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Rayapolu RG, Yadav B, Apte SS, Venuganti VVK. Development of posaconazole nanocrystalline solid dispersion: preparation, characterization and in vivo evaluation. Pharm Dev Technol 2024; 29:530-540. [PMID: 38713634 DOI: 10.1080/10837450.2024.2353314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/06/2024] [Indexed: 05/09/2024]
Abstract
OBJECTIVE Posaconazole (PCZ) is an antifungal drug, which acts by inhibiting the lanosterol-14α-demethylase enzyme. It is a biopharmaceutical classification system class II drug with its bioavailability being limited by poor aqueous solubility. The aim of this study was to improve the oral bioavailability of PCZ by preparing nanocrystalline solid dispersion (NCS). METHODS PCZ-NCS was prepared by a combination of precipitation and high-pressure homogenization followed by freeze-drying. Several different surfactants and polymers were screened to produce NCS with smaller particle size and higher stability. RESULTS The optimized NCS formulation containing 0.2% Eudragit S100 and 0.2% SLS was found to provide the average particle size of 73.31 ± 4.7 nm with a polydispersity index of 0.23 ± 0.03. Scanning electron microscopy revealed the preparation of homogeneous and rounded particles. Differential scanning calorimetry and X-ray diffraction confirmed crystalline nature of NCS. Nanonization increased the saturation solubility of PCZ by about 18-fold in comparison with the neat drug. Intrinsic dissolution study showed 93% dissolution of PCZ within the first 10 min. In vivo pharmacokinetic study in Wistar rats showed that Cmax and AUCtotal of PCZ-NCS increased by 2.58- and 2.64-fold compared to the marketed formulation. CONCLUSION PCZ-NCS formulation presents a viable approach for enhancing the oral bioavailability of PCZ.
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Affiliation(s)
- Ranga Goud Rayapolu
- Birla Institute of Technology and Science (BITS) Pilani, Hyderabad Campus, Shameerpet, Hyderabad, Telangana, India
- Natco Research Center, Natco Pharma Limited, Sanath Nagar, Hyderabad, Telangana, India
| | - Balvant Yadav
- Natco Research Center, Natco Pharma Limited, Sanath Nagar, Hyderabad, Telangana, India
| | - Shashank S Apte
- Natco Research Center, Natco Pharma Limited, Sanath Nagar, Hyderabad, Telangana, India
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Winchell G, de Greef R, Ouerdani A, Fauchet F, Wrishko RE, Mangin E, Bruno C, Waskin H. A population pharmacokinetic model for posaconazole intravenous solution and oral powder for suspension formulations in pediatric patients with neutropenia. Antimicrob Agents Chemother 2024; 68:e0119723. [PMID: 38376229 PMCID: PMC10994819 DOI: 10.1128/aac.01197-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/15/2023] [Indexed: 02/21/2024] Open
Abstract
The objective of this study was to support posaconazole dose regimens in pediatric patients aged ≥2 years, using a population pharmacokinetic (PK) approach with data from a phase 1b study (NCT02452034). A one-compartment model with first-order absorption was fit to pharmacokinetic data from 144 participants aged 2 to 17 years, who were administered posaconazole as intravenous (IV) and powder for oral suspension (PFS) formulations, or IV only, at dosing regimens of 3.5, 4.5, and 6 mg/kg. The influence of demographic and clinical factors on pharmacokinetic parameters was evaluated using a stepwise forward inclusion/backward exclusion procedure. The final model simulated posaconazole exposure in patients aged 2 to <7 and 7 to 17 years at dosing regimens of 4.5, 6, and 7.5 mg/kg. Plasma concentration data following IV and PFS administration were well-described by a one-compartment model with first-order absorption and estimated bioavailability, where clearance and volume were subject to allometric scaling by body weight. The 6-mg/kg dosing regimen achieved the pharmacokinetic target (90% of the pediatric population having an average steady-state plasma concentration of ≥500 and <2,000 ng/mL) for both age groups, regardless of whether patients received IV and PFS or IV only. In a virtual adolescent population (body weight >40 kg), the 300 mg/day posaconazole tablet was also predicted to achieve the pharmacokinetic target and remain within a safe range of exposure. These data informed a weight-based nomogram for PFS dosing to maximize the number of pediatric patients achieving the pharmacokinetic target across weight bands, while also maintaining a favorable benefit/risk profile.
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3
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Boppana M, Sengar M, Jain H, Gurjar M, Ambotkar M, Gota V, Bonda A, Bagal B, Thorat J, Gokarn A, Nayak L, Shetty N, Baheti A, Mokal S, Kannan S, Shetty A, Eipe T. A Prospective Study to Evaluate the Effect of Therapeutic Drug Monitoring-Based Posaconazole Prophylaxis on Invasive Fungal Infection Rate During Acute Myeloid Leukemia Induction Therapy. Indian J Hematol Blood Transfus 2024; 40:204-212. [PMID: 38708158 PMCID: PMC11065854 DOI: 10.1007/s12288-023-01709-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 10/04/2023] [Indexed: 05/07/2024] Open
Abstract
Invasive fungal infections (IFIs) are a significant cause of morbidity and mortality in de-novo acute myeloid leukemia patients receiving induction chemotherapy. Despite using posaconazole, a broad-spectrum antifungal, for IFI prophylaxis, the breakthrough IFI rate is high in the real-world setting. One of the reasons could be frequent suboptimal plasma posaconazole levels. In the present study, we evaluated if therapeutic drug monitoring (TDM) guided posaconazole prophylaxis can reduce the IFI rates in comparison to a historical cohort. We enrolled 90 patients, > / = 16 years of age, without baseline IFIs, planned for remission induction therapy. All patients were started on posaconazole suspension 200 mg TDS and the dose was increased in a stepwise manner if trough levels were found to be suboptimal (< 350 ng/ml for day 2 or < 700 ng/ml subsequently). The TDM based approach resulted in a significant decline in breakthrough IFI rates (18% versus 52%, P < 0.0001) A total of 69 patients (78%) required dose escalation. Thirty-one patients required change in antifungals due to either suboptimal levels, persistent fever, diarrhoea or vomiting. We could not demonstrate an exposure-response relationship but the difference in IFI rates in patients with a median posaconazole level > / = 700 ng/ml (0%) and < 700 ng/ml (21.6%) was clinically meaningful. Posaconazole levels were found to be significantly lower in patients on antacids and prokinetics. The incidence of posaconazole-related grade 3 toxicity was low (2.3%). Thus TDM-based dosing of posaconazole helps reduce breakthrough IFI rate and should be a part of posaconazole prophylaxis. Supplementary Information The online version contains supplementary material available at 10.1007/s12288-023-01709-3.
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Affiliation(s)
- Mounika Boppana
- Department of Medical Oncology, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
- Present Address: Department of Medical Oncology, Krishna Institute of Medical Sciences, Minister Road, Secunderabad, Telangana 500003, India
| | - Manju Sengar
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National University, Earnest Borges Road, Parel, Mumbai 400012 India
| | - Hasmukh Jain
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Murari Gurjar
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Madhavi Ambotkar
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Vikram Gota
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Avinash Bonda
- Department of Medical Oncology, Asian Institute of Gastroenterology (AIG) Hospitals, Mindspace Road, P Janardhan Reddy Nagar, Gachibowli, Hyderabad, Telangana 500032, India
| | - Bhausaheb Bagal
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Jayashree Thorat
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Anant Gokarn
- Adult Hematolymphoid Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Lingaraj Nayak
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Nitin Shetty
- Department of Radiodiagnosis, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Akshay Baheti
- Department of Radiodiagnosis, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Smruti Mokal
- Clinical Research Secretariat, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Sadhana Kannan
- Clinical Research Secretariat, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Alok Shetty
- Department of Medical Oncology, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Thomas Eipe
- Department of Medical Oncology, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
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McCann S, Sinha J, Wilson WS, McKinzie CJ, Garner LM, Gonzalez D. Population Pharmacokinetics of Posaconazole in Immune-Compromised Children and Assessment of Target Attainment in Invasive Fungal Disease. Clin Pharmacokinet 2023; 62:997-1009. [PMID: 37179512 PMCID: PMC10338595 DOI: 10.1007/s40262-023-01254-2] [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] [Accepted: 04/18/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND AND OBJECTIVE Posaconazole (PSZ) is a triazole antifungal for the management of invasive fungal disease (IFD) in adults and children. Although PSZ is available as an intravenous (IV) solution, oral suspension (OS) and delayed-release tablets (DRTs), OS is the preferred formulation for pediatric use because of potential safety concerns associated with an excipient in the IV formulation and difficulty in swallowing intact tablets by children. However, poor biopharmaceutical characteristics of the OS formulation leads to an unpredictable dose-exposure profile of PSZ in children, potentially risking therapeutic failure. The goal of this study was to characterize the population pharmacokinetics (PK) of PSZ in immunocompromised children and assess therapeutic target attainment. METHODS Serum concentrations of PSZ were collected retrospectively from records of hospitalized patients. A population PK analysis was performed in a nonlinear mixed-effects modeling framework with NONMEM (v7.4). The PK parameters were scaled to body weight, then potential covariate effects were assessed. The final PK model was used to evaluate recommended dosing schemes through simulation of target attainment (as a percentage of the population having steady-state trough concentrations above the recommended target) using Simulx (v2021R1). RESULTS Repeated measurement data of 202 serum concentrations of total PSZ were acquired from 47 immunocompromised patients between 1 and 21 years of age receiving PSZ either intravenously or orally, or both. A one-compartment PK model with first-order absorption and linear elimination best fit the data. The estimated absolute bioavailability (95% confidence interval) for suspension (Fs) was 16% (8-27%), which was significantly lower than the reported tablet bioavailability (Ft) [67%]. Fs was reduced by 62% and 75% upon concomitant administration with pantoprazole (PAN) and omeprazole (OME), respectively. Famotidine resulted in a reduction of Fs by only 22%. Both fixed dosing and weight-based adaptive dosing provided adequate target attainment when PAN or OME were not coadministered with the suspension. CONCLUSIONS The results of this study revealed that both fixed and weight-based adaptive dosing schemes can be appropriate for target attainment across all PSZ formulations, including suspension. Additionally, covariate analysis suggests that concomitant proton pump inhibitors should be contraindicated during PSZ suspension dosing.
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Affiliation(s)
- Sean McCann
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA
| | - Jaydeep Sinha
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA
- Department of Pediatrics, UNC School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William S Wilson
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Cameron J McKinzie
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Lauren M Garner
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA.
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Chiang PC, Dolton MJ, Nagapudi K, Liu J. Exploring the Use of a Kinetic pH Calculation to Correct the ACAT Model with a Single Stomach Compartment Setting: Impact of Stomach Setting on Food Effect Prediction for Basic Compounds. J Pharm Sci 2023; 112:1888-1896. [PMID: 36796637 DOI: 10.1016/j.xphs.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/08/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023]
Abstract
Advanced compartmental absorption and transit (ACAT) based computational models have become increasingly popular in the industry for predicting oral drug product performance. However, due to its complexity, some compromises have been made in practice, and the stomach is often assigned as a single compartment. Although this assignment worked generally, it may not be sufficient to reflect the complexity of the gastric environment under certain conditions. For example, this setting was found to be less accurate in estimating stomach pH and solubilization of certain drugs under food intake, which leads to a misprediction of the food effect. To overcome the above, we explored the use of a kinetic pH calculation (KpH) for the single-compartment stomach setting. Several drugs have been tested with the KpH approach and compared with the default setting of Gastroplus. In general, the Gastroplus prediction of food effect is greatly improved, suggesting this approach is effective in improving the estimation of physicochemical properties related to food effect for several basic drugs by Gastroplus.
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Affiliation(s)
| | - Michael J Dolton
- Roche Products Australia Pty Ltd, Level 8, 30-34 Hickson Road, Sydney, NSW 2000 Australia
| | | | - Jia Liu
- Genentech, Inc., South San Francisco, CA, USA
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Kruk K, Szekalska M, Basa A, Winnicka K. The Impact of Hypromellose on Pharmaceutical Properties of Alginate Microparticles as Novel Drug Carriers for Posaconazole. Int J Mol Sci 2023; 24:10793. [PMID: 37445975 DOI: 10.3390/ijms241310793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Fungal infections are a group of diseases which are challenging to treat because of drug-resistant fungi species, drug toxicity, and often severe patient conditions. Hence, research into new treatments, including new therapeutic substances and novel drug delivery systems, is being performed. Mucoadhesive dosage forms are beneficial to improving drug bioavailability by prolonging the residence time at the site of application. Sodium alginate is a natural polymer with favorable mucoadhesive and gelling properties, although its precipitation in acidic pH significantly disrupts the process of drug release in gastric conditions. Hypromellose is a hydrophilic, semi-synthetic cellulose derivative with mucoadhesive properties, which is widely used as a control release agent in pharmaceutical technology. The aim of this study was to evaluate the impact of hypromellose on alginate microparticles with posaconazole, designed to modify drug release and to improve their mucoadhesive properties for both oral or vaginal application.
