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Dong L, Zhuang X, Yang T, Yan K, Cai Y. A physiologically based pharmacokinetic model of voriconazole in human CNS-Integrating time-dependent inhibition of CYP3A4, genetic polymorphisms of CYP2C19 and possible transporter mechanisms. Int J Antimicrob Agents 2024; 64:107310. [PMID: 39168418 DOI: 10.1016/j.ijantimicag.2024.107310] [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: 03/04/2024] [Revised: 07/26/2024] [Accepted: 08/12/2024] [Indexed: 08/23/2024]
Abstract
OBJECTIVES Voriconazole is a classical antifungal drug that is often used to treat CNS fungal infections due to its permeability through the BBB. However, its clinical use remains challenging because of its narrow therapeutic window and wide inter-individual variability. In this study, we proposed an optimised and validated PBPK model by integrating in vitro, in vivo and clinical data to simulate the distribution and PK process of voriconazole in the CNS, providing guidance for clinical individualised treatment. METHODS The model structure was optimised and tissue-to-plasma partition coefficients were obtained through animal experiments. Using the allometric relationships, the distribution of voriconazole in the human CNS was predicted. The model integrated factors affecting inter-individual variation and drug interactions of voriconazole-polymorphisms in the CYP2C19 gene and auto-inhibition and then was validated using real clinical data. RESULTS The overall AFE value showing model predicted differences was 1.1420 in the healthy population; and in the first prediction of plasma and CSF in actual clinical patients, 89.5% of the values were within the 2-fold error interval, indicating good predictive performance of the model. The bioavailability of voriconazole varied at different doses (39%-86%), and the optimised model conformed to this pattern (46%-83%). CONCLUSIONS Combined with the relevant pharmacodynamic indexes, the PBPK model provides a feasible way for precise medication in patients with CNS infection and improve the treatment effect and prognosis.
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Affiliation(s)
- Liuhan Dong
- Center of Medicine Clinical Research, Department of Pharmacy, Chinese PLA General Hospital, Beijing, China; State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing, China
| | - Xiaomei Zhuang
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing, China
| | - Tianli Yang
- Center of Medicine Clinical Research, Department of Pharmacy, Chinese PLA General Hospital, Beijing, China
| | - Kaicheng Yan
- Center of Medicine Clinical Research, Department of Pharmacy, Chinese PLA General Hospital, Beijing, China
| | - Yun Cai
- Center of Medicine Clinical Research, Department of Pharmacy, Chinese PLA General Hospital, Beijing, China.
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Lewis GJ, Ahire D, Taskar KS. Physiologically-based pharmacokinetic modeling of prominent oral contraceptive agents and applications in drug-drug interactions. CPT Pharmacometrics Syst Pharmacol 2024; 13:563-575. [PMID: 38130003 PMCID: PMC11015076 DOI: 10.1002/psp4.13101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/24/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023] Open
Abstract
Considerable interest remains across the pharmaceutical industry and regulatory landscape in capabilities to model oral contraceptives (OCs), whether combined (COCs) with ethinyl estradiol (EE) or progestin-only pill. Acceptance of COC drug-drug interaction (DDI) assessment using physiologically-based pharmacokinetic (PBPK) is often limited to the estrogen component (EE), requiring further verification, with extrapolation from EE to progestins discouraged. There is a paucity of published progestin component PBPK models to support the regulatory DDI guidance for industry to evaluate a new chemical entity's (NCE's) DDI potential with COCs. Guidance recommends a clinical interaction study to be considered if an investigational drug is a weak or moderate inducer, or a moderate/strong inhibitor, of CYP3A4. Therefore, availability of validated OC PBPK models within one software platform, will be useful in predicting the DDI potential with NCEs earlier in the clinical development. Thus, this work was focused on developing and validating PBPK models for progestins, DNG, DRSP, LNG, and NET, within Simcyp, and assessing the DDI potential with known CYP3A4 inhibitors (e.g., ketoconazole) and inducers (e.g., rifampicin) with published clinical data. In addition, this work demonstrated confidence in the Simcyp EE model for regulatory and clinical applications by extensive verification in 70+ clinical PK and CYP3A4 interaction studies. The results provide greater capability to prospectively model clinical CYP3A4 DDI with COCs using Simcyp PBPK to interrogate the regulatory decision-tree to contextualize the potential interaction by known perpetrators and NCEs, enabling model-informed decision making, clinical study designs, and delivering potential alternative COC options for women of childbearing potential.
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Affiliation(s)
- Gareth J. Lewis
- Drug Metabolism and Pharmacokinetics, In Vitro In Vivo Translation, Research, GlaxoSmithKlineStevenageUK
| | - Deepak Ahire
- Department of Pharmaceutical SciencesWashington State UniversitySpokaneWashingtonUSA
| | - Kunal S. Taskar
- Drug Metabolism and Pharmacokinetics, In Vitro In Vivo Translation, Research, GlaxoSmithKlineStevenageUK
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Fasero M, Quereda F, Andraca L, Coronado PJ. Pharmacological interactions and menopausal hormone therapy: a review. Menopause 2023:00042192-990000000-00211. [PMID: 37449718 DOI: 10.1097/gme.0000000000002219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
IMPORTANCE AND OBJECTIVE Menopausal hormone therapy (HT) is widely used, and there are several statements of international scientific societies to guide prescribers; however, a summary of existing literature about possible drug interactions with HT does not exist, although many midlife women take medications for other conditions. Therefore, our objective was to create a document that presents and synthesizes the most relevant interactions. The impact of the interaction itself and the number of candidates for HT who are likely to use other treatments are considered based on the best available evidence. METHODS A systematic review was performed to determine the best evidence of interaction effects on relevant outcomes of interest for decision making. A working framework was developed to formulate explicit and reasoned recommendations according to four predefined categories for coadministration: (1) can be used without expected risks, (2) acceptable use (no evidence of negative interaction), (3) alternative treatment should be considered, and (4) nonuse without express justification. The project protocol was registered in the Open Science Framework platform (doi: 10.17605/OSF.IO/J6WBC) and in PROSPERO (registration number CRD42020166658). RESULTS Studies targeting our objective are scarce, but 23 pharmacological groups were assigned to one of the predefined categories of recommendation for concomitant use of HT. Vaginal HT was assigned to category 1 for 21 of the analyzed pharmacological groups. For oral and transdermal HT (estrogen-only or combined) and tibolone, there were 12 pharmacological groups assigned to category 1, 12 to category 2, 5 to category 3, and 4 to category 4. Results are shown in crossed-tables that are useful for counseling and prescription. DISCUSSION AND CONCLUSIONS Available evidence of HT interactions with other drugs is scarce and mainly indirect. It comes from biological plausibility, knowledge of extensive concomitant use without reported incidents, and/or extrapolation from hormonal contraception, but there are pharmacological groups in all categories showing that information is useful. These eligibility criteria summarize it and can help in the decision process of HT coadministration with other drugs. Decisions should be taken based on these recommendations but also individualized risk/benefit evaluation, according to underlying pathology, patient's clinical requirements, and the existence or nonexistence of alternatives.
