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Gouju J, Legeay S. Pharmacokinetics of obese adults: Not only an increase in weight. Biomed Pharmacother 2023; 166:115281. [PMID: 37573660 DOI: 10.1016/j.biopha.2023.115281] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/04/2023] [Indexed: 08/15/2023] Open
Abstract
Obesity is a pathophysiological state defined by a body mass index > 30 kg/m2 and characterized by an adipose tissue accumulation leading to an important weight increased. Several pathologies named comorbidities such as cardiovascular disease, type 2 diabetes and cancer make obesity the fifth cause of death in the world. Physiological changes impact the four main phases of pharmacokinetics of some drugs and leads to an inappropriate drug-dose. For absorption, the gastrointestinal transit is accelerated, and the gastric empty time is shortened, that can reduce the solubilization and absorption of some oral drugs. The drug distribution is probably the most impacted by the obesity-related changes because the fat mass (FM) increases at the expense of the lean body weight (LBW), leading to an important increase of the volume of distribution for lipophilic drugs and a low or moderately increase of this parameter for hydrophilic drugs. This modification of the distribution may require drug-dose adjustments. By various mechanisms, the metabolism and elimination of drugs are impacted by obesity and should be considered as similar or lower than that non-obese patients. To better understand the necessary drug-dose adjustments in obese patients, a narrative review of the literature was conducted to highlight the main elements to consider in the therapeutic management of adult obese patients.
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Affiliation(s)
- Julien Gouju
- MINT, INSERM U1066, CNRS 6021, UNIV Angers, SFR-ICAT 4208, IBS-CHU Angers, 4 rue Larrey, Angers 49933 Cedex 9, France; CHU Angers, 4 rue Larrey, Angers 49933 Cedex 9, France.
| | - Samuel Legeay
- MINT, INSERM U1066, CNRS 6021, UNIV Angers, SFR-ICAT 4208, IBS-CHU Angers, 4 rue Larrey, Angers 49933 Cedex 9, France
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2
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Wynn J, Chan S, Yeung JM, Pellegrino SA. Gastrointestinal histoplasmosis presenting as a small bowel obstruction in an immunocompetent patient. BMJ Case Rep 2023; 16:e255349. [PMID: 37562860 PMCID: PMC10423768 DOI: 10.1136/bcr-2023-255349] [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] [Indexed: 08/12/2023] Open
Abstract
The clinical presentation of gastrointestinal histoplasmosis (GIH) is often non-specific, mimicking several other gastrointestinal diseases, making diagnosis difficult. We present a case of GIH, causing bowel obstruction in an immunocompetent patient. A woman in her 80s presented with anorexia and a distended abdomen. A CT scan of the abdomen and pelvis (CTAP) showed ileal thickening. Endoscopy was performed and ileal biopsies were taken. A diagnosis of histoplasmosis was made by histopathology, and she began treatment with liposomal amphotericin and itraconazole. Despite presenting well at her routine follow-up appointments, she presented 4 months after diagnosis with worsening symptoms of anorexia and abdominal distention. CTAP showed the ileal stricture causing bowel obstruction. She underwent itraconazole and steroid treatment while having nasogastric tube decompression. Subsequent gastrografin follow through showing partial obstruction and surgical resection was planned. Unfortunately, her condition deteriorated, her kidney function worsened and she suffered from aspiration pneumonia with eventual demise.
