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Wang S, Li C, Dong Y, Dong W. Approaches for posaconazole therapeutic drug monitoring and their clinical benefits. Eur J Clin Pharmacol 2024:10.1007/s00228-024-03756-9. [PMID: 39249114 DOI: 10.1007/s00228-024-03756-9] [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: 05/14/2024] [Accepted: 08/31/2024] [Indexed: 09/10/2024]
Abstract
OBJECTIVE This review examines the progress of research on posaconazole therapeutic drug monitoring (TDM) that has focused on differences in the TDM of posaconazole after clinical application in different formulations and in different populations, the factors that affect posaconazole concentrations, the advantages of posaconazole TDM in terms of clinical efficacy and cost savings, and measurement methods. METHODS A literature search (2006 to 2024) was performed in PubMed and Embase with the following search terms: noxafil, posaconazole hydrate, posaconazole, drug monitoring, therapeutic drug monitoring, and TDM. Abstracts of review articles, prospective studies, and retrospective studies were reviewed. RESULTS TDM should be implemented earlier for posaconazole tablets and injections than for oral posaconazole suspensions. Posaconazole TDM is beneficial for improving clinical efficacy, and the incidence of breakthrough invasive fungal infections (IFIs) can be significantly reduced by gradually adjusting the posaconazole dose in response to TDM in patients with inadequate trough concentrations. Early TDM allows more patients to achieve target therapeutic posaconazole concentrations. TDM can also facilitate dose adjustments, which reduce the cost of this expensive drug. Different assay techniques, including chromatography, microbiological detection, chemofluorimetry, paper spray mass spectrometry, and capillary electrophoresis, can be used for posaconazole TDM. CONCLUSIONS Posaconazole TDM has potential clinical utility and cost-saving benefits and could improve the outcomes of IFI treatment.
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Affiliation(s)
- Silu Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Changkun Li
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Weihua Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
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2
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Handley G, Greene J, Cannella AP, Velez AP, Shah S, Pasikhova Y. Real-world Experience of Posaconazole Therapeutic Drug Monitoring in Oncology Patients: Clinical Implications of Hypoalbuminemia as a Predictor of Subtherapeutic Posaconazole Levels. Open Forum Infect Dis 2024; 11:ofae185. [PMID: 38680607 PMCID: PMC11055390 DOI: 10.1093/ofid/ofae185] [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: 02/15/2024] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
Background Posaconazole maintains broad antifungal activity and is employed for prevention and treatment of invasive fungal infections in oncology patients. Older formulations required therapeutic drug monitoring, and specific plasma drug levels have been recommended. This study evaluated factors associated with subtherapeutic concentrations with the newer delayed-release tablet formulation. Methods In this retrospective, single-center cohort study at a national comprehensive cancer center, all oncology patients receiving delayed-release posaconazole at standard dosing of 300 mg orally per day from 06/2021 to 07/2023 with plasma drug concentration evaluation were identified. Demographic, clinical, and laboratory data were evaluated to identify risk factors associated with subtherapeutic drug levels at targets of ≥1.25 µg/mL and ≥1.8 µg/mL. Results Of 110 patients identified, 98 met criteria for inclusion in the study. The median time from initiation of posaconazole to drug level assessment was 13 days, and the median concentration was 1.29 µg/mL. Of the 22 patients receiving posaconazole for prophylaxis, 5 (22.7%) failed to achieve concentrations ≥0.7 µg/mL, and of 76 patients receiving posaconazole for treatment, 38 (50%) failed to achieve concentrations of ≥1.25 µg/mL. In multivariable analysis, albumin of ≤3 g/dL and ideal body weight ≥60 kg were found to be associated with subtherapeutic levels. For a higher target of ≥1.8 µg/mL, only albumin ≤3 g/dL was associated with subtherapeutic levels for the variables evaluated. Conclusions A higher initial dosing strategy and therapeutic drug monitoring for oncology patients with albumin ≤3 g/dL receiving posaconazole, particularly for the treatment of invasive fungal infection, could be considered.
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Affiliation(s)
- Guy Handley
- Division of Infectious Disease and International Medicine, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - John Greene
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Anthony P Cannella
- Division of Infectious Disease and International Medicine, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Ana Paula Velez
- Division of Infectious Disease and International Medicine, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Shivan Shah
- Division of Infectious Disease and International Medicine, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Yanina Pasikhova
- Department of Pharmacy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
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3
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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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McCreary EK, Davis MR, Narayanan N, Andes DR, Cattaneo D, Christian R, Lewis RE, Watt KM, Wiederhold NP, Johnson MD. Utility of triazole antifungal therapeutic drug monitoring: Insights from the Society of Infectious Diseases Pharmacists: Endorsed by the Mycoses Study Group Education and Research Consortium. Pharmacotherapy 2023; 43:1043-1050. [PMID: 37459118 DOI: 10.1002/phar.2850] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/23/2023] [Accepted: 05/26/2023] [Indexed: 08/15/2023]
Abstract
Triazole antifungals (i.e., fluconazole, itraconazole, voriconazole, posaconazole, and isavuconazole) are commonly used in clinical practice to prevent or treat invasive fungal infections. Most triazole antifungals require therapeutic drug monitoring (TDM) due to highly variable pharmacokinetics, known drug interactions, and established relationships between exposure and response. On behalf of the Society of Infectious Diseases Pharmacists (SIDP), this insight describes the pharmacokinetic principles and pharmacodynamic targets of commonly used triazole antifungals and provides the rationale for utility of TDM within each agent.
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Affiliation(s)
- Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Matthew R Davis
- Infectious Disease Connect, Inc., Pittsburgh, Pennsylvania, USA
| | - Navaneeth Narayanan
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey, USA
| | - David R Andes
- Departments of Medicine and Medical Microbiology & Immunology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, Department of Laboratory Medicine, Luigi Sacco University Hospital, Milan, Italy
| | - Robbie Christian
- Department of Pharmacy, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | - Russell E Lewis
- Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Kevin M Watt
- Division of Pediatric Clinical Pharmacology and Division of Critical Care, University of Utah, Salt Lake City, Utah, USA
| | - Nathan P Wiederhold
- Department of Pathology and Laboratory Medicine, Fungus Testing Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Melissa D Johnson
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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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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6
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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: 4] [Impact Index Per Article: 2.0] [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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7
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Ding Q, Huang S, Sun Z, Chen K, Li X, Pei Q. A Review of Population Pharmacokinetic Models of Posaconazole. Drug Des Devel Ther 2022; 16:3691-3709. [PMID: 36277600 PMCID: PMC9584355 DOI: 10.2147/dddt.s384637] [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] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/22/2022] [Indexed: 11/05/2022] Open
Abstract
Posaconazole is often used for the prophylaxis and treatment of invasive fungal infections (IFI). However, intra- and inter-individual differences and drug interactions affect the efficacy and safety of posaconazole. Precision dosing of posaconazole based on the population pharmacokinetic (PopPK) model may assist in making significant clinical decisions. This review aimed to comprehensively summarize the published PopPK models of posaconazole and analyze covariates that significantly influence posaconazole exposure. Articles published until May 2022 for PopPK analysis of posaconazole were searched in PubMed and EMBASE databases. Demographic characteristics, model characteristics, and results of PopPK analysis were extracted from the selected articles. In addition, the steady-state pharmacokinetic profiles of posaconazole were simulated at different covariate levels and dosing regimens. Out of the 13 studies included in our review, nine studies included adults, three included children, and one included both adults and children. All oral administration models were one-compartment models, and all intravenous administration models were two-compartment models. Body weight, proton pump inhibitors, and incidence of diarrhea were found to be important covariates. Clinically, the potential impact of factors such as patient physiopathologic characteristics and comorbid medications on posaconazole pharmacokinetics should be considered. Dose adjustment in combination with TDM or replacement with a tablet or intravenous formulation with higher exposure may be an effective way to ensure drug efficacy as well as to reduce fungal resistance. Meanwhile, published models require further external evaluation to examine extrapolation.
