennes, France
- INSERM, CIC-P 1414 Clinical Investigation Centre, Rennes, France
- Rennes University Hospital, INSERM, EHESP, IRSET (Institut de Recherche en Santé, Environnement et Travail) -UMR_S 1085, F-35000 Rennes, France
| | - Camille Tron
- Rennes University Hospital, Department of Biological Pharmacology, 2, rue Henri le Guilloux, F-35000 Rennes, France
- INSERM, CIC-P 1414 Clinical Investigation Centre, Rennes, France
- Rennes University Hospital, INSERM, EHESP, IRSET (Institut de Recherche en Santé, Environnement et Travail) -UMR_S 1085, F-35000 Rennes, France
| | - Marie-Clémence Verdier
- Rennes University Hospital, Department of Biological Pharmacology, 2, rue Henri le Guilloux, F-35000 Rennes, France
- INSERM, CIC-P 1414 Clinical Investigation Centre, Rennes, France
- Rennes University Hospital, INSERM, EHESP, IRSET (Institut de Recherche en Santé, Environnement et Travail) -UMR_S 1085, F-35000 Rennes, France
| | - Jean-Pierre Gangneux
- Rennes University Hospital, INSERM, EHESP, IRSET (Institut de Recherche en Santé, Environnement et Travail) -UMR_S 1085, F-35000 Rennes, France
- Rennes University Hospital, Department of Parasitology and Mycology, National Reference Centre for Mycoses and Antifungals (LA Asp-C) and European Excellence Centre in Medical Mycology (ECMM EC), Rennes, France
| | - Florian Lemaitre
- Rennes University Hospital, Department of Biological Pharmacology, 2, rue Henri le Guilloux, F-35000 Rennes, France
- INSERM, CIC-P 1414 Clinical Investigation Centre, Rennes, France
- Rennes University Hospital, INSERM, EHESP, IRSET (Institut de Recherche en Santé, Environnement et Travail) -UMR_S 1085, F-35000 Rennes, France
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6
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High-Performance Liquid Chromatography for Ultra-Simple Determination of Plasma Voriconazole Concentration. J Fungi (Basel) 2022; 8:jof8101035. [PMID: 36294600 PMCID: PMC9604553 DOI: 10.3390/jof8101035] [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: 08/05/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Voriconazole is an antifungal drug used to treat invasive aspergillosis. Voriconazole exhibits nonlinear behavior and considerable individual variability in its pharmacokinetic profile. Invasive aspergillosis has a poor prognosis, and failure of treatment owing to low voriconazole blood levels is undesirable. Thus, therapeutic drug monitoring (TDM) of voriconazole is recommended. However, plasma voriconazole concentration is rarely measured in hospitals, and the TDM of voriconazole is not widely practiced in Japan. We aimed to develop an ultra-simple method to measure plasma voriconazole concentration. Ten microliters of plasma sample was extracted, and proteins were precipitated using methanol extraction. Voriconazole and ketoconazole (internal standard) were separated using high-performance liquid chromatography. A calibration curve was prepared, which was linear over plasma voriconazole concentrations of 0.125−12.5 µg/mL, with a coefficient of determination of 0.9999. The intra-day and inter-day validation coefficients were 0.9−2.2% and 1.3−6.1%, respectively. The assay accuracy was −4.2% to 1.6%, and recovery was >97.8%. Our ultra-simple, sensitive, and inexpensive high-performance liquid chromatography ultraviolet method to determine plasma voriconazole concentration will help improve the voriconazole TDM implementation rate and contribute to effective and safe voriconazole use.