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Affiliation(s)
- Jessica Wynn
- Department of General Surgery, Western Health, Footscray, Victoria, Australia
| | - Stephen Chan
- Department of Pathology, Western Health, Footscray, Victoria, Australia
| | - Justin Mc Yeung
- Department of Colorectal Surgery, Western Health, Footscray, Victoria, Australia
- Department of Surgery, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia
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3
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Yang E, Yu K, Lee S. Prediction of gastric pH-mediated drug exposure using physiologically-based pharmacokinetic modeling: A case study of itraconazole. CPT Pharmacometrics Syst Pharmacol 2023; 12:865-877. [PMID: 36967484 PMCID: PMC10272297 DOI: 10.1002/psp4.12959] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/01/2023] [Accepted: 02/14/2023] [Indexed: 05/24/2024] Open
Abstract
Abnormal gastric acidity, including achlorhydria, can act as a significant source of variability in orally administered drugs especially with pH-sensitive solubility profiles, such as weak bases, potentially resulting in an undesirable therapeutic response. This study aimed to evaluate the utility of physiologically-based pharmacokinetic (PBPK) modeling in the prediction of gastric pH-mediated drug exposure by using itraconazole, a weak base, as a case. An itraconazole PBPK model was developed on the mechanistic basis of its absorption kinetics in a middle-out manner from a stepwise in vitro-in vivo extrapolation to in vivo refinement. Afterward, an independent prospective clinical study evaluating gastric pH and itraconazole pharmacokinetics (PKs) under normal gastric acidity and esomeprazole-induced gastric hypoacidity was conducted for model validation. Validation was performed by comparing the predicted data with the clinical observations, and the valid model was subsequently applied to predict PK changes under achlorhydria. The developed itraconazole PBPK model showed reasonable reproducibility for gastric pH-mediated exposure observed in the clinical investigation. Based on the model-based simulations, itraconazole exposure was expected to be decreased up to 65% under achlorhydria, and furthermore, gastric pH-mediated exposure could be mechanistically interpreted according to sequential variation in total solubility, dissolution, and absorption. This study suggested the utility of PBPK modeling in the prediction of gastric pH-mediated exposure, especially for drugs whose absorption is susceptible to gastric pH. Our findings will serve as a leading model for further mechanistic assessment of exposure depending on gastric pH for various drugs, ultimately contributing to personalized pharmacotherapy.
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Affiliation(s)
- Eunsol Yang
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of Medicine and Hospital101 Daehak‐ro, Jongno‐guSeoul03080Republic of Korea
- Kidney Research InstituteSeoul National University Medical Research Center103 Daehak‐ro, Jongno‐guSeoul03080Republic of Korea
| | - Kyung‐Sang Yu
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of Medicine and Hospital101 Daehak‐ro, Jongno‐guSeoul03080Republic of Korea
| | - SeungHwan Lee
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of Medicine and Hospital101 Daehak‐ro, Jongno‐guSeoul03080Republic of Korea
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Verma SB, Panda S, Nenoff P, Singal A, Rudramurthy SM, Uhrlass S, Das A, Bisherwal K, Shaw D, Vasani R. The unprecedented epidemic-like scenario of dermatophytosis in India: III. Antifungal resistance and treatment options. Indian J Dermatol Venereol Leprol 2021; 87:468-482. [PMID: 34219433 DOI: 10.25259/ijdvl_303_20] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 08/01/2020] [Indexed: 02/03/2023]
Abstract
One of the canonical features of the current outbreak of dermatophytosis in India is its unresponsiveness to treatment in majority of cases. Though there appears to be discordance between in vivo and in vitro resistance, demonstration of in vitro resistance of dermatophytes to antifungals by antifungal susceptibility testing is essential as it may help in appropriate management. The practical problem in the interpretation of antifungal susceptibility testing is the absence of clinical breakpoints and epidemiologic cutoff values. In their absence, evaluation of the upper limit of a minimal inhibitory concentration of wild type isolates may be beneficial for managing dermatophytosis and monitoring the emergence of isolates with reduced susceptibility. In the current scenario, most of the cases are unresponsive to standard dosages and duration of treatment recommended until now. This has resulted in many ex-cathedra modalities of treatment that are being pursued without any evidence. There is an urgent need to carry out methodical research to develop an evidence base to formulate a rational management approach in the current scenario.