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Affiliation(s)
- Qin Ding
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Shuqi Huang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Zexu Sun
- Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, People’s Republic of China
| | - Kaifeng Chen
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Xin Li
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China,Xin Li, Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, 410013, People’s Republic of China, Email
| | - Qi Pei
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China,Correspondence: Qi Pei, Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, People’s Republic of China, Tel +86 1 317 041 9804, Email
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8
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Huang S, Ding Q, Yang N, Sun Z, Cheng Q, Liu W, Li Y, Chen X, Wu C, Pei Q. External evaluation of published population pharmacokinetic models of posaconazole. Front Pharmacol 2022; 13:1005348. [PMID: 36249756 PMCID: PMC9561726 DOI: 10.3389/fphar.2022.1005348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
Population pharmacokinetic (PopPK) models of posaconazole have been established to promote the precision dosing. However, the performance of these models extrapolated to other centers has not been evaluated. This study aimed to conduct an external evaluation of published posaconazole PopPK models to evaluate their predictive performance. Posaconazole PopPK models screened from the PubMed and MEDLINE databases were evaluated using an external dataset of 213 trough concentration samples collected from 97 patients. Their predictive performance was evaluated by prediction-based diagnosis (prediction error), simulation-based diagnosis (visual predictive check), and Bayesian forecasting. In addition, external cohorts with and without proton pump inhibitor were used to evaluate the models respectively. Ten models suitable for the external dataset were finally included into the study. In prediction-based diagnostics, none of the models met pre-determined criteria for predictive indexes. Only M4, M6, and M10 demonstrated favorable simulations in visual predictive check. The prediction performance of M5, M7, M8, and M9 evaluated using the cohort without proton pump inhibitor showed a significant improvement compared to that evaluated using the whole cohort. Consistent with our expectations, Bayesian forecasting significantly improved the predictive per-formance of the models with two or three prior observations. In general, the applicability of these published posaconazole PopPK models extrapolated to our center was unsatisfactory. Prospective studies combined with therapeutic drug monitoring are needed to establish a PopPK model for posaconazole in the Chinese population to promote individualized dosing.
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Affiliation(s)
- Shuqi Huang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Qin Ding
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Nan Yang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Zexu Sun
- Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, China
| | - Qian Cheng
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Wei Liu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yejun Li
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xin Chen
- Department of Pharmacy, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Cuifang Wu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Cuifang Wu, ; Qi Pei,
| | - Qi Pei
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Cuifang Wu, ; Qi Pei,
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9
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Abstract
Isavuconazole is the newest of the clinically available advanced generation triazole antifungals and is active against a variety of yeasts, molds, and dimorphic fungi. Its current FDA-approved indications include the management of invasive aspergillosis as well as mucormycosis, though the latter indication is supported by limited clinical data. Isavuconazole did not achieve noninferiority to caspofungin for the treatment of invasive candidiasis and therefore lacks an FDA-approved indication for this invasive disease. Significant advantages of isavuconazole, primarily over voriconazole but in some circumstances posaconazole as well, make it an appealing option for the management of complex patients with invasive fungal infections. These potential advantages include lack of QTc interval prolongation, more predictable pharmacokinetics, a less complicated drug interaction profile, and improved tolerability, particularly when compared to voriconazole. This review discusses these topics in addition to addressing the in vitro activity of the compound against a variety of fungi and provides insight into other distinguishing factors among isavuconazole, voriconazole, and posaconazole. The review concludes with an opinion section in which the authors provide the reader with a framework for the current role of isavuconazole in the antifungal armamentarium and where further data are required.
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10
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Prayag PS, Panchakshari SP, Mahalle NP, Dhupad S, Patwardhan SA, Naik SS, Narawade S, Melinkeri S, Prayag AP. Factors associated with subtherapeutic levels of oral posaconazole tablet- a detailed analysis from a tertiary care center in India. Int J Infect Dis 2022; 124:76-80. [PMID: 36089153 DOI: 10.1016/j.ijid.2022.09.004] [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: 05/10/2022] [Revised: 08/30/2022] [Accepted: 09/03/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Posaconazole is a broad spectrum triazole antifungal with activity against various clinically important fungi. The delayed release (DR) tablet of posaconazole has been shown to have a superior pharmacokinetic profile in comparison with the oral suspension. METHODS We retrospectively analyzed the factors associated with posaconazole levels < 1.25 μg/ml in 164 patients receiving the DR tablet for therapeutic purposes. RESULTS Of the 164 patients, 53 (32.3%) showed subtherapeutic trough levels of posaconazole. The use of proton pump inhibitors (PPIs) (95% CI: 1.41 - 3.91; p value = 0.028) and the presence of diarrhea (95% CI: 1.95 - 6.93; p value = 0.001) were significantly associated with subtherapeutic levels. Thirteen of the 21 patients receiving posaconazole tablets via the nasogastric (NG) tube had therapeutic levels. CONCLUSION This is the largest study from India analyzing factors associated with subtherapeutic levels of the DR tablet of posaconazole. These findings reinforce the importance of therapeutic drug monitoring. Unlike in previous studies, obesity and hypoalbuminemia were not found to be significant factors in our settings. The use of PPIs and diarrhea remained significant factors as found in previous studies. Administering the DR tablet of posaconazole via the NG tube may be a viable option.