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Affiliation(s)
- Maria Fasero
- From the Menopause Unit, Clínica Corofas, Universidad Francisco de Vitoria, Madrid, Spain
| | - Francisco Quereda
- Hospital Universitario de San Juan de Alicante, Universidad Miguel Hernández, Elche, Alicante, Spain
| | - Leire Andraca
- Sociedad Española de Farmacia Comunitaria (SEFAC), Madrid, Spain
| | - Pluvio J Coronado
- Departamento de Obstetricia y Ginecología, Hospital clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
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Mushtaq M, Fatima K, Ahmad A, Mohamed Ibrahim O, Faheem M, Shah Y. Pharmacokinetic interaction of voriconazole and clarithromycin in Pakistani healthy male volunteers: a single dose, randomized, crossover, open-label study. Front Pharmacol 2023; 14:1134803. [PMID: 37361220 PMCID: PMC10288581 DOI: 10.3389/fphar.2023.1134803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/26/2023] [Indexed: 06/28/2023] Open
Abstract
Background: Voriconazole an antifungal drug, has a potential for drug-drug interactions (DDIs) with administered drugs. Clarithromycin is a Cytochromes P450 CYP (3A4 and 2C19) enzyme inhibitor, and voriconazole is a substrate and inhibitor of these two enzymes. Being a substrate of the same enzyme for metabolism and transport, the chemical nature and pKa of both interacting drugs make these drugs better candidates for potential pharmacokinetic drug-drug interactions (PK-DDIs). This study aimed to evaluate the effect of clarithromycin on the pharmacokinetic profile of voriconazole in healthy volunteers. Methods: A single oral dose, open-label, randomized, crossover study was designed for assessing PK-DDI in healthy volunteers, consisting of 2 weeks washout period. Voriconazole, either alone (2 mg × 200 mg, tablet, P/O) or along with clarithromycin (voriconazole 2 mg × 200 mg, tablet + clarithromycin 500 mg, tablet, P/O), was administered to enrolled volunteers in two sequences. The blood samples (approximately 3 cc) were collected from volunteers for up to 24 h. Plasma concentrations of voriconazole were analyzed by an isocratic, reversed-phase high-performance-liquid chromatography ultraviolet-visible detector (RP HPLC UV-Vis) and a non-compartmental method. Results: In the present study, when voriconazole was administered with clarithromycin versus administered alone, a significant increase in peak plasma concentration (Cmax) of voriconazole by 52% (geometric mean ratio GMR: 1.52; 90% CI 1.04, 1.55; p = 0.000) was observed. Similarly, the area under the curve from time zero to infinity (AUC0-∞) and the area under the concentration-time curve from time zero to time-t (AUC0-t) of voriconazole also significantly increased by 21% (GMR: 1.14; 90% CI 9.09, 10.02; p = 0.013), and 16% (GMR: 1.15; 90% CI 8.08, 10.02; p = 0.007), respectively. In addition, the results also showed a reduction in the apparent volume of distribution (Vd) by 23% (GMR: 0.76; 90% CI 5.00, 6.20; p = 0.051), and apparent clearance (CL) by 13% (GMR: 0.87; 90% CI 41.95, 45.73; p = 0.019) of voriconazole. Conclusion: The alterations in PK parameters of voriconazole after concomitant administration of clarithromycin are of clinical significance. Therefore, adjustments in dosage regimens are warranted. In addition, extreme caution and therapeutic drug monitoring are necessary while co-prescribing both drugs. Clinical Trial Registration: clinicalTrials.gov, Identifier NCT05380245.
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Affiliation(s)
- Mehwish Mushtaq
- Department of Pharmacy, Abdul Wali Khan University Mardan, Mardan, Pakistan
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| | - Kshaf Fatima
- University Medical and Dental College, The University of Faisalabad, Faisalabad, Pakistan
| | - Aneeqa Ahmad
- Punjab Medical College, Faisalabad Medical University, Faisalabad, Pakistan
| | - Osama Mohamed Ibrahim
- College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
- Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Muhammad Faheem
- Department of Pharmacy, University of Swabi, Swabi, Pakistan
| | - Yasar Shah
- Department of Pharmacy, Abdul Wali Khan University Mardan, Mardan, Pakistan
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Mendoza N, Ramírez I, de la Viuda E, Coronado P, Baquedano L, Llaneza P, Nieto V, Otero B, Sánchez-Méndez S, de Frutos VÁ, Andraca L, Barriga P, Benítez Z, Bombas T, Cancelo MJ, Cano A, Branco CC, Correa M, Doval JL, Fasero M, Fiol G, Garello NC, Genazzani AR, Gómez AI, Gómez MÁ, González S, Goulis DG, Guinot M, Hernández LR, Herrero S, Iglesias E, Jurado AR, Lete I, Lubián D, Martínez M, Nieto A, Nieto L, Palacios S, Pedreira M, Pérez-Campos E, Plá MJ, Presa J, Quereda F, Ribes M, Romero P, Roca B, Sánchez-Capilla A, Sánchez-Borrego R, Santaballa A, Santamaría A, Simoncini T, Tinahones F, Calaf J. Eligibility criteria for Menopausal Hormone Therapy (MHT): a position statement from a consortium of scientific societies for the use of MHT in women with medical conditions. MHT Eligibility Criteria Group. Maturitas 2022; 166:65-85. [PMID: 36081216 DOI: 10.1016/j.maturitas.2022.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/21/2022] [Accepted: 08/17/2022] [Indexed: 11/26/2022]
Abstract
This project aims to develop eligibility criteria for menopausal hormone therapy (MHT). The tool should be similar to those already established for contraception A consortium of scientific societies coordinated by the Spanish Menopause Society met to formulate recommendations for the use of MHT by women with medical conditions based on the best available evidence. The project was developed in two phases. As a first step, we conducted 14 systematic reviews and 32 metanalyses on the safety of MHT (in nine areas: age, time of menopause onset, treatment duration, women with thrombotic risk, women with a personal history of cardiovascular disease, women with metabolic syndrome, women with gastrointestinal diseases, survivors of breast cancer or of other cancers, and women who smoke) and on the most relevant pharmacological interactions with MHT. These systematic reviews and metanalyses helped inform a structured process in which a panel of experts defined the eligibility criteria according to a specific framework, which facilitated the discussion and development process. To unify the proposal, the following eligibility criteria have been defined in accordance with the WHO international nomenclature for the different alternatives for MHT (category 1, no restriction on the use of MHT; category 2, the benefits outweigh the risks; category 3, the risks generally outweigh the benefits; category 4, MHT should not be used). Quality was classified as high, moderate, low or very low, based on several factors (including risk of bias, inaccuracy, inconsistency, lack of directionality and publication bias). When no direct evidence was identified, but plausibility, clinical experience or indirect evidence were available, "Expert opinion" was categorized. For the first time, a set of eligibility criteria, based on clinical evidence and developed according to the most rigorous methodological tools, has been defined. This will provide health professionals with a powerful decision-making tool that can be used to manage menopausal symptoms.