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Affiliation(s)
| | - Saumya Panda
- Department of Dermatology, Belle Vue Clinic, Kolkata, West Bengal, India, India
| | - Pietro Nenoff
- Department of Dermatology and Laboratory Medicine, Laboratory for Medical Microbiology, Moelbis, Germany
| | - Archana Singal
- Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital, Delhi, India
| | - Shivprakash M Rudramurthy
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Silke Uhrlass
- Department of Dermatology and Laboratory Medicine, Laboratory for Medical Microbiology, Moelbis, Germany
| | - Anupam Das
- Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India
| | - Kavita Bisherwal
- Department of Dermatology, Venereology and Leprosy, Lady Hardinge Medical College and SSK Hospital, Delhi
| | - Dipika Shaw
- Department of Medical Microbiology, PGI, Chandigarh, India
| | - Resham Vasani
- Department of Dermatology, Bhojani Clinic, Mumbai, Maharashtra, India
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5
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Chivate A, Garkal A, Hariharan K, Mehta T. Exploring novel carrier for improving bioavailability of Itraconazole: Solid dispersion through hot-melt extrusion. J Drug Deliv Sci Technol 2021. [DOI: 10.1016/j.jddst.2021.102541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Sardana K, Mathachan SR. Super Bioavailable Itraconazole and Its Place and Relevance in Recalcitrant Dermatophytosis: Revisiting Skin Levels of Itraconazole and Minimum Inhibitory Concentration Data. Indian Dermatol Online J 2021; 12:1-5. [PMID: 33768016 PMCID: PMC7982045 DOI: 10.4103/idoj.idoj_618_20] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/04/2020] [Accepted: 10/05/2020] [Indexed: 11/29/2022] Open
Abstract
Itraconazole, is the most commonly prescribed oral antifungal agent in India, and has a low minimum inhibitory concentration as compared to other oral antifungals, and in conjunction with the markedly high skin levels, the drug should have a predictably good clinical response which is not the consistent experience of clinicians. Probably the variation in pelletization parameters might affect the bioavailability of the drug and consequently affect the serum levels. The maximum bioavailability of conventional itraconazole is 55 percent, which is neither consistent nor predictable. However, the novel itraconazole (Super bioavailable Itraconazole) with targeted drug release in the small intestine has predictable serum levels with minimum interindividual variability, which could make it a potentially useful drug in recalcitrant dermatophytosis.
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Affiliation(s)
- Kabir Sardana
- Department of Dermatology, Venereology and Leprosy, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. RML Hospital, New Delhi, India
| | - Sinu Rose Mathachan
- Department of Dermatology, Venereology and Leprosy, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. RML Hospital, New Delhi, India
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Murakami T, Bodor E, Bodor N. Factors and dosage formulations affecting the solubility and bioavailability of P-glycoprotein substrate drugs. Expert Opin Drug Metab Toxicol 2021; 17:555-580. [PMID: 33703995 DOI: 10.1080/17425255.2021.1902986] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Expression of P-glycoprotein (P-gp) increases toward the distal small intestine, implying that the duodenum is the preferential absorption site for P-gp substrate drugs. Oral bioavailability of poorly soluble P-gp substrate drugs is low and varied but increases with high-fat meals that supply lipoidal components and bile in the duodenum.Areas covered: Absorption properties of P-gp substrate drugs along with factors and oral dosage formulations affecting their solubility and bioavailability were reviewed with PubMed literature searches. An overview is provided from the viewpoint of the 'spring-and-parachute approach' that generates supersaturation of poorly soluble P-gp substrate drugs.Expert opinion: The oral bioavailability of P-gp substrate drugs is difficult to predict because of their low solubility, preferential absorption sites, and overlapping substrate specificities with CYP3A4, along with the scattered intestinal P-gp expression/function. To attain high and steady oral bioavailability of poorly soluble P-gp substrate drugs, physicochemical modification of drugs to improve solubility, or oral dosage formulations that generate long-lasting supersaturation in the duodenum, is preferred. In particular, supersaturable lipid-based drug delivery systems that can increase passive diffusion and/or lymphatic absorption are effective and applicable to many poorly soluble P-gp substrate drugs.