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Affiliation(s)
- Parikshit S Prayag
- Department of Infectious Diseases, Deenanath Mangeshkar Hospital, Pune, India.
| | | | - Namita P Mahalle
- Department of Biochemistry, Deenanath Mangeshkar Hospital, Pune, India
| | - Surabhi Dhupad
- Department of Infectious Diseases, Deenanath Mangeshkar Hospital, Pune, India
| | | | - Sadanand S Naik
- Department of Biochemistry, Deenanath Mangeshkar Hospital, Pune, India
| | - Sharwari Narawade
- Department of Biochemistry, Deenanath Mangeshkar Hospital, Pune, India
| | - Sameer Melinkeri
- Department of Clinical Hematology, Deenanath Mangeshkar Hospital, Pune, India
| | - Amrita P Prayag
- Department of In-house research, Deenanath Mangeshkar Hospital, Pune, India
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11
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Kably B, Launay M, Derobertmasure A, Lefeuvre S, Dannaoui E, Billaud EM. Antifungal Drugs TDM: Trends and Update. Ther Drug Monit 2022; 44:166-197. [PMID: 34923544 DOI: 10.1097/ftd.0000000000000952] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/09/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The increasing burden of invasive fungal infections results in growing challenges to antifungal (AF) therapeutic drug monitoring (TDM). This review aims to provide an overview of recent advances in AF TDM. METHODS We conducted a PubMed search for articles during 2016-2020 using "TDM" or "pharmacokinetics" or "drug-drug-interaction" with "antifungal," consolidated for each AF. Selection was limited to English language articles with human data on drug exposure. RESULTS More than 1000 articles matched the search terms. We selected 566 publications. The latest findings tend to confirm previous observations in real-life clinical settings. The pharmacokinetic variability related to special populations is not specific but must be considered. AF benefit-to-risk ratio, drug-drug interaction (DDI) profiles, and minimal inhibitory concentrations for pathogens must be known to manage at-risk situations and patients. Itraconazole has replaced ketoconazole in healthy volunteers DDI studies. Physiologically based pharmacokinetic modeling is widely used to assess metabolic azole DDI. AF prophylactic use was studied more for Aspergillus spp. and Mucorales in oncohematology and solid organ transplantation than for Candida (already studied). Emergence of central nervous system infection and severe infections in immunocompetent individuals both merit special attention. TDM is more challenging for azoles than amphotericin B and echinocandins. Fewer TDM requirements exist for fluconazole and isavuconazole (ISZ); however, ISZ is frequently used in clinical situations in which TDM is recommended. Voriconazole remains the most challenging of the AF, with toxicity limiting high-dose treatments. Moreover, alternative treatments (posaconazole tablets, ISZ) are now available. CONCLUSIONS TDM seems to be crucial for curative and/or long-term maintenance treatment in highly variable patients. TDM poses fewer cost issues than the drugs themselves or subsequent treatment issues. The integration of clinical pharmacology into multidisciplinary management is now increasingly seen as a part of patient care.
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Affiliation(s)
- Benjamin Kably
- Laboratoire de Pharmacologie-Toxicologie, Hôpital Européen Georges Pompidou, AP-HP Centre
- Faculté de Médecine, Université de Paris, Paris, France
| | - Manon Launay
- Laboratoire de Pharmacologie-Toxicologie-Gaz du sang, Hôpital Nord-CHU Saint Etienne, Saint-Etienne
| | - Audrey Derobertmasure
- Laboratoire de Pharmacologie-Toxicologie, Hôpital Européen Georges Pompidou, AP-HP Centre
| | - Sandrine Lefeuvre
- Laboratoire de Toxicologie et Pharmacocinétique, CHU de Poitiers, Poitiers; and
| | - Eric Dannaoui
- Faculté de Médecine, Université de Paris, Paris, France
- Unité de Parasitologie-Mycologie, Laboratoire de Microbiologie, Hôpital Européen Georges Pompidou, Paris, France
| | - Eliane M Billaud
- Laboratoire de Pharmacologie-Toxicologie, Hôpital Européen Georges Pompidou, AP-HP Centre
- Faculté de Médecine, Université de Paris, Paris, France
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12
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Teh BW, Yeoh DK, Haeusler GM, Yannakou CK, Fleming S, Lindsay J, Slavin MA. Consensus guidelines for antifungal prophylaxis in haematological malignancy and haemopoietic stem cell transplantation, 2021. Intern Med J 2021; 51 Suppl 7:67-88. [PMID: 34937140 DOI: 10.1111/imj.15588] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Antifungal prophylaxis can reduce morbidity and mortality from invasive fungal disease (IFD). However, its use needs to be optimised and appropriately targeted to patients at highest risk to derive the most benefit. In addition to established risks for IFD, considerable recent progress in the treatment of malignancies has resulted in the development of new 'at-risk' groups. The changing epidemiology of IFD and emergence of drug resistance continue to impact choice of prophylaxis, highlighting the importance of active surveillance and knowledge of local epidemiology. These guidelines aim to highlight emerging risk groups and review the evidence and limitations around new formulations of established agents and new antifungal drugs. It provides recommendations around use and choice of antifungal prophylaxis, discusses the potential impact of the changing epidemiology of IFD and emergence of drug resistance, and future directions for risk stratification to assist optimal management of highly vulnerable patients.
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Affiliation(s)
- Benjamin W Teh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Daniel K Yeoh
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Costas K Yannakou
- Department of Molecular Oncology and Cancer Immunology, Epworth Freemasons Hospital, Epworth HealthCare, Melbourne, Victoria, Australia
| | - Shaun Fleming
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Health, Melbourne, Victoria, Australia
| | - Julian Lindsay
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Immunocompromised Host Infection Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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13
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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: 26] [Impact Index Per Article: 8.7] [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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14
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Effect of High-Dose Posaconazole on Serum Levels in Adult Patients with Hematologic Malignancy. Antimicrob Agents Chemother 2021; 65:e0123021. [PMID: 34570643 DOI: 10.1128/aac.01230-21] [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: 11/20/2022] Open
Abstract
Posaconazole (POS) appears to have dose-proportional pharmacokinetics; however, there is a paucity of real-life data. We retrospectively evaluated 67 patients with hematologic cancer who had POS dose increases from 300 mg/day to either 400 mg/day (n = 52) or 300 mg twice daily (BID) (n = 15) and for whom POS serum levels were measured. Median POS levels were 840 ng/ml, 1,625 ng/ml, and 2,710 ng/ml for the dosages of 300 mg/day, 400 mg/day, and 300 mg BID, respectively. Significant interpatient variability in serum levels was noted.
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15
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Coussement J, Lindsay J, Teh BW, Slavin M. Choice and duration of antifungal prophylaxis and treatment in high-risk haematology patients. Curr Opin Infect Dis 2021; 34:297-306. [PMID: 34039878 DOI: 10.1097/qco.0000000000000737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review aims to summarize available guidelines as well as the emerging evidence for the prevention and treatment of invasive fungal diseases in high-risk haematology patients. RECENT FINDINGS Primary mould-active prophylaxis is the strategy used in many centres to manage the risk of invasive fungal disease in high-risk haematology patients, and posaconazole remains the antifungal of choice for most of these patients. Data on the use of other antifungals for primary prophylaxis, including isavuconazole, are limited. There is considerable interest in identifying a strategy that would limit the use of mould-active agents to the patients who are the most likely to benefit from them. In this regard, a recent trial demonstrated that the preemptive strategy is noninferior to the empiric strategy. For primary treatment of invasive aspergillosis, two randomized trials found isavuconazole and posaconazole to be noninferior to voriconazole. Isavuconazole does not appear to require therapeutic drug monitoring. SUMMARY Prophylaxis and treatment of invasive fungal diseases in high-risk haematology patients is a rapidly evolving field. Critical clinical questions remain unanswered, especially regarding the management of suspected invasive fungal diseases breaking through mould-active prophylaxis, and the duration of antifungal therapy for invasive mould infections.