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Affiliation(s)
- Nicolás Mendoza
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain.
| | - Isabel Ramírez
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | | | - Pluvio Coronado
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | - Laura Baquedano
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | - Plácido Llaneza
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | - Verónica Nieto
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | - Borja Otero
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | | | | | - Leire Andraca
- Sociedad Española de Farmacia Comunitaria (SEFAC), Spain
| | | | - Zully Benítez
- Federación Latino Americana de Sociedades de Climaterio y Menopausia (FLASCYM)
| | - Teresa Bombas
- Red Iberoamericana de Salud Sexual y Reproductiva (REDISSER)
| | | | - Antonio Cano
- European Menopause and Andropause Society (EMAS)
| | | | | | - José Luis Doval
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | - María Fasero
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | - Gabriel Fiol
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | - Nestor C Garello
- Federación Latino-Americana de Sociedades de Obstetricia y Ginecología (FLASOG)
| | | | - Ana Isabel Gómez
- Sociedad Española de Senología y Patología Mamaria (SESPM), Spain
| | - Mª Ángeles Gómez
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | - Silvia González
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | | | | | | | - Sonia Herrero
- Sociedad Española de Trombosis y Hemostasia (SETH), Spain
| | - Eva Iglesias
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | - Ana Rosa Jurado
- Sociedad Española de Médicos de Atención Primaria (SEMERGEN), Spain
| | - Iñaki Lete
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | - Daniel Lubián
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | | | - Aníbal Nieto
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | - Laura Nieto
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | | | | | | | | | - Jesús Presa
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | | | - Miriam Ribes
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | - Pablo Romero
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | - Beatriz Roca
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | | | | | | | | | | | | | - Joaquín Calaf
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
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Sun H, Sivasubramanian R, Vaidya S, Barve A, Jarugula V. Drug-Drug Interaction Studies With Oral Contraceptives: Pharmacokinetic/Pharmacodynamic and Study Design Considerations. J Clin Pharmacol 2020; 60 Suppl 2:S49-S62. [PMID: 33274510 DOI: 10.1002/jcph.1765] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/28/2020] [Indexed: 11/08/2022]
Abstract
Oral contraceptives (OCs) are the most widely used form of birth control among women of childbearing potential. Knowledge of potential drug-drug interactions (DDIs) with OCs becomes imperative to provide information on the medication to women of childbearing potential and enable their inclusion in clinical trials, especially if the new molecular entity is a teratogen. Although a number of DDI guidance documents are available, they do not provide recommendations for the design and conduct of OC DDI studies. The evaluation of DDI potential of a new molecular entity and OCs is particularly challenging because of the availability of a wide variety of combinations of hormonal contraceptives, different doses of the ethinyl estradiol, and different metabolic profiles of the progestin component. The aim of this review is to comprehensively discuss factors to be considered such as pharmacokinetics (PK), pharmacodynamics (PD), choice of OC, and study population for the conduct of in vivo OC DDI studies. In this context, metabolic pathways of OCs, the effect of enzyme inhibitors and inducers, the role of sex hormone-binding globulin in the PK of progestins, current evidence on OC DDIs, and the interpretation of PD end points are reviewed. With the emergence of new tools like physiologically based PK modeling, the decision to conduct an in vivo study can be made with much more confidence. This review provides a comprehensive overview of various factors that need to be considered in designing OC DDI studies and recommends PK-based DDI studies with PK end points as adequate measures to establish clinical drug interaction and measurement of PD end points when there is basis for PD interaction.
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Affiliation(s)
- Haiying Sun
- Novartis Institutes for BioMedical Research, East Hanover, New Jersey, USA
| | | | - Soniya Vaidya
- Current affiliation: Axcella Health Inc., Cambridge, Massachusetts, USA
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7
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Majeed SR, West S, Ling KH, Das M, Kearney BP. Confirmation of the drug-drug interaction potential between cobicistat-boosted antiretroviral regimens and hormonal contraceptives. Antivir Ther 2020; 24:557-566. [PMID: 31933482 DOI: 10.3851/imp3343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cobicistat (COBI), a CYP3A inhibitor, is a pharmacokinetic enhancer that increases exposures of the HIV protease inhibitors (PIs) atazanavir (ATV) and darunavir (DRV). The potential drug interaction between COBI-boosted PIs and hormonal contraceptives, which are substrates of intestinal efflux transporters and extensively metabolized by CYP enzymes, glucuronidation and sulfation, was evaluated. METHODS This was a Phase I, open-label, two cohort (n=18/cohort), fixed-sequence study in healthy females that evaluated the drug-drug interaction (DDI) between multiple-dose ATV+COBI or DRV+COBI and single-dose drospirenone/ethinyl estradiol (EE). DDIs were evaluated using 90% confidence intervals of the geometric least-squares mean ratios of the test (drospirenone/EE+boosted PI) versus reference (drospirenone/EE) using lack of DDI boundaries of 70-143%. Safety was assessed throughout the study. RESULTS 29/36 participants completed the study. Relative to drospirenone/EE alone, drospirenone area under the plasma concentration versus time curve extrapolated to infinity (AUCinf) was 1.6-fold and 2.3-fold higher, and maximum observed plasma concentration (Cmax) was unaltered, upon coadministration with DRV+COBI and ATV+COBI, respectively. EE AUCinf decreased 30% with drospirenone/EE + DRV+COBI and was unchanged with ATV+COBI + drospirenone/EE, relative to drospirenone/EE alone. Study treatments were generally well tolerated. The majority of adverse events were mild and consistent with known safety profiles of the compounds. CONCLUSIONS Consistent with COBI-mediated CYP3A inhibition, drospirenone exposure increased following coadministration with COBI-containing regimens, with a greater increase with ATV+COBI. Thus, clinical monitoring for drospirenone-associated hyperkalaemia is recommended with DRV+COBI and ATV+COBI should not be used with drospirenone. Lower EE exposure with DRV+COBI may be attributed to inductive effects of DRV on CYP enzymes and/or intestinal efflux transporters (that is, P-gp) involved in EE disposition.
