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Gatti M, Campoli C, Muratore E, Belotti T, Masetti R, Lanari M, Viale P, Pea F. Impact of Inflammatory Burden on Voriconazole Exposure in Oncohematological Pediatric Patients Receiving Antifungal Prophylaxis after Allogeneic HCT. Microorganisms 2024; 12:1388. [PMID: 39065156 PMCID: PMC11278995 DOI: 10.3390/microorganisms12071388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 07/04/2024] [Accepted: 07/07/2024] [Indexed: 07/28/2024] Open
Abstract
(1) Background: The impact of inflammation on voriconazole exposure in oncohematological pediatric patients represents a debated issue. We aimed to investigate the impact of serum C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6) levels on voriconazole exposure in oncohematological pediatric patients requiring allogeneic hematopoietic stem cell transplantation (HCT). (2) Methods: Pediatric patients undergoing allogeneic HCT and receiving therapeutic drug monitoring (TDM)-guided voriconazole as primary antifungal prophylaxis between January 2021 and December 2023 were included. The ratio between concentration and dose (C/D) of voriconazole was used as a surrogate marker of total clearance. A receiving operating characteristic curve analysis was performed by using CRP, PCT, or IL-6 values as the test variable and voriconazole C/D ratio > 0.188 or >0.375 (corresponding to a trough concentration value [Cmin] of 3 mg/L normalized to the maintenance dose of 16 mg/kg/day in patients of age < 12 years and of 8 mg/kg/day in those ≥12 years, respectively) as the state variable. Area under the curve (AUC) and 95% confidence interval (CI) were calculated. (3) Results: Overall, 39 patients were included. The median (IQR) voriconazole Cmin was 1.7 (0.7-3.0) mg/L. A CRP value > 8.49 mg/dL (AUC = 0.72; 95%CI 0.68-0.76; p < 0.0001), a PCT value > 2.6 ng/mL (AUC = 0.71; 95%CI 0.63-0.77; p < 0.0001), and an IL-6 value > 27.9 pg/mL (AUC = 0.80; 95%CI 0.71-0.88; p < 0.0001) were significantly associated with voriconazole overexposure. Consistent results were found in patients aged <12 and ≥12 years. (4) Conclusions: A single specific threshold of inflammatory biomarkers may be linked to a significantly higher risk of voriconazole exposure in oncohematological pediatric patients after HCT, irrespective of age. Adopting a TDM-guided strategy could be useful for minimizing the risk of voriconazole overexposure.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (R.M.); (M.L.); (P.V.); (F.P.)
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Caterina Campoli
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Edoardo Muratore
- Pediatric Hematology and Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.M.); (T.B.)
| | - Tamara Belotti
- Pediatric Hematology and Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.M.); (T.B.)
| | - Riccardo Masetti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (R.M.); (M.L.); (P.V.); (F.P.)
- Pediatric Hematology and Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.M.); (T.B.)
| | - Marcello Lanari
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (R.M.); (M.L.); (P.V.); (F.P.)
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (R.M.); (M.L.); (P.V.); (F.P.)
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (R.M.); (M.L.); (P.V.); (F.P.)
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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Klomp SD, Veringa A, Alffenaar JC, de Boer MGJ, Span LFR, Guchelaar H, Swen JJ. Inflammation altered correlation between CYP2C19 genotype and CYP2C19 activity in patients receiving voriconazole. Clin Transl Sci 2024; 17:e13887. [PMID: 39010708 PMCID: PMC11250525 DOI: 10.1111/cts.13887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/24/2024] [Accepted: 06/27/2024] [Indexed: 07/17/2024] Open
Abstract
Voriconazole is the cornerstone of the treatment and prevention of fungal infections. While there is a good correlation between CYP2C19 genotype and voriconazole exposure during prophylactic treatment, no correlation was found in patients with invasive aspergillosis. Proinflammatory cytokines result in inhibition of CYP2C19 enzyme activity (and may result in phenoconversion). Here we investigated the relationship between inflammation, CYP2C19 genotype-predicted-phenotype, and CYP2C19 activity in patients receiving voriconazole. Data were obtained from two prospective studies investigating voriconazole treatment (NCT02074462 and NCT00893555). Dose-corrected voriconazole plasma concentration and C-reactive protein (CRP) were used as proxies for CYP2C19 activity and inflammation, respectively. After data extraction and synthesis, data from 39 patients with paired voriconazole and CRP measurements were available. The distribution of CYP2C19 genotype-predicted metabolizer phenotypes was 31% intermediate (IM), 41% normal (NM), and 28% rapid metabolizer (RM). During inflammation, dose-corrected voriconazole levels were increased by 245%, 278%, and 486% for CYP2C19 NMs IMs and RMs, respectively. Patients with moderate or high CRP levels (>50 mg/L) were phenoconverted to a lower metabolizer phenotype irrespective of their CYP2C19 genotype. In a subgroup analysis of eight patients with longitudinal data available with and without inflammation, the pattern of the dose-corrected voriconazole and CRP measurements were similar, with CYP2C19 activity following decreasing or increasing CRP levels. In conclusion, voriconazole plasma concentrations increase during inflammation due to downregulation of CYP2C19 activity. While this effect appears largest for CYP2C19 RMs, no clinically relevant differences were observed between the CYP2C19 genotypes.
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Affiliation(s)
- Sylvia D. Klomp
- Department of Clinical Pharmacy & ToxicologyLeiden University Medical CenterLeidenThe Netherlands
| | - Anette Veringa
- Department of Clinical Pharmacy and PharmacologyUniversity Medical Center GroningenGroningenThe Netherlands
- Apotheek, OLVGAmsterdamThe Netherlands
| | - Jan‐Willem C. Alffenaar
- Department of Clinical Pharmacy and PharmacologyUniversity Medical Center GroningenGroningenThe Netherlands
- Faculty of Medicine and HealthSydney School of PharmacySydneyNew South WalesAustralia
- The University of Sydney Institute for Infectious DiseasesSydneyNew South WalesAustralia
- Westmead HospitalSydneyNew South WalesAustralia
| | - Mark G. J. de Boer
- Department of Infectious DiseasesLeiden University Medical CenterLeidenThe Netherlands
| | - Lambert F. R. Span
- Department of HematologyUniversity Medical Center GroningenGroningenThe Netherlands
| | - Henk‐Jan Guchelaar
- Department of Clinical Pharmacy & ToxicologyLeiden University Medical CenterLeidenThe Netherlands
| | - Jesse J. Swen
- Department of Clinical Pharmacy & ToxicologyLeiden University Medical CenterLeidenThe Netherlands
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3
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Boglione-Kerrien C, Zerrouki S, Le Bot A, Camus C, Marchand T, Bellissant E, Tron C, Verdier MC, Gangneux JP, Lemaitre F. Can we predict the influence of inflammation on voriconazole exposure? An overview. J Antimicrob Chemother 2023; 78:2630-2636. [PMID: 37796931 DOI: 10.1093/jac/dkad293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Voriconazole is a triazole antifungal indicated for invasive fungal infections that exhibits a high degree of inter-individual and intra-individual pharmacokinetic variability. Voriconazole pharmacokinetics is non-linear, making dosage adjustments more difficult. Therapeutic drug monitoring is recommended by measurement of minimum plasma concentrations. Several factors are responsible for the high pharmacokinetic variability of voriconazole: age, feeding (which decreases absorption), liver function, genetic polymorphism of the CYP2C19 gene, drug interactions and inflammation. Invasive fungal infections are indeed very frequently associated with inflammation, which engenders a risk of voriconazole overexposure. Many studies have reviewed this topic in both the adult and paediatric populations, but few studies have focused on the specific point of the prediction, to evaluate the influence of inflammation on voriconazole pharmacokinetics. Predicting the impact of inflammation on voriconazole pharmacokinetics could help optimize antifungal therapy and improve patient management. This review summarizes the existing data on the influence of inflammation on voriconazole pharmacokinetics in adult populations. We also evaluate the role of C-reactive protein, the impact of inflammation on patient metabolic phenotypes, and the tools that can be used to predict the effect of inflammation on voriconazole pharmacokinetics.