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Affiliation(s)
- Julien Coussement
- Department of Infectious Diseases.,National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne
| | - Julian Lindsay
- National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia.,Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Benjamin W Teh
- Department of Infectious Diseases.,National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
| | - Monica Slavin
- Department of Infectious Diseases.,National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
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16
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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: 8] [Impact Index Per Article: 2.7] [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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17
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Highsmith EA, Doan VP, Canada TW. Subtherapeutic posaconazole prophylaxis in a gastric bypass patient following hematopoietic stem cell transplantation. Am J Health Syst Pharm 2021; 78:1282-1286. [PMID: 33884401 PMCID: PMC8083209 DOI: 10.1093/ajhp/zxab164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE A case of invasive fungal infections (IFIs) with subtherapeutic posaconazole prophylaxis in a gastric bypass patient following hematopoietic stem cell transplantation (HSCT) is reported. SUMMARY A 52-year-old malnourished male with a medical history of Roux-en-Y gastric bypass for obesity developed acute myelogenous leukemia and underwent allogeneic HSCT approximately 17 months later. He was admitted 1 month after HSCT for failure to thrive and initiated on parenteral nutrition due to worsening diarrhea and suspected gastrointestinal graft-versus-host disease (GI GVHD). During admission, the patient was continued on daily oral posaconazole for antifungal prophylaxis and was found to have subtherapeutic posaconazole and deficient vitamin levels, likely secondary to his gastrojejunostomy and increased gastric transit time. The oral posaconazole was altered to twice-daily dosing in an effort to increase serum drug levels and prevent IFIs. CONCLUSION Patients with a history of gastric bypass are at increased risk for malabsorption of oral posaconazole and nutrients, especially following HSCT with suspected GI GVHD.
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Affiliation(s)
- Emily A Highsmith
- Department of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Address correspondence to Dr. Highsmith ()
| | - Vi P Doan
- Department of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Todd W Canada
- Department of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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18
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Abstract
Mucormycosis is a rare but aggressive fungal disease that mainly affects patients with poorly controlled diabetes mellitus and those who are severely immunocompromised, including patients with hematological malignancies and solid organ transplant recipients. Early recognition of infection is critical for treatment success, followed by prompt initiation of antifungal therapy with lipid formulation amphotericin B. Posaconazole and isavuconazole should be used for stepdown and salvage therapy. Surgical debridement is key for tissue diagnosis and treatment and should be pursued urgently whenever possible. In addition to surgery and antifungal therapy, reverting the underlying risk factor for infection is important for treatment response.
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Affiliation(s)
- Julie M Steinbrink
- Division of Infectious Diseases, Department of Internal Medicine, Duke University Medical Center, Hanes House, Duke University Medical Center, 315 Trent Drive, Durham, NC 27710, USA
| | - Marisa H Miceli
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, F4005 UH-South- SPC 5226, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA.
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19
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Clinical and Pharmacological Considerations for Concomitant Administration of Posaconazole and Isavuconazole with Letermovir. Antimicrob Agents Chemother 2021; 65:AAC.00274-21. [PMID: 33782007 DOI: 10.1128/aac.00274-21] [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: 02/11/2021] [Accepted: 03/22/2021] [Indexed: 12/22/2022] Open
Abstract
We sought in this case-control retrospective study to compare posaconazole and isavuconazole (PCZ and IVC, respectively) plasma trough concentration (C trough) levels in high-risk allogeneic hematopoietic cell transplant (HCT) recipients who received letermovir (LET) or not. PCZ/IVC C trough levels were not found to be significantly different between cases and controls, as they were 1.31 mg/liter (median) (interquartile range [IQR], 0.90) versus 1.36 mg/liter (IQR, 1.16) (P = 0.31) and 3.20 mg/liter (IQR, 2.40) versus 2.35 mg/liter (IQR, 1.50) (P = 0.17), respectively. In conclusion, we observed PCZ/IVC C trough levels within the expected range and no significant effect of LET coadministration.
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20
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Zhou PY, Lim TP, Tang SLS, Lim JL, Liew Y, Chua NG, Lim LLC, Lee HLW, Lai OF, Tan TT, Wong GC, Kwa LHA. Therapeutic drug monitoring is necessary for patients receiving posaconazole tablet. J Infect 2021; 82:e18-e21. [PMID: 33794263 DOI: 10.1016/j.jinf.2021.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Peijun Yvonne Zhou
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Tze Peng Lim
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Si Lin Sarah Tang
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Jia Le Lim
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Yixin Liew
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Nathalie Grace Chua
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Li Ling Cheryl Lim
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Hui Ling Winnie Lee
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Oi Fah Lai
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Thuan Tong Tan
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Gee Chuan Wong
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Lay Hoon Andrea Kwa
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore.
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21
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Beck KR, Odermatt A. Antifungal therapy with azoles and the syndrome of acquired mineralocorticoid excess. Mol Cell Endocrinol 2021; 524:111168. [PMID: 33484741 DOI: 10.1016/j.mce.2021.111168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 12/31/2020] [Accepted: 01/06/2021] [Indexed: 10/22/2022]
Abstract
The syndromes of mineralocorticoid excess describe a heterogeneous group of clinical manifestations leading to endocrine hypertension, typically either through direct activation of mineralocorticoid receptors or indirectly by impaired pre-receptor enzymatic regulation or through disturbed renal sodium homeostasis. The phenotypes of these disorders can be caused by inherited gene variants and somatic mutations or may be acquired upon exposures to exogenous substances. Regarding the latter, the symptoms of an acquired mineralocorticoid excess have been reported during treatment with azole antifungal drugs. The current review describes the occurrence of mineralocorticoid excess particularly during the therapy with posaconazole and itraconazole, addresses the underlying mechanisms as well as inter- and intra-individual differences, and proposes a therapeutic drug monitoring strategy for these two azole antifungals. Moreover, other therapeutically used azole antifungals and ongoing efforts to avoid adverse mineralocorticoid effects of azole compounds are shortly discussed.
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Affiliation(s)
- Katharina R Beck
- Swiss Centre for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Alex Odermatt
- Swiss Centre for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland.