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Li X, Frechen S, Moj D, Lehr T, Taubert M, Hsin CH, Mikus G, Neuvonen PJ, Olkkola KT, Saari TI, Fuhr U. A Physiologically Based Pharmacokinetic Model of Voriconazole Integrating Time-Dependent Inhibition of CYP3A4, Genetic Polymorphisms of CYP2C19 and Predictions of Drug–Drug Interactions. Clin Pharmacokinet 2019; 59:781-808. [DOI: 10.1007/s40262-019-00856-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Zhang N, Shon J, Kim M, Yu C, Zhang L, Huang S, Lee L, Tran D, Li L. Role of CYP3A in Oral Contraceptives Clearance. Clin Transl Sci 2018; 11:251-260. [PMID: 28986954 PMCID: PMC5944580 DOI: 10.1111/cts.12499] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/26/2017] [Indexed: 12/12/2022] Open
Affiliation(s)
- Nan Zhang
- Office of Clinical Pharmacology (OCP), Office of Translational Sciences (OTS)Center for Drug Evaluation and Research (CDER)US Food and Drug Administration (FDA)Silver SpringMarylandUSA
- Oak Ridge Institute for Science and Education (ORISE)TennesseeOak RidgeUSA
| | - Jihong Shon
- Office of Clinical Pharmacology (OCP), Office of Translational Sciences (OTS)Center for Drug Evaluation and Research (CDER)US Food and Drug Administration (FDA)Silver SpringMarylandUSA
| | - Myong‐Jin Kim
- Office of Clinical Pharmacology (OCP), Office of Translational Sciences (OTS)Center for Drug Evaluation and Research (CDER)US Food and Drug Administration (FDA)Silver SpringMarylandUSA
| | - Chongwoo Yu
- Office of Clinical Pharmacology (OCP), Office of Translational Sciences (OTS)Center for Drug Evaluation and Research (CDER)US Food and Drug Administration (FDA)Silver SpringMarylandUSA
| | - Lei Zhang
- Office of Clinical Pharmacology (OCP), Office of Translational Sciences (OTS)Center for Drug Evaluation and Research (CDER)US Food and Drug Administration (FDA)Silver SpringMarylandUSA
| | - Shiew‐Mei Huang
- Office of Clinical Pharmacology (OCP), Office of Translational Sciences (OTS)Center for Drug Evaluation and Research (CDER)US Food and Drug Administration (FDA)Silver SpringMarylandUSA
| | - LaiMing Lee
- Office of Clinical Pharmacology (OCP), Office of Translational Sciences (OTS)Center for Drug Evaluation and Research (CDER)US Food and Drug Administration (FDA)Silver SpringMarylandUSA
| | - Doanh Tran
- Office of Clinical Pharmacology (OCP), Office of Translational Sciences (OTS)Center for Drug Evaluation and Research (CDER)US Food and Drug Administration (FDA)Silver SpringMarylandUSA
| | - Li Li
- Office of Clinical Pharmacology (OCP), Office of Translational Sciences (OTS)Center for Drug Evaluation and Research (CDER)US Food and Drug Administration (FDA)Silver SpringMarylandUSA
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10
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Ezuruike U, Humphries H, Dickins M, Neuhoff S, Gardner I, Rowland Yeo K. Risk-Benefit Assessment of Ethinylestradiol Using a Physiologically Based Pharmacokinetic Modeling Approach. Clin Pharmacol Ther 2018; 104:1229-1239. [PMID: 29637542 PMCID: PMC6282492 DOI: 10.1002/cpt.1085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/09/2018] [Accepted: 03/14/2018] [Indexed: 02/03/2023]
Abstract
Current formulations of combined oral contraceptives (COC) containing ethinylestradiol (EE) have ≤35 μg due to increased risks of cardiovascular diseases (CVD) with higher doses of EE. Low‐dose formulations however, have resulted in increased incidences of breakthrough bleeding and contraceptive failure, particularly when coadministered with inducers of cytochrome P450 enzymes (CYP). The developed physiologically based pharmacokinetic model quantitatively predicted the effect of CYP3A4 inhibition and induction on the pharmacokinetics of EE. The predicted Cmax and AUC ratios when coadministered with voriconazole, fluconazole, rifampicin, and carbamazepine were within 1.25 of the observed data. Based on published clinical data, an AUCss value of 1,000 pg/ml.h was selected as the threshold for breakthrough bleeding. Prospective application of the model in simulations of different doses of EE (20 μg, 35 μg, and 50 μg) identified percentages of the population at risk of breakthrough bleeding alone and with varying degrees of CYP modulation.
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Affiliation(s)
| | | | | | | | - Iain Gardner
- Simcyp Limited (a Certara company), Sheffield, UK
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11
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Townsend R, Dietz A, Hale C, Akhtar S, Kowalski D, Lademacher C, Lasseter K, Pearlman H, Rammelsberg D, Schmitt-Hoffmann A, Yamazaki T, Desai A. Pharmacokinetic Evaluation of CYP3A4-Mediated Drug-Drug Interactions of Isavuconazole With Rifampin, Ketoconazole, Midazolam, and Ethinyl Estradiol/Norethindrone in Healthy Adults. Clin Pharmacol Drug Dev 2016; 6:44-53. [PMID: 27273461 PMCID: PMC5298035 DOI: 10.1002/cpdd.285] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/18/2016] [Accepted: 06/03/2016] [Indexed: 01/31/2023]
Abstract
This report describes the phase 1 trials that evaluated the metabolism of the novel triazole antifungal isavuconazole by cytochrome P450 3A4 (CYP3A4) and isavuconazole's effects on CYP3A4‐mediated metabolism in healthy adults. Coadministration of oral isavuconazole (100 mg once daily) with oral rifampin (600 mg once daily; CYP3A4 inducer) decreased isavuconazole area under the concentration‐time curve (AUCτ) during a dosing interval by 90% and maximum concentration (Cmax) by 75%. Conversely, coadministration of isavuconazole (200 mg single dose) with oral ketoconazole (200 mg twice daily; CYP3A4 inhibitor) increased isavuconazole AUC from time 0 to infinity (AUC0‐∞) and Cmax by 422% and 9%, respectively. Isavuconazole was coadministered (200 mg 3 times daily for 2 days, then 200 mg once daily) with single doses of oral midazolam (3 mg; CYP3A4 substrate) or ethinyl estradiol/norethindrone (35 μg/1 mg; CYP3A4 substrate). Following coadministration, AUC0‐∞ increased 103% for midazolam, 8% for ethinyl estradiol, and 16% for norethindrone; Cmax increased by 72%, 14%, and 6%, respectively. Most adverse events were mild to moderate in intensity; there were no deaths, and serious adverse events and adverse events leading to study discontinuation were rare. These results indicate that isavuconazole is a sensitive substrate and moderate inhibitor of CYP3A4.
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Affiliation(s)
- Robert Townsend
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Albert Dietz
- Spaulding Clinical Research, LLC, West Bend, WI, USA
| | | | - Shahzad Akhtar
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Donna Kowalski
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | | | - Helene Pearlman
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | | | - Takao Yamazaki
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Amit Desai
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
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12
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Wiesinger H, Berse M, Klein S, Gschwend S, Höchel J, Zollmann FS, Schütt B. Pharmacokinetic interaction between the CYP3A4 inhibitor ketoconazole and the hormone drospirenone in combination with ethinylestradiol or estradiol. Br J Clin Pharmacol 2015; 80:1399-410. [PMID: 26271371 DOI: 10.1111/bcp.12745] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 07/28/2015] [Accepted: 08/09/2015] [Indexed: 12/25/2022] Open
Abstract
AIMS The present study was conducted to investigate the influence of the strong CYP3A4 inhibitor ketoconazole (KTZ) on the pharmacokinetics of drospirenone (DRSP) administered in combination with ethinylestradiol (EE) or estradiol (E2). METHODS This was a randomized, multicentre, open label, one way crossover, fixed sequence study with two parallel treatment arms. A group sequential design allowed terminating the study for futility after first study cohort. About 50 healthy young women were randomized 1 : 1 to 'DRSP/EE' or 'DRSP/E2'. Subjects in the 'DRSP/EE' group received DRSP 3 mg/EE 0.02 mg (YAZ®, Bayer) once daily for 21 to 28 days followed by DRSP 3 mg/EE 0.02 mg once daily plus KTZ 200 mg twice daily for 10 days. Subjects in the 'DRSP/E2' group received DRSP 3 mg/E2 1.5 mg (research combination) once daily for 21 to 28 days followed by DRSP 3 mg/E2 1.5 mg once daily plus KTZ 200 mg twice daily for 10 days. RESULTS Oral co-administration of DRSP/EE or DRSP/E2 and KTZ resulted in an increase in DRSP exposure (AUC(0,24 h)) in both treatment groups: DRSP/EE group: 2.68-fold DRSP increase (90% CI 2.44, 2.95); DRSP/E2 group: 2.30-fold DRSP increase (90% CI 2.08, 2.54). EE and estrone (metabolite of E2) exposures were increased ~1.4-fold whereas E2 exposure was largely unaffected by KTZ co-administration. CONCLUSIONS A moderate pharmacokinetic drug-drug interaction between DRSP and KTZ was demonstrated in this study. No relevant changes of medical concern were detected in the safety data collected in this study.