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Affiliation(s)
- Katarzyna Kruk
- Department of Pharmaceutical Technology, Medical University of Białystok, Mickiewicza 2C, 15-222 Białystok, Poland
| | - Marta Szekalska
- Department of Pharmaceutical Technology, Medical University of Białystok, Mickiewicza 2C, 15-222 Białystok, Poland
| | - Anna Basa
- Institute of Chemistry, University of Białystok, Ciołkowskiego 1K, 15-245 Białystok, Poland
| | - Katarzyna Winnicka
- Department of Pharmaceutical Technology, Medical University of Białystok, Mickiewicza 2C, 15-222 Białystok, Poland
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Miners JO, Polasek TM, Hulin JA, Rowland A, Meech R. Drug-drug interactions that alter the exposure of glucuronidated drugs: Scope, UDP-glucuronosyltransferase (UGT) enzyme selectivity, mechanisms (inhibition and induction), and clinical significance. Pharmacol Ther 2023:108459. [PMID: 37263383 DOI: 10.1016/j.pharmthera.2023.108459] [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: 02/21/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
Drug-drug interactions (DDIs) arising from the perturbation of drug metabolising enzyme activities represent both a clinical problem and a potential economic loss for the pharmaceutical industry. DDIs involving glucuronidated drugs have historically attracted little attention and there is a perception that interactions are of minor clinical relevance. This review critically examines the scope and aetiology of DDIs that result in altered exposure of glucuronidated drugs. Interaction mechanisms, namely inhibition and induction of UDP-glucuronosyltransferase (UGT) enzymes and the potential interplay with drug transporters, are reviewed in detail, as is the clinical significance of known DDIs. Altered victim drug exposure arising from modulation of UGT enzyme activities is relatively common and, notably, the incidence and importance of UGT induction as a DDI mechanism is greater than generally believed. Numerous DDIs are clinically relevant, resulting in either loss of efficacy or an increased risk of adverse effects, necessitating dose individualisation. Several generalisations relating to the likelihood of DDIs can be drawn from the known substrate and inhibitor selectivities of UGT enzymes, highlighting the importance of comprehensive reaction phenotyping studies at an early stage of drug development. Further, rigorous assessment of the DDI liability of new chemical entities that undergo glucuronidation to a significant extent has been recommended recently by regulatory guidance. Although evidence-based approaches exist for the in vitro characterisation of UGT enzyme inhibition and induction, the availability of drugs considered appropriate for use as 'probe' substrates in clinical DDI studies is limited and this should be research priority.
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Affiliation(s)
- John O Miners
- Discipline of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - Thomas M Polasek
- Certara, Princeton, NJ, USA; Centre for Medicines Use and Safety, Monash University, Melbourne, Australia
| | - Julie-Ann Hulin
- Discipline of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Andrew Rowland
- Discipline of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Robyn Meech
- Discipline of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Flinders University, Adelaide, Australia
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Promising Antifungal Molecules against Mucormycosis Agents Identified from Pandemic Response Box ®: In Vitro and In Silico Analyses. J Fungi (Basel) 2023; 9:jof9020187. [PMID: 36836302 PMCID: PMC9959553 DOI: 10.3390/jof9020187] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023] Open
Abstract
Mucormycosis is considered concerning invasive fungal infections due to its high mortality rates, difficult diagnosis and limited treatment approaches. Mucorales species are highly resistant to many antifungal agents and the search for alternatives is an urgent need. In the present study, a library with 400 compounds called the Pandemic Response Box® was used and four compounds were identified: alexidine and three non-commercial molecules. These compounds showed anti-biofilm activity, as well as alterations in fungal morphology and cell wall and plasma membrane structure. They also induced oxidative stress and mitochondrial membrane depolarization. In silico analysis revealed promising pharmacological parameters. These results suggest that these four compounds are potent candidates to be considered in future studies for the development of new approaches to treat mucormycosis.
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A Physiologically-Based Pharmacokinetic Model of Ruxolitinib and Posaconazole to Predict CYP3A4-Mediated Drug-Drug Interaction Frequently Observed in Graft versus Host Disease Patients. Pharmaceutics 2022; 14:pharmaceutics14122556. [PMID: 36559050 PMCID: PMC9785192 DOI: 10.3390/pharmaceutics14122556] [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: 10/24/2022] [Revised: 11/13/2022] [Accepted: 11/18/2022] [Indexed: 11/23/2022] Open
Abstract
Ruxolitinib (RUX) is approved for the treatment of steroid-refractory acute and chronic graft versus host disease (GvHD). It is predominantly metabolized via cytochrome P450 (CYP) 3A4. As patients with GvHD have an increased risk of invasive fungal infections, RUX is frequently combined with posaconazole (POS), a strong CYP3A4 inhibitor. Knowledge of RUX exposure under concomitant POS treatment is scarce and recommendations on dose modifications are inconsistent. A physiologically based pharmacokinetic (PBPK) model was developed to investigate the drug-drug interaction (DDI) between POS and RUX. The predicted RUX exposure was compared to observed concentrations in patients with GvHD in the clinical routine. PBPK models for RUX and POS were independently set up using PK-Sim® Version 11. Plasma concentration-time profiles were described successfully and all predicted area under the curve (AUC) values were within 2-fold of the observed values. The increase in RUX exposure was predicted with a DDI ratio of 1.21 (Cmax) and 1.59 (AUC). Standard dosing in patients with GvHD led to higher RUX exposure than expected, suggesting further dose reduction if combined with POS. The developed model can serve as a starting point for further simulations of the implemented DDI and can be extended to further perpetrators of CYP-mediated PK-DDIs or disease-specific physiological changes.
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Jana ID, Bhattacharya P, Mayilsamy K, Banerjee S, Bhattacharje G, Das S, Aditya S, Ghosh A, McGill AR, Srikrishnan S, Das AK, Basak A, Mohapatra SS, Chandran B, Bhimsaria D, Mohapatra S, Roy A, Mondal A. Targeting an evolutionarily conserved "E-L-L" motif in spike protein to identify a small molecule fusion inhibitor against SARS-CoV-2. PNAS NEXUS 2022; 1:pgac198. [PMID: 36712339 PMCID: PMC9802491 DOI: 10.1093/pnasnexus/pgac198] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Abstract
As newer variants of SARS-CoV-2 continue to pose major threats to global human health and economy, identifying novel druggable antiviral targets is the key toward sustenance. Here, we identify an evolutionarily conserved "Ex3Lx6L" ("E-L-L") motif present within the HR2 domain of all human and nonhuman coronavirus spike (S) proteins that play a crucial role in stabilizing its postfusion six-helix bundle (6-HB) structure and thus, fusion-mediated viral entry. Mutations within this motif reduce the fusogenicity of the S protein without affecting its stability or membrane localization. We found that posaconazole, an FDA-approved drug, binds to this "E-L-L" motif and impedes the formation of 6-HB, thus effectively inhibiting SARS-CoV-2 infection in cells. While posaconazole exhibits high efficacy in blocking S protein-mediated viral entry, mutations within the "E-L-L" motif rendered the protein completely resistant to the drug, establishing its specificity toward this motif. Our data demonstrate that posaconazole restricts early stages of infection through specific inhibition of membrane fusion and viral genome release into the host cell and is equally effective toward all major variants of concerns of SARS-CoV-2, including Beta, Kappa, Delta, and Omicron. Together, we show that this conserved essential "E-L-L" motif is an ideal target for the development of prophylactic and therapeutic interventions against SARS-CoV-2.
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Affiliation(s)
- Indrani Das Jana
- School of Bioscience, Indian Institute of Technology Kharagpur, Kharagpur 721302, India
| | | | - Karthick Mayilsamy
- Department of Molecular Medicine, University of South Florida, Tampa, FL 33620, USA
- Department of Veterans Affairs, James A Haley Veterans Hospital, Tampa, FL 33612, USA
| | - Saptarshi Banerjee
- School of Bioscience, Indian Institute of Technology Kharagpur, Kharagpur 721302, India
| | - Gourab Bhattacharje
- Department of Biotechnology, Indian Institute of Technology Kharagpur, Kharagpur 721302, India
| | - Sayan Das
- School of Bioscience, Indian Institute of Technology Kharagpur, Kharagpur 721302, India
| | - Seemanti Aditya
- School of Bioscience, Indian Institute of Technology Kharagpur, Kharagpur 721302, India
| | - Anandita Ghosh
- Department of Molecular Medicine, University of South Florida, Tampa, FL 33620, USA
| | - Andrew R McGill
- Department of Molecular Medicine, University of South Florida, Tampa, FL 33620, USA
- Department of Veterans Affairs, James A Haley Veterans Hospital, Tampa, FL 33612, USA
- Department of Internal Medicine, University of South Florida, Tampa, FL 33620, USA
| | - Syamanthak Srikrishnan
- Department of Biotechnology, Indian Institute of Technology Kharagpur, Kharagpur 721302, India
| | - Amit Kumar Das
- Department of Biotechnology, Indian Institute of Technology Kharagpur, Kharagpur 721302, India
| | - Amit Basak
- Division of Chemical Science, Indian Institute of Science Education and Research, Kolkata, Mohanpur 741246, India
| | - Shyam S Mohapatra
- Department of Veterans Affairs, James A Haley Veterans Hospital, Tampa, FL 33612, USA
- Department of Internal Medicine, University of South Florida, Tampa, FL 33620, USA
| | - Bala Chandran
- Department of Molecular Medicine, University of South Florida, Tampa, FL 33620, USA
| | - Devesh Bhimsaria
- Department of Bioscience and Bioengineering, Indian Institute of Technology Roorkee, Roorkee 247667, India
| | - Subhra Mohapatra
- Department of Molecular Medicine, University of South Florida, Tampa, FL 33620, USA
- Department of Veterans Affairs, James A Haley Veterans Hospital, Tampa, FL 33612, USA
| | - Arunava Roy
- Department of Molecular Medicine, University of South Florida, Tampa, FL 33620, USA
| | - Arindam Mondal
- School of Bioscience, Indian Institute of Technology Kharagpur, Kharagpur 721302, India
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Alharbi KS, Joshi N, Singh Y, Almalki WH, Kazmi I, Al-Abbasi FA, Alzarea SI, Afzal O, Altamimi ASA, Gupta G. Molecular exploration of hidden pleiotropic activities of azoles on dermatophytes in human tinea corporis infection. J Mycol Med 2022; 32:101311. [PMID: 35908359 DOI: 10.1016/j.mycmed.2022.101311] [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: 04/29/2021] [Revised: 06/21/2022] [Accepted: 07/14/2022] [Indexed: 10/31/2022]
Abstract
Dermatophyte infections are widespread worldwide and are the most prevalent cause of fungal infection of the skin, hair, and nails. Tinea corporis is most commonly caused by dermatophytes belonging to three genera: Trichophyton , Microsporum , and Epidermophyton. The disease may be acquired through person-to-person transmission, typically by direct communication with an infected individual. Since dermatophytes causing tinea corporis infection are restricted to superficial keratinized tissue, topical treatments are most effective in patients with naïve tinea corporis unless the disease is widespread. Dermatophyte adherence to a keratinized structure is an essential step in dermatophytosis pathogenesis, whereby proteolytic enzyme activity is converted into a particular keratolytic activity that encourages the dermatophyte to use keratin as the sole source of carbon. Despite increasing dermatophytosis worldwide, particularly in the tropics, this research has often been neglected, appears to predominate globally, and presents practitioners with a therapeutic challenge. However, experts supported the use of allylamines in the pleiotropic molecular exploration of azoles, including reactive oxygen species (ROS) inducer, anti-inflammatory, antibacterial, and wide-spectrum antimycotic effects. Therefore, the current review aims to update and reform this essential subject and illustrate the recent advancement of the hidden pleiotropic activity of azoles at the molecular level on dermatophytes in human tinea corporis infection.