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22
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Andretto V, Rosso A, Briançon S, Lollo G. Nanocomposite systems for precise oral delivery of drugs and biologics. Drug Deliv Transl Res 2021; 11:445-470. [PMID: 33534107 DOI: 10.1007/s13346-021-00905-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 12/15/2022]
Abstract
Oral delivery is considered the favoured route of administration for both local and systemic delivery of active molecules. Formulation of drugs in conventional systems and nanoparticles has provided opportunities for targeting the gastrointestinal (GI) tract, increasing drug solubility and bioavailability. Despite the achievements of these delivery approaches, the development of a product with the ability of delivering drug molecules at a specific site and according to patients' needs remains a challenging endeavour. The complexity of the physicochemical properties of colloidal systems, their stability in different regions of the gastrointestinal tract, and interaction with the restrictive biological barriers hampered their success for oral precise medicine. To overcome these issues, nanoparticles have been combined with polymers to create hybrid nanosystems, namely nanocomposites. They offer enormous possibilities of structural and mechanical modifications to both nanoparticles and polymeric matrixes to generate systems with new properties, functions, and applications for oral delivery. In this review, nanocomposites' physicochemical and functional properties intended to target specific regions of the GI tract-oral cavity, stomach, small bowel, and colon-are analysed. In parallel, it is provided an insight in the nanocomposite solutions for oral delivery intended for systemic and local absorption, together with a focus on inflammatory bowel diseases (IBDs). Additional difficulties in managing IBD related to the alteration in the physiology of the intestine are described. Finally, future perspectives and opportunities for advancement in this field are discussed.
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Affiliation(s)
- Valentina Andretto
- LAGEPP UMR 5007, Univ Lyon, Université Claude Bernard Lyon 1, CNRS, 43 Boulevard du 11 Novembre 1918, 69100, Villeurbanne, France
| | - Annalisa Rosso
- LAGEPP UMR 5007, Univ Lyon, Université Claude Bernard Lyon 1, CNRS, 43 Boulevard du 11 Novembre 1918, 69100, Villeurbanne, France
| | - Stéphanie Briançon
- LAGEPP UMR 5007, Univ Lyon, Université Claude Bernard Lyon 1, CNRS, 43 Boulevard du 11 Novembre 1918, 69100, Villeurbanne, France
| | - Giovanna Lollo
- LAGEPP UMR 5007, Univ Lyon, Université Claude Bernard Lyon 1, CNRS, 43 Boulevard du 11 Novembre 1918, 69100, Villeurbanne, France.
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23
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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: 8] [Impact Index Per Article: 2.0] [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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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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25
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Kosmidis C, Rodriguez-Goncer I, Rautemaa-Richardson R, Richardson MD, Moore CB, Denning DW. Therapeutic drug monitoring and adverse events of delayed-release posaconazole tablets in patients with chronic pulmonary aspergillosis. J Antimicrob Chemother 2020; 74:1056-1061. [PMID: 30590533 DOI: 10.1093/jac/dky539] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/12/2018] [Accepted: 11/24/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Posaconazole delayed-release tablets offer better bioavailability than the liquid suspension, but no post-marketing data are available in immunocompetent hosts such as those with chronic pulmonary aspergillosis (CPA). OBJECTIVES To explore the pharmacokinetics and adverse event (AE) profile of posaconazole tablets in patients with CPA. METHODS Patients started on posaconazole tablets at the National Aspergillosis Centre (NAC), Manchester, UK between February 2014 and October 2015 were identified from the NAC database and analysed retrospectively. The medical records were reviewed for factors that could affect posaconazole serum levels and the development of AEs. RESULTS Seventy-two patients were included; 50 (69%) were male and the mean age was 48.5 ± 12 years. Therapeutic levels (≥1 mg/L) were achieved in 90% of cases on 200 mg versus 90% of cases on 300 mg daily (P = not significant). Based on multivariate analysis, female sex (P = 0.041), a 100 mg daily dose (P < 0.001), asthma (P = 0.01) and bronchiectasis (P = 0.001) were associated with subtherapeutic levels. Forty-nine (68%) patients developed AEs, mainly fatigue (37%), dyspnoea (18%) and nausea (12%). AEs were present on 115/196 (59%) occasions on 300 mg/day and on 45/115 (39%) occasions on 200 mg/day (P < 0.01). The mean level was 1.81 ± 0.96 mg/L for patients reporting no AEs and 1.90 ± 1.11 mg/L for those reporting AEs (P = not significant). Factors associated with AEs of grade ≥2 were a daily dose of 300 versus 200 mg (P = 0.001) and asthma (P = 0.008). CONCLUSIONS A lower-than-recommended posaconazole tablet dose achieved therapeutic levels in most patients and was better tolerated. Males were more likely to achieve a therapeutic level. Underlying conditions affected the degree and frequency of AEs.
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Affiliation(s)
- Chris Kosmidis
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,National Aspergillosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Manchester, UK
| | - Isabel Rodriguez-Goncer
- National Aspergillosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Manchester, UK
| | - Riina Rautemaa-Richardson
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,National Aspergillosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Manchester, UK.,Mycology Reference Centre Manchester, ECMM Centre of Excellence, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Malcolm D Richardson
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Mycology Reference Centre Manchester, ECMM Centre of Excellence, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Caroline B Moore
- Mycology Reference Centre Manchester, ECMM Centre of Excellence, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - David W Denning
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,National Aspergillosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Manchester, UK
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26
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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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27
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Ruhnke M, Cornely OA, Schmidt-Hieber M, Alakel N, Boell B, Buchheidt D, Christopeit M, Hasenkamp J, Heinz WJ, Hentrich M, Karthaus M, Koldehoff M, Maschmeyer G, Panse J, Penack O, Schleicher J, Teschner D, Ullmann AJ, Vehreschild M, von Lilienfeld-Toal M, Weissinger F, Schwartz S. Treatment of invasive fungal diseases in cancer patients-Revised 2019 Recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Mycoses 2020; 63:653-682. [PMID: 32236989 DOI: 10.1111/myc.13082] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/05/2020] [Accepted: 03/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Invasive fungal diseases remain a major cause of morbidity and mortality in cancer patients undergoing intensive cytotoxic therapy. The choice of the most appropriate antifungal treatment (AFT) depends on the fungal species suspected or identified, the patient's risk factors (eg length and depth of granulocytopenia) and the expected side effects. OBJECTIVES Since the last edition of recommendations for 'Treatment of invasive fungal infections in cancer patients' of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) in 2013, treatment strategies were gradually moving away from solely empirical therapy of presumed or possible invasive fungal diseases (IFDs) towards pre-emptive therapy of probable IFD. METHODS The guideline was prepared by German clinical experts for infections in cancer patients in a stepwise consensus process. MEDLINE was systematically searched for English-language publications from January 1975 up to September 2019 using the key terms such as 'invasive fungal infection' and/or 'invasive fungal disease' and at least one of the following: antifungal agents, cancer, haematological malignancy, antifungal therapy, neutropenia, granulocytopenia, mycoses, aspergillosis, candidosis and mucormycosis. RESULTS AFT of IFDs in cancer patients may include not only antifungal agents but also non-pharmacologic treatment. In addition, the armamentarium of antifungals for treatment of IFDs has been broadened (eg licensing of isavuconazole). Additional antifungals are currently under investigation or in clinical trials. CONCLUSIONS Here, updated recommendations for the treatment of proven or probable IFDs are given. All recommendations including the levels of evidence are summarised in tables to give the reader rapid access to key information.