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Marr KA, Schlamm HT, Herbrecht R, Rottinghaus ST, Bow EJ, Cornely OA, Heinz WJ, Jagannatha S, Koh LP, Kontoyiannis DP, Lee DG, Nucci M, Pappas PG, Slavin MA, Queiroz-Telles F, Selleslag D, Walsh TJ, Wingard JR, Maertens JA. Combination antifungal therapy for invasive aspergillosis: a randomized trial. Ann Intern Med 2015; 162:81-9. [PMID: 25599346 DOI: 10.7326/m13-2508] [Citation(s) in RCA: 307] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Invasive aspergillosis (IA) is associated with poor outcomes in patients with hematologic malignancies (HMs) and hematopoietic cell transplantation (HCT). Small studies suggest a role for combination antifungal therapy. OBJECTIVE To assess the safety and efficacy of voriconazole and anidulafungin compared with voriconazole monotherapy for treatment of IA. DESIGN Randomized, double-blind, placebo-controlled multicenter trial. (ClinicalTrials.gov: NCT00531479). SETTING 93 international sites. PATIENTS 454 patients with HM or HCT and suspected or documented IA were randomly assigned to treatment with voriconazole and anidulafungin or placebo. Primary analysis was done in the modified intention-to-treat population of 277 patients in whom IA was confirmed. MEASUREMENTS The primary outcome was 6-week mortality; secondary outcomes included 12-week mortality, mortality in major subgroups, and safety measures. RESULTS Mortality rates at 6 weeks were 19.3% (26 of 135) for combination therapy and 27.5% (39 of 142) for monotherapy (difference, -8.2 percentage points [95% CI, -19.0 to 1.5]; P = 0.087). Secondary mortality outcomes favored combination therapy. Multivariable regression analysis suggested that maximum galactomannan value, Karnofsky score, and baseline platelet count had prognostic significance. Most patients (218 of 277 [78.7%]) had IA diagnosis established by radiographic findings and maximum galactomannan positivity. In a post hoc analysis of this dominant subgroup, 6-week mortality was lower in combination therapy than monotherapy (15.7% [17 of 108] vs. 27.3% [30 of 110]; difference, -11.5 percentage points [CI, -22.7 to -0.4]; P = 0.037). Safety measures, including hepatotoxicity, were not different. LIMITATIONS Mortality at 6 weeks was higher than expected, and the difference in mortality was lower than expected, which reduced power to detect a treatment effect. Enrollment was restricted to patients with HM or HCT, which limited generalizability. CONCLUSION Compared with voriconazole monotherapy, combination therapy with anidulafungin led to higher survival in subgroups of patients with IA. Limitations in power preclude definitive conclusions about superiority. PRIMARY FUNDING SOURCE Pfizer.
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Affiliation(s)
- Kieren A. Marr
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Haran T. Schlamm
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Raoul Herbrecht
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Scott T. Rottinghaus
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Eric J. Bow
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Oliver A. Cornely
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Werner J. Heinz
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Shyla Jagannatha
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Liang Piu Koh
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Dimitrios P. Kontoyiannis
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Dong-Gun Lee
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Marcio Nucci
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Peter G. Pappas
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Monica A. Slavin
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Flavio Queiroz-Telles
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Dominik Selleslag
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Thomas J. Walsh
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - John R. Wingard
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
| | - Johan A. Maertens
- From Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland; Pfizer and Weill Cornell Medical Center, Cornell University, New York, New York; Hôpital de Hautepierre, Strasbourg, France; CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada; First Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Köln, Germany; University of Würzburg Medical Centre, Würzburg, Germany; National
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14
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Pharmacokinetics and safety of voriconazole intravenous-to-oral switch regimens in immunocompromised Japanese pediatric patients. Antimicrob Agents Chemother 2014; 59:1004-13. [PMID: 25451051 DOI: 10.1128/aac.04093-14] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The aim of this study was to investigate the pharmacokinetics, safety, and tolerability of voriconazole following intravenous-to-oral switch regimens used with immunocompromised Japanese pediatric subjects (age 2 to <15 years) at high risk for systemic fungal infection. Twenty-one patients received intravenous-to-oral switch regimens based on a recent population pharmacokinetic modeling; they were given 9 mg/kg of body weight followed by 8 mg/kg of intravenous (i.v.) voriconazole every 12 h (q12h), and 9 mg/kg (maximum, 350 mg) of oral voriconazole q12h (for patients age 2 to <12 or 12 to <15 years and <50 kg) or 6 mg/kg followed by 4 mg/kg of i.v. voriconazole q12h and 200 mg of oral voriconazole q12h (for patients age 12 to <15 years and ≥50 kg). The steady-state area under the curve over the 12-h dosing interval (AUC0-12,ss) was calculated using the noncompartmental method and compared with the predicted exposures in Western pediatric subjects based on the abovementioned modeling. The geometric mean (coefficient of variation) AUC0-12,ss values for the intravenous and oral regimens were 51.1 μg · h/ml (68%) and 45.8 μg·h/ml (90%), respectively; there was a high correlation between AUC0-12,ss and trough concentration. Although the average exposures were higher in the Japanese patients than those in the Western pediatric subjects, the overall voriconazole exposures were comparable between these two groups due to large interindividual variability. The exposures in the 2 cytochrome P450 2C19 poor metabolizers were among the highest. Voriconazole was well tolerated. The most common treatment-related adverse events were photophobia and abnormal hepatic function. These recommended doses derived from the modeling appear to be appropriate for Japanese pediatric patients, showing no additional safety risks compared to those with adult patients. (This study has been registered at ClinicalTrials.gov under registration no. NCT01383993.).
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15
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Robertson SM, Luo X, Dubey N, Li C, Chavan AB, Gilmartin GS, Higgins M, Mahnke L. Clinical drug-drug interaction assessment of ivacaftor as a potential inhibitor of cytochrome P450 and P-glycoprotein. J Clin Pharmacol 2014; 55:56-62. [PMID: 25103957 DOI: 10.1002/jcph.377] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 08/05/2014] [Indexed: 11/12/2022]
Abstract
Ivacaftor is approved in the USA for the treatment of cystic fibrosis (CF) in patients with a G551D-CFTR mutation or one of eight other CFTR mutations. A series of in vitro experiments conducted early in the development of ivacaftor indicated ivacaftor and metabolites may have the potential to inhibit cytochrome P450 (CYP) 2C8, CYP2C9, CYP3A, and CYP2D6, as well as P-glycoprotein (P-gp). Based on these results, a series of clinical drug-drug interaction (DDI) studies were conducted to evaluate the effect of ivacaftor on sensitive substrates of CYP2C8 (rosiglitazone), CYP3A (midazolam), CYP2D6 (desipramine), and P-gp (digoxin). In addition, a DDI study was conducted to evaluate the effect of ivacaftor on a combined oral contraceptive, as this is considered an important comedication in CF patients. The results indicate ivacaftor is a weak inhibitor of CYP3A and P-gp, but has no effect on CYP2C8 or CYP2D6. Ivacaftor caused non-clinically significant increases in ethinyl estradiol and norethisterone exposure. Based on these results, caution and appropriate monitoring are recommended when concomitant substrates of CYP2C9, CYP3A and/or P-gp are used during treatment with ivacaftor, particularly drugs with a narrow therapeutic index, such as warfarin.