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Affiliation(s)
- Christelle Boglione-Kerrien
- Rennes University Hospital, Department of Biological Pharmacology, 2, rue Henri le Guilloux, F-35000 Rennes, France
| | - Selim Zerrouki
- Rennes University Hospital, Department of Biochemistry, Rennes, France
| | - Audrey Le Bot
- Rennes University Hospital, Department of Infectious Diseases, Rennes, France
| | - Christophe Camus
- Rennes University Hospital, Department of Intensive Care Medicine, Rennes, France
| | - Tony Marchand
- Rennes University Hospital, Department of Clinical Haematology, Rennes, France
| | - Eric Bellissant
- Rennes University Hospital, Department of Biological Pharmacology, 2, rue Henri le Guilloux, F-35000 Rennes, France
- INSERM, CIC-P 1414 Clinical Investigation Centre, Rennes, France
- Rennes University Hospital, INSERM, EHESP, IRSET (Institut de Recherche en Santé, Environnement et Travail) -UMR_S 1085, F-35000 Rennes, France
| | - Camille Tron
- Rennes University Hospital, Department of Biological Pharmacology, 2, rue Henri le Guilloux, F-35000 Rennes, France
- INSERM, CIC-P 1414 Clinical Investigation Centre, Rennes, France
- Rennes University Hospital, INSERM, EHESP, IRSET (Institut de Recherche en Santé, Environnement et Travail) -UMR_S 1085, F-35000 Rennes, France
| | - Marie-Clémence Verdier
- Rennes University Hospital, Department of Biological Pharmacology, 2, rue Henri le Guilloux, F-35000 Rennes, France
- INSERM, CIC-P 1414 Clinical Investigation Centre, Rennes, France
- Rennes University Hospital, INSERM, EHESP, IRSET (Institut de Recherche en Santé, Environnement et Travail) -UMR_S 1085, F-35000 Rennes, France
| | - Jean-Pierre Gangneux
- Rennes University Hospital, INSERM, EHESP, IRSET (Institut de Recherche en Santé, Environnement et Travail) -UMR_S 1085, F-35000 Rennes, France
- Rennes University Hospital, Department of Parasitology and Mycology, National Reference Centre for Mycoses and Antifungals (LA Asp-C) and European Excellence Centre in Medical Mycology (ECMM EC), Rennes, France
| | - Florian Lemaitre
- Rennes University Hospital, Department of Biological Pharmacology, 2, rue Henri le Guilloux, F-35000 Rennes, France
- INSERM, CIC-P 1414 Clinical Investigation Centre, Rennes, France
- Rennes University Hospital, INSERM, EHESP, IRSET (Institut de Recherche en Santé, Environnement et Travail) -UMR_S 1085, F-35000 Rennes, France
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4
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Lin L, Fu X, Hong M. Lower Prealbumin and Higher CRP Increase the Risk of Voriconazole Overexposure and Adverse Reactions. Cureus 2023; 15:e46107. [PMID: 37900477 PMCID: PMC10611983 DOI: 10.7759/cureus.46107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND Voriconazole (VRZ) is a commonly used antifungal drug. However, the drug has nonlinear metabolic kinetic characteristics. Many factors can affect the plasma drug concentration, thus affecting the safety and effectiveness of VRZ. OBJECTIVE The aim of this study is to characterize the correlation between prealbumin (PA) or CRP and VRZ overexposure and adverse reactions. METHODS Patients who received VRZ as a treatment and performed therapeutic drug monitoring (TDM) were included. Biomarkers and combined medications were analyzed to find out factors that were related to VRZ trough concentrations (Cmin) and overexposure (Cmin >5.0 mg/L). Receiver operating characteristic (ROC) curves were used to determine the cut-off levels. Patients were divided into three groups according to different PA and CRP levels. Then, the incidence rate of VRZ adverse reactions between groups was analyzed. RESULTS A total of 123 patients were included in the study. PA was negatively correlated, while CRP was positively correlated with VRZ concentrations. Lower PA or higher CRP was related to VRZ overexposure with a cut-off level of 145.5 mg/L and 102.23 mg/L, respectively. Patients in Group 2 (PA <145.5 mg/L and CRP >102.23 mg/L) had an incidence rate of adverse reactions up to 70.27%, while the incidence rates in Group 1 (PA >145.5 mg/L and CRP <102.23 mg/L) and Group 3 (PA <145.5 mg/L and CRP <102.23 mg/L or PA >145.5 mg/L and CRP >102.23 mg/L) were 15.38% and 32.43%, respectively. CONCLUSIONS PA and CRP were both related to VRZ concentrations and overexposure. The risk of VRZ overexposure and adverse reactions significantly increased in patients with PA <145.5 mg/L and CRP >102.23 mg/L at the same time.