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Affiliation(s)
- Khalid Saad Alharbi
- Department of Pharmacology, College of Pharmacy, Jouf University, Sakaka, Al-Jouf, Saudi Arabia
| | - Navneet Joshi
- Department of Biosciences, School of Liberal Arts and Sciences, Mody University of Science and Technology, Lakshmangarh-332311, District-Sikar, Rajasthan, India.
| | - Yogendra Singh
- Department of Pharmacology, Maharishi Arvind College of Pharmacy, Ambabari Circle, Ambabari, Jaipur 302023, India
| | - Waleed Hassan Almalki
- Department of Pharmacology, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Imran Kazmi
- Department of Biochemistry, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Fahad A Al-Abbasi
- Department of Biochemistry, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sami I Alzarea
- Department of Pharmacology, College of Pharmacy, Jouf University, Sakaka, Al-Jouf, Saudi Arabia
| | - Obaid Afzal
- Department of Pharmaceutical Chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al Kharj 11942, Saudi Arabia
| | | | - Gaurav Gupta
- School of Pharmacy, Suresh Gyan Vihar University, Mahal Road, Jagatpura, Jaipur 302017, India; Department of Pharmacology, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India; Uttaranchal Institute of Pharmaceutical Sciences, Uttaranchal University, Dehradun, India.
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12
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Jia M, Zhang Q, Qin Z, Wang D, Liu P, Yang J, Zhang X. Dose Optimisation of Posaconazole and Therapeutic Drug Monitoring in Pediatric Patients. Front Pharmacol 2022; 13:833303. [PMID: 35517786 PMCID: PMC9061949 DOI: 10.3389/fphar.2022.833303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Experience in the clinical use of posaconazole (PCZ) in pediatric patients is limited, and no specific dose recommendations exist. This study aimed to investigate an appropriate dosing regimen, and assess the exposure-response relationships of PCZ in children. We reviewed the medical records of inpatients aged <18 years who subjected to PCZ concentrations monitoring. Clinical data, PCZ dosing and monitoring data were collected. A total of 375 PCZ trough concentrations (C min) from 105 pediatric patients were included. For children receiving PCZ for prophylaxis, the median doses required to achieve the therapeutic range at the ages of <6, 6-12 and >12 years were 14.80, 14.52 and 12.90 mg/kg/day, respectively (p = 0.001); and for those receiving PCZ for treatment, the median doses were 23.50, 20.96 and 15.38 mg/kg/day, respectively (p = 0.001). Among children taking PCZ for prophylaxis, 12% developed a proven or probable breakthrough IFIs; the median PCZ concentrations were significantly lower than those children with successful treatment response (0.43 versus 1.20 μg mL-1; p < 0.001). 79.2% patients taking PCZ for treatment had a positive clinical response, and the median PCZ concentrations were significantly higher than those children with disease progression (1.06 versus 0.53 μg mL-1; p = 0.024). No association between C min values and hepatotoxicity was observed. Factors such as age, CRP, ALT and co-administration with proton pump inhibitors exhibited significant effects on PCZ C min. It is necessary to adjust the dosing regimens based on PCZ C min to individualize antifungal therapy and provide guidelines for dose adjustment in children.
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Affiliation(s)
- Mengmeng Jia
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Qiwen Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Zifei Qin
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Dao Wang
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peng Liu
- Pediatric Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Yang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Xiaojian Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
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13
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Experience of Isavuconazole as a Salvage Therapy in Chronic Pulmonary Fungal Disease. J Fungi (Basel) 2022; 8:jof8040362. [PMID: 35448593 PMCID: PMC9029347 DOI: 10.3390/jof8040362] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/20/2022] [Accepted: 03/27/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Instances of resistant fungal infection are rising in pulmonary disease, with limited therapeutic options. Therapeutic drug monitoring of azole antifungals has been necessary to ensure safety and efficacy but is considered unnecessary for the newest triazole isavuconazole. Aims: To characterise the prevalence of isavuconazole resistance and use in a tertiary respiratory centre. Methods: A retrospective observational analysis (2016−2021) of adult respiratory patients analysing fungal culture, therapeutic drug monitoring, and outcome post-isavuconazole therapy. Results: During the study period, isavuconazole susceptibility testing was performed on 26 Aspergillus spp. isolates. A total of 80.8% of A. fumigatus isolates had isavuconazole (MIC > 1 mg/L, and 73.0% > 2 mg/L) with a good correlation to voriconazole MIC (r = 0.7, p = 0.0002). A total of 54 patients underwent isavuconazole therapy during the study period (median duration 234 days (IQR: 24−499)). A total of 67% of patients tolerated isavuconazole, despite prior azole toxicity in 61.8%, with increased age (rpb = 0.31; p = 0.021) and male sex (φc = 0.30; p = 0.027) being associated with toxicity. A total of 132 isavuconazole levels were performed with 94.8% > 1 mg/L and 72% > 2 mg/L. Dose change from manufacturer’s recommendation was, however, required in 9.3% to achieve a concentration of >2 mg/L. Conclusion: We describe the use of isavuconazole as a salvage therapy in a chronic pulmonary fungal disease setting with a high prevalence of azole resistance. Therapeutic concentrations at standard dosing were high; however, results reinforce antifungal stewardship for optimization.
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14
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Jana ID, Bhattacharya P, Mayilsamy K, Banerjee S, Bhattacharje G, Das S, Aditya S, Ghosh A, McGill AR, Srikrishnan S, Das AK, Basak A, Mohapatra SS, Chandran B, Bhimsaria D, Mohapatra S, Roy A, Mondal A. Targeting an evolutionarily conserved "E-L-L" motif in the spike protein to develop a small molecule fusion inhibitor against SARS-CoV-2. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2022:2022.03.16.484554. [PMID: 35313575 PMCID: PMC8936095 DOI: 10.1101/2022.03.16.484554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
As newer variants of SARS-CoV-2 continue to pose major threats to global human health and economy, identifying novel druggable antiviral targets is the key towards sustenance. Here, we identify an evolutionary conserved E-L-L motif present within the HR2 domain of all human and non-human coronavirus spike (S) proteins that play a crucial role in stabilizing the post-fusion six-helix bundle (6-HB) structure and thus, fusion-mediated viral entry. Mutations within this motif reduce the fusogenicity of the S protein without affecting its stability or membrane localization. We found that posaconazole, an FDA-approved drug, binds to this E-L-L motif resulting in effective inhibition of SARS-CoV-2 infection in cells. While posaconazole exhibits high efficacy towards blocking S protein-mediated viral entry, mutations within the E-L-L motif rendered the protein completely resistant to the drug, establishing its specificity towards this motif. Our data demonstrate that posaconazole restricts early stages of infection through specific inhibition of membrane fusion and viral genome release into the host cell and is equally effective towards all major variants of concerns of SARS-CoV-2 including beta, kappa, delta, and omicron. Together, we show that this conserved essential E-L-L motif is an ideal target for the development of prophylactic and therapeutic interventions against SARS-CoV-2.
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Affiliation(s)
- Indrani Das Jana
- School of Bioscience, Indian Institute of Technology Kharagpur, Kharagpur, India
| | | | - Karthick Mayilsamy
- Department of Molecular Medicine, University of South Florida, Tampa, USA
- Department of Veterans Affairs, James A Haley Veterans Hospital, Tampa, USA
| | - Saptarshi Banerjee
- School of Bioscience, Indian Institute of Technology Kharagpur, Kharagpur, India
| | - Gourab Bhattacharje
- Department of Biotechnology, Indian Institute of Technology Kharagpur, Kharagpur, India
| | - Sayan Das
- School of Bioscience, Indian Institute of Technology Kharagpur, Kharagpur, India
| | - Seemanti Aditya
- School of Bioscience, Indian Institute of Technology Kharagpur, Kharagpur, India
| | - Anandita Ghosh
- Department of Molecular Medicine, University of South Florida, Tampa, USA
| | - Andrew R. McGill
- Department of Molecular Medicine, University of South Florida, Tampa, USA
- Department of Internal Medicine, University of South Florida, Tampa, USA
- Department of Veterans Affairs, James A Haley Veterans Hospital, Tampa, USA
| | | | - Amit Kumar Das
- Department of Biotechnology, Indian Institute of Technology Kharagpur, Kharagpur, India
| | - Amit Basak
- Division of Chemical Science, Indian Institute of Science Education and Research Kolkata, Mohanpur, India
| | - Shyam S. Mohapatra
- Department of Internal Medicine, University of South Florida, Tampa, USA
- Department of Veterans Affairs, James A Haley Veterans Hospital, Tampa, USA
| | - Bala Chandran
- Department of Molecular Medicine, University of South Florida, Tampa, USA
| | | | - Subhra Mohapatra
- Department of Molecular Medicine, University of South Florida, Tampa, USA
- Department of Veterans Affairs, James A Haley Veterans Hospital, Tampa, USA
| | - Arunava Roy
- Department of Molecular Medicine, University of South Florida, Tampa, USA
| | - Arindam Mondal
- School of Bioscience, Indian Institute of Technology Kharagpur, Kharagpur, India
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15
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Czyrski A, Resztak M, Świderski P, Brylak J, Główka FK. The Overview on the Pharmacokinetic and Pharmacodynamic Interactions of Triazoles. Pharmaceutics 2021; 13:pharmaceutics13111961. [PMID: 34834376 PMCID: PMC8620887 DOI: 10.3390/pharmaceutics13111961] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/09/2021] [Accepted: 11/15/2021] [Indexed: 12/24/2022] Open
Abstract
Second generation triazoles are widely used as first-line drugs for the treatment of invasive fungal infections, including aspergillosis and candidiasis. This class, along with itraconazole, voriconazole, posaconazole, and isavuconazole, is characterized by a broad range of activity, however, individual drugs vary considerably in safety, tolerability, pharmacokinetics profiles, and interactions with concomitant medications. The interaction may be encountered on the absorption, distribution, metabolism, and elimination (ADME) step. All triazoles as inhibitors or substrates of CYP isoenzymes can often interact with many drugs, which may result in the change of the activity of the drug and cause serious side effects. Drugs of this class should be used with caution with other agents, and an understanding of their pharmacokinetic profile, safety, and drug-drug interaction profiles is important to provide effective antifungal therapy. The manuscript reviews significant drug interactions of azoles with other medications, as well as with food. The PubMed and Google Scholar bases were searched to collect the literature data. The interactions with anticonvulsants, antibiotics, statins, kinase inhibitors, proton pump inhibitors, non-nucleoside reverse transcriptase inhibitors, opioid analgesics, benzodiazepines, cardiac glycosides, nonsteroidal anti-inflammatory drugs, immunosuppressants, antipsychotics, corticosteroids, biguanides, and anticoagulants are presented. We also paid attention to possible interactions with drugs during experimental therapies for the treatment of COVID-19.
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Affiliation(s)
- Andrzej Czyrski
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland; (M.R.); (F.K.G.)
- Correspondence: ; Tel.: +48-61-854-64-33
| | - Matylda Resztak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland; (M.R.); (F.K.G.)
| | - Paweł Świderski
- Department of Forensic Medicine, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland;
| | - Jan Brylak
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, 27/33 Szpitalna Street, 60-572 Poznań, Poland;
| | - Franciszek K. Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland; (M.R.); (F.K.G.)
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16
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Shubitz LF, Schlacks S, Vishkautsan P, Butkiewicz CD, Worthing KA. Posaconazole treatment of refractory coccidioidomycosis in dogs. J Vet Intern Med 2021; 35:2772-2777. [PMID: 34658074 PMCID: PMC8692207 DOI: 10.1111/jvim.16282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/01/2021] [Accepted: 10/01/2021] [Indexed: 11/30/2022] Open
Abstract
Background The majority of dogs with coccidioidomycosis recover with administration of fluconazole or itraconazole, although some cases are refractory or the dogs do not tolerate administration of these medications. Objectives The objective was to describe the treatment outcomes and therapeutic monitoring of 8 dogs with refractory coccidioidomycosis treated with posaconazole. Animals Eight dogs with refractory coccidioidomycosis. Methods Retrospective case series. Medical records from Veterinary Specialty Center of Tucson were searched to identify dogs with refractory coccidioidomycosis that were treated with posaconazole. Clinical information and the results of monitoring trough serum posaconazole concentrations were retrieved. Results Eight dogs with refractory coccidioidomycosis were treated with 2.5 to 10 mg/kg per day of posaconazole. Six of 8 dogs recovered or developed clinical remission while administered posaconazole. Thirteen serum concentrations from 8 dogs tested were >1 μg/mL (range, 1.52 to >6 μg/mL) and the drug was well‐tolerated by 7 dogs. One dog required dosage reductions and treatment was ultimately discontinued because of hepatotoxicosis. Conclusions and Clinical Importance Posaconazole should be considered as a treatment option for dogs with refractory coccidioidomycosis. Monitoring of indicators of liver function or injury along with therapeutic drug monitoring is recommended to tailor dosage in the event of hepatic toxicosis.