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16
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Dolton MJ, McLachlan AJ. Voriconazole pharmacokinetics and exposure-response relationships: assessing the links between exposure, efficacy and toxicity. Int J Antimicrob Agents 2014; 44:183-93. [PMID: 25106074 DOI: 10.1016/j.ijantimicag.2014.05.019] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 05/19/2014] [Indexed: 11/15/2022]
Abstract
The triazole antifungal voriconazole (VCZ) exhibits broad-spectrum antifungal activity and is the first-line treatment for invasive aspergillosis. Highly variable, non-linear pharmacokinetics, metabolism via the polymorphic drug-metabolising enzyme CYP2C19, and a range of serious adverse events (AEs) including hepatotoxicity and neurotoxicity complicate the clinical utility of VCZ. As interest in optimising VCZ treatment has increased, a growing number of studies have examined the relationships between VCZ exposure and efficacy in the treatment and prevention of invasive fungal infections, as well as associations with VCZ-related AEs. This review provides a critical analysis of VCZ pharmacokinetics and exposure-response (E-R) relationships, assessing the links between VCZ exposure, efficacy and toxicity. Low VCZ exposure has frequently been associated with a higher incidence of treatment failure; fewer studies have addressed E-R relationships with prophylactic VCZ. VCZ-related neurotoxicity appears common at high VCZ concentrations and can be minimised by maintaining concentrations below the recommended upper concentration thresholds; hepatotoxicity appears to be associated with increased VCZ exposure but is also prevalent at low concentrations. Further research should aim to inform and optimise the narrow therapeutic range of VCZ as well as develop interventions to individualise VCZ dosing to achieve maximal efficacy with minimal toxicity.
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Affiliation(s)
- Michael J Dolton
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Andrew J McLachlan
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia; Centre for Education and Research on Ageing, Concord Repatriation General Hospital, Sydney, NSW, Australia.
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17
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German P, Moorehead L, Pang P, Vimal M, Mathias A. Lack of a clinically important pharmacokinetic interaction between sofosbuvir or ledipasvir and hormonal oral contraceptives norgestimate/ethinyl estradiol in HCV-Uninfected female subjects. J Clin Pharmacol 2014; 54:1290-8. [DOI: 10.1002/jcph.346] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 06/10/2014] [Indexed: 11/10/2022]
Affiliation(s)
- P. German
- Gilead Sciences, Inc.; Foster City CA USA
| | | | | | - M. Vimal
- Gilead Sciences, Inc.; Foster City CA USA
| | - A. Mathias
- Gilead Sciences, Inc.; Foster City CA USA
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18
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Population pharmacokinetic analysis of voriconazole and anidulafungin in adult patients with invasive aspergillosis. Antimicrob Agents Chemother 2014; 58:4718-26. [PMID: 24913161 DOI: 10.1128/aac.02808-13] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
To assess the pharmacokinetics (PK) of voriconazole and anidulafungin in patients with invasive aspergillosis (IA) in comparison with other populations, sparse PK data were obtained for 305 adults from a prospective phase 3 study comparing voriconazole and anidulafungin in combination versus voriconazole monotherapy (voriconazole, 6 mg/kg intravenously [IV] every 12 h [q12h] for 24 h followed by 4 mg/kg IV q12h, switched to 300 mg orally q12h as appropriate; with placebo or anidulafungin IV, a 200-mg loading dose followed by 100 mg q24h). Voriconazole PK was described by a two-compartment model with first-order absorption and mixed linear and time-dependent nonlinear (Michaelis-Menten) elimination; anidulafungin PK was described by a two-compartment model with first-order elimination. For voriconazole, the normal inverse Wishart prior approach was implemented to stabilize the model. Compared to previous models, no new covariates were identified for voriconazole or anidulafungin. PK parameter estimates of voriconazole and anidulafungin are in agreement with those reported previously except for voriconazole clearance (the nonlinear clearance component became minimal). At a 4-mg/kg IV dose, voriconazole exposure tended to increase slightly as age, weight, or body mass index increased, but the difference was not considered clinically relevant. Estimated voriconazole exposures in IA patients at 4 mg/kg IV were higher than those reported for healthy adults (e.g., the average area under the curve over a 12-hour dosing interval [AUC0-12] at steady state was 46% higher); while it is not definitive, age and concomitant medications may impact this difference. Estimated anidulafungin exposures in IA patients were comparable to those reported for the general patient population. This study was approved by the appropriate institutional review boards or ethics committees and registered on ClinicalTrials.gov (NCT00531479).
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Quantification of brain voriconazole levels in healthy adults using fluorine magnetic resonance spectroscopy. Antimicrob Agents Chemother 2013; 57:5271-6. [PMID: 23939898 DOI: 10.1128/aac.00394-13] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Voriconazole is more effective for aspergillosis infections with central nervous system involvement than other antifungal agents. The clinical efficacy of voriconazole for central nervous system infections has been attributed to its ability to cross the blood-brain barrier. However, pharmacokinetic studies are limited to plasma and cerebrospinal fluid, so it remains unclear how much of the drug enters the brain. Fluorinated compounds such as voriconazole can be quantified in the brain using fluorine-19 magnetic resonance spectroscopy (MRS). Twelve healthy adult males participated in a pharmacokinetic analysis of voriconazole levels in the brain and plasma. Open-label voriconazole was dosed per clinical protocol with a loading dose of 400 mg every 12 h on day 1, followed by 200 mg every 12 h administered orally over a 3-day period. MRS was performed before and after dosing on the third day. Voriconazole levels in the brain exceeded the MIC for Aspergillus. The brain/plasma ratios were 3.0 at steady state on day 3 (predose) and 1.9 postdose. We found that voriconazole is able to penetrate the brain tissue, which can be quantified using a noninvasive MRS technique. (This study has been registered at ClinicalTrials.gov under registration no. NCT00300677.).
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Kakuda TN, Van Solingen-Ristea R, Aharchi F, Smedt GD, Witek J, Nijs S, Vyncke V, Hoetelmans RMW. Pharmacokinetics and Short-Term Safety of Etravirine in Combination With Fluconazole or Voriconazole in HIV-Negative Volunteers. J Clin Pharmacol 2013; 53:41-50. [DOI: 10.1177/0091270011433329] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 11/09/2011] [Indexed: 11/15/2022]
Affiliation(s)
| | | | | | | | - James Witek
- Janssen Research & Development, LLC; Titusville, NJ; USA
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Steady-state pharmacokinetics of oral voriconazole and its primary metabolite, N-oxide voriconazole, pre- and post-autologous peripheral stem cell transplantation. Antimicrob Agents Chemother 2013; 57:3420-3. [PMID: 23629717 DOI: 10.1128/aac.00046-13] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Voriconazole (VCZ) is frequently utilized for prevention and treatment of invasive fungal infections in peripheral stem cell transplant (PSCT) patients. We performed an open-label pharmacokinetic study to compare VCZ and N-oxide voriconazole (N-oxide VCZ) pharmacokinetics in patients pre- and post-PSCT. Ten patients completed both sampling periods. The pharmacokinetics of VCZ were unchanged; however, those of N-oxide VCZ were significantly different pre- and post-PSCT.