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Affiliation(s)
- Markus Ruhnke
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Oliver A Cornely
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | | | - Nael Alakel
- Department I of Internal Medicine, Haematology and Oncology, University Hospital Dresden, Dresden, Germany
| | - Boris Boell
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation & Oncology, University Medical Center Eppendorf, Hamburg, Germany
| | - Justin Hasenkamp
- Clinic for Haematology and Medical Oncology with Department for Stem Cell Transplantation, University Medicine Göttingen, Göttingen, Germany
| | - Werner J Heinz
- Schwerpunkt Infektiologie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Marcus Hentrich
- Hämatologie und Internistische Onkologie, Innere Medizin III, Rotkreuzklinikum München, München, Germany
| | - Meinolf Karthaus
- Department of Haematology & Oncology, Municipal Hospital Neuperlach, München, Germany
| | - Michael Koldehoff
- Klinik für Knochenmarktransplantation, Westdeutsches Tumorzentrum Essen, Universitätsklinikum Essen (AöR), Essen, Germany
| | - Georg Maschmeyer
- Department of Hematology, Onclogy and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Jens Panse
- Klinik für Onkologie, Hämatologie und Stammzelltransplantation, Universitätsklinikum Aachen, Aachen, Germany
| | - Olaf Penack
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Rudolf Virchow, Berlin, Germany
| | - Jan Schleicher
- Klinik für Hämatologie Onkologie und Palliativmedizin, Katharinenhospital, Stuttgart, Germany
| | - Daniel Teschner
- III. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Andrew John Ullmann
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Maria Vehreschild
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Zentrum für Innere Medizin, Infektiologie, Goethe Universität Frankfurt, Frankfurt am Main, Deutschland.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Bonn-Köln, Deutschland
| | - Marie von Lilienfeld-Toal
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Florian Weissinger
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Stefan Schwartz
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Benjamin Franklin, Berlin, Germany
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Li W, Xia F, Zhou H, Qiu H, Wu D, Ma X, Sun A. Efficacy of Posaconazole Prophylaxis for Fungal Disease in Hematology Patients Treated With Chemotherapy and Transplantation: An Open-Label, Prospective, Observational Study. Front Microbiol 2020; 11:349. [PMID: 32265849 PMCID: PMC7096356 DOI: 10.3389/fmicb.2020.00349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/17/2020] [Indexed: 11/16/2022] Open
Abstract
Background Posaconazole (PCZ) is used prophylactically to prevent invasive fungal infections (IFIs) in patients with hematological malignancies. Objective To evaluate the cut-off serum concentration of PCZ for successful IFI prophylaxis in Chinese subjects. Patients and Methods A total of 74 patients treated with induction chemotherapy (n = 10) and allogeneic hematopoietic stem cell transplantation (HSCT) (n = 64), who received PCZ prophylactically as an oral suspension for >7 days, were included in the study. Clinical, radiological, microbiological culture results, and treatment responses were analyzed and drug concentration assays performed. Results The overall incidence of possible, probable, and proven IFIs was 13.5% (10/74), with five patients in the chemotherapy group and five in the HSCT group. The PCZ serum concentration in most patients (54/63) was in the range of 0.25–1.0 μg/ml, and this concentration range was significantly associated with the success rate of PCZ prophylaxis. A cut-off value of 0.47 μg/ml can be considered as an evaluation index for PCZ prophylaxis. Taking a proton pump inhibitor (PPI) would reduce the PCZ blood concentration, but not affect the IFD breakthrough point. PCZ treatment for hematopoietic malignancy or HSCT patients with a serum concentration of PCZ < 0.47 μg/ml were risk factors for PCZ prophylaxis of IFIs, determined by univariable and multivariable regression analyses. Conclusion The serum concentration of PCZ was related to the incidence of IFIs and a serum concentration of >0.47 μg/ml is highly recommended to avoid IFIs after chemotherapy or HSCT. Clinical Trial Registration Chinese Clinical Trial Registry: ChiCTR1900026294.
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Affiliation(s)
- Weiyang Li
- Department of Hematology, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Fan Xia
- Department of Clinical Pharmacology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Haixia Zhou
- Department of Hematology, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Huiying Qiu
- Department of Hematology, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Depei Wu
- Department of Hematology, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiao Ma
- Department of Hematology, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Aining Sun
- Department of Hematology, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
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29
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Chae H, Cho SY, Yi Y, Lee JJ, Cha K, Kim M, Kim Y, Kim YJ, Kim HJ, Lee DG. Evaluation of posaconazole plasma concentrations achieved with the delayed-release tablets in Korean high-risk patients with haematologic malignancy. Mycoses 2019; 63:131-138. [PMID: 31698506 DOI: 10.1111/myc.13031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 11/03/2019] [Accepted: 11/04/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Posaconazole (PCZ) is a triazole approved for prophylaxis of invasive fungal infections. OBJECTIVES Herein, the impact of clinical variables on PCZ plasma concentrations (PPCs) attained with PCZ delayed-release tablet (DRT) was investigated and compared with a historical cohort treated with PCZ oral suspension (OS). PATIENTS/METHODS Steady-state PCZ PPCs in 513 patients with haematologic malignancy treated with PCZ-DRT were assessed and impact of variables were analysed. Also, a comparison with matched historical cohort treated with PCZ-OS was made. RESULTS The median PPC in the PCZ-DRT group was 1,308.9 ng/mL (range: 29.8-10 455.9). Use of proton pump inhibitor (1181 vs 1344 ng/mL, P = .0337) in the AML/myelodysplastic syndrome remission induction group, diarrhoea (867 vs 1543 ng/mL, P = .0325) and gastrointestinal graft-versus-host disease (870 vs 1713 ng/mL, P = .0178) in the HSCT group were associated with lower PPCs. There was lack of evidence that hepatotoxicity was related with PCZ-DRT. Higher prevalence of UGT1A4*3 allele (33.0%) was noted compared to allele frequency in Koreans in those with PPCs < 500 mg/mL. The median PPC in the PCZ-DRT group was significantly higher than that in the PCZ-OS group (1308.9 vs 713.0 ng/mL, P < .0001). Significantly less patients had PPCs < 700 ng/mL in the PCZ-DRT group compared to the PCZ-OS group (18.7% vs 48.0%, P < .0001). CONCLUSIONS Our study demonstrates that PCZ-DRT has enhanced absorption and bioavailability than PCZ-OS in real-world clinical settings. In addition, specific factors associated with lower PPCs should prompt consideration of therapeutic drug monitoring in patients treated with PCZ-DRT.