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7
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Li X, Lai F, Jiang Z, Li M, Chen Z, Cheng J, Cui H, Wen F. Effects of inflammation on voriconazole levels: a systematic review. Br J Clin Pharmacol 2022; 88:5166-5182. [PMID: 35973037 DOI: 10.1111/bcp.15495] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 11/30/2022] Open
Abstract
AIMS This study aimed to review the studies evaluating the effect of the inflammatory state on voriconazole (VRZ) levels. METHODS The study included randomized clinical trials, cohort studies, and case-control studies that focused on the influence of the inflammatory state on VRZ levels. Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, relevant articles published until 2021 were searched in several databases, including PubMed, Embase, Web of Science, and the Cochrane Library. RESULTS Twenty studies were included in this review, of which 15 described adult populations, 3 described pediatric populations, and 2 included both adult and pediatric populations. Seventeen studies used C-reactive protein (CRP) as an indicator of inflammation, 6 described a dose-response relationship for the effect of inflammation represented by CRP on VRZ concentrations, and 4 examined the effect of CRP on the metabolic rate of VRZ. CONCLUSIONS Our findings showed that the level of inflammation can significantly affect VRZ levels. However, the effect of inflammation on VRZ concentrations in children is controversial and must be analyzed along with age. Clinicians dosing VRZ should take into account the patient's inflammatory state. The impact of inflammation on genotype-based dosing decisions requires further study to explain the high pharmacokinetic variability of VRZ.
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Affiliation(s)
- Xuejuan Li
- Shenzhen Children's Hospital of China Medical University, Shenzhen, China.,Department of Pharmacy, Shenzhen Children's Hospital, Shenzhen, China
| | - Fangyuan Lai
- Department of Pharmacy, Shenzhen Children's Hospital, Shenzhen, China
| | - Zhaohui Jiang
- Department of Oncology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Meng Li
- Department of Pharmacy, Shenzhen Children's Hospital, Shenzhen, China
| | - Zebin Chen
- Department of Pharmacy, Shenzhen Children's Hospital, Shenzhen, China
| | - Junjie Cheng
- Department of Pharmacy, Shenzhen Children's Hospital, Shenzhen, China
| | - Hao Cui
- Department of Pharmacy, Shenzhen Children's Hospital, Shenzhen, China
| | - Feiqiu Wen
- Shenzhen Children's Hospital of China Medical University, Shenzhen, China
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8
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Maeda Y, Tanaka R, Tatsuta R, Takano K, Hashimoto T, Ogata M, Hiramatsu K, Itoh H. Impact of Inflammation on Intra-individual Variation in Trough Voriconazole Concentration in Patients with Hematological Malignancies. Biol Pharm Bull 2022; 45:1084-1090. [DOI: 10.1248/bpb.b22-00097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Yu Maeda
- Department of Clinical Pharmacy, Oita University Hospital
| | - Ryota Tanaka
- Department of Clinical Pharmacy, Oita University Hospital
| | | | | | - Takehiro Hashimoto
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Masao Ogata
- Department of Hematology, Oita University Hospital
| | - Kazufumi Hiramatsu
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Hiroki Itoh
- Department of Clinical Pharmacy, Oita University Hospital
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9
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Chen J, Wu Y, He Y, Feng X, Ren Y, Liu S. Combined Effect of CYP2C19 Genetic Polymorphisms and C-Reactive Protein on Voriconazole Exposure and Dosing in Immunocompromised Children. Front Pediatr 2022; 10:846411. [PMID: 35386257 PMCID: PMC8978631 DOI: 10.3389/fped.2022.846411] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/09/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Pediatric patients have significant interindividual variability in voriconazole exposure. The aim of the study was to identify factors associated with voriconazole concentrations and dose requirements to achieve therapeutic concentrations in pediatric patients. METHODS Medical