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Co-administration of vismodegib with rosiglitazone or combined oral contraceptive in patients with locally advanced or metastatic solid tumors: a pharmacokinetic assessment of drug-drug interaction potential. Cancer Chemother Pharmacol 2012; 71:193-202. [PMID: 23064958 DOI: 10.1007/s00280-012-1996-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 09/29/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Vismodegib, a first-in-class oral hedgehog pathway inhibitor, is an effective treatment for advanced basal cell carcinoma. Based on in vitro data, a clinical drug-drug interaction (DDI) assessment of cytochrome P450 (CYP) 2C8 was necessary; vismodegib's teratogenic potential warranted a DDI study with oral contraceptives (OCs). METHODS This single-arm, open-label study included two cohorts of patients with locally advanced or metastatic solid malignancies [Cohort 1: rosiglitazone 4 mg (selective CYP2C8 probe); Cohort 2: OC (norethindrone 1 mg/ethinyl estradiol 35 μg; CYP3A4 substrate)]. On Day 1, patients received rosiglitazone or OC. On Days 2-7, patients received vismodegib 150 mg/day. On Day 8, patients received vismodegib plus rosiglitazone or OC. The effect of vismodegib on rosiglitazone and OC pharmacokinetic parameters (primary objective) was evaluated through pharmacokinetic sampling over a 24-h period (Days 1 and 8). RESULTS The mean ± SD vismodegib steady-state plasma concentration (Day 8, N = 51) was 20.6 ± 9.72 μM (range 7.93-62.4 μM). Rosiglitazone AUC(0-inf) and C(max) were similar with concomitant vismodegib [≤8% change in geometric mean ratios (GMRs); N = 24]. Concomitant vismodegib with OC did not affect ethinyl estradiol AUC(0-inf) and C(max) (≤5% change in GMRs; N = 27); norethindrone C(max) and AUC(0-inf) GMRs were higher (12 and 23%, respectively) with concomitant vismodegib. CONCLUSIONS This DDI study in patients with cancer demonstrated that systemic exposure of rosiglitazone (a CYP2C8 substrate) or OC (ethinyl estradiol/norethindrone) is not altered with concomitant vismodegib. Overall, there appears to be a low potential for DDIs when vismodegib is co-administered with other medications.
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Glotzbecker B, Duncan C, Alyea E, Campbell B, Soiffer R. Important Drug Interactions in Hematopoietic Stem Cell Transplantation: What Every Physician Should Know. Biol Blood Marrow Transplant 2012; 18:989-1006. [DOI: 10.1016/j.bbmt.2011.11.029] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Accepted: 11/23/2011] [Indexed: 10/14/2022]
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Comparison of pharmacokinetics and safety of voriconazole intravenous-to-oral switch in immunocompromised children and healthy adults. Antimicrob Agents Chemother 2011; 55:5770-9. [PMID: 21968355 DOI: 10.1128/aac.00531-11] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Voriconazole pharmacokinetics are not well characterized in children despite prior studies. To assess the appropriate pediatric dosing, a study was conducted in 40 immunocompromised children aged 2 to <12 years to evaluate the pharmacokinetics and safety of voriconazole following intravenous (IV)-to-oral (PO) switch regimens based on a previous population pharmacokinetic modeling: 7 mg/kg IV every 12 h (q12h) and 200 mg PO q12h. Area under the curve over the 12-h dosing interval (AUC(0-12)) was calculated using the noncompartmental method and compared to that for adults receiving approved dosing regimens (6 → 4 mg/kg IV q12h, 200 mg PO q12h). On average, the AUC(0-12) in children receiving 7 mg/kg IV q12h on day 1 and at IV steady state were 7.85 and 21.4 μg · h/ml, respectively, and approximately 44% and 40% lower, respectively, than those for adults at 6 → 4 mg/kg IV q12h. Large intersubject variability was observed. At steady state during oral treatment (200 mg q12h), children had higher average exposure than adults, with much larger intersubject variability. The exposure achieved with oral dosing in children tended to decrease as weight and age increased. The most common treatment-related adverse events were transient elevated liver function tests. No clear threshold of voriconazole exposure was identified that would predict the occurrence of treatment-related hepatic events. Overall, voriconazole IV doses higher than 7 mg/kg are needed in children to closely match adult exposures, and a weight-based oral dose may be more appropriate for children than a fixed dose. Safety of voriconazole in children was consistent with the known safety profile of voriconazole.
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Comparison of pharmacokinetics and safety of voriconazole intravenous-to-oral switch in immunocompromised adolescents and healthy adults. Antimicrob Agents Chemother 2011; 55:5780-9. [PMID: 21911570 DOI: 10.1128/aac.05010-11] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The current voriconazole dosing recommendation in adolescents is based on limited efficacy and pharmacokinetic data. To confirm the appropriateness of dosing adolescents like adults, a pharmacokinetic study was conducted in 26 immunocompromised adolescents aged 12 to <17 years following intravenous (IV) voriconazole to oral switch regimens: 6 mg/kg IV every 12 h (q12h) on day 1 followed by 4 mg/kg IV q12h, then switched to 300 mg orally q12h. Area under the curve over a 12-hour dosing interval (AUC(0-12)) was calculated using a noncompartmental method and compared to the value for adults receiving the same dosing regimens. On average, the AUC(0-12) in adolescents after the first loading dose on day 1 and at steady state during IV treatment were 9.14 and 22.4 μg·h/ml, respectively (approximately 34% and 36% lower, respectively, than values for adults). At steady state during oral treatment, adolescents also had lower average exposure than adults (16.7 versus 34.0 μg·h/ml). Larger intersubject variability was observed in adolescents than in adults. There was a slight trend for some young adolescents with low body weight to have lower voriconazole exposure. It is likely that these young adolescents may metabolize voriconazole more similarly to children than to adults. Overall, with the same dosing regimens, voriconazole exposures in the majority of adolescents were comparable to those in adults. The young adolescents with low body weight during the transitioning period from childhood to adolescence (e.g., 12 to 14 years old) may need to receive higher doses to match the adult exposures. Safety of voriconazole in adolescents was consistent with the known safety profile of voriconazole.
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Pharmacokinetics of voriconazole administered concomitantly with fluconazole and population-based simulation for sequential use. Antimicrob Agents Chemother 2011; 55:5172-7. [PMID: 21876043 DOI: 10.1128/aac.00423-11] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In clinical practice, antifungal therapy may be switched from fluconazole to voriconazole; such sequential use poses the potential for drug interaction due to cytochrome P450 2C19 (CYP2C19)-mediated inhibition of voriconazole metabolism. This open-label, randomized, two-way crossover study investigated the effect of concomitant fluconazole on voriconazole pharmacokinetics in 10 subjects: 8 extensive metabolizers and 2 poor metabolizers of CYP2C19. The study consisted of 4-day voriconazole-only and 5-day voriconazole-plus-fluconazole treatments, separated by a 14-day washout. Voriconazole pharmacokinetics were determined by noncompartmental analyses. A physiologically based pharmacokinetic model was developed in Simcyp (Simcyp Ltd., Sheffield, United Kingdom) to predict the magnitude of drug interaction should antifungal therapy be switched from fluconazole to voriconazole, following various simulated lag times for the switch. In CYP2C19 extensive metabolizers, fluconazole increased the maximum plasma concentration and the area under the plasma concentration-time curve (AUC) of voriconazole by 57% and 178%, respectively. In poor metabolizers, however, voriconazole pharmacokinetics were unaffected by fluconazole. The simulations based on pharmacokinetic modeling predicted that if voriconazole was started 6, 12, 24, or 36 h after the last dose of fluconazole, the voriconazole AUC ratios (sequential therapy versus voriconazole only) after the first dose would be 1.51, 1.41, 1.28, and 1.14, respectively. This suggests that the remaining systemic fluconazole would result in a marked drug interaction with voriconazole for ≥ 24 h. Although no safety issues were observed during coadministration, concomitant use of fluconazole and voriconazole is not recommended. Frequent monitoring for voriconazole-related adverse events is advisable if voriconazole is used sequentially after fluconazole.