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Affiliation(s)
| | | | - Nicholas Bodor
- Bodor Laboratories, Miami, Florida, USA.,College of Pharmacy, University of Florida, Gainesville, Florida, USA
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Elkheir LYM, Haroun R, Mohamed MA, Fahal AH. Madurella mycetomatis causing eumycetoma medical treatment: The challenges and prospects. PLoS Negl Trop Dis 2020; 14:e0008307. [PMID: 32853199 PMCID: PMC7452721 DOI: 10.1371/journal.pntd.0008307] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Lamis Y. M. Elkheir
- The Mycetoma Research Centre, University of Khartoum, Khartoum, Sudan
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
| | - Rayan Haroun
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
| | - Magdi Awadalla Mohamed
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
- Department of Pharmaceutical Chemistry, College of Pharmacy, Jouf University, Jouf, KSA
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9
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Lindsay J, Mudge S, Thompson GR. Effects of Food and Omeprazole on a Novel Formulation of Super Bioavailability Itraconazole in Healthy Subjects. Antimicrob Agents Chemother 2018; 62:e01723-18. [PMID: 30297369 PMCID: PMC6256753 DOI: 10.1128/aac.01723-18] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/26/2018] [Indexed: 02/03/2023] Open
Abstract
To address the limited bioavailability and intolerance of the conventional itraconazole (ITZ) formulations, a new formulation labeled super bioavailability (SUBA) itraconazole has been developed; however, the specific effects of food and gastric pH are unknown. This study evaluated the pharmacokinetic profile of SUBA itraconazole under fasting and fed conditions, as well as with the concomitant administration of a proton pump inhibitor. First, the effect of food was assessed in an open-label, randomized, crossover bioavailability study of 65-mg SUBA itraconazole capsules (2 65-mg capsules twice a day) in healthy adults (n = 20) under fasting and fed conditions to steady-state levels. Second, an open-label, two-treatment, fixed-sequence comparative bioavailability study in healthy adults (n = 28) under fasted conditions compared the pharmacokinetics of a single oral dose of SUBA itraconazole capsules (2 65-mg capsules/day) with and without coadministration of daily omeprazole delayed-release capsules (1 40-mg capsule/day) under steady-state conditions. In the fed and fasted states, SUBA itraconazole demonstrated similar concentrations at the end of the dosing interval, with modestly lower total and peak ITZ exposure being shown when it was administered under fed conditions than when it was administered in the fasted state, with fed state/fasted state ratios of 78.09% (90% confidence interval [CI], 74.49 to 81.86%) for the area under the concentration-time curve over the dosing interval (14,183.2 versus 18,479.8 ng · h/ml), 73.05% (90% CI, 69.01 to 77.33%) for the maximum concentration at steady state (1,519.1 versus 2,085.2 ng/ml), and 91.53% (90% CI, 86.41 to 96.96%) for the trough concentration (1,071.5 versus 1,218.5 ng/ml) being found. When dosed concomitantly with omeprazole, there was a 22% increase in the total plasma exposure of ITZ, as measured by the area under the concentration-time curve from time zero to infinity (P = 0.0069), and a 31% increase in the peak plasma exposure of ITZ, as measured by the maximum concentration (P = 0.0083).
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Affiliation(s)
- Julian Lindsay
- Royal North Shore Hospital, Sydney, Australia
- Melbourne University, Melbourne, Australia
| | - Stuart Mudge
- Mayne Pharma International, Salisbury, South Australia, Australia
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10
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Mechanistic Assessment of the Effect of Omeprazole on the In Vivo Pharmacokinetics of Itraconazole in Healthy Volunteers. Eur J Drug Metab Pharmacokinet 2018; 44:201-215. [DOI: 10.1007/s13318-018-0519-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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11
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Litou C, Effinger A, Kostewicz ES, Box KJ, Fotaki N, Dressman JB. Effects of medicines used to treat gastrointestinal diseases on the pharmacokinetics of coadministered drugs: a PEARRL Review. J Pharm Pharmacol 2018; 71:643-673. [DOI: 10.1111/jphp.12983] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 06/27/2018] [Indexed: 12/16/2022]
Abstract
Abstract
Objectives
Drugs used to treat gastrointestinal diseases (GI drugs) are widely used either as prescription or over-the-counter (OTC) medications and belong to both the 10 most prescribed and 10 most sold OTC medications worldwide. The objective of this review article is to discuss the most frequent interactions between GI and other drugs, including identification of the mechanisms behind these interactions, where possible.
Key findings
Current clinical practice shows that in many cases, these drugs are administered concomitantly with other drug products. Due to their metabolic properties and mechanisms of action, the drugs used to treat gastrointestinal diseases can change the pharmacokinetics of some coadministered drugs. In certain cases, these interactions can lead to failure of treatment or to the occurrence of serious adverse events. The mechanism of interaction depends highly on drug properties and differs among therapeutic categories. Understanding these interactions is essential to providing recommendations for optimal drug therapy.