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Affiliation(s)
- Lisa F Shubitz
- Valley Fever Center for Excellence, The University of Arizona, Tucson, Arizona, USA.,Veterinary Specialty Center of Tucson, Tucson, Arizona, USA
| | | | | | | | - Kate A Worthing
- University of Arizona College of Veterinary Medicine, Oro Valley, Arizona, USA
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17
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The Impact of Gelatin on the Pharmaceutical Characteristics of Fucoidan Microspheres with Posaconazole. MATERIALS 2021; 14:ma14154087. [PMID: 34361285 PMCID: PMC8347644 DOI: 10.3390/ma14154087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/12/2021] [Accepted: 07/19/2021] [Indexed: 11/23/2022]
Abstract
Fungal infections and invasive mycoses, despite the continuous medicine progress, are an important globally therapeutic problem. Multicompartment dosage formulations (e.g., microparticles) ensure a short drug diffusion way and high surface area of drug release, which as a consequence can provide improvement of therapeutic efficiency compared to the traditional drug dosage forms. As fucoidan is promising component with wide biological activity per se, the aim of this study was to prepare fucospheres (fucoidan microparticles) and fucoidan/gelatin microparticles with posaconazole using the one-step spray-drying technique. Pharmaceutical properties of designed fucospheres and the impact of the gelatin addition on their characteristics were evaluated. An important stage of this research was in vitro evaluation of antifungal activity of developed microparticles using different Candida species. It was observed that gelatin presence in microparticles significantly improved swelling capacity and mucoadhesiveness, and provided a sustained POS release. Furthermore, it was shown that gelatin addition enhanced antifungal activity of microparticles against tested Candida spp. strains. Microparticles formulation GF6, prepared by the spray drying of 20% fucoidan, 5% gelatin and 10% Posaconazole, were characterized by optimal mucoadhesive properties, high drug loading and the most sustained drug release (after 8 h 65.34 ± 4.10% and 33.81 ± 5.58% of posaconazole was dissolved in simulated vaginal fluid pH 4.2 or 0.1 M HCl pH 1.2, respectively).
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18
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Highsmith EA, Doan VP, Canada TW. Subtherapeutic posaconazole prophylaxis in a gastric bypass patient following hematopoietic stem cell transplantation. Am J Health Syst Pharm 2021; 78:1282-1286. [PMID: 33884401 PMCID: PMC8083209 DOI: 10.1093/ajhp/zxab164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE A case of invasive fungal infections (IFIs) with subtherapeutic posaconazole prophylaxis in a gastric bypass patient following hematopoietic stem cell transplantation (HSCT) is reported. SUMMARY A 52-year-old malnourished male with a medical history of Roux-en-Y gastric bypass for obesity developed acute myelogenous leukemia and underwent allogeneic HSCT approximately 17 months later. He was admitted 1 month after HSCT for failure to thrive and initiated on parenteral nutrition due to worsening diarrhea and suspected gastrointestinal graft-versus-host disease (GI GVHD). During admission, the patient was continued on daily oral posaconazole for antifungal prophylaxis and was found to have subtherapeutic posaconazole and deficient vitamin levels, likely secondary to his gastrojejunostomy and increased gastric transit time. The oral posaconazole was altered to twice-daily dosing in an effort to increase serum drug levels and prevent IFIs. CONCLUSION Patients with a history of gastric bypass are at increased risk for malabsorption of oral posaconazole and nutrients, especially following HSCT with suspected GI GVHD.
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Affiliation(s)
- Emily A Highsmith
- Department of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Address correspondence to Dr. Highsmith ()
| | - Vi P Doan
- Department of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Todd W Canada
- Department of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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19
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Azmanis P, Pappalardo L, Sara ZAJ, Silvanose C, Naidoo V. Disposition of posaconazole after single oral administration in large falcons (Falco spp): Effect of meal and dosage and a non-compartmental model to predict effective dosage. Med Mycol 2021; 59:901-908. [PMID: 33891699 DOI: 10.1093/mmy/myab019] [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: 11/09/2020] [Revised: 03/11/2021] [Accepted: 04/19/2021] [Indexed: 11/13/2022] Open
Abstract
Posaconazole has been used anecdotally to treat aspergillosis in falcons resistant to voriconazole. In human medicine, it is used prophylactically in immunosuppressed human subjects with invasive pulmonary aspergillosis. So far, no studies have been performed in birds. The aim of this study was to evaluate the in-vivo pharmacokinetic behavior of oral posaconazole after a single administration in six large falcons (i.e gyrfalcons, saker falcons). Posaconazole oral suspension (Noxafil, 40 mg/ml, Schering-Plough) was administered per os without meal in a single dosage of 12.5 mg/kg in 3 falcons. A comparison was done in two more falcons, one with a natural fatty meal at the same single dose, and one with a natural fatty meal and a higher dosage (20 mg/kg). Finally, six falcons received posaconazole pre-dissolved in corn oil with a natural low-fat meal in the higher single dose (20 mg/kg). No side effects were observed in the falcons in any of the experiments. In starved state posaconazole was poorly absorbed, more so than in other species. As expected, absorption of posaconazole was higher with the administration of meal or in the presence of plant (corn) oil, with a fourfold increase in apparent bioavailability. Despite the preferential absorption in the presence of fat, for both dosing schemes the AUC24 : MIC ratio was lower than described in human medicine to achieve a therapeutic effect. The AUCinf : MIC which is an indicator of efficacy after steady-state, while variable, did indicate that the drug is worth trying when susceptibility testing shows to be the only effective drug. LAY ABSTRACT The focus of this work is to determine the pharmacokinetic parameters of oral posaconazole in large falcons for the first time after a single dose. Posaconazole has higher bioavailability when administered with meal and fatty components. No adverse reactions have been observed. The ratio of the area under the curve (AUC24) to minimum inhibitory concentration was lower compared to the therapeutic level in human.
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Affiliation(s)
- Panagiotis Azmanis
- Dubai Falcon Hospital, 23919, Dubai, United Arab Emirates (Azmanis, Silvanose)
| | - Lucia Pappalardo
- Department of Biology, Chemistry and Environmental Studies, American University of Sharjah (AUS), United Arab Emirates (Pappalardo, Sara)
| | - Ziad A J Sara
- Department of Biology, Chemistry and Environmental Studies, American University of Sharjah (AUS), United Arab Emirates (Pappalardo, Sara)
| | | | - Vinny Naidoo
- Biomedical Research Center (BRC), Faculty of Veterinary Science, University of Pretoria, Republic of South Africa (Naidoo)
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20
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Power N, Lynch F, Denning DW, Bazaz R. Attainment of therapeutic posaconazole serum levels during co-administration with rifampicin. J Glob Antimicrob Resist 2020; 23:284-285. [DOI: 10.1016/j.jgar.2020.09.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/19/2020] [Accepted: 09/12/2020] [Indexed: 02/06/2023] Open
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21
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Docci L, Klammers F, Ekiciler A, Molitor B, Umehara K, Walter I, Krähenbühl S, Parrott N, Fowler S. In Vitro to In Vivo Extrapolation of Metabolic Clearance for UGT Substrates Using Short-Term Suspension and Long-Term Co-cultured Human Hepatocytes. AAPS JOURNAL 2020; 22:131. [DOI: 10.1208/s12248-020-00482-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/10/2020] [Indexed: 01/08/2023]
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22
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Chanoine S, Gautier-Veyret E, Pluchart H, Tonini J, Fonrose X, Claustre J, Bedouch P, Stanke-Labesque F. Tablets or oral suspension for posaconazole in lung transplant recipients? Consequences for trough concentrations of tacrolimus and everolimus. Br J Clin Pharmacol 2020; 87:427-435. [PMID: 32472569 DOI: 10.1111/bcp.14398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 11/28/2022] Open
Abstract
AIMS A new formulation of posaconazole (PCZ), delayed-release tablets (PCZ-tab), increases PCZ bioavailability and plasma trough concentrations (Cmin ) over those achieved with an oral suspension (PCZ-susp). PCZ is an inhibitor of cytochrome P450 3A4 and P-glycoprotein. We therefore investigated the impact of PCZ-tab treatment on blood Cmin and doses of tacrolimus (TAC) and everolimus (EVR). METHODS Eighteen lung transplant patients receiving TAC (n = 13) or TAC + EVR (n = 5) between June 2015 and March 2016 were retrospectively included. Ten of these patients received both PCZ-tab and PCZ-susp (i.e. switched patients); the other 8 received only PCZ-tab. Plasma Cmin of PCZ (n = 64), blood Cmin of TAC (n = 299) and EVR (n = 80) were determined during routine therapeutic drug monitoring by liquid chromatography-tandem mass spectrometry. RESULTS PCZ Cmin on PCZ-tab treatment (n = 48) was 2.5 times higher than that on PCZ-susp therapy (n = 16), for both PCZ patients (P < .0001) and for switched patients (P = .003). PCZ initiation, regardless of galenic form, increased TAC and EVR Cmin adjusted for dose (D), 3-fold and 3.5-fold, respectively (P < .0001 for both). PCZ-tab treatment was associated with a higher TAC Cmin /D (PCZ-tab vs PCZ-susp: 0.004 ± 0.004 L-1 vs 0.009 ± 0.006 L-1 , P < .0001) and lower TAC daily dose than PCZ-susp (PCZ-tab vs PCZ-susp: 1.08 ± 0.92 vs 2.32 ± 1.62 mg d-1 , P < .0001). EVR Cmin /D was higher and EVR dose tended to be lower on PCZ-tab than on PCZ-susp. CONCLUSION The greater PCZ exposure achieved during PCZ-tab treatment increased drug-drug interactions with TAC and EVR, resulting in greater exposure, potentially exposing patients to higher risks of adverse effects.
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Affiliation(s)
- Sébastien Chanoine
- Université Grenoble Alpes, Faculté de Pharmacie, Grenoble, France.,Institute for Advanced Biosciences UGA - Inserm U 1209 - CNRS UMR 5309, Grenoble, France.,Pôle Pharmacie, CHU Grenoble Alpes, Grenoble, France
| | - Elodie Gautier-Veyret
- Université Grenoble Alpes, HP2, Grenoble, France.,INSERM U1042, Grenoble, France.,Laboratoire de Pharmacologie, Pharmacogénétique et Toxicologie, CHU Grenoble Alpes, Grenoble, France
| | - Hélène Pluchart
- Université Grenoble Alpes, Faculté de Pharmacie, Grenoble, France.,Pôle Pharmacie, CHU Grenoble Alpes, Grenoble, France
| | - Julia Tonini
- Laboratoire de Pharmacologie, Pharmacogénétique et Toxicologie, CHU Grenoble Alpes, Grenoble, France
| | - Xavier Fonrose
- Laboratoire de Pharmacologie, Pharmacogénétique et Toxicologie, CHU Grenoble Alpes, Grenoble, France
| | - Johanna Claustre
- Université Grenoble Alpes, Faculté de Médecine, Grenoble, France.,Service hospitalo-universitaire de Pneumologie-Physiologie, CHU Grenoble Alpes, Grenoble, France
| | - Pierrick Bedouch
- Université Grenoble Alpes, Faculté de Pharmacie, Grenoble, France.,Pôle Pharmacie, CHU Grenoble Alpes, Grenoble, France.,CNRS, TIMC-IMAG UMR5525/ThEMAS, Univ Grenoble Alpes, Grenoble, France
| | - Françoise Stanke-Labesque
- Université Grenoble Alpes, HP2, Grenoble, France.,INSERM U1042, Grenoble, France.,Laboratoire de Pharmacologie, Pharmacogénétique et Toxicologie, CHU Grenoble Alpes, Grenoble, France
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Van Daele R, Spriet I, Maertens J. Posaconazole in prophylaxis and treatment of invasive fungal infections: a pharmacokinetic, pharmacodynamic and clinical evaluation. Expert Opin Drug Metab Toxicol 2020; 16:539-550. [DOI: 10.1080/17425255.2020.1764939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Ruth Van Daele
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
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Abstract
Objectives The objectives of this study were to investigate the population pharmacokinetics of posaconazole in immunocompromised children, evaluate the influence of patient characteristics on posaconazole exposure and perform simulations to recommend optimal starting doses. Methods Posaconazole plasma concentrations from paediatric patients undergoing therapeutic drug monitoring were extracted from a tertiary paediatric hospital database. These were merged with covariates collected from electronic sources and case-note reviews. An allometrically scaled population-pharmacokinetic model was developed to investigate the effect of tablet and suspension relative bioavailability, nonlinear bioavailability of suspension, followed by a step-wise covariate model building exercise to identify other important sources of variability. Results A total of 338 posaconazole plasma concentrations samples were taken from 117 children aged 5 months to 18 years. A one-compartment model was used, with tablet apparent clearance standardised to a 70-kg individual of 15 L/h. Suspension was found to have decreasing bioavailability with increasing dose; the estimated suspension dose to yield half the tablet bioavailability was 99 mg/m2. Diarrhoea and proton pump inhibitors were also associated with reduced suspension bioavailability. Conclusions In the largest population-pharmacokinetic study to date in children, we have found similar covariate effects to those seen in adults, but low bioavailability of suspension in patients with diarrhoea or those taking concurrent proton pump inhibitors, which may in particular limit the use of posaconazole in these patients. Electronic supplementary material The online version of this article (10.1007/s40262-018-0658-1) contains supplementary material, which is available to authorized users.