records of pediatric patients were retrospectively reviewed. Covariates associated with voriconazole plasma concentrations and dose requirements were adjusted by using generalized linear mixed-effect models. RESULTS A total of 682 voriconazole steady-state trough concentrations from 91 Chinese pediatric patients were included. Voriconazole exposure was lower in the CYP2C19 normal metabolizer (NM) group compared with the intermediate metabolizer (IM) group and the poor metabolizer (PM) group (p = 0.0016, p < 0.0001). The median daily dose of voriconazole required to achieve therapeutic range demonstrated a significant phenotypic dose effect: 20.8 mg/kg (range, 16.2-26.8 mg/kg) for the CYP2C19 NM group, 18.2 mg/kg (range, 13.3-21.8 mg/kg) for the CYP2C19 IM group, and 15.2 mg/kg (range, 10.7-19.1 mg/kg) for the CYP2C19 PM group, respectively. The extent of impact of C-reactive protein (CRP) levels on voriconazole trough concentrations and dose requirements varied between CYP2C19 phenotypes. Increases of 20, 120, 245, and 395 mg/L from 5 mg/L in CRP levels were associated with increases in voriconazole trough concentration by 22.22, 50, 64.81, and 75% respectively, in the NM group; by 39.26, 94.48, 123.93, and 146.63%, respectively, in the IM group; and by 17.17, 37.34, 46.78, and 53.65%, respectively, in the PM group. Meanwhile, increases of 20, 120, 245, and 395 mg/L from 5 mg/L in CRP levels were associated with increases in voriconazole dose requirements by 7.15, 14.23, 17.35, and 19.43%, respectively, in the PM group; with decreases in voriconazole dose requirements by 3.71, 7.38, 8.97, and 10.03%, respectively, in the NM group; and with decreases by 4, 9.10, 11.05, and 12.35%, respectively, in the IM group. In addition, age and presence of immunosuppressants had significant effects on voriconazole exposure. CONCLUSIONS Our study suggests that CYP2C19 phenotypes, CRP concentrations, age, and the presence of immunosuppressants were factors associated with the pharmacokinetic changes in voriconazole. There was heterogeneity in the effect of CRP on voriconazole plasma concentrations across different CYP2C19 genotypes. Combining relevant factors with dose adaptation strategies in therapeutic drug monitoring may help to reduce the incidence of subtherapeutic and supratherapeutic concentrations in clinical practice.
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Affiliation(s)
- Juan Chen
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ying Wu
- Department of Biostatistics, Guangdong Provincial Key Laboratory of Tropical Disease Research, School of Public Health, Southern Medical University, Guangzhou, China
| | - Yuelin He
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaoqin Feng
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuqiong Ren
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shiting Liu
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, China
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10
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Lin XB, Hu XG, Xia YZ, Liu XM, Liang T, Chen X, Cai CJ. Voriconazole pharmacokinetics in a critically ill patient during extracorporeal membrane oxygenation. J Chemother 2021; 34:272-276. [PMID: 34904531 DOI: 10.1080/1120009x.2021.2014725] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The pharmacokinetics (PK) of several drugs including antimicrobials might be highly altered during extracorporeal membrane oxygenation (ECMO) therapy. We present the change of voriconazole (VRC) PK during ECMO in a critically ill patient who received intravenous VRC at a maintenance dose of 200 mg every 12 h for empirical antifungal therapy. Two PK profiles were drawn before and after the initiation of ECMO therapy. Though the trough levels (both C0 and C12) with ECMO were slightly lower than that without ECMO (12.58 and 12.84 vs. 14.02 μg/mL), the peak levels and the area under the concentration-time curve from 0 h to 6 h (AUC0-6) were comparable (16.36 vs. 16.06 μg/mL and 90.78 vs. 91.45 μg·h/mL, respectively), indicating that VRC plasma exposure during ECMO therapy did not greatly decrease in our patient. The circuit factors including the type of membrane should be taken into account to further identify the effects of ECMO on the PK of VRC.