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Affiliation(s)
- Hyojin Chae
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Catholic Laboratory Development and Evaluation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Yeon Cho
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Catholic Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yunmi Yi
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Catholic Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jeong Joong Lee
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyoungho Cha
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Myungshin Kim
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Catholic Laboratory Development and Evaluation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yonggoo Kim
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Catholic Laboratory Development and Evaluation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoo-Jin Kim
- Catholic Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hee-Je Kim
- Catholic Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Catholic Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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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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Treatment by Posaconazole Tablets, Compared to Posaconazole Suspension, Does Not Reduce Variability of Posaconazole Trough Concentrations. Antimicrob Agents Chemother 2019; 63:AAC.00484-19. [PMID: 31358587 DOI: 10.1128/aac.00484-19] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/14/2019] [Indexed: 12/26/2022] Open
Abstract
The delayed-release tablet formulation of posaconazole (POS-tab) results in higher plasma POS trough concentrations (Cmin) than the oral suspension (POS-susp), which raises the question of the utility of therapeutic drug monitoring (TDM). We aimed to compare the variability of the POS Cmin for the two formulations and identify determinants of the POS-tab Cmin and its variability. Demographic, biological, and clinical data from 77 allogeneic hematopoietic stem cell transplant patients (874 Cmin) treated with POS-tab (n = 41), POS-susp (n = 29), or both (n = 7) from January 2015 to December 2016 were collected retrospectively. Interpatient and within-subject coefficients of variation (CVs) of the Cmin adjusted to dose (D) were calculated for each formulation. Between-group comparisons were performed using a linear mixed effects model. The POS Cmin was higher for the tablet than for the suspension (median [25th-75th percentile]: 1.8 [1.2-2.4] mg/liter versus 1.2 [0.7-1.6] mg/liter, P < 0.0001). Interpatient CVs for the tablet and suspension were 60.8 versus 63.5% (P = 0.7), whereas within-subject CVs were 39.7 and 44.9%, respectively (P = 0.3). Univariate analysis showed that age and treatment by POS-tab were significantly and positively associated with the POS Cmin, whereas diarrhea was associated with a diminished POS Cmin Multivariate analysis identified treatment with POS-tab and diarrhea as independent factors of the POS Cmin, with a trend toward a lower impact of diarrhea during treatment with POS-tab (P = 0.07). Despite increased POS exposure with the tablet formulation, the variability of the POS Cmin was not significantly lower than that of the suspension. This suggests that TDM may still be useful to optimize tablet POS therapy.
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Using State Transition Models to Explore How the Prevalence of Subtherapeutic Posaconazole Exposures Impacts the Clinical Utility of Therapeutic Drug Monitoring for Posaconazole Tablets and Oral Suspension. Antimicrob Agents Chemother 2019:AAC.01435-19. [PMID: 31527039 DOI: 10.1128/aac.01435-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Therapeutic drug monitoring (TDM) has been recommended in guidelines for patients receiving posaconazole oral suspension, but its utility in patients receiving posaconazole tablet, which has an improved bioavailability, remains unclear. We used state transition models with first-order Monte Carlo microsimulation to re-examine the posaconazole exposure-response relationships reported in two Phase III clinical trials (prophylaxis with posaconazole oral suspension - Models 1 & 2) and a third multicenter observational TDM study (Model 3). We simulated the impact of TDM-guided interventions to improve initial average posaconazole concentrations (Cavg) to reduce clinical failure (in Models 1 & 2) and breakthrough invasive fungal disease (bIFD) in Model 3. Simulations were then repeated using posaconazole tablet Cavg distributions in place of the oral suspension formulation. In all three models with posaconazole oral suspension, TDM interventions associated with maximal improvement in posaconazole Cavg reduced absolute rates of subtherapeutic exposures (Cavg < 700 ng/mL) by 25-49%. Predicted reductions in absolute clinical failure rates were 11% in Model 1 and 6.5% in Model 2, and a 12.6% reduction in bIFD in Model 3. With the tablet formulation, maximally-effective TDM interventions reduced subtherapeutic exposures by approximately 5% in all three models and absolute clinical failure rates by 3.9% in Model 1, and 1.6% in Model 2; and a 1.6% reduction in bIFD in Model 3. Our modeling suggests that routine TDM during prophylaxis with posaconazole tablets may have limited clinical utility unless populations with higher prevalence (>10%) of subtherapeutic exposures can be identified based on clinical risk factors.
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Aslam S, Rotstein C. Candida infections in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13623. [PMID: 31155770 DOI: 10.1111/ctr.13623] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/29/2019] [Indexed: 12/11/2022]
Abstract
These updated guidelines from the American Society of Transplantation Infectious Diseases Community of Practice provide recommendations for the diagnosis and management of Candida infections in solid organ transplant recipients. Candida infections manifest primarily as candidemia and invasive candidiasis and cause considerable morbidity and mortality. Early diagnosis and initiation of treatment are necessary to reduce mortality. For both candidemia and invasive candidiasis, an echinocandin is recommended for initial therapy. However, early transition to oral therapy is encouraged when patients are stable and the organism is susceptible. Candida prophylaxis should be targeted for high-risk patients in liver, small bowel, and pancreas transplant recipients. Future research should address which patient groups may benefit most from preventative antifungal therapy strategies.
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Affiliation(s)
- Saima Aslam
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California
| | - Coleman Rotstein
- Multi-organ Transplant Program, Division of Infectious Diseases, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada
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Paige E, Haywood P, Xie M, Worth L, Thursky K, Urbancic K, Bajel A, Slavin M. Auditing fungal disease in leukemia patients in a tertiary care center: opportunities and challenges for an antifungal stewardship program. Leuk Lymphoma 2019; 60:2373-2383. [PMID: 31096813 DOI: 10.1080/10428194.2019.1590570] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Invasive fungal disease (IFD) is responsible for significant morbidity and mortality in patients with acute leukemia. Antifungal stewardship (AFS) programs are utilized in this patient group but have been infrequently evaluated in clinical practice. Adults diagnosed with acute leukemia at an Australian tertiary center over two years were identified, with subsequent auditing of IFD prophylaxis and treatment, and identification of further opportunities for AFS activities. Proven or probable IFD occurred in 6% of cases, including 14% of acute lymphoblastic leukemia (ALL) patients and 6% of acute myeloid leukemia (AML) patients. Mold-active antifungal prophylaxis was used in 84% of cases overall, including in 94% of AML cases and 23% of ALL cases. Local auditing identified target areas for AFS in this complex patient cohort, including modification of clinical guidelines, enhanced patient screening, improved access to fungal diagnostics and therapeutic drug monitoring, and the establishment of a specialized, embedded AFS program.