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Affiliation(s)
- Liangmo Lin
- Pharmacy, Hainan General Hospital, Haikou, CHN
| | - Xiangjun Fu
- Hematology, Hainan General Hospital, Haikou, CHN
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5
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Boglione-Kerrien C, Morcet J, Scailteux LM, Bénézit F, Camus C, Mear JB, Gangneux JP, Bellissant E, Tron C, Verdier MC, Lemaitre F. Contribution of voriconazole N-oxide plasma concentration measurements to voriconazole therapeutic drug monitoring in patients with invasive fungal infection. Mycoses 2023; 66:396-404. [PMID: 36698317 DOI: 10.1111/myc.13570] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/18/2023] [Accepted: 01/21/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Voriconazole (VRC), a widely used triazole antifungal, exhibits significant inter- and intra-individual pharmacokinetic variability. The main metabolite voriconazole N-oxide (NOX) can provide information on the patient's drug metabolism capacity. OBJECTIVES Our objectives were to implement routine measurement of NOX concentrations and to describe the metabolic ratio (MR), and the contribution of the MR to VRC therapeutic drug monitoring (TDM) by proposing a suggested dosage-adjustment algorithm. PATIENTS AND METHODS Sixty-one patients treated with VRC were prospectively included in the study, and VRC and NOX levels were assayed by LC-MS/MS. A mixed logistic model on repeated measures was implemented to analyse risk factors for the patient's concentration to be outside the therapeutic range. RESULTS Based on 225 measurements, the median and interquartile range were 2.4 μg/ml (1.2; 4.2), 2.1 μg/ml (1.5; 3.0) and 1.0 (0.6; 1.9) for VRC, NOX and the MR, respectively. VRC Cmin <2 μg/ml were associated with a higher MR during the previous visit. MR values >1.15 and <0.48 were determined to be the best predictors for having a VRC Cmin lower than 2 μg/ml and above 5.5 μg/ml, respectively, at the next visit. CONCLUSIONS Measurement of NOX resulted useful for TDM of patients treated with VRC. The MR using NOX informed interpretation and clinical decision-making and is very interesting for complex patients. VRC phenotyping based on the MR is now performed routinely in our institution. A dosing algorithm has been suggested from these results.
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Affiliation(s)
| | - Jeff Morcet
- Inserm, CIC-P 1414 Clinical Investigation Centre, Rennes, France
| | - Lucie-Marie Scailteux
- Department of Clinical Pharmacology, Rennes University Hospital, Pharmacovigilance, Pharmacoepidemiology and Drug Information Centre, Rennes, France
| | - François Bénézit
- Department of Infectious Diseases, Rennes University Hospital, Rennes, France
| | - Christophe Camus
- Department of Intensive Care Medicine, Rennes University Hospital, Rennes, France
| | - Jean-Baptiste Mear
- Department of Clinical Haematology, Rennes University Hospital, Rennes, France
| | - Jean-Pierre Gangneux
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR_S 1085, Rennes, France
| | - Eric Bellissant
- Department of Biological Pharmacology, CHU Rennes, Rennes, France.,Inserm, CIC-P 1414 Clinical Investigation Centre, Rennes, France
| | - Camille Tron
- Department of Biological Pharmacology, CHU Rennes, Rennes, France.,Inserm, CIC-P 1414 Clinical Investigation Centre, Rennes, France
| | - Marie-Clémence Verdier
- Department of Biological Pharmacology, CHU Rennes, Rennes, France.,Inserm, CIC-P 1414 Clinical Investigation Centre, Rennes, France
| | - Florian Lemaitre
- Department of Biological Pharmacology, CHU Rennes, Rennes, France.,Inserm, CIC-P 1414 Clinical Investigation Centre, Rennes, France
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Li X, Lai F, Jiang Z, Li M, Chen Z, Cheng J, Cui H, Wen F. Effects of inflammation on voriconazole levels: a systematic review. Br J Clin Pharmacol 2022; 88:5166-5182. [PMID: 35973037 DOI: 10.1111/bcp.15495] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 11/30/2022] Open
Abstract
AIMS This study aimed to review the studies evaluating the effect of the inflammatory state on voriconazole (VRZ) levels. METHODS The study included randomized clinical trials, cohort studies, and case-control studies that focused on the influence of the inflammatory state on VRZ levels. Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, relevant articles published until 2021 were searched in several databases, including PubMed, Embase, Web of Science, and the Cochrane Library. RESULTS Twenty studies were included in this review, of which 15 described adult populations, 3 described pediatric populations, and 2 included both adult and pediatric populations. Seventeen studies used C-reactive protein (CRP) as an indicator of inflammation, 6 described a dose-response relationship for the effect of inflammation represented by CRP on VRZ concentrations, and 4 examined the effect of CRP on the metabolic rate of VRZ. CONCLUSIONS Our findings showed that the level of inflammation can significantly affect VRZ levels. However, the effect of inflammation on VRZ concentrations in children is controversial and must be analyzed along with age. Clinicians dosing VRZ should take into account the patient's inflammatory state. The impact of inflammation on genotype-based dosing decisions requires further study to explain the high pharmacokinetic variability of VRZ.
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Affiliation(s)
- Xuejuan Li
- Shenzhen Children's Hospital of China Medical University, Shenzhen, China.,Department of Pharmacy, Shenzhen Children's Hospital, Shenzhen, China
| | - Fangyuan Lai
- Department of Pharmacy, Shenzhen Children's Hospital, Shenzhen, China
| | - Zhaohui Jiang
- Department of Oncology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Meng Li
- Department of Pharmacy, Shenzhen Children's Hospital, Shenzhen, China
| | - Zebin Chen
- Department of Pharmacy, Shenzhen Children's Hospital, Shenzhen, China
| | - Junjie Cheng
- Department of Pharmacy, Shenzhen Children's Hospital, Shenzhen, China
| | - Hao Cui
- Department of Pharmacy, Shenzhen Children's Hospital, Shenzhen, China
| | - Feiqiu Wen
- Shenzhen Children's Hospital of China Medical University, Shenzhen, China
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7
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Therapeutic Drug Monitoring of Sputum Voriconazole in Pulmonary Aspergillosis. Pharmaceutics 2022; 14:pharmaceutics14081598. [PMID: 36015224 PMCID: PMC9414625 DOI: 10.3390/pharmaceutics14081598] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/25/2022] [Accepted: 07/28/2022] [Indexed: 02/04/2023] Open
Abstract
Voriconazole is one of the most used antifungal azoles against pulmonary aspergillosis. Therapeutic drug monitoring (TDM) of the voriconazole concentration in plasma is recommended in clinical practice guidelines to prevent treatment failure and toxicity. The aim of this study was to evaluate the feasibility and utility of TDM of the voriconazole concentration in the sputum of patients treated for pulmonary aspergillosis. Fifty sputum and 31 plasma samples were analysed with high-performance tandem mass spectrometry (HPLC-MS/MS) in 24 patients included in the study. The voriconazole concentration was simultaneously assessed in the plasma and sputum in 22 samples. The correlation between the sputum and plasma levels was estimated with a univariate linear regression model, and the observed R2 was 0.86. We determined the following equation, Csputum = 0.45 (Cplasma) + 0.21, which could predict the voriconazole concentration in plasma from sputum. TDM of the voriconazole concentration in sputum is an easy, non-invasive and accurate method with which to evaluate voriconazole exposure in patients with pulmonary aspergillosis.