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Elkhabaz A, Sarkar S, Simpson GJ, Taylor LS. Characterization of Phase Transformations for Amorphous Solid Dispersions of a Weakly Basic Drug upon Dissolution in Biorelevant Media. Pharm Res 2019; 36:174. [DOI: 10.1007/s11095-019-2718-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 10/06/2019] [Indexed: 12/18/2022]
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26
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Jović Z, Janković SM, Ružić Zečević D, Milovanović D, Stefanović S, Folić M, Milovanović J, Kostić M. Clinical Pharmacokinetics of Second-Generation Triazoles for the Treatment of Invasive Aspergillosis and Candidiasis. Eur J Drug Metab Pharmacokinet 2019; 44:139-157. [PMID: 30284178 DOI: 10.1007/s13318-018-0513-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Second-generation triazoles were developed in response to the quest for more efficacious and safer therapeutic options for the treatment of severe systemic aspergillosis and candidiasis. These agents include voriconazole, posaconazole, isavuconazole, and ravuconazole. The aim of this review was to present and compare the pharmacokinetic characteristics of second-generation triazoles for the treatment of invasive aspergillosis and candidiasis, emphasizing their clinical implications. The MEDLINE, Scopus, EBSCO, Google Scholar, and SCIndeks databases were searched using advanced search options, including the names of second-generation triazoles and pharmacokinetic terms as keywords. The intravenous administration of voriconazole, posaconazole, and isavuconazole results in stable pharmacokinetics of these drugs, with mostly predictable variations influenced by common and usually known factors in routine clinical settings. The high oral bioavailability of isavuconazole and, to some extent, voriconazole makes them suitable for intravenous-to-oral switch strategies. Except for intravenous voriconazole (due to the accumulation of the toxic vehicle hydroxypropyl betadex), dose reduction of second-generation triazoles is not needed in patients with renal failure; patients with hepatic insufficiency require dose reduction only in advanced disease stages. The introduction of therapeutic drug monitoring could aid attempts to optimize the blood concentrations of triazoles and other drugs that are known to or that possibly interact, thus increasing treatment efficacy and safety. There is a need for new studies that are designed to provide useful data on second-generation triazole pharmacokinetics, particularly in special circumstances such as central nervous system and ocular infections, infections in newborns and infants, and in subjects with genetic polymorphisms of metabolizing enzymes.
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Affiliation(s)
- Zorica Jović
- Faculty of Medicine, University of Niš, Niš, Serbia
| | - Slobodan M Janković
- Faculty of Medical Sciences, University of Kragujevac, Zmaj Jovina Street, 30, Kragujevac, 34000, Serbia.
| | - Dejana Ružić Zečević
- Faculty of Medical Sciences, University of Kragujevac, Zmaj Jovina Street, 30, Kragujevac, 34000, Serbia
| | - Dragan Milovanović
- Faculty of Medical Sciences, University of Kragujevac, Zmaj Jovina Street, 30, Kragujevac, 34000, Serbia
| | - Srđan Stefanović
- Faculty of Medical Sciences, University of Kragujevac, Zmaj Jovina Street, 30, Kragujevac, 34000, Serbia
| | - Marko Folić
- Faculty of Medical Sciences, University of Kragujevac, Zmaj Jovina Street, 30, Kragujevac, 34000, Serbia
| | - Jasmina Milovanović
- Faculty of Medical Sciences, University of Kragujevac, Zmaj Jovina Street, 30, Kragujevac, 34000, Serbia
| | - Marina Kostić
- Faculty of Medical Sciences, University of Kragujevac, Zmaj Jovina Street, 30, Kragujevac, 34000, Serbia
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Prakash K, Richman D. A case report of disseminated histoplasmosis and concurrent cryptococcal meningitis in a patient treated with ruxolitinib. BMC Infect Dis 2019; 19:287. [PMID: 30917797 PMCID: PMC6437885 DOI: 10.1186/s12879-019-3922-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 03/19/2019] [Indexed: 12/22/2022] Open
Abstract
Background Ruxolitinib is a highly potent janus kinase inhibitor that places its users at risk for various bacterial infections and viral reactivation. However new reports are also emerging that suggest greater immunosuppression and risk for fungal disease. Case presentation We report the case of a 51 year-old veteran from Guam, treated with ruxolitinib for polycythemia vera, who developed disseminated histoplasmosis and concurrent cryptococcal meningitis. Conclusion This case draws attention to the degree of immunosuppression that may be seen with this drug and the need for heightened vigilance for opportunistic infections in those treated with inhibitors of janus kinase/signal transducers and activators of transcription (JAK/STAT) such as ruxolitinib.
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Affiliation(s)
- Katya Prakash
- Division of Infectious Diseases, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0711, USA.
| | - Douglas Richman
- Division of Infectious Diseases, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0711, USA.,VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA, 92161, USA
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28
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Vuletić L, Herceg M, Ferderber K, Tunjić I, Rizea-Savu S, Duna SN, Cetina-Čižmek B, Filipović-Grčić J. Single-Dose Pharmacokinetic Properties and Relative Bioavailability of Different Formulations of Posaconazole Oral Suspension in Healthy Volunteers. Clin Pharmacol Drug Dev 2018; 8:827-836. [PMID: 30536797 DOI: 10.1002/cpdd.636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/05/2018] [Indexed: 11/10/2022]
Abstract
The rate and extent of absorption of drugs belonging to Biopharmaceutics Classification System class II are rate-limited by dissolution and highly dependent on the performance of the formulated product. The purpose of the present study was to investigate the potential impact of a surfactant and the particle size of the active substance on the in vitro drug dissolution profiles and in vivo pharmacokinetics of the poorly soluble drug posaconazole. A comparative physicochemical evaluation was conducted, and 3 formulations of posaconazole oral suspension were tested in various dissolution media compared with the reference product. In addition, a comparative bioavailability study was conducted in healthy volunteers under high-fat fed conditions. Bioequivalence was assessed based on plasma concentrations of the parent drug (posaconazole) measured by a validated high-pressure liquid chromatography-tandem mass spectrometry method. The 90% confidence intervals for Cmax and AUC0-72 least-squares mean T/R ratios of all 3 posaconazole formulations were within the bioequivalence acceptance range of 80.00% to 125.00%. The study was useful in the formulation development process and demonstrated that neither surfactant type nor particle size of the active substance within the studied range affected the extent or rate of absorption of posaconazole under the tested fed conditions.
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Affiliation(s)
- Lucija Vuletić
- R&D, PLIVA Croatia Ltd, TEVA Group Member, Zagreb, Croatia.,University of Zagreb, Faculty of Pharmacy and Biochemistry, Department of Pharmaceutical Technology, Zagreb, Croatia
| | - Marina Herceg
- R&D, PLIVA Croatia Ltd, TEVA Group Member, Zagreb, Croatia
| | | | - Iva Tunjić
- R&D, PLIVA Croatia Ltd, TEVA Group Member, Zagreb, Croatia
| | | | | | | | - Jelena Filipović-Grčić
- University of Zagreb, Faculty of Pharmacy and Biochemistry, Department of Pharmaceutical Technology, Zagreb, Croatia
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29
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Cojutti PG, Candoni A, Lazzarotto D, Rabassi N, Fanin R, Hope W, Pea F. Co-administration of proton pump inhibitors and/or of steroids may be a risk factor for low trough concentrations of posaconazole delayed-released tablets in adult patients with haematological malignancies. Br J Clin Pharmacol 2018; 84:2544-2550. [PMID: 29975796 DOI: 10.1111/bcp.13707] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 06/27/2018] [Accepted: 06/29/2018] [Indexed: 01/07/2023] Open
Abstract
AIMS The aim of this study was to determine clinical variables associated with posaconazole exposure among adult patients with haematological malignancies who received posaconazole tablets for prophylaxis of invasive fungal infections (IFIs). METHODS The study population included adult patients with haematological malignancies who received posaconazole delayed-release tablets for prophylaxis of IFIs after induction chemotherapy for acute leukaemia or graft-versus-host-disease (GVHD) complicating hematopoietic stem cell transplantation (HSCT) in the period January 2016-December 2017. RESULTS Sixty-six consecutive patients with 176 posaconazole Cmin were included for evaluation in the study. Subtherapeutic posaconazole concentrations (< 0.7 mg l-1 ) were observed at least once in 33.3% of patients (22/66), and overall in 17.0% of therapeutic drug monitoring (TDM) episodes (30/176). At multilevel linear regression, use of PPIs (P = 0.008), use of intermediate or high dose steroids (>0.7 mg kg-1 daily) (P = 0.022) and male gender (P = 0.025) were significantly associated with decreased Cmin , whereas time from starting therapy (P = 0.032) was associated with increased Cmin in our patient population. CONCLUSION Posaconazole exposure during treatment with delayed-released tablet formulation may be affected by the use of PPIs and/or of intermediate or high dose steroids.
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Affiliation(s)
- Pier Giorgio Cojutti
- Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy.,Department of Medicine, University of Udine, Udine, Italy
| | - Anna Candoni
- Division of Haematology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Davide Lazzarotto
- Division of Haematology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Nicholas Rabassi
- Division of Haematology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Renato Fanin
- Department of Medicine, University of Udine, Udine, Italy.,Division of Haematology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Federico Pea
- Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy.,Department of Medicine, University of Udine, Udine, Italy
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30
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Sustained Impairment of Lurasidone Clearance After Discontinuation of Posaconazole: Impact of Obesity, and Implications for Patient Safety. J Clin Psychopharmacol 2018; 38:289-295. [PMID: 29851709 DOI: 10.1097/jcp.0000000000000892] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE/BACKGROUND The antipsychotic agent lurasidone (Latuda®) is metabolized by Cytochrome P450-3A (CYP3A) enzymes. Coadministration with strong CYP3A inhibitors (such as ketoconazole, posaconazole, and ritonavir) is contraindicated due to the risk of sedation and movement disorders from high levels of lurasidone. This study evaluated the time-course of recovery from the posaconazole drug interaction, and the effect of obesity on the recovery process. METHODS/PROCEDURES Healthy normal-weight volunteers (n = 11, mean body mass index, BMI, = 23.1 kg/m) and otherwise healthy obese subjects (n = 13, mean BMI = 49.3 kg/m) received single doses of lurasidone in the baseline control condition, again during coadministration of posaconazole, and at 4 additional time points during the 2 weeks after posaconazole discontinuation. FINDINGS/RESULTS With posaconazole coadministration, lurasidone area under the concentration curve (AUC) increased by an arithmetic mean factor of 6.2 in normals, and by 4.9 in obese subjects. Post-treatment washout of posaconazole was slow in normals (mean half-life 31 hours), and further prolonged in obese subjects (53 hours). Recovery of lurasidone AUC toward baseline was correspondingly slow, and was incomplete. AUC remained significantly elevated above baseline both in normals (factor of 2.1) and obese subjects (factor of 3.4) even at 2 weeks after stopping posaconazole. IMPLICATIONS/CONCLUSIONS Product labeling does not address the necessary delay after discontinuation of a strong CYP3A inhibitor before lurasidone can be safely administered. We recommend requiring normal-weight and obese patients to limit the dosage of lurasidone, or undergo a washout period, for two and three weeks, respectively, after discontinuation of posaconazole.