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Affiliation(s)
- Xiao-Bin Lin
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiao-Guang Hu
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yan-Zhe Xia
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiao-Man Liu
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Tao Liang
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiao Chen
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chang-Jie Cai
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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11
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Lenoir C, Rollason V, Desmeules JA, Samer CF. Influence of Inflammation on Cytochromes P450 Activity in Adults: A Systematic Review of the Literature. Front Pharmacol 2021; 12:733935. [PMID: 34867341 PMCID: PMC8637893 DOI: 10.3389/fphar.2021.733935] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/13/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Available in-vitro and animal studies indicate that inflammation impacts cytochromes P450 (CYP) activity via multiple and complex transcriptional and post-transcriptional mechanisms, depending on the specific CYP isoforms and the nature of inflammation mediators. It is essential to review the current published data on the impact of inflammation on CYP activities in adults to support drug individualization based on comorbidities and diseases in clinical practice. Methods: This systematic review was conducted in PubMed through 7th January 2021 looking for articles that investigated the consequences of inflammation on CYP activities in adults. Information on the source of inflammation, victim drugs (and CYPs involved), effect of disease-drug interaction, number of subjects, and study design were extracted. Results: The search strategy identified 218 studies and case reports that met our inclusion criteria. These articles were divided into fourteen different sources of inflammation (such as infection, autoimmune diseases, cancer, therapies with immunomodulator…). The impact of inflammation on CYP activities appeared to be isoform-specific and dependent on the nature and severity of the underlying disease causing the inflammation. Some of these drug-disease interactions had a significant influence on drug pharmacokinetic parameters and on clinical management. For example, clozapine levels doubled with signs of toxicity during infections and the concentration ratio between clopidogrel's active metabolite and clopidogrel is 48-fold lower in critically ill patients. Infection and CYP3A were the most cited perpetrator of inflammation and the most studied CYP, respectively. Moreover, some data suggest that resolution of inflammation results in a return to baseline CYP activities. Conclusion: Convincing evidence shows that inflammation is a major factor to be taken into account in drug development and in clinical practice to avoid any efficacy or safety issues because inflammation modulates CYP activities and thus drug pharmacokinetics. The impact is different depending on the CYP isoform and the inflammatory disease considered. Moreover, resolution of inflammation appears to result in a normalization of CYP activity. However, some results are still equivocal and further investigations are thus needed.
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Affiliation(s)
- Camille Lenoir
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Victoria Rollason
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jules A Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Caroline F Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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12
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White CM. Inflammation Suppresses Patients' Ability to Metabolize Cytochrome P450 Substrate Drugs. Ann Pharmacother 2021; 56:809-819. [PMID: 34590872 DOI: 10.1177/10600280211047864] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To assess the impact of inflammation on cytochrome P450 (CYP) drug metabolism in human subjects. DATA SOURCES A PubMed search was done from 1980 to July 2021 limited to human subjects and English language using a search strategy of (((phase I metabolism) OR (CYP) OR (cytochrome P450)) AND (inflammatory OR inflammation)). STUDY SELECTION AND DATA EXTRACTION Narrative review of human studies assessing the impact of inflammation or inflammatory suppression with biologic drugs on CYP drug metabolism were used. DATA SYNTHESIS Patients with inflammatory conditions ranging from fungal, viral, or bacterial infections to noninfectious causes (critical illness, surgical procedure, cancer, or transplantation of stem cells or organs) have suppressed drug metabolism. Markers of inflammation such as C-reactive protein or α-1-acid glycoprotein are correlated with reduced clearance through CYP3A4, CYP1A2, and CYP2C19. Elevated interleukin-6 concentrations are also associated or correlated with reduced clearance for CYP3A4 and CYP2C-19 isoenzymes. There was insufficient information to properly assess CYP2D6. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Health professionals should appreciate that patients with acute or chronic inflammation from infectious or noninfectious causes could have suppressed drug metabolism through CYP3A4, CYP1A2, and CYP2C19. For narrow therapeutic index drugs, such as many of the drugs assessed in this review, that means more judicious drug monitoring to prevent adverse events. CONCLUSIONS Like other types of drug-drug or drug-disease interactions, inflammation can alter the steady-state concentration of CYP metabolized drugs.
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Affiliation(s)
- C Michael White
- University of Connecticut School of Pharmacy, Storrs, CT, USA.,Hartford Hospital, Hartford, CT, USA
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13
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Lenoir C, Rodieux F, Desmeules JA, Rollason V, Samer CF. Impact of Inflammation on Cytochromes P450 Activity in Pediatrics: A Systematic Review. Clin Pharmacokinet 2021; 60:1537-1555. [PMID: 34462878 PMCID: PMC8613112 DOI: 10.1007/s40262-021-01064-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2021] [Indexed: 12/22/2022]
Abstract
Background and Objective Cytochromes P450 (CYP) are the major enzymes involved in hepatic metabolism of drugs. Personalization of treatment in pediatrics is a major challenge, as it must not only take into account genetic, environmental, and physiological factors but also ontogeny. Published data in adults show that inflammation had an isoform-specific impact on CYP activities and we aimed to evaluate this impact in the pediatric population. Methods Articles listed in PubMed through 7 January, 2021 that studied the impact of inflammation on CYP activities in pediatrics were included in this systematic review. Sources of inflammation, victim drugs (CYP involved), effect of drug–disease interactions, number and age of subjects, and study design were extracted. Results Twenty-seven studies and case reports were included. The impact of inflammation on CYP activities appeared to be age dependent and isoform-specific, with some drug–disease interactions having significant pharmacokinetic and clinical impact. For example, midazolam clearance decreases by 70%, while immunosuppressant and theophylline concentrations increase three-fold and two-fold with intensive care unit admission and infection. Cytochrome P450 activity appears to return to baseline level when the disease is resolved. Conclusions Studies that have assessed the impact of inflammation on CYP activity are lacking in pediatrics, yet it is a major factor to consider to improve drug efficacy or safety. The scarce current data show that the impact of inflammation is isoform and age dependent. An effort must be made to improve the understanding of the impact of inflammation on CYP activities in children to better individualize treatment.