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8
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Challenges in the Treatment of Invasive Aspergillosis in Immunocompromised Children. Antimicrob Agents Chemother 2022; 66:e0215621. [PMID: 35766509 PMCID: PMC9295552 DOI: 10.1128/aac.02156-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Invasive aspergillosis (IA) is associated with significant morbidity and mortality. Voriconazole remains the drug of choice for the treatment of IA in children; however, the complex kinetics of voriconazole in children make dosing challenging and therapeutic drug monitoring (TDM) essential for treatment success. The overarching goal of this review is to discuss the role of voriconazole, posaconazole, isavuconazole, liposomal amphotericin B, echinocandins, and combination antifungal therapy for the treatment of IA in children. We also provide a detailed discussion of antifungal TDM in children.
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9
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Liang Z, Yu M, Liu Z, Liu F, Jia C, Xiong L, Dai Q, Qin S, Cheng L, Sun F. Inflammation Affects Liver Function and the Metabolism of Voriconazole to Voriconazole-N-Oxide in Adult and Elderly Patients. Front Pharmacol 2022; 13:835871. [PMID: 35462904 PMCID: PMC9019686 DOI: 10.3389/fphar.2022.835871] [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: 12/16/2021] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background: The inner association of inflammation with voriconazole (VCZ) metabolism has not been fully investigated. We intend to investigate the effects of inflammation on liver function, VCZ trough concentration (C0), C0/dose ratio and the ratio of VCZ to VCZ-N-oxide concentration (C0/CN) in adult and elderly patients. Methods: A single-center retrospective study was conducted among patients who were treated in our hospital between January 2018 and December 2021. For each eligible patient, demographic details, medical history, laboratory parameters, procalcitonin (PCT), C reactive protein (CRP), and interleukin-6 (IL-6) were collected from the medical chart. VCZ CN, TNF-α, IL-1β, IL-8, and IL-10 concentrations were detected in blood samples. Results: A total of 356 patients were included in our study, with 195 patients in the adult cohort (<60 years) and 161 patients in the elderly cohort (≥60 years). In adult patients, CRP and IL-8 levels showed moderate association with VCZ C0/CN ratio (CRP: r = 0.512, p < 0.001; IL-8: r = 0.476, p = 0.002). IL-6 level shallowly associated with VCZ C0/CN ratio both in adult and elderly patients (r = 0.355, p = 0.003; r = 0.386, p = 0.001). A significantly higher VCZ C0, C0/dose ratio and C0/CN ratio was observed in adult patients with severe inflammation compared with patients with moderate inflammation and no to mild inflammation, as reflected by PCT levels (p < 0.05). However, there was no significant difference observed among different inflammation degrees in elderly patients. Lower albumin (AL) and higher total bilirubin (TBIL) were observed along with the degree of inflammation in both adult and elderly patients, as reflected by CRP and PCT levels (p < 0.05). Conclusion: Inflammation may affect the metabolism of VCZ to VCZ-N-oxide both in adult and elderly patients, and decreased plasma AL levels and increased TBIL levels under inflammatory conditions may also alter VCZ metabolism.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Lin Cheng
- *Correspondence: Lin Cheng, ; Fengjun Sun,
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10
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Aiuchi N, Nakagawa J, Sakuraba H, Takahata T, Kamata K, Saito N, Ueno K, Ishiyama M, Yamagata K, Kayaba H, Niioka T. Impact of polymorphisms of pharmacokinetics-related genes and the inflammatory response on the metabolism of voriconazole. Pharmacol Res Perspect 2022; 10:e00935. [PMID: 35199485 PMCID: PMC8866912 DOI: 10.1002/prp2.935] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 01/17/2022] [Accepted: 01/24/2022] [Indexed: 12/13/2022] Open
Abstract
The effects of inflammatory responses and polymorphisms of the genes encoding cytochrome P450 (CYP) (CYP2C19 and CYP3A5), flavin-containing monooxygenase 3 (FMO3), pregnane X receptor (NR1I2), constitutive androstane receptor (NR1I3), and CYP oxidoreductase (POR) on the ratio of voriconazole (VRCZ) N-oxide to VRCZ (VNO/VRCZ) and steady-state trough concentrations (C0h ) of VRCZ were investigated. A total of 56 blood samples were collected from 36 Japanese patients. Results of multiple linear regression analyses demonstrated that the presence of the extensive metabolizer CYP2C19 genotype, the dose per administration, and the presence of the NR1I2 rs3814057 C/C genotype were independent factors influencing the VNO/VRCZ ratio in patients with CRP levels of less than 40 mg/L (standardized regression coefficients (SRC) = 0.448, -0.301, and 0.390, respectively; all p < .05). With regard to the concentration of VRCZ itself, in addition to the above factors, the presence of the NR1I2 rs7643645 G/G and rs3814055 T/T genotypes were found to be independent factors influencing the VRCZ C0h in these patients (SRC = -0.430, 0.424, -0.326, 0.406 and -0.455, respectively; all p < .05). On the contrary, in patients with CRP levels of at least 40 mg/L, no independent factors were found to affect VNO/VRCZ and VRCZ C0h . Inflammatory responses, and CYP2C19 and NR1I2 polymorphisms may be useful information for the individualization of VRCZ dosages.
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Affiliation(s)
- Naoya Aiuchi
- Department of Pharmacy, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Junichi Nakagawa
- Department of Pharmacy, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Hirotake Sakuraba
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Takenori Takahata
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Kosuke Kamata
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Norihiro Saito
- Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Kayo Ueno
- Department of Pharmacy, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Masahiro Ishiyama
- Department of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Kazufumi Yamagata
- Department of Bioscience and Laboratory Medicine, Hirosaki University Graduate School of Health Sciences, Hirosaki, Japan
| | - Hiroyuki Kayaba
- Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Takenori Niioka
- Department of Pharmacy, Hirosaki University Hospital, Hirosaki, Aomori, Japan.,Department of Pharmaceutical Science, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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11
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Feys S, Almyroudi MP, Braspenning R, Lagrou K, Spriet I, Dimopoulos G, Wauters J. A Visual and Comprehensive Review on COVID-19-Associated Pulmonary Aspergillosis (CAPA). J Fungi (Basel) 2021; 7:1067. [PMID: 34947049 PMCID: PMC8708864 DOI: 10.3390/jof7121067] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 01/08/2023] Open
Abstract
Coronavirus disease 19 (COVID-19)-associated pulmonary aspergillosis (CAPA) is a severe fungal infection complicating critically ill COVID-19 patients. Numerous retrospective and prospective studies have been performed to get a better grasp on this lethal co-infection. We performed a qualitative review and summarized data from 48 studies in which 7047 patients had been included, of whom 820 had CAPA. The pooled incidence of proven, probable or putative CAPA was 15.1% among 2953 ICU-admitted COVID-19 patients included in 18 prospective studies. Incidences showed great variability due to multiple factors such as discrepancies in the rate and depth of the fungal work-up. The pathophysiology and risk factors for CAPA are ill-defined, but therapy with corticosteroids and anti-interleukin-6 therapy potentially confer the biggest risk. Sampling for mycological work-up using bronchoscopy is the cornerstone for diagnosis, as imaging is often aspecific. CAPA is associated with an increased mortality, but we do not have conclusive data whether therapy contributes to an increased survival in these patients. We conclude our review with a comparison between influenza-associated pulmonary aspergillosis (IAPA) and CAPA.