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31
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Sime FB, Stuart J, Butler J, Starr T, Wallis SC, Pandey S, Lipman J, Roberts JA. A pharmacokinetic case study of intravenous posaconazole in a critically ill patient with hypoalbuminaemia receiving continuous venovenous haemodiafiltration. Int J Antimicrob Agents 2018; 52:506-509. [PMID: 30031203 DOI: 10.1016/j.ijantimicag.2018.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/27/2018] [Accepted: 07/07/2018] [Indexed: 11/18/2022]
Abstract
This article reports a pharmacokinetic case study of intravenous posaconazole in a 49-year-old male patient with intra-abdominal sepsis and hypoalbuminaemia receiving continuous venovenous haemodiafiltration. Concentration-time data following 300 mg intravenous posaconazole was analysed using a population pharmacokinetics approach. The 300-mg intravenous dose appears to be adequate for the treatment of yeast infections; however, for the treatment of invasive aspergillosis in isolated cases of critically ill patients with hypoalbuminaemia, the current dosing may not achieve desired exposure, although steady state exposure data are needed.
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Affiliation(s)
- Fekade B Sime
- School of Pharmacy, Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia
| | - Janine Stuart
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jenie Butler
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Therese Starr
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Steven C Wallis
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Saurabh Pandey
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jeffrey Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jason A Roberts
- School of Pharmacy, Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia; Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia.
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32
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Geist MJP, Egerer G, Mikus G, Blank A, Hohmann N, Heinz WJ, Carls A. Impact of patient education on plasma concentrations and effectiveness of posaconazole oral suspension under clinical conditions. Basic Clin Pharmacol Toxicol 2018; 124:56-61. [PMID: 29989301 DOI: 10.1111/bcpt.13093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 07/04/2018] [Indexed: 02/06/2023]
Abstract
Posaconazole prophylaxis is recommended for patients with acute myeloid leukaemia during induction chemotherapy. Although a tablet formulation with better oral bioavailability is available, some patients have to rely on the oral suspension in clinical routine. Therefore, effectiveness of posaconazole oral suspension under real-life clinical conditions and impact of patient education about the correct intake on its plasma concentrations were assessed in this study. Altogether 96 patients receiving 160 cycles of induction chemotherapy were retrospectively (40 patients) and prospectively (56 patients) analysed. Patients were assigned into two groups for each chemotherapy cycle according to the application of antifungal prophylaxis (A: posaconazole oral suspension, 200 mg three times a day ≥7 days; B: intake <7 days, fluconazole or no prophylaxis). Antifungal prophylaxis and therapy were analysed for each cycle. Additionally, plasma concentrations were determined from prospectively included subjects of group A who were intensively educated to perform a correct drug intake. Systemic antifungal therapy was statistically started less often in group A (26% vs 53%; P = 0.002). Posaconazole prophylaxis was associated with a lower risk of proven invasive fungal infection (P = 0.003). Median plasma concentration apparently increased between the first and second time of determination effected by an initial intensive on-site patient education. The clinical effectiveness of posaconazole oral suspension was confirmed. A detailed patient education at the beginning of the treatment with posaconazole oral suspensions seems to be of primary importance for efficient plasma concentrations.
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Affiliation(s)
- Marcus J P Geist
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Gerlinde Egerer
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Antje Blank
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Nicolas Hohmann
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Werner J Heinz
- Department of Internal Medicine II, University of Wuerzburg Medical Center, Wuerzburg, Germany
| | - Alexandra Carls
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
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Breakthrough invasive aspergillosis and diagnostic accuracy of serum galactomannan enzyme immune assay during acute myeloid leukemia induction chemotherapy with posaconazole prophylaxis. Oncotarget 2018; 9:26724-26736. [PMID: 29928481 PMCID: PMC6003556 DOI: 10.18632/oncotarget.25477] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/07/2018] [Indexed: 12/19/2022] Open
Abstract
Posaconazole prophylaxis has demonstrated efficacy in the prevention of invasive aspergillosis during prolonged neutropenia following acute myeloid leukemia induction chemotherapy. Antifungal treatment decreases serum galactomannan enzyme immunoassay diagnostic accuracy that could delay the diagnosis and treatment. We retrospectively studied patients with acute myeloid leukemia who underwent intensive chemotherapy and antifungal prophylaxis by posaconazole oral suspension. Clinical, radiological, microbiological features and treatment response of patients with invasive aspergillosis that occurred despite posaconazole prophylaxis were analyzed. Diagnostic accuracy of serum galactomannan assay according to posaconazole plasma concentrations has been performed. A total of 288 patients with acute myeloid leukemia, treated by induction chemotherapy, who received posaconazole prophylaxis for more than five days were included in the present study. The incidence of invasive aspergillosis was 8% with 12 (4.2%), 8 (2.8%) and 3 (1%), possible, probable and proven invasive aspergillosis, respectively. Posaconazole plasma concentration was available for 258 patients. Median duration of posaconazole treatment was 17 days, and median posaconazole plasma concentration was 0.5 mg/L. None of patients with invasive aspergillosis and posaconazole concentration ≥ 0.5 mg/L had a serum galactomannan positive test. Sensitivity of serum galactomannan assay to detect probable and proven invasive aspergillosis was 81.8%. Decreasing the cut-off value for serum galactomannan optical density index from 0.5 to 0.3 increased sensitivity to 90.9%. In a homogenous cohort of acute myeloid leukemia patients during induction chemotherapy, increasing the posaconazole concentration decreases the sensitivity of serum galactomannan assay.
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Pharmacokinetics of Intravenous Posaconazole in Critically Ill Patients. Antimicrob Agents Chemother 2018; 62:AAC.00242-18. [PMID: 29581122 PMCID: PMC5971586 DOI: 10.1128/aac.00242-18] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 03/20/2018] [Indexed: 12/18/2022] Open
Abstract
To date, there is no information on the intravenous (i.v.) posaconazole pharmacokinetics for intensive care unit (ICU) patients. This prospective observational study aimed to describe the pharmacokinetics of a single dose of i.v. posaconazole in critically ill patients. Patients with no history of allergy to triazole antifungals and requiring systemic antifungal therapy were enrolled if they were aged ≥18 years, central venous access was available, they were not pregnant, and they had not received prior posaconazole or drugs interacting with posaconazole. A single dose of 300 mg posaconazole was administered over 90 min. Total plasma concentrations were measured from serial plasma samples collected over 48 h, using a validated chromatographic method. The pharmacokinetic data set was analyzed by noncompartmental methods. Eight patients (7 male) were enrolled with the following characteristics: median age, 46 years (interquartile range [IQR], 40 to 51 years); median weight, 68 kg (IQR, 65 to 82 kg); and median albumin concentration, 20 g/liter (IQR, 18 to 24 g/liter). Median (IQR) pharmacokinetic parameter estimates were as follows: observed maximum concentration during sampling period (Cmax), 1,702 ng/ml (1,352 to 2,141 ng/ml); area under the concentration-time curve from zero to infinity (AUC0-∞), 17,932 ng · h/ml (13,823 to 27,905 ng · h/ml); clearance (CL), 16.8 liters/h (11.1 to 21.7 liters/h); and volume of distribution (V), 529.1 liters (352.2 to 720.6 liters). The V and CL were greater than 2-fold and the AUC0-∞ was 39% of the values reported for heathy volunteers. The AUC0-∞ was only 52% of the steady-state AUC0-24 reported for hematology patients. The median of estimated average steady-state concentrations was 747 ng/ml (IQR, 576 to 1,163 ng/ml), which is within but close to the lower end of the previously recommended therapeutic range of 500 to 2,500 ng/ml. In conclusion, we observed different pharmacokinetics of i.v. posaconazole in this cohort of critically ill patients compared to those in healthy volunteers and hematology patients.
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Launay M, Roux A, Beaumont L, Douvry B, Lecuyer L, Douez E, Picard C, Grenet D, Jullien V, Boussaud V, Guillemain R, Billaud EM. Posaconazole Tablets in Real-Life Lung Transplantation: Impact on Exposure, Drug-Drug Interactions, and Drug Management in Lung Transplant Patients, Including Those with Cystic Fibrosis. Antimicrob Agents Chemother 2018; 62:e02061-17. [PMID: 29311077 PMCID: PMC5826104 DOI: 10.1128/aac.02061-17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 12/14/2017] [Indexed: 01/02/2023] Open
Abstract
Appropriate exposure to posaconazole (PSZ) has been limited until the recent approval of the delayed-release oral tablet formulation. Our goal was to determine the exposure obtained by using the standard dose of 300 mg once a day in lung transplant (LT) patients, including patients with cystic fibrosis (CF). PSZ trough concentrations (C0) were determined using a liquid chromatography-tandem mass spectrometry assay. Indicative thresholds of interest were <0.7 mg/liter for prophylaxis and 1 to 3 mg/liter for cure. The tacrolimus (TRL) and everolimus (ERL) C0 measured during PSZ exposure were also collected. The interaction with proton-pump inhibitors (PPI) was evaluated. We recorded the results for 21 CF patients with LT (CFLT patients), 11 non-CF patients with LT (NCFLT patients), and 27 nontransplant (NT) patients in pneumology departments. The weights of the NCFLT, CFLT, and NT patients were 59.2 ± 8.4, 48.8 ± 8.4, and 63.7 ± 16.6 kg, respectively (P = 0.001* [asterisk means that statistical test is significant]), and the PSZ C0 exposures for these patients were 1.9 ± 1.5, 1.1 ± 0.8, and 2.4 ± 1.8 mg/liter, respectively (P < 0.00001*). More than 60% of the concentrations were in the therapeutic range. In CFLT patients, the administration of one 300-mg PSZ tablet quickly achieved an exposure similar to that achieved with the PSZ oral suspension formulation (OSF) administered 3 or 4 times a day for several months. The TRL C0/dose ratio (C0/D) was 7.4 ± 4.4 mg/liter with PSZ tablets, whereas it was 4.6 ± 0.8 mg/liter with the PSZ oral solution (P = 0.034*). The ERL C0/D was similar with both formulations. PPI had no impact on the PSZ concentration (1.49 ± 1.07 mg/liter without PPI versus 1.33 ± 1.17 mg/liter with PPI; P = 0.4134*). Despite the high levels of exposure, PSZ remained well tolerated (one case of diarrhea and one case of fatigue were reported). PSZ tablet administration allows satisfactory exposure, even in CFLT patients, with a dosage lower than that of the PSZ OSF. This once-a-day formulation was not impacted by PPI, which are extensively used in CF patients.
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Affiliation(s)
- Manon Launay
- Laboratory of Pharmacology and Toxicology, European Hospital Georges Pompidou-APHP, Paris, France
| | - Antoine Roux
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
- Université Versailles Saint-Quentin, Versailles, France
| | - Laurence Beaumont
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Benoit Douvry
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Lucien Lecuyer
- Thoracic Transplantation, European Hospital Georges Pompidou-APHP, Paris, France
| | - Emmanuel Douez
- Laboratory of Pharmacology and Toxicology, European Hospital Georges Pompidou-APHP, Paris, France
| | - Clément Picard
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Dominique Grenet
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Vincent Jullien
- Laboratory of Pharmacology and Toxicology, European Hospital Georges Pompidou-APHP, Paris, France
| | - Véronique Boussaud
- Thoracic Transplantation, European Hospital Georges Pompidou-APHP, Paris, France
| | - Romain Guillemain
- Thoracic Transplantation, European Hospital Georges Pompidou-APHP, Paris, France
| | - Eliane M Billaud
- Laboratory of Pharmacology and Toxicology, European Hospital Georges Pompidou-APHP, Paris, France
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Döring M, Cabanillas Stanchi KM, Klinker H, Eikemeier M, Feucht J, Blaeschke F, Schwarze CP, Ebinger M, Feuchtinger T, Handgretinger R, Heinz WJ. Posaconazole plasma concentrations in pediatric patients receiving antifungal prophylaxis during neutropenia. Med Mycol 2018; 55:375-384. [PMID: 27703016 DOI: 10.1093/mmy/myw091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 08/15/2016] [Indexed: 02/03/2023] Open
Abstract
Invasive fungal infections are one of the major complications in pediatric patients during prolonged neutropenia after chemotherapy. Evaluation of the efficacy and safety of the triazole posaconazole in these patients is missing. This multicenter survey analyzed trough concentrations of 33 pediatric patients with a median age of 8 years during 108 neutropenic episodes who received prophylactic posaconazole oral suspension. A total of 172 posaconazole trough levels were determined to median 438 ng/ml (range 111-2011 ng/ml; mean 468 ± 244 ng/ml). Age and gender had no influence on posaconazole plasma levels. Posaconazole was not discontinued due to adverse events in any of the patients. Only hepatic parameters significantly increased beyond the upper normal limit to median values of ALT of 87 U/l (P < .0001), and AST of 67 U/l (P < .0001). One patient with a median posaconazole trough concentration of 306 ng/ml experienced an invasive fungal infection. In conclusion, posaconazole was effective, safe and feasible in 33 pediatric patients with neutropenia ≥5 days after chemotherapy. Median posaconazole plasma concentrations were approximately 1.6-fold lower than the recommended plasma level of 700 ng/ml. Larger patient cohorts are needed to evaluate these findings.