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Affiliation(s)
- Camille Lenoir
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), University of Geneva, Geneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Frédérique Rodieux
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Jules A Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), University of Geneva, Geneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Victoria Rollason
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Caroline F Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland. .,Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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14
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Yasu T, Matsumoto Y, Sugita T. Pharmacokinetics of voriconazole and its alteration by Candida albicans infection in silkworms. J Antibiot (Tokyo) 2021; 74:443-449. [PMID: 34045695 DOI: 10.1038/s41429-021-00428-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/14/2021] [Accepted: 05/15/2021] [Indexed: 11/09/2022]
Abstract
Voriconazole (VRCZ) is a triazole antifungal agent used for the treatment and prophylaxis of invasive fungal infections. Therapeutic drug monitoring of VRCZ is widely applied clinically because of the large inter-individual variability that is generally observed in VRCZ exposure. The blood levels of VRCZ are increased during an underlying inflammatory reaction, which is associated with infections. Silkworms are useful experimental animals for evaluating the pharmacokinetics and toxicity of compounds. In this study, we investigated the pharmacokinetic parameters, such as elimination half-life, clearance, and distribution volume of VRCZ using silkworms. The pharmacokinetic parameters of VRCZ were determined based on the concentrations in silkworm hemolymph after injection of VRCZ. The elimination half-life of VRCZ in silkworms was found to be similar to that observed in humans. In addition, we assessed the impact of Candida albicans infection on VRCZ concentrations in a silkworm infection model. The VRCZ concentration at 12 h after injection in the Candida albicans-infected group was significantly higher than that in the non-infected group. In the silkworm infection model, we were able to reproduce the relationship between inflammation and VRCZ blood concentrations, as observed in humans. We demonstrate that silkworms can be an effective alternative model animal for studying the pharmacokinetics of VRCZ. We also show that silkworms can be used to indicate essential infection and inflammation-based pharmacokinetic variations in VRCZ, which is usually observed in the clinic.
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Affiliation(s)
- Takeo Yasu
- Department of Medicinal Therapy Research, Pharmaceutical Education and Research Center, Meiji Pharmaceutical University, Kiyose, Japan.
| | - Yasuhiko Matsumoto
- Department of Microbiology, Meiji Pharmaceutical University, Kiyose, Japan.
| | - Takashi Sugita
- Department of Microbiology, Meiji Pharmaceutical University, Kiyose, Japan
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15
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Nakashima T, Inamoto Y, Fukushi Y, Doke Y, Hashimoto H, Fukuda T, Yamaguchi M. Drug interaction between letermovir and voriconazole after allogeneic hematopoietic cell transplantation. Int J Hematol 2021; 113:872-876. [PMID: 33677768 DOI: 10.1007/s12185-021-03105-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 02/08/2021] [Accepted: 02/18/2021] [Indexed: 12/19/2022]
Abstract
Letermovir has been approved for the prevention of cytomegalovirus (CMV) infection after allogeneic hematopoietic stem cell transplantation (HCT). Letermovir is a cytochrome P450 (CYP) 2C19 inducer. Voriconazole, which is a broad-spectrum triazole antifungal agent, is mainly metabolized by CYP2C19. Thus, voriconazole trough concentration may decrease due to the drug interaction between voriconazole and letermovir. This study aimed to clarify the effects of letermovir on voriconazole trough concentration in allogeneic HCT recipients. We retrospectively examined voriconazole trough concentration in 24 allogeneic HCT recipients who had letermovir for prevention of CMV infection. The median voriconazole C/D ratios significantly decreased after starting letermovir from 0.25 L/kg to 0.11 L/kg (p < 0.01), and increased after discontinuing letermovir from 0.15 L/kg to 0.24 L/kg (p = 0.02). The median fold change of voriconazole trough concentration during letermovir administration was 0.40. Our results suggest that voriconazole trough concentration decreases when voriconazole is combined with letermovir in allogeneic HCT recipients. Therefore, close therapeutic drug monitoring of voriconazole trough concentration is warranted in allogeneic HCT recipients after starting or discontinuing letermovir.