Summary
Interactions with GI drugs are numerous and can be highly significant clinically in some cases. While alterations in bioavailability due to changes in solubility, dissolution rate, GI transit and metabolic interactions can be (for the most part) easily identified, interactions that are mediated through other mechanisms, such as permeability or microbiota, are less well-understood. Future work should focus on characterising these aspects.
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Affiliation(s)
- Chara Litou
- Institute of Pharmaceutical Technology, Goethe University, Frankfurt am Main, Germany
| | - Angela Effinger
- Department of Pharmacy and Pharmacology, Faculty of Science, University of Bath, Bath, UK
| | - Edmund S Kostewicz
- Institute of Pharmaceutical Technology, Goethe University, Frankfurt am Main, Germany
| | - Karl J Box
- Pion Inc. (UK) Ltd., Forest Row, East Sussex, UK
| | - Nikoletta Fotaki
- Department of Pharmacy and Pharmacology, Faculty of Science, University of Bath, Bath, UK
| | - Jennifer B Dressman
- Institute of Pharmaceutical Technology, Goethe University, Frankfurt am Main, Germany
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Shih S, Dai C, Ansari A, Urso BA, Laughlin AI, Solomon JA. Advances in genetic understanding of gorlin syndrome and emerging treatment options. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1483233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Shawn Shih
- Department of Dermatology, University of Central Florida College of Medicine, Orlando, Florida
| | - Christina Dai
- Department of Dermatology, University of Central Florida College of Medicine, Orlando, Florida
| | - Ahmed Ansari
- Department of Dermatology, University of Central Florida College of Medicine, Orlando, Florida
| | - Brittany A Urso
- Department of Dermatology, University of Central Florida College of Medicine, Orlando, Florida
| | - Amy I Laughlin
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James A Solomon
- Department of Dermatology, University of Central Florida College of Medicine, Orlando, Florida
- University of Illinois College of Medicine, Urbana, Illinois
- Ameriderm Research, Ormond Beach, FL
- Department of Dermatology, Florida State University College of Medicine, Tallahassee, FL
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Choi DH, Kim YS, Kim DD, Jeong SH. QbD based development and evaluation of topical microemulsion-based hydrogel against superficial fungal infections. JOURNAL OF PHARMACEUTICAL INVESTIGATION 2018. [DOI: 10.1007/s40005-018-0386-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Lohitnavy M, Lohitnavy O, Yang RSH. A physiologically-based pharmacokinetic model of methotrexate incorporating hepatic excretion via multidrug-resistance-associated protein 2 (Mrp2) in mice, rats, dogs, and humans. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2017:2728-2731. [PMID: 29060462 DOI: 10.1109/embc.2017.8037421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
An updated physiologically-based pharmacokinetic (PBPK) model of methotrexate (MTX) was built based on an earlier model developed by Bischoff et al. (1971). MTX has been known to be a substrate of multidrug-resistance-associated protein 2 (Mrp2). A three-dimensional quantitative structure-activity relationship model (3D-QSAR) of Mrp2 was developed by Hirono et al. (2005). In our updated PBPK model of MTX, using the computational chemistry-derived binding affinity (Km), a Mrp2-mediated biliary excretion process was incorporated as the MTX excretory pathway. Our model simulation results are consistent with numerous datasets obtained from mice, rats, dogs, and humans, at a variety of dose levels. Comparisons were made between our updated PBPK model and the earlier one from Bischoff et al. using a PBPK Index approach. Our new PBPK model was further verified against additional pharmacokinetic datasets from rats under special experimental conditions (cannulated bile duct) and Eisai hyperbirilubinemic rats.