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Affiliation(s)
- Michaela Döring
- University Hospital Tübingen, Children's Hospital, Department I - General Paediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Karin Melanie Cabanillas Stanchi
- University Hospital Tübingen, Children's Hospital, Department I - General Paediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Hartwig Klinker
- University Medical Center, Würzburg, Department of Infectiology, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
| | - Melinda Eikemeier
- University Hospital Tübingen, Children's Hospital, Department I - General Paediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Judith Feucht
- University Hospital Tübingen, Children's Hospital, Department I - General Paediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Franziska Blaeschke
- Ludwig-Maximilians-University München, Dr. von Hauner'sches Kinderspital, Pediatric Hematology, Oncology and Stem Cell Transplantation, Lindwurmstrasse 4, 80337 Munich, Germany
| | - Carl-Philipp Schwarze
- University Hospital Tübingen, Children's Hospital, Department I - General Paediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Martin Ebinger
- University Hospital Tübingen, Children's Hospital, Department I - General Paediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Tobias Feuchtinger
- Ludwig-Maximilians-University München, Dr. von Hauner'sches Kinderspital, Pediatric Hematology, Oncology and Stem Cell Transplantation, Lindwurmstrasse 4, 80337 Munich, Germany
| | - Rupert Handgretinger
- University Hospital Tübingen, Children's Hospital, Department I - General Paediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Werner J Heinz
- University Medical Center, Würzburg, Department of Infectiology, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
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Roger C, Sasso M, Lefrant JY, Muller L. Antifungal Dosing Considerations in Patients Undergoing Continuous Renal Replacement Therapy. CURRENT FUNGAL INFECTION REPORTS 2018. [DOI: 10.1007/s12281-018-0305-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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38
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Leclerc E, Combarel D, Uzunov M, Leblond V, Funck-Brentano C, Zahr N. Prevention of Invasive Aspergillus Fungal Infections with the Suspension and Delayed-Release Tablet Formulations of Posaconazole in Patients with Haematologic Malignancies. Sci Rep 2018; 8:1681. [PMID: 29374234 PMCID: PMC5785994 DOI: 10.1038/s41598-018-20136-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/10/2018] [Indexed: 11/30/2022] Open
Abstract
Posaconazole is a triazole antifungal used to prevent invasive fungal infections (IFIs) in patients receiving chemotherapy or haemotopoietic stem cell transplantation. Due to highly variable bioavailability of the oral suspension formulation, a delayed-release tablet was developed which showed improved bioavailability. A minimal target posaconazole plasma concentration of 0.7 mg/L is recommended for prophylaxis of IFIs. However, the relationship between plasma concentration of posaconazole and its efficacy against IFIs remains unclear. We analysed trough posaconazole concentrations and response against IFIs in 50 and 104 patients with haematologic malignancies receiving prophylactic posaconazole as the tablet or suspension formulation, respectively. Mean plasma concentration of posaconazole was 1.91 ± 1.06 mg/L and 0.82 ± 0.57 mg/L in the tablet and the oral suspension group, respectively (p < 0.0001). The percentage of patients reaching the minimal target concentration of 0.7 mg/L was 92.0% and 47.1% in the tablet and oral suspension groups, respectively (p < 0.0001). Emergent aspergillosis occurred in 9 (8.7%) patients in the suspension group and in none of the patients taking the tablet formulation (p = 0.032). Our results show a relationship between plasma concentrations of posaconazole and its prophylactic efficacy in patients with haematologic malignancies. Target posaconazole concentrations are reached more efficiently with the tablet than with the suspension formulation.
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Affiliation(s)
- Elisabeth Leclerc
- Department of Pharmacology and CIC-1421, AP-HP, Pitié-Salpêtrière Hospital, F-75013, Paris, France
| | - David Combarel
- Department of Pharmacology and CIC-1421, AP-HP, Pitié-Salpêtrière Hospital, F-75013, Paris, France
| | - Madalina Uzunov
- Department of Haematology, AP-HP, Pitié-Salpêtrière Hospital, F-75013, Paris, France
| | - Véronique Leblond
- Department of Haematology, Sorbonne Université, UPMC Univ Paris 06, Faculty of Medicine, F-75013, Paris, France
| | - Christian Funck-Brentano
- INSERM, CIC-1421 and UMR ICAN 1166, F-75013, Paris, France. .,Department of Pharmacology and UMR ICAN 1166, Sorbonne Université, UPMC Univ Paris 06, Faculty of Medicine, F-75013, Paris, France.
| | - Noël Zahr
- Department of Pharmacology and CIC-1421, AP-HP, Pitié-Salpêtrière Hospital, F-75013, Paris, France
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Stelzer D, Weber A, Ihle F, Matthes S, Ceelen F, Zimmermann G, Kneidinger N, Schramm R, Winter H, Zoller M, Vogeser M, Behr J, Neurohr C. Posaconazole liquid vs tablet formulation in lung transplant recipients. Mycoses 2017; 61:186-194. [DOI: 10.1111/myc.12724] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 08/13/2017] [Accepted: 10/29/2017] [Indexed: 12/12/2022]
Affiliation(s)
- D. Stelzer
- Department of Internal Medicine V; LMU-Munich; Munich Germany
- Comprehensive Pneumology Center; Member of the German Center for Lung Research DZL; Munich Germany
- Hospital Pharmacy; LMU-Munich; Munich Germany
| | - A. Weber
- Hospital Pharmacy; LMU-Munich; Munich Germany
| | - F. Ihle
- Department of Internal Medicine V; LMU-Munich; Munich Germany
- Comprehensive Pneumology Center; Member of the German Center for Lung Research DZL; Munich Germany
| | - S. Matthes
- Department of Internal Medicine V; LMU-Munich; Munich Germany
- Comprehensive Pneumology Center; Member of the German Center for Lung Research DZL; Munich Germany
| | - F. Ceelen
- Department of Internal Medicine V; LMU-Munich; Munich Germany
- Comprehensive Pneumology Center; Member of the German Center for Lung Research DZL; Munich Germany
| | - G. Zimmermann
- Department of Internal Medicine V; LMU-Munich; Munich Germany
- Comprehensive Pneumology Center; Member of the German Center for Lung Research DZL; Munich Germany
| | - N. Kneidinger
- Department of Internal Medicine V; LMU-Munich; Munich Germany
- Comprehensive Pneumology Center; Member of the German Center for Lung Research DZL; Munich Germany
| | - R. Schramm
- Department of Cardiac Surgery; LMU-Munich; Munich Germany
| | - H. Winter
- Department of Thoracic Surgery; LMU-Munich; Munich Germany
| | - M. Zoller
- Department of Anesthesiology; LMU-Munich; Munich Germany
| | - M. Vogeser
- Institute of Laboratory Medicine; LMU-Munich; Munich Germany
| | - J. Behr
- Department of Internal Medicine V; LMU-Munich; Munich Germany
- Comprehensive Pneumology Center; Member of the German Center for Lung Research DZL; Munich Germany
| | - C. Neurohr
- Department of Internal Medicine V; LMU-Munich; Munich Germany
- Comprehensive Pneumology Center; Member of the German Center for Lung Research DZL; Munich Germany
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40
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Real-Life Assessment of the Safety and Effectiveness of the New Tablet and Intravenous Formulations of Posaconazole in the Prophylaxis of Invasive Fungal Infections via Analysis of 343 Courses. Antimicrob Agents Chemother 2017; 61:AAC.00188-17. [PMID: 28507111 DOI: 10.1128/aac.00188-17] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 05/06/2017] [Indexed: 12/14/2022] Open
Abstract
Posaconazole is the preferred mold-active azole for prophylaxis against invasive fungal infections (IFIs) in patients with hematological malignancy. Delayed-release tablet and intravenous formulations of posaconazole have recently become available, but clinical data are limited. We sought to examine the real-world pharmacokinetics and prophylactic effectiveness of the new formulations of posaconazole given as prophylaxis for patients with hematological malignancy. A retrospective cohort of all consecutive adult inpatients with hematological malignancy who received ≥3 days of tablet or intravenous posaconazole therapy for primary IFI prophylaxis at the M. D. Anderson Cancer Center between 1 December 2013 and 31 December 2015 was established. Clinical information was collected and correlated with low posaconazole serum levels (<700 ng/ml). Rates of IFIs and safety events were assessed. A total of 1,321 courses of posaconazole were administered at the M. D. Anderson Cancer Center during the study period, of which 343 courses were assessed for prophylactic safety and effectiveness. Seventy-nine patients (23%) had posaconazole serum level measurements available for interpretation. Acute myeloid leukemia was the primary malignancy (62%), with 20% of all patients having previously received a stem cell transplant. The median posaconazole level was 1,380 ng/ml (interquartile range, 864 to 1,860 ng/ml). Low posaconazole levels (<700 ng/ml) were observed for 14 patients (18%). Proven or probable breakthrough IFIs occurred in 8 patients (2%); posaconazole therapeutic drug monitoring (TDM) was performed for 6 of those patients, all with levels above 700 ng/ml. Overall, 19% of patients experienced grade 3 or 4 liver injury, manifesting primarily as hyperbilirubinemia and being correlated with serum levels of >1,830 ng/ml. Although hepatotoxicity in a small percentage of patients is of concern, posaconazole tablets appeared to be generally safe and effective. As all breakthrough IFIs for which TDM was performed occurred in patients with levels of >700 ng/ml, and a posaconazole level of >1,830 ng/ml was correlated with grade 3 or 4 liver toxicity, further studies are needed to assess the role of TDM.
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Impact of Mucositis on Absorption and Systemic Drug Exposure of Isavuconazole. Antimicrob Agents Chemother 2017; 61:AAC.00101-17. [PMID: 28289034 PMCID: PMC5444187 DOI: 10.1128/aac.00101-17] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 03/04/2017] [Indexed: 12/02/2022] Open
Abstract
Isavuconazonium sulfate is the water-soluble prodrug of isavuconazole. Population analyses have demonstrated relatively predictable pharmacokinetic (PK) behavior in diverse patient populations. We evaluated the impact of mucositis on the oral isavuconazole exposure using population PK modeling. This study included patients treated in two phase 3 trials of isavuconazole, SECURE for treatment of invasive aspergillosis (IA) and other filamentous fungi and VITAL for patients with mucormycosis, invasive fungal disease (IFD) caused by other rare fungi, or IA and renal impairment. Mucositis was reported by site investigators and its impact on oral bioavailability was assessed. Use of the oral formulation was at the discretion of the investigator. Patients with plasma samples collected during the use of isavuconazonium sulfate were included in the construction of population PK model. Of 250 patients included, 56 patients had mucositis at therapy onset or as an adverse event during oral isavuconazole therapy. Levels of oral bioavailability were comparable, at 98.3% and 99.8%, respectively. The average drug exposures (average area under the curve [AUCave]) calculated from either the mean or median parameter estimates were not different between patients with and without mucositis. Mortality and overall clinical responses were similar between patients receiving oral therapy with and without mucositis. We found that isavuconazole exposures and clinical outcomes in this subset of patients with mucositis who were able to take oral isavuconazonium sulfate were comparable to those in patients without mucositis, despite the difference in oral bioavailability. Therefore, mucositis may not preclude use of the oral formulation of isavuconazonium sulfate.