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Affiliation(s)
- Emma Paige
- Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne , Australia.,Department of Infectious Diseases, Alfred Hospital , Melbourne , Australia
| | - Peter Haywood
- Department of Haematology, Royal Melbourne Hospital , Parkville , Australia
| | - Mingdi Xie
- Department of Haematology, Royal Melbourne Hospital , Parkville , Australia
| | - Leon Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Antimicrobial Stewardship, Peter Doherty Institute , Melbourne , Australia
| | - Karin Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Antimicrobial Stewardship, Peter Doherty Institute , Melbourne , Australia
| | - Karen Urbancic
- NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Antimicrobial Stewardship, Peter Doherty Institute , Melbourne , Australia.,Department of Medicine, University of Melbourne , Parkville , Australia
| | - Ashish Bajel
- Department of Haematology, Royal Melbourne Hospital , Parkville , Australia
| | - Monica Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia
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Zhou PY, Lim TP, Tang SLS, Lee HLW, Tan TT, Tan BH, Tan SYM, Wong GC, Kwa LHA. Subtherapeutic posaconazole troughs despite high-dose posaconazole tablets in a patient with terminal ileum resection. J Infect 2019; 78:409-421. [DOI: 10.1016/j.jinf.2019.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 02/13/2019] [Accepted: 02/24/2019] [Indexed: 12/21/2022]
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36
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Jeong W, Snell GI, Levvey BJ, Westall GP, Morrissey CO, Wolfe R, Ivulich S, Neoh CF, Slavin MA, Kong DCM. Single-centre study of therapeutic drug monitoring of posaconazole in lung transplant recipients: factors affecting trough plasma concentrations. J Antimicrob Chemother 2019; 73:748-756. [PMID: 29211913 DOI: 10.1093/jac/dkx440] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 10/31/2017] [Indexed: 11/12/2022] Open
Abstract
Objectives This study describes therapeutic drug monitoring (TDM) of posaconazole suspension and modified release (MR) tablets in lung transplant (LTx) recipients and evaluates factors that may affect posaconazole trough plasma concentration (Cmin). Methods A single-centre, retrospective study evaluating posaconazole Cmin in LTx recipients receiving posaconazole suspension or MR tablets between January 2014 and December 2016. Results Forty-seven LTx patients received posaconazole suspension, and 78 received the MR tablet formulation; a total of 421 and 617 Cmin measurements were made, respectively. Posaconazole was concurrently administered with proton pump inhibitor in ≥ 90% of patients. The median (IQR) of initial posaconazole Cmin following 300 mg daily of posaconazole tablet was significantly higher than that of 800 mg daily of posaconazole suspension [1.65 (0.97-2.13) mg/L versus 0.81 (0.48-1.15) mg/L, P < 0.01]. Variability in posaconazole Cmin was apparent regardless of the formulations prescribed and dose adjustments were routinely undertaken to maintain therapeutic Cmin. A clear dose-response relationship was observed in patients receiving posaconazole MR tablets. Non-specific adverse events (fatigue, tremor, lethargy, sweating, nausea/vomiting and weight loss) were reported in 3/78 (4%) patients receiving posaconazole MR tablets. Posaconazole Cmin in these three patients was determined to be 9.6, 6.2 and 2.3 mg/L. Conclusions The current study has provided clinically important insights into the TDM of posaconazole in LTx recipients. Routine TDM should be undertaken in LTx recipients receiving posaconazole suspension and/or MR tablets.
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Affiliation(s)
- Wirawan Jeong
- Centre for Medicine Use and Safety, Monash University, Victoria, Australia
| | - Gregory I Snell
- Lung Transplant Service, Alfred Health & Monash University, Victoria, Australia
| | - Bronwyn J Levvey
- Lung Transplant Service, Alfred Health & Monash University, Victoria, Australia
| | - Glen P Westall
- Lung Transplant Service, Alfred Health & Monash University, Victoria, Australia
| | - C Orla Morrissey
- Department of Infectious Diseases, Alfred Health & Monash University, Victoria, Australia
| | - Rory Wolfe
- Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
| | | | - Chin Fen Neoh
- Collaborative Drug Discovery Research (CDDR) Group, Faculty of Pharmacy, Universiti Teknologi MARA, Selangor, Malaysia
| | - Monica A Slavin
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Victoria, Australia.,Victorian Infectious Diseases Service, Royal Melbourne Hospital, Victoria, Australia
| | - David C M Kong
- Centre for Medicine Use and Safety, Monash University, Victoria, Australia.,Pharmacy Department, Ballarat Health Services, Victoria, Australia.,The National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Victoria, Australia
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Cojutti PG, Candoni A, Lazzarotto D, Rabassi N, Fanin R, Hope W, Pea F. Co-administration of proton pump inhibitors and/or of steroids may be a risk factor for low trough concentrations of posaconazole delayed-released tablets in adult patients with haematological malignancies. Br J Clin Pharmacol 2018; 84:2544-2550. [PMID: 29975796 DOI: 10.1111/bcp.13707] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 06/27/2018] [Accepted: 06/29/2018] [Indexed: 01/07/2023] Open
Abstract
AIMS The aim of this study was to determine clinical variables associated with posaconazole exposure among adult patients with haematological malignancies who received posaconazole tablets for prophylaxis of invasive fungal infections (IFIs). METHODS The study population included adult patients with haematological malignancies who received posaconazole delayed-release tablets for prophylaxis of IFIs after induction chemotherapy for acute leukaemia or graft-versus-host-disease (GVHD) complicating hematopoietic stem cell transplantation (HSCT) in the period January 2016-December 2017. RESULTS Sixty-six consecutive patients with 176 posaconazole Cmin were included for evaluation in the study. Subtherapeutic posaconazole concentrations (< 0.7 mg l-1 ) were observed at least once in 33.3% of patients (22/66), and overall in 17.0% of therapeutic drug monitoring (TDM) episodes (30/176). At multilevel linear regression, use of PPIs (P = 0.008), use of intermediate or high dose steroids (>0.7 mg kg-1 daily) (P = 0.022) and male gender (P = 0.025) were significantly associated with decreased Cmin , whereas time from starting therapy (P = 0.032) was associated with increased Cmin in our patient population. CONCLUSION Posaconazole exposure during treatment with delayed-released tablet formulation may be affected by the use of PPIs and/or of intermediate or high dose steroids.
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Affiliation(s)
- Pier Giorgio Cojutti
- Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy.,Department of Medicine, University of Udine, Udine, Italy
| | - Anna Candoni
- Division of Haematology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Davide Lazzarotto
- Division of Haematology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Nicholas Rabassi
- Division of Haematology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Renato Fanin
- Department of Medicine, University of Udine, Udine, Italy.,Division of Haematology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Federico Pea
- Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy.,Department of Medicine, University of Udine, Udine, Italy
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