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Affiliation(s)
| | - Yoshihiro Inamoto
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
| | - Yayoi Fukushi
- Department of Pharmacy, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshiyuki Doke
- Department of Pharmacy, National Cancer Center Hospital, Tokyo, Japan
| | | | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
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16
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Chavant A, Gautier-Veyret E, Chhun S, Guilhaumou R, Stanke-Labesque F. [Pharmacokinetic changes related to acute infection. Examples from the SARS-CoV-2 pandemic]. Therapie 2020; 76:319-333. [PMID: 33129512 PMCID: PMC7833468 DOI: 10.1016/j.therap.2020.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/18/2020] [Accepted: 10/12/2020] [Indexed: 01/08/2023]
Abstract
The knowledge of factors of pharmacokinetic variability is important in order to personalize pharmacological treatment, particularly for drugs with a narrow therapeutic range for which pharmacological therapeutic monitoring is recommended. Inflammation is a protective response against acute infections and injuries that contributes to intra- and inter-individual variability in drug exposure by modulating the activity of enzymes involved in drug metabolism, and by altering the binding of drugs to plasma proteins. The understanding of the impact of inflammation on drug metabolism and the related clinical consequences allow to better take into consideration the effect of inflammation on the variability of drug exposure. We first summarized the molecular mechanisms by which inflammation contributes to the inhibition of drug metabolism enzymes. We then presented an updated overview of the consequences of the outcome of acute infectious event on pharmacokinetic exposure of drugs with a narrow therapeutic range and that are substrates of cytochrome P450, and the related clinical consequences. Finally, in the context of the COVID-19 pandemic, we reported examples of drug overexposures in COVID- 19 infected patients.
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Affiliation(s)
- Anaëlle Chavant
- Laboratoire de pharmacologie-pharmacogénétique-toxicologie, pôle de biologie et pathologie, CHU Grenoble Alpes, 38700 La Tronche, France
| | - Elodie Gautier-Veyret
- Laboratoire de pharmacologie-pharmacogénétique-toxicologie, pôle de biologie et pathologie, CHU Grenoble Alpes, 38700 La Tronche, France; University Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, 38043 Grenoble, France
| | - Stéphanie Chhun
- UFR de médecine Paris centre, 75015 Paris, France; Institut Necker-Enfants Malades (INEM), Inserm U1151-CNRS UMR 8253, 75015 Paris, France; Laboratoire d'immunologie biologique, département médico universitaire BioPhyGen, hôpital universitaire Necker-enfants malades, AP-HP, 75015 Paris, France
| | - Romain Guilhaumou
- Unité de pharmacologie clinique et pharmacovigilance AP-HM, 13354 Marseille, France; Aix Marseille Univ, Inserm, INS Inst Neurosci Syst, 13354 Marseille, France
| | - Françoise Stanke-Labesque
- Laboratoire de pharmacologie-pharmacogénétique-toxicologie, pôle de biologie et pathologie, CHU Grenoble Alpes, 38700 La Tronche, France; University Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, 38043 Grenoble, France.