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42
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Determination of Posaconazole in Plasma/Serum by High-Performance Liquid Chromatography with Fluorescence Detection. SEPARATIONS 2017. [DOI: 10.3390/separations4020016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Stelzer D, Weber A, Ihle F, Matthes S, Ceelen F, Zimmermann G, Kneidinger N, Schramm R, Winter H, Zoller M, Vogeser M, Behr J, Neurohr C. Comparing Azole Plasma Trough Levels in Lung Transplant Recipients: Percentage of Therapeutic Levels and Intrapatient Variability. Ther Drug Monit 2017; 39:93-101. [PMID: 28282366 PMCID: PMC5348107 DOI: 10.1097/ftd.0000000000000371] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study compared therapeutic azole plasma trough levels (APL) of the azole antimycotics itraconazole (ITR), voriconazole (VOR), and posaconazole (POS) in lung transplant recipients and analyzed the influencing factors. In addition, intrapatient variability for each azole was determined. METHODS From July 2012 to July 2015, 806 APL of ITR, VOR, posaconazole liquid (POS-Liq), and posaconazole tablets (POS-Tab) were measured in 173 patients of the Munich Lung Transplantation Program. Therapeutic APL were defined as follows: ITR, ≥700 ng/mL; VOR, 1000-5500 ng/mL; and POS, ≥700 ng/mL (prophylaxis) and ≥1000 ng/mL (therapy). RESULTS VOR and POS-Tab reached the highest number of therapeutic APL, whereas POS-Liq showed the lowest percentage (therapy: ITR 50%, VOR 70%, POS-Liq 38%, and POS-Tab 82%; prophylaxis: ITR 62%, VOR 85%, POS-Liq 49%, and POS-Tab 76%). Risk factors for subtherapeutic APL of all azoles were the azole dose (ITR, P < 0.001; VOR, P = 0.002; POS-Liq, P = 0.006) and age over 60 years (ITR, P = 0.003; VOR, P = 0.002; POS-Liq, P = 0.039; POS-Tab, P < 0.001). Cystic fibrosis was a significant risk factor for subtherapeutic APL for VOR and POS-Tab (VOR, P = 0.002; POS-Tab, P = 0.005). Double lung transplantation (LTx) was significantly associated with less therapeutic APL for VOR and POS-Liq (VOR, P = 0.030; POS-Liq, P < 0.001). Concomitant therapy with 80 mg pantoprazole led to significantly fewer therapeutic POS APL as compared to 40 mg (POS-Liq, P = 0.015; POS-Tab, P < 0.001). VOR displayed the greatest intrapatient variability (46%), whereas POS-Tab showed the lowest (32%). CONCLUSIONS Our study showed that VOR and POS-Tab achieve the highest percentage of therapeutic APL in patients with LTx; POS-Tab showed the lowest intrapatient variability. APL are significantly influenced by azole dose, age, cystic fibrosis, type of LTx, and comedication with proton-pump inhibitors. Considering the high number of subtherapeutic APL, therapeutic drug monitoring should be integrated in the post-LTx management.
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Affiliation(s)
- Daniela Stelzer
- Department of Internal Medicine V, LMU-Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research DZL, Munich, Germany
- Departments of Hospital Pharmacy,
| | | | - Franziska Ihle
- Department of Internal Medicine V, LMU-Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research DZL, Munich, Germany
| | - Sandhya Matthes
- Department of Internal Medicine V, LMU-Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research DZL, Munich, Germany
| | - Felix Ceelen
- Department of Internal Medicine V, LMU-Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research DZL, Munich, Germany
| | - Gregor Zimmermann
- Department of Internal Medicine V, LMU-Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research DZL, Munich, Germany
| | - Nikolaus Kneidinger
- Department of Internal Medicine V, LMU-Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research DZL, Munich, Germany
| | | | | | | | - Michael Vogeser
- Institute of Laboratory Medicine, LMU-Munich, Munich, Germany
| | - Juergen Behr
- Department of Internal Medicine V, LMU-Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research DZL, Munich, Germany
| | - Claus Neurohr
- Department of Internal Medicine V, LMU-Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research DZL, Munich, Germany
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44
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Dekkers BGJ, Bakker M, van der Elst KCM, Sturkenboom MGG, Veringa A, Span LFR, Alffenaar JWC. Therapeutic Drug Monitoring of Posaconazole: an Update. CURRENT FUNGAL INFECTION REPORTS 2016; 10:51-61. [PMID: 27358662 PMCID: PMC4896980 DOI: 10.1007/s12281-016-0255-4] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Posaconazole is a second-generation triazole agent with a potent and broad antifungal activity. In addition to the oral suspension, a delayed-release tablet and intravenous formulation with improved pharmacokinetic properties have been introduced recently. Due to the large interindividual and intraindividual variation in bioavailability and drug-drug interactions, therapeutic drug monitoring (TDM) is advised to ensure adequate exposure and improve clinical response for posaconazole. Here, we highlight and discuss the most recent findings on pharmacokinetics and pharmacodynamics of posaconazole in the setting of prophylaxis and treatment of fungal infections and refer to the challenges associated with TDM of posaconazole.
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Affiliation(s)
- Bart G. J. Dekkers
- />Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Martijn Bakker
- />Department of Hematology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Marieke G. G. Sturkenboom
- />Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Anette Veringa
- />Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Lambert F. R. Span
- />Department of Hematology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan-Willem C. Alffenaar
- />Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
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45
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Verwei M, Minekus M, Zeijdner E, Schilderink R, Havenaar R. Evaluation of two dynamic in vitro models simulating fasted and fed state conditions in the upper gastrointestinal tract (TIM-1 and tiny-TIM) for investigating the bioaccessibility of pharmaceutical compounds from oral dosage forms. Int J Pharm 2016; 498:178-86. [DOI: 10.1016/j.ijpharm.2015.11.048] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/25/2015] [Accepted: 11/26/2015] [Indexed: 12/31/2022]
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Abstract
Posaconazole, a broad-spectrum triazole antifungal agent, is approved for the prevention of invasive aspergillosis and candidiasis in addition to the treatment of oropharyngeal candidiasis. There is evidence of efficacy in the treatment and prevention of rarer, more difficult-to-treat fungal infections. Posaconazole oral suspension solution has shown limitations with respect to fasting state absorption, elevated gastrointestinal pH and increased motility. The newly approved delayed-release oral tablet and intravenous solution formulations provide an attractive treatment option by reducing interpatient variability and providing flexibility in critically ill patients. On the basis of clinical experience and further clinical studies, posaconazole was found to be a valuable pharmaceutical agent for the treatment of life-threatening fungal infections. This review will examine the development history of posaconazole and highlight the most recent advances.
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Affiliation(s)
- Jason N Moore
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, 132 South Tenth Street, Main Building, Room 1170, Philadelphia, PA 19107, USA
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47
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Mast N, Lin JB, Pikuleva IA. Marketed Drugs Can Inhibit Cytochrome P450 27A1, a Potential New Target for Breast Cancer Adjuvant Therapy. Mol Pharmacol 2015; 88:428-36. [PMID: 26082378 DOI: 10.1124/mol.115.099598] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Accepted: 06/16/2015] [Indexed: 02/06/2023] Open
Abstract
Cytochrome P450 CYP27A1 is the only enzyme in humans converting cholesterol to 27-hydroxycholesterol, an oxysterol of multiple functions, including tissue-specific modulation of estrogen and liver X receptors. Both receptors seem to mediate adverse effects of 27-hydroxycholesterol in breast cancer when the levels of this oxysterol are elevated. The present work assessed druggability of CYP27A1 as a potential antibreast cancer target. We selected 26 anticancer and noncancer medications, most approved by the Food and Drug Administration, and evaluated them first in vitro for inhibition of purified recombinant CYP27A1 and binding to the enzyme active site. Six strong CYP27A1 inhibitors/binders were identified. These were the two antibreast cancer pharmaceuticals anastrozole and fadrozole, antiprostate cancer drug bicalutamide, sedative dexmedetomidine, and two antifungals ravuconazole and posaconazole. Anastrozole was then tested in vivo on mice, which received subcutaneous drug injections for 1 week. Mouse plasma and hepatic 27-hydroxycholesterol levels were decreased 2.6- and 1.6-fold, respectively, whereas plasma and hepatic cholesterol content remained unchanged. Thus, pharmacologic CYP27A1 inhibition is possible in the whole body and individual organs, but does not negatively affect cholesterol elimination. Our results enhance the potential of CYP27A1 as an antibreast cancer target, could be of importance for the interpretation of Femara versus Anastrozole Clinical Evaluation Trial, and bring attention to posaconazole as a potential complementary anti-breast cancer medication. More medications on the US market may have unanticipated off-target inhibition of CYP27A1, and we propose strategies for their identification.
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Affiliation(s)
- Natalia Mast
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Joseph B Lin
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Irina A Pikuleva
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, Ohio
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48
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Cattaneo C, Panzali A, Passi A, Borlenghi E, Lamorgese C, Petullà M, Re A, Caimi L, Rossi G. Serum posaconazole levels during acute myeloid leukaemia induction therapy: correlations with breakthrough invasive fungal infections. Mycoses 2015; 58:362-7. [DOI: 10.1111/myc.12326] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 03/28/2015] [Accepted: 03/28/2015] [Indexed: 11/27/2022]
Affiliation(s)
| | | | | | | | | | | | | | - Luigi Caimi
- Laboratory of Hormonology and Toxicology; Spedali Civili; Brescia Italy
- Clinical Biochemistry; Department of Molecular and Translational Medicine; University of Brescia; Brescia Italy
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49
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McKeage K. Posaconazole: A Review of the Gastro-Resistant Tablet and Intravenous Solution in Invasive Fungal Infections. Drugs 2015; 75:397-406. [DOI: 10.1007/s40265-015-0348-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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50
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Pharmacokinetics and pharmacodynamics of antifungals in children and their clinical implications. Clin Pharmacokinet 2014; 53:429-54. [PMID: 24595533 DOI: 10.1007/s40262-014-0139-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Invasive fungal infections are a significant cause of morbidity and mortality in children. Successful management of these systemic infections requires identification of the causative pathogen, appropriate antifungal selection, and optimisation of its pharmacokinetic and pharmacodynamic properties to maximise its antifungal activity and minimise toxicity and the emergence of resistance. This review highlights salient scientific advancements in paediatric antifungal pharmacotherapies and focuses on pharmacokinetic and pharmacodynamic studies that underpin current clinical decision making. Four classes of drugs are widely used in the treatment of invasive fungal infections in children, including the polyenes, triazoles, pyrimidine analogues and echinocandins. Several lipidic formulations of the polyene amphotericin B have substantially reduced the toxicity associated with the traditional amphotericin B formulation. Monotherapy with the pyrimidine analogue flucytosine rapidly promotes the emergence of resistance and cannot be recommended. However, when used in combination with other antifungal agents, therapeutic drug monitoring of flucytosine has been shown to reduce high peak flucytosine concentrations, which are strongly associated with toxicity. The triazoles feature large inter-individual pharmacokinetic variability, although this pattern is less pronounced with fluconazole. In clinical trials, posaconazole was associated with fewer adverse effects than other members of the triazole family, though both posaconazole and itraconazole display erratic absorption that is influenced by gastric pH and the gastric emptying rate. Limited data suggest that the clinical response to therapy may be improved with higher plasma posaconazole and itraconazole concentrations. For voriconazole, pharmacokinetic studies among children have revealed that children require twice the recommended adult dose to achieve comparable blood concentrations. Voriconazole clearance is also affected by the cytochrome P450 (CYP) 2C19 genotype and hepatic impairment. Therapeutic drug monitoring is recommended as voriconazole pharmacokinetics are highly variable and small dose increases can result in marked changes in plasma concentrations. For the echinocandins, the primary source of pharmacokinetic variability stems from an age-dependent decrease in clearance with increasing age. Consequently, young children require larger doses per kilogram of body weight than older children and adults. Routine therapeutic drug monitoring for the echinocandins is not recommended. The effectiveness of many systemic antifungal agents has been correlated with pharmacodynamic targets in in vitro and in murine models of invasive candidiasis and aspergillosis. Further study is needed to translate these findings into optimal dosing regimens for children and to understand how these agents interact when multiple antifungal agents are used in combination.
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