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Affiliation(s)
- Simon Feys
- Medical Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium;
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium;
| | - Maria Panagiota Almyroudi
- Department of Emergency Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Reinout Braspenning
- Medical Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium;
- Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, 3000 Leuven, Belgium;
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
| | - George Dimopoulos
- ICU of 1st Department of Critical Care, Sotiria Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Joost Wauters
- Medical Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium;
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium;
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12
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Lenoir C, Rollason V, Desmeules JA, Samer CF. Influence of Inflammation on Cytochromes P450 Activity in Adults: A Systematic Review of the Literature. Front Pharmacol 2021; 12:733935. [PMID: 34867341 PMCID: PMC8637893 DOI: 10.3389/fphar.2021.733935] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/13/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Available in-vitro and animal studies indicate that inflammation impacts cytochromes P450 (CYP) activity via multiple and complex transcriptional and post-transcriptional mechanisms, depending on the specific CYP isoforms and the nature of inflammation mediators. It is essential to review the current published data on the impact of inflammation on CYP activities in adults to support drug individualization based on comorbidities and diseases in clinical practice. Methods: This systematic review was conducted in PubMed through 7th January 2021 looking for articles that investigated the consequences of inflammation on CYP activities in adults. Information on the source of inflammation, victim drugs (and CYPs involved), effect of disease-drug interaction, number of subjects, and study design were extracted. Results: The search strategy identified 218 studies and case reports that met our inclusion criteria. These articles were divided into fourteen different sources of inflammation (such as infection, autoimmune diseases, cancer, therapies with immunomodulator…). The impact of inflammation on CYP activities appeared to be isoform-specific and dependent on the nature and severity of the underlying disease causing the inflammation. Some of these drug-disease interactions had a significant influence on drug pharmacokinetic parameters and on clinical management. For example, clozapine levels doubled with signs of toxicity during infections and the concentration ratio between clopidogrel's active metabolite and clopidogrel is 48-fold lower in critically ill patients. Infection and CYP3A were the most cited perpetrator of inflammation and the most studied CYP, respectively. Moreover, some data suggest that resolution of inflammation results in a return to baseline CYP activities. Conclusion: Convincing evidence shows that inflammation is a major factor to be taken into account in drug development and in clinical practice to avoid any efficacy or safety issues because inflammation modulates CYP activities and thus drug pharmacokinetics. The impact is different depending on the CYP isoform and the inflammatory disease considered. Moreover, resolution of inflammation appears to result in a normalization of CYP activity. However, some results are still equivocal and further investigations are thus needed.
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Affiliation(s)
- Camille Lenoir
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Victoria Rollason
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jules A Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Caroline F Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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13
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Suetsugu K, Muraki S, Fukumoto J, Matsukane R, Mori Y, Hirota T, Miyamoto T, Egashira N, Akashi K, Ieiri I. Effects of Letermovir and/or Methylprednisolone Coadministration on Voriconazole Pharmacokinetics in Hematopoietic Stem Cell Transplantation: A Population Pharmacokinetic Study. Drugs R D 2021; 21:419-429. [PMID: 34655050 PMCID: PMC8602551 DOI: 10.1007/s40268-021-00365-0] [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] [Accepted: 09/20/2021] [Indexed: 11/26/2022] Open
Abstract
Objective The aim of this study was to identify factors affecting blood concentrations of voriconazole following letermovir coadministration using population pharmacokinetic (PPK) analysis in allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients. Methods The following data were retrospectively collected: voriconazole trough levels, patient characteristics, concomitant drugs, and laboratory information. PPK analysis was performed with NONMEM® version 7.4.3, using the first-order conditional estimation method with interaction. We collected data on plasma voriconazole steady-state trough concentrations at 216 timepoints for 47 patients. A nonlinear pharmacokinetic model with the Michaelis–Menten equation was applied to describe the relationship between steady-state trough concentration and daily maintenance dose of voriconazole. After stepwise covariate modeling, the final model was evaluated using a goodness-of-fit plot, case deletion diagnostics, and bootstrap methods. Results The maximum elimination rate (Vmax) of voriconazole in patients coadministered letermovir and methylprednisolone was 1.72 and 1.30 times larger than that in patients not coadministered these drugs, respectively, resulting in decreased voriconazole trough concentrations. The developed PPK model adequately described the voriconazole trough concentration profiles in allo-HSCT recipients. Simulations clearly showed that increased daily doses of voriconazole were required to achieve an optimal trough voriconazole concentration (1–5 mg/L) when patients received voriconazole with letermovir and/or methylprednisolone. Conclusions The development of individualized dose adjustment is critical to achieve optimal voriconazole concentration, especially among allo-HSCT recipients receiving concomitant letermovir and/or methylprednisolone. Supplementary Information The online version contains supplementary material available at 10.1007/s40268-021-00365-0.
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Affiliation(s)
- Kimitaka Suetsugu
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Shota Muraki
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Junshiro Fukumoto
- Department of Clinical Pharmacology and Biopharmaceutics, The Pharmaceutical College, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Ryosuke Matsukane
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yasuo Mori
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takeshi Hirota
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.,Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Toshihiro Miyamoto
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Nobuaki Egashira
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.,Department of Clinical Pharmacology and Biopharmaceutics, The Pharmaceutical College, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Ichiro Ieiri
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. .,Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. .,Department of Clinical Pharmacology and Biopharmaceutics, The Pharmaceutical College, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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14
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White CM. Inflammation Suppresses Patients' Ability to Metabolize Cytochrome P450 Substrate Drugs. Ann Pharmacother 2021; 56:809-819. [PMID: 34590872 DOI: 10.1177/10600280211047864] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To assess the impact of inflammation on cytochrome P450 (CYP) drug metabolism in human subjects. DATA SOURCES A PubMed search was done from 1980 to July 2021 limited to human subjects and English language using a search strategy of (((phase I metabolism) OR (CYP) OR (cytochrome P450)) AND (inflammatory OR inflammation)). STUDY SELECTION AND DATA EXTRACTION Narrative review of human studies assessing the impact of inflammation or inflammatory suppression with biologic drugs on CYP drug metabolism were used. DATA SYNTHESIS Patients with inflammatory conditions ranging from fungal, viral, or bacterial infections to noninfectious causes (critical illness, surgical procedure, cancer, or transplantation of stem cells or organs) have suppressed drug metabolism. Markers of inflammation such as C-reactive protein or α-1-acid glycoprotein are correlated with reduced clearance through CYP3A4, CYP1A2, and CYP2C19. Elevated interleukin-6 concentrations are also associated or correlated with reduced clearance for CYP3A4 and CYP2C-19 isoenzymes. There was insufficient information to properly assess CYP2D6. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Health professionals should appreciate that patients with acute or chronic inflammation from infectious or noninfectious causes could have suppressed drug metabolism through CYP3A4, CYP1A2, and CYP2C19. For narrow therapeutic index drugs, such as many of the drugs assessed in this review, that means more judicious drug monitoring to prevent adverse events. CONCLUSIONS Like other types of drug-drug or drug-disease interactions, inflammation can alter the steady-state concentration of CYP metabolized drugs.