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Marks DI, Pagliuca A, Kibbler CC, Glasmacher A, Heussel CP, Kantecki M, Miller PJS, Ribaud P, Schlamm HT, Solano C, Cook G. Voriconazole versus itraconazole for antifungal prophylaxis following allogeneic haematopoietic stem-cell transplantation. Br J Haematol 2011; 155:318-27. [PMID: 21880032 PMCID: PMC3253339 DOI: 10.1111/j.1365-2141.2011.08838.x] [Citation(s) in RCA: 172] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Antifungal prophylaxis for allogeneic haematopoietic stem-cell transplant (alloHCT) recipients should prevent invasive mould and yeast infections (IFIs) and be well tolerated. This prospective, randomized, open-label, multicentre study compared the efficacy and safety of voriconazole (234 patients) versus itraconazole (255 patients) in alloHCT recipients. The primary composite endpoint, success of prophylaxis, incorporated ability to tolerate study drug for ≥100 d (with ≤14 d interruption) with survival to day 180 without proven/probable IFI. Success of prophylaxis was significantly higher with voriconazole than itraconazole (48·7% vs. 33·2%, P <0·01); more voriconazole patients tolerated prophylaxis for 100 d (53·6% vs. 39·0%, P<0·01; median total duration 96 vs. 68 d). The most common (>10%) treatment-related adverse events were vomiting (16·6%), nausea (15·8%) and diarrhoea (10·4%) for itraconazole, and hepatotoxicity/liver function abnormality (12·9%) for voriconazole. More itraconazole patients received other systemic antifungals (41·9% vs. 29·9%, P<0·01). There was no difference in incidence of proven/probable IFI (1·3% vs. 2·1%) or survival to day 180 (81·9% vs. 80·9%) for voriconazole and itraconazole respectively. Voriconazole was superior to itraconazole as antifungal prophylaxis after alloHCT, based on differences in the primary composite endpoint. Voriconazole could be given for significantly longer durations, with less need for other systemic antifungals.
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Affiliation(s)
- David I Marks
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK.
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Effect of pregnane X receptor (PXR) prototype agonists on chemoprotective and drug metabolizing enzymes in mice. Eur J Pharmacol 2011; 660:291-7. [PMID: 21496454 DOI: 10.1016/j.ejphar.2011.03.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Revised: 03/04/2011] [Accepted: 03/22/2011] [Indexed: 01/28/2023]
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Mikus G, Scholz IM, Weiss J. Pharmacogenomics of the triazole antifungal agent voriconazole. Pharmacogenomics 2011; 12:861-72. [DOI: 10.2217/pgs.11.18] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Genetic polymorphisms in drug-metabolizing enzymes are frequently responsible for high variability in the pharmacokinetics of certain drugs leading to large variations in drug efficacy and adverse drug effects, or large ranges of the doses required for optimal drug efficacy. Voriconazole is a triazole antifungal agent which has been available for several years and has potent in vitro and in vivo activity against a broad spectrum of medically important pathogens, including Aspergillus, Cryptococcus and Candida. Voriconazole is extensively metabolized by the cytochrome P450 system with CYP2C19 being the major route for elimination. Thus, polymorphisms in the CYP2C19 gene have substantial impact on the pharmacokinetics of voriconazole and its interactions with other drugs. This article summarizes the current knowledge regarding CYP2C19 and discusses the influences of other drug-metabolizing enzymes and drug transporters on voriconazole disposition.
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Affiliation(s)
| | - Ina Maria Scholz
- Department of Dermatology, University Hospital of Heidelberg, Voßstraße 2, 69115 Heidelberg, Germany
| | - Johanna Weiss
- Department of Clinical Pharmacology & Pharmacoepidemiology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
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Bronchopulmonary disposition of intravenous voriconazole and anidulafungin given in combination to healthy adults. Antimicrob Agents Chemother 2009; 53:5102-7. [PMID: 19770284 DOI: 10.1128/aac.01042-09] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Voriconazole and anidulafungin in combination are being investigated for use for the treatment of pulmonary aspergillosis. We determined the pulmonary disposition of these agents. Twenty healthy participants received intravenous voriconazole (at 6 mg/kg of body weight every 12 h [q12h] on day 1 and then at 4 mg/kg q12h) and anidulafungin (200 mg on day 1 and then 100 mg every 24 h) for 3 days. Five participants each were randomized for collection of bronchoalveolar lavage samples at times of 4, 8, 12, and 24 h. Drug penetration was determined by the ratio of the total drug area under the concentration-time curve during the dosing interval (AUC(0-tau)) for epithelial lining fluid (ELF) and alveolar macrophages (AM) to the total drug AUC(0-tau) in plasma. The mean (standard deviation) half-life and AUC(0-tau) were 6.9 (2.1) h and 39.5 (19.8) microg h/ml, respectively, for voriconazole and 20.8 (3.1) h and 101 (21.8) microg h/ml, respectively, for anidulafungin. The AUC(0-tau) values for ELF and AM were 282 and 178 microg h/ml, respectively, for voriconazole, and 21.9 and 1,430 microg h/ml, respectively, for anidulafungin. This resulted in penetration ratios into ELF and AM of 7.1 and 4.5, respectively, for voriconazole and 0.22 and 14.2, respectively, for anidulafungin. The mean total concentrations of both drugs in ELF and AM at 4, 8, 12, and 24 h remained above the MIC(90)/90% minimum effective concentration for most Aspergillus species. In healthy adult volunteers, voriconazole achieved high levels of exposure in both ELF and AM, while anidulafungin predominantly concentrated in AM.
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Lionakis MS, Samonis G, Kontoyiannis DP. Endocrine and metabolic manifestations of invasive fungal infections and systemic antifungal treatment. Mayo Clin Proc 2008; 83:1046-60. [PMID: 18775205 DOI: 10.4065/83.9.1046] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Systemic fungal infections are increasingly reported in immunocompromised patients with hematological malignancies, recipients of bone marrow and solid organ allografts, and patients with AIDS. Mycoses may infiltrate endocrine organs and adversely affect their function or produce metabolic complications, such as hypopituitarism, hyperthyroidism or hypothyroidism, pancreatitis, hypoadrenalism, hypogonadism, hypernatremia or hyponatremia, and hypercalcemia. Antifungal agents used for prophylaxis and/or treatment of mycoses also have adverse endocrine and metabolic effects, including hypoadrenalism, hypogonadism, hypoglycemia, dyslipidemia, hypernatremia, hypocalcemia, hyperphosphatemia, hyperkalemia or hypokalemia, and hypomagnesemia. Herein, we review how mycoses and conventional systemic antifungal treatment can affect the endocrine system and cause metabolic abnormalities. If clinicians are equipped with better knowledge of the endocrine and metabolic complications of fungal infections and antifungal therapy, they can more readily recognize them and favorably affect outcome.
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Affiliation(s)
- Michail S Lionakis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M D Anderson Cancer Center, Houston, TX 77030, USA
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