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17
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Stanke-Labesque F, Gautier-Veyret E, Chhun S, Guilhaumou R. Inflammation is a major regulator of drug metabolizing enzymes and transporters: Consequences for the personalization of drug treatment. Pharmacol Ther 2020; 215:107627. [PMID: 32659304 PMCID: PMC7351663 DOI: 10.1016/j.pharmthera.2020.107627] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/06/2020] [Indexed: 12/22/2022]
Abstract
Inflammation is an evolutionary process that allows survival against acute infection or injury. Inflammation is also a pathophysiological condition shared by numerous chronic diseases. In addition, inflammation modulates important drug-metabolizing enzymes and transporters (DMETs), thus contributing to intra- and interindividual variability of drug exposure. A better knowledge of the impact of inflammation on drug metabolism and its related clinical consequences would help to personalize drug treatment. Here, we summarize the kinetics of inflammatory mediators and the underlying transcriptional and post-transcriptional mechanisms by which they contribute to the inhibition of important DMETs. We also present an updated overview of the effect of inflammation on the pharmacokinetic parameters of most of the drugs that are DMET substrates, for which therapeutic drug monitoring is recommended. Furthermore, we provide opinions on how to integrate the inflammatory status into pharmacogenetics, therapeutic drug monitoring, and population pharmacokinetic strategies to improve the personalization of drug treatment for each patient.
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Affiliation(s)
- Françoise Stanke-Labesque
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, Grenoble 38000, France; Laboratory of Pharmacology-Pharmacogenetics-Toxicology, Pôle de Biologie et Pathologie, CHU Grenoble Alpes, France.
| | - Elodie Gautier-Veyret
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, Grenoble 38000, France; Laboratory of Pharmacology-Pharmacogenetics-Toxicology, Pôle de Biologie et Pathologie, CHU Grenoble Alpes, France
| | - Stephanie Chhun
- Faculty of Medicine, Paris University, Paris, France; Institut Necker-Enfants Malades (INEM), INSERM U1151-CNRS UMR 8253, Paris, France; AP-HP, Paris Centre, Laboratory of Immunology, Necker-Enfants Malades Hospital, Paris, France
| | - Romain Guilhaumou
- Clinical Pharmacology and Pharmacovigilance Unit, AP-HM, Marseille, France; Aix Marseille Univ, INSERM, INS Inst Neurosci Syst, Marseille, France
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18
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Luo X, Li T, Hu L, Liu S, Zhao H, Zhang J, Feng Y, Huang L. Differential effects of C-reactive protein levels on voriconazole metabolism at three age groups in allogeneic hematopoietic cell transplant recipients. J Chemother 2020; 33:95-105. [PMID: 32441568 DOI: 10.1080/1120009x.2020.1765604] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The aim of this study was to evaluate the impact of inflammation on voriconazole (VRCZ) metabolism at three age groups in the allogeneic hematopoietic cell transplant recipients of the Chinese population. The study was performed with collecting more than one VRCZ trough concentration and C-reactive protein (CRP) levels. Longitudinal analysis, correlation and comparative analysis were conducted to evaluate. A total of 104 patients with 386 VRCZ trough concentration and CRP level measured on the same day were collected. For children, CRP levels significantly associated with VRCZ pharmacokinetics in age 11-18 years but not in age 2-10 years. For adults, VRCZ concentrations were increased slightly by 0.006 mg/L when every 1 mg/L increased in CRP levels. Additionally, meropenem and inflammation might work together to cause a higher VRCZ concentration. Therefore, therapeutic drug monitoring of VRCZ should be warranted at age >10 years in allogeneic hematopoietic cell transplant recipients with elevated CRP level.