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Affiliation(s)
- C Michael White
- University of Connecticut School of Pharmacy, Storrs, CT, USA.,Hartford Hospital, Hartford, CT, USA
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15
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Lenoir C, Rodieux F, Desmeules JA, Rollason V, Samer CF. Impact of Inflammation on Cytochromes P450 Activity in Pediatrics: A Systematic Review. Clin Pharmacokinet 2021; 60:1537-1555. [PMID: 34462878 PMCID: PMC8613112 DOI: 10.1007/s40262-021-01064-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2021] [Indexed: 12/22/2022]
Abstract
Background and Objective Cytochromes P450 (CYP) are the major enzymes involved in hepatic metabolism of drugs. Personalization of treatment in pediatrics is a major challenge, as it must not only take into account genetic, environmental, and physiological factors but also ontogeny. Published data in adults show that inflammation had an isoform-specific impact on CYP activities and we aimed to evaluate this impact in the pediatric population. Methods Articles listed in PubMed through 7 January, 2021 that studied the impact of inflammation on CYP activities in pediatrics were included in this systematic review. Sources of inflammation, victim drugs (CYP involved), effect of drug–disease interactions, number and age of subjects, and study design were extracted. Results Twenty-seven studies and case reports were included. The impact of inflammation on CYP activities appeared to be age dependent and isoform-specific, with some drug–disease interactions having significant pharmacokinetic and clinical impact. For example, midazolam clearance decreases by 70%, while immunosuppressant and theophylline concentrations increase three-fold and two-fold with intensive care unit admission and infection. Cytochrome P450 activity appears to return to baseline level when the disease is resolved. Conclusions Studies that have assessed the impact of inflammation on CYP activity are lacking in pediatrics, yet it is a major factor to consider to improve drug efficacy or safety. The scarce current data show that the impact of inflammation is isoform and age dependent. An effort must be made to improve the understanding of the impact of inflammation on CYP activities in children to better individualize treatment.
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Affiliation(s)
- Camille Lenoir
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), University of Geneva, Geneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Frédérique Rodieux
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Jules A Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), University of Geneva, Geneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Victoria Rollason
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Caroline F Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva (HUG), Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland. .,Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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16
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Combined Impact of Inflammation and Pharmacogenomic Variants on Voriconazole Trough Concentrations: A Meta-Analysis of Individual Data. J Clin Med 2021; 10:jcm10102089. [PMID: 34068031 PMCID: PMC8152514 DOI: 10.3390/jcm10102089] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/11/2021] [Accepted: 05/11/2021] [Indexed: 01/23/2023] Open
Abstract
Few studies have simultaneously investigated the impact of inflammation and genetic polymorphisms of cytochromes P450 2C19 and 3A4 on voriconazole trough concentrations. We aimed to define the respective impact of inflammation and genetic polymorphisms on voriconazole exposure by performing individual data meta-analyses. A systematic literature review was conducted using PubMed to identify studies focusing on voriconazole therapeutic drug monitoring with data of both inflammation (assessed by C-reactive protein level) and the pharmacogenomics of cytochromes P450. Individual patient data were collected and analyzed in a mixed-effect model. In total, 203 patients and 754 voriconazole trough concentrations from six studies were included. Voriconazole trough concentrations were independently influenced by age, dose, C-reactive protein level, and both cytochrome P450 2C19 and 3A4 genotype, considered individually or through a combined genetic score. An increase in the C-reactive protein of 10, 50, or 100 mg/L was associated with an increased voriconazole trough concentration of 6, 35, or 82%, respectively. The inhibitory effect of inflammation appeared to be less important for patients with loss-of-function polymorphisms for cytochrome P450 2C19. Voriconazole exposure is influenced by age, inflammatory status, and the genotypes of both cytochromes P450 2C19 and 3A4, suggesting that all these determinants need to be considered in approaches of personalization of voriconazole treatment.
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17
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Le Daré B, Boglione-Kerrien C, Reizine F, Gangneux JP, Bacle A. Toward the personalized and integrative management of voriconazole dosing during COVID-19-associated pulmonary aspergillosis. Crit Care 2021; 25:152. [PMID: 33879175 PMCID: PMC8056831 DOI: 10.1186/s13054-021-03568-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/05/2021] [Indexed: 12/01/2022] Open
Affiliation(s)
- Brendan Le Daré
- Centre Hospitalier Universitaire de Rennes, Service Pharmacie, 35000, Rennes, France. .,INSERM, INRAE, CHU Rennes, Institut NuMeCan (Nutrition, Metabolisms and Cancer), Réseau PREVITOX, Univ Rennes, Rennes, France.
| | - Christelle Boglione-Kerrien
- Department of Clinical and Biological Pharmacology and Pharmacovigilance, Pharmacoepidemiology and Drug Information Centre, Rennes University Hospital, 35033, Rennes, France
| | - Florian Reizine
- Service des Maladies Infectieuses et Réanimation Médicale, CHU Rennes, 35033, Rennes, France.,Faculté de Médecine, Biosit, Université Rennes 1, 35043, Rennes, France
| | - Jean-Pierre Gangneux
- Inserm, EHESP, Irset (Institut de Recherche en Santé, environnement et travail) - UMR_S 1085, CHU Rennes, Univ Rennes, 35000, Rennes, France
| | - Astrid Bacle
- Centre Hospitalier Universitaire de Rennes, Service Pharmacie, 35000, Rennes, France.,Inserm, EHESP, Irset (Institut de Recherche en Santé, environnement et travail) - UMR_S 1085, CHU Rennes, Univ Rennes, 35000, Rennes, France
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18
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Simon F, Gautier-Veyret E, Truffot A, Chenel M, Payen L, Stanke-Labesque F, Tod M. Modeling Approach to Predict the Impact of Inflammation on the Pharmacokinetics of CYP2C19 and CYP3A4 Substrates. Pharm Res 2021; 38:415-428. [PMID: 33686560 DOI: 10.1007/s11095-021-03019-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/18/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE For decades, inflammation has been considered a cause of pharmacokinetic variability, mainly in relation to the inhibitory effect of pro-inflammatory cytokines on the expression level and activity of cytochrome P450 (CYP). In vitro and clinical studies have shown that two major CYPs, CYP2C19 and CYP3A4, are both impaired. The objective of the present study was to quantify the impact of the inflammatory response on the activity of both CYPs in order to predict the pharmacokinetic profile of their substrates according to systemic C-reactive protein (CRP). METHODS The relationships between CRP concentration and both CYPs activities were estimated and validated using clinical data first on midazolam then on voriconazole. Finally, clinical data on omeprazole were used to validate the findings. For each substrate, a physiologically based pharmacokinetics model was built using a bottom-up approach, and the relationships between CRP level and CYP activities were estimated by a top-down approach. After incorporating the respective relationships, we compared the predictions and observed drug concentrations. RESULTS Changes in pharmacokinetic profiles and parameters induced by inflammation seem to be captured accurately by the models. CONCLUSIONS These findings suggest that the pharmacokinetics of CYP2C19 and CYP3A4 substrates can be predicted depending on the CRP concentration.
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Affiliation(s)
- Florian Simon
- EA3738, Faculté de médecine de Lyon-Sud, Université de Lyon 1, 69921, Université de Lyon 1, Oullins cedex, France. .,Laboratoire de biochimie-toxicologie, Centre hospitalier Lyon-Sud, Hospices civils de Lyon, Pierre Bénite, Lyon, France.
| | - Elodie Gautier-Veyret
- Laboratoire de Pharmacologie, Pharmacogenetique et Toxicologie, Centre Hospitalier Universitaire des Alpes, 38043, Grenoble, France.,University Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, 38000, Grenoble, France
| | - Aurélie Truffot
- Laboratoire de Pharmacologie, Pharmacogenetique et Toxicologie, Centre Hospitalier Universitaire des Alpes, 38043, Grenoble, France
| | - Marylore Chenel
- Institut de recherches internationales Servier, Direction of clinical PK and pharmacometrics, Suresnes, France
| | - Léa Payen
- Laboratoire de biochimie-toxicologie, Centre hospitalier Lyon-Sud, Hospices civils de Lyon, Pierre Bénite, Lyon, France
| | - Françoise Stanke-Labesque
- Laboratoire de Pharmacologie, Pharmacogenetique et Toxicologie, Centre Hospitalier Universitaire des Alpes, 38043, Grenoble, France.,University Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, 38000, Grenoble, France
| | - Michel Tod
- EA3738, Faculté de médecine de Lyon-Sud, Université de Lyon 1, 69921, Université de Lyon 1, Oullins cedex, France
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19
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Gautier-Veyret E, Thiebaut-Bertrand A, Roustit M, Bolcato L, Depeisses J, Schacherer M, Schummer G, Fonrose X, Stanke-Labesque F. Optimization of voriconazole therapy for treatment of invasive aspergillosis: Pharmacogenomics and inflammatory status need to be evaluated. Br J Clin Pharmacol 2020; 87:2534-2541. [PMID: 33217017 DOI: 10.1111/bcp.14661] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/04/2020] [Accepted: 11/11/2020] [Indexed: 12/13/2022] Open
Abstract
AIMS Cytochrome 2C19 genotype-directed dosing of voriconazole (VRC) reduces the incidence of insufficient VRC trough concentrations (Cmin ) but does not account for CYP3A polymorphisms, also involved in VRC metabolism. This prospective observational study aimed to evaluate the utility of a genetic score combining CYP2C19 and CYP3A genotypes to predict insufficient initial VRC Cmin (<1 mg/L). METHODS The genetic score was determined in hematological patients treated with VRC. The higher the genetic score, the faster the metabolism of the patient. The impact of the genetic score was evaluated considering initial VRC Cmin and all VRC Cmin (n = 159) determined during longitudinal therapeutic drug monitoring. RESULTS Forty-three patients were included, of whom 41 received VRC for curative indication. Thirty-six patients had a genetic score ≥2, of whom 11 had an initial insufficient VRC Cmin . A genetic score ≥2 had a positive predictive value of 0.31 for having an initial insufficient VRC Cmin and initial VRC Cmin was not associated with the genetic score. The lack of association between the genetic score and VRC Cmin may be related to the inflammatory status of the patients (C-reactive protein [CRP] levels: median [Q1-Q3]: 43.0 [11.0-110.0] mg/L), as multivariate analysis performed on all VRC Cmin identified CRP as an independent determinant of the VRC Cmin adjusted for dose (P < .0001). CONCLUSION The combined genetic score did not predict low VRC exposure in patients with inflammation, which is frequent in patients with invasive fungal infections. Strategies for the individualization of VRC dose should integrate the inflammatory status of patients in addition to pharmacogenetic variants.
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Affiliation(s)
- Elodie Gautier-Veyret
- Inserm, CHU Grenoble Alpes, HP2, Universitaire Grenoble Alpes, Grenoble, 38000, France
| | | | - Matthieu Roustit
- Inserm, CHU Grenoble Alpes, HP2, Universitaire Grenoble Alpes, Grenoble, 38000, France
| | - Léa Bolcato
- Laboratoire de Pharmacologie, Pharmacogénétique et Toxicologie, CHU Grenoble Alpes, France
| | | | | | - Gabriel Schummer
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, Grenoble, France
| | - Xavier Fonrose
- Laboratoire de Pharmacologie, Pharmacogénétique et Toxicologie, CHU Grenoble Alpes, France
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20
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Venisse N, Peytavin G, Bouchet S, Gagnieu MC, Garraffo R, Guilhaumou R, Solas C. Concerns about pharmacokinetic (PK) and pharmacokinetic-pharmacodynamic (PK-PD) studies in the new therapeutic area of COVID-19 infection. Antiviral Res 2020; 181:104866. [PMID: 32659293 PMCID: PMC7351053 DOI: 10.1016/j.antiviral.2020.104866] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 01/07/2023]
Abstract
In the context of the COVID-19 pandemic, several drugs have been repurposed as potential candidates for the treatment of COVID-19 infection. While preliminary choices were essentially based on in vitro potency, clinical translation into effective therapies may be challenging due to unfavorable in vivo pharmacokinetic properties at the doses chosen for this new indication of COVID-19 infection. However, available pharmacokinetic and pharmacokinetic-pharmacodynamic studies suffer from severe limitations leading to unreliable conclusions, especially in term of dosing optimization. In this paper we propose to highlight these limitations and to identify some of the major requirements that need to be addressed in designing PK and PK-PD studies in this era of COVID. A special attention should be paid to pre-analytical and analytical requirements and to the proper collection of covariates affecting dose-exposure relationships (co-medications, use of specific organ support techniques and other clinical and para-clinical data). We also promote the development of population PK and PK-PD models specifically dedicated to COVID-19 patients since those previously developed for other diseases (SEL, malaria, HIV) and clinical situations (steady-state, non-ICU patients) are not representative of severe patients. Therefore, implementation of well-designed PK and PD studies targeted to COVID-19 patients is urgently needed. For that purpose we call for multi-institutional collaborative work and involvement of clinical pharmacologists in multidisciplinary research consortia.