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Affiliation(s)
- Xingxian Luo
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Taifeng Li
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Lei Hu
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Silu Liu
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Haiyan Zhao
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Jiaqi Zhang
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Yufei Feng
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Lin Huang
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
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19
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Ren QX, Li XG, Mu JS, Bi JF, Du CH, Wang YH, Zhu H, Lv P, Zhao QG. Population Pharmacokinetics of Voriconazole and Optimization of Dosage Regimens Based on Monte Carlo Simulation in Patients With Liver Cirrhosis. J Pharm Sci 2019; 108:3923-3931. [PMID: 31562869 DOI: 10.1016/j.xphs.2019.09.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/19/2019] [Accepted: 09/19/2019] [Indexed: 12/21/2022]
Abstract
Because voriconazole metabolism is highly influenced by liver function, the dose regimen of voriconazole should be carefully assessed in patients with liver cirrhosis. We aimed to identify significant factors associated with plasma concentrations. Blood samples were collected from patients with liver cirrhosis who received voriconazole, and voriconazole concentrations were determined. One-compartment model with first-order absorption and elimination appropriately characterized the in vivo process of voriconazole. The typical population value of voriconazole clearance (CL) was 1.45 L/h and the volume of distribution (V) was 132.12 L. The covariate analysis identified that CYP2C19 gene phenotype and Child-Pugh classification were strongly associated with CL and body weight had a significant influence on V. The results of the Monte Carlo simulation suggested that CYP2C19 gene phenotype was a critical factor for determining voriconazole dosage in patients with liver cirrhosis. The extensive metabolizer patients with Aspergillus fumigatus infections could be treated effectively with a recommended dose of 75 mg twice daily in mild to moderate liver cirrhosis and 100 mg once daily in moderate severe liver cirrhosis. However, the recommended dosage for Candida albicans infections patients was not achieved in present study.
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Affiliation(s)
- Qiu-Xia Ren
- Department of Pharmacy, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Xin-Gang Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Jin-Song Mu
- Intensive Care Unit, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Jing-Feng Bi
- Research Center for Clinical and Translational Medicine, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Chun-Hui Du
- Department of Pharmacy, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Yan-Hong Wang
- Department of Pharmacy, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan 250117, China
| | - Hong Zhu
- Department of Pharmacy, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Peng Lv
- Department of Pharmacy, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Qing-Guo Zhao
- Department of Pharmacy, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China.
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Schulz J, Kluwe F, Mikus G, Michelet R, Kloft C. Novel insights into the complex pharmacokinetics of voriconazole: a review of its metabolism. Drug Metab Rev 2019; 51:247-265. [PMID: 31215810 DOI: 10.1080/03602532.2019.1632888] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Voriconazole, a second-generation triazole frequently used for the prophylaxis and treatment of invasive fungal infections, undergoes complex metabolism mainly involving various (polymorphic) cytochrome P450 enzymes in humans. Although high inter- and intraindividual variability in voriconazole pharmacokinetics have been observed and the therapeutic range for this compound is relatively narrow, the metabolism of voriconazole has not been fully elucidated yet. The available literature data investigating the multiple different pathways and metabolites are extremely unbalanced and thus the absolute or relative contribution of the different pathways and enzymes involved in the metabolism of voriconazole remains uncertain. Furthermore, other factors such as nonlinear pharmacokinetics caused by auto-inhibition or -induction and polymorphisms of the metabolizing enzymes hinder safe and effective voriconazole dosing in clinical practice and have not yet been studied sufficiently. This review aimed at amalgamating the available literature on the pharmacokinetics of voriconazole in vitro and in vivo, with a special focus on metabolism in adults and children, in order to congregate an overall landscape of the current body of knowledge and identify knowledge gaps, opening the way towards further research in order to foster the understanding, towards better therapeutic dosing decisions.
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Affiliation(s)
- Josefine Schulz
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin , Berlin , Germany
| | - Franziska Kluwe
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin , Berlin , Germany.,Graduate Research Training Program PharMetrX , Berlin/Potsdam , Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg , Heidelberg , Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin , Berlin , Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin , Berlin , Germany
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22
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Effect of Cumulative Intravenous Voriconazole Dose on Renal Function in Hematological Patients. Antimicrob Agents Chemother 2018; 62:AAC.00507-18. [PMID: 29987145 DOI: 10.1128/aac.00507-18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 07/06/2018] [Indexed: 01/24/2023] Open
Abstract
Intravenous voriconazole (VRC) is formulated by the incorporation of sulfobutylether-β-cyclodextrin (SBECD), which may accumulate to adversely affect renal function. However, the effect of long-term use of intravenous VRC on renal function is unclear. Our retrospective analysis of data confirmed that worsening of renal function was significantly associated with a cumulative dose of intravenous VRC (≥400 mg/kg), suggesting that a higher cumulative dose of intravenous VRC is a risk factor for renal dysfunction.
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