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Affiliation(s)
- Nicolas Venisse
- INSERM CIC1402, University Hospital of Poitiers, University of Poitiers, 86021, Poitiers Cedex, France,Biology-Pharmacy-Public Health Department, University Hospital of Poitiers, 2 Rue de La Milétrie, 86021, Poitiers Cedex, France,Corresponding author. Laboratoire de Toxicologie et Pharmacocinétique, et CIC INSERM 1402, Centre Hospitalier Universitaire de Poitiers 2, rue de la Milétrie, 86021, Poitiers, France
| | - Gilles Peytavin
- AP-HP, Bichat Claude Bernard Hospital, Pharmacology-Toxicology Department and IAME, INSERM, UMRS1137, Université de Paris, 75018, Paris, 7, France
| | - Stephane Bouchet
- Laboratoire de Pharmaco-Toxicologie, Service de Pharmacologie Médicale, CHU De Bordeaux, INSERM U1219, F-33076, Bordeaux Cedex, France
| | - Marie-Claude Gagnieu
- Hospices Civils de Lyon, GHS-Centre de Biologie Sud, Pierre Bénite, Lyon, France
| | - Rodolphe Garraffo
- Pharmacologie et Toxicologie Médicales, CHU et Faculté de Médecine de Nice, Université Côte D'Azur, Nice, France
| | - Romain Guilhaumou
- Service de Pharmacologie Clinique et Pharmacovigilance, APHM, Institut de Neurosciences des Systèmes, Inserm UMR 1106, Université D'Aix-Marseille, 13005, Marseille, France
| | - Caroline Solas
- Aix-Marseille Univ, APHM, Unité des Virus Emergents (UVE) IRD 190, INSERM 1207, Laboratoire de Pharmacocinétique et Toxicologie, Hôpital La Timone, 13005, Marseille, France,Corresponding author. Laboratoire de Pharmacocinétique et de Toxicologie, APHM et Unité des Virus Émergents - (UVE) Aix-Marseille Université - IRD_190 - Inserm_1207 EFS - IRBA Hôpital de La Timone 264 rue Saint-Pierre 13005, Marseille, France
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Bonneville E, Gautier‐Veyret E, Ihl C, Hilleret M, Baudrant M, Fonrose X, Stanke‐Labesque F. Unexpected overdose blood concentration of tacrolimus: Keep in mind the role of inflammation. Br J Clin Pharmacol 2020; 86:1888-1891. [PMID: 32199027 PMCID: PMC7444753 DOI: 10.1111/bcp.14292] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/19/2020] [Accepted: 02/26/2020] [Indexed: 12/21/2022] Open
Abstract
Tacrolimus is the cornerstone of the therapeutic immunosuppressive strategy in liver transplantation. The inter-individual and intra-individual variability of its trough blood concentrations is a surrogated biomarker of allograft rejection. Here we described two cases of patients with liver transplant who exhibited increases of tacrolimus blood trough concentration adjusted on the dose while experiencing acute inflammatory episodes. These case reports highlight the inhibitory effect of acute inflammation on tacrolimus metabolism and show that it accounts for the longitudinal intra-individual variability of tacrolimus blood concentrations, beyond drug-drug interaction and observance.
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Affiliation(s)
- Edouard Bonneville
- Laboratory of Pharmacology‐Pharmacogenetics‐Toxicology, Pôle de Biologie et PathologieCHUGrenobleAlpesFrance
| | - Elodie Gautier‐Veyret
- Laboratory of Pharmacology‐Pharmacogenetics‐Toxicology, Pôle de Biologie et PathologieCHUGrenobleAlpesFrance
- Inserm, CHU Grenoble Alpes, HP2Univ. Grenoble AlpesGrenoble38000France
| | | | | | | | - Xavier Fonrose
- Laboratory of Pharmacology‐Pharmacogenetics‐Toxicology, Pôle de Biologie et PathologieCHUGrenobleAlpesFrance
| | - Françoise Stanke‐Labesque
- Laboratory of Pharmacology‐Pharmacogenetics‐Toxicology, Pôle de Biologie et PathologieCHUGrenobleAlpesFrance
- Inserm, CHU Grenoble Alpes, HP2Univ. Grenoble AlpesGrenoble38000France
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Stanke-Labesque F, Gautier-Veyret E, Chhun S, Guilhaumou R. Inflammation is a major regulator of drug metabolizing enzymes and transporters: Consequences for the personalization of drug treatment. Pharmacol Ther 2020; 215:107627. [PMID: 32659304 PMCID: PMC7351663 DOI: 10.1016/j.pharmthera.2020.107627] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/06/2020] [Indexed: 12/22/2022]
Abstract
Inflammation is an evolutionary process that allows survival against acute infection or injury. Inflammation is also a pathophysiological condition shared by numerous chronic diseases. In addition, inflammation modulates important drug-metabolizing enzymes and transporters (DMETs), thus contributing to intra- and interindividual variability of drug exposure. A better knowledge of the impact of inflammation on drug metabolism and its related clinical consequences would help to personalize drug treatment. Here, we summarize the kinetics of inflammatory mediators and the underlying transcriptional and post-transcriptional mechanisms by which they contribute to the inhibition of important DMETs. We also present an updated overview of the effect of inflammation on the pharmacokinetic parameters of most of the drugs that are DMET substrates, for which therapeutic drug monitoring is recommended. Furthermore, we provide opinions on how to integrate the inflammatory status into pharmacogenetics, therapeutic drug monitoring, and population pharmacokinetic strategies to improve the personalization of drug treatment for each patient.
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Affiliation(s)
- Françoise Stanke-Labesque
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, Grenoble 38000, France; Laboratory of Pharmacology-Pharmacogenetics-Toxicology, Pôle de Biologie et Pathologie, CHU Grenoble Alpes, France.
| | - Elodie Gautier-Veyret
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, Grenoble 38000, France; Laboratory of Pharmacology-Pharmacogenetics-Toxicology, Pôle de Biologie et Pathologie, CHU Grenoble Alpes, France
| | - Stephanie Chhun
- Faculty of Medicine, Paris University, Paris, France; Institut Necker-Enfants Malades (INEM), INSERM U1151-CNRS UMR 8253, Paris, France; AP-HP, Paris Centre, Laboratory of Immunology, Necker-Enfants Malades Hospital, Paris, France
| | - Romain Guilhaumou
- Clinical Pharmacology and Pharmacovigilance Unit, AP-HM, Marseille, France; Aix Marseille Univ, INSERM, INS Inst Neurosci Syst, Marseille, France
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