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Affiliation(s)
| | | | - Paul E Verweij
- Radboud University Medical Center, Nijmegen, the Netherlands
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Allegra S, Fatiguso G, De Francia S, Favata F, Pirro E, Carcieri C, De Nicolò A, Cusato J, Di Perri G, D'Avolio A. Pharmacokinetic evaluation of oral itraconazole for antifungal prophylaxis in children. Clin Exp Pharmacol Physiol 2017; 44:1083-1088. [PMID: 28744925 DOI: 10.1111/1440-1681.12822] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 07/18/2017] [Accepted: 07/18/2017] [Indexed: 01/02/2023]
Abstract
Itraconazole is a first-generation triazole agent with an extended spectrum of activity; it is licensed in adults for superficial and systemic fungal infections; no recommendation has been yet established for use in children patients. Its variable and unpredictable oral bioavailability make it difficult to determine the optimal dosing regimen. Hence, therapeutic drug monitoring, highly available in clinical practice, may improve itraconazole treatment success and safety. The aim of the study was to describe in paediatrics the oral itraconazole pharmacokinetics, used for prophylaxis. Moreover, we evaluated the utility of its therapeutic drug monitoring in this cohort. A fully validated chromatographic method was used to quantify itraconazole concentration in plasma collected from paediatric patients, at the end of dosing interval. Associations between variables were tested using the Pearson test. Mann-Whitney U test has been used to probe the influence of categorical variables on continuous ones. Any predictive power of the considered variables was finally evaluated through univariate and multivariate linear and logistic regression analyses. A high inter-individual variability was shown; ethnicity (beta coefficient, β -0.161 and interval of confidence at 95%, IC -395.035; -62.383) and gender (β 0.123 and IC 9.590; 349.395) remained in the final linear regression model with P value of .007 and .038, respectively. This study highlights that therapeutic drug monitoring is required to achieve an adequate target itraconazole serum exposure.
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Affiliation(s)
- Sarah Allegra
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, Unit of Infectious Diseases, University of Torino, ASL Città di Torino, Amedeo di Savoia Hospital, Turin, Italy
| | - Giovanna Fatiguso
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, Unit of Infectious Diseases, University of Torino, ASL Città di Torino, Amedeo di Savoia Hospital, Turin, Italy
| | - Silvia De Francia
- Department of Biological and Clinical Sciences, University of Turin, S. Luigi Gonzaga Hospital, Orbassano (TO), Italy
| | - Fabio Favata
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, Unit of Infectious Diseases, University of Torino, ASL Città di Torino, Amedeo di Savoia Hospital, Turin, Italy
| | - Elisa Pirro
- Department of Biological and Clinical Sciences, University of Turin, S. Luigi Gonzaga Hospital, Orbassano (TO), Italy
| | - Chiara Carcieri
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, Unit of Infectious Diseases, University of Torino, ASL Città di Torino, Amedeo di Savoia Hospital, Turin, Italy
| | - Amedeo De Nicolò
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, Unit of Infectious Diseases, University of Torino, ASL Città di Torino, Amedeo di Savoia Hospital, Turin, Italy
| | - Jessica Cusato
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, Unit of Infectious Diseases, University of Torino, ASL Città di Torino, Amedeo di Savoia Hospital, Turin, Italy
| | - Giovanni Di Perri
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, Unit of Infectious Diseases, University of Torino, ASL Città di Torino, Amedeo di Savoia Hospital, Turin, Italy
| | - Antonio D'Avolio
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, Unit of Infectious Diseases, University of Torino, ASL Città di Torino, Amedeo di Savoia Hospital, Turin, Italy
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Abuhelwa AY, Williams DB, Upton RN, Foster DJ. Food, gastrointestinal pH, and models of oral drug absorption. Eur J Pharm Biopharm 2017; 112:234-248. [DOI: 10.1016/j.ejpb.2016.11.034] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 11/27/2016] [Accepted: 11/29/2016] [Indexed: 12/14/2022]
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18
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Abuhelwa AY, Foster DJR, Upton RN. A Quantitative Review and Meta-Models of the Variability and Factors Affecting Oral Drug Absorption—Part I: Gastrointestinal pH. AAPS JOURNAL 2016; 18:1309-1321. [DOI: 10.1208/s12248-016-9952-8] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 06/30/2016] [Indexed: 12/29/2022]
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Goldman JL, Abdel-Rahman SM. Pharmacokinetic considerations in treating invasive pediatric fungal infections. Expert Opin Drug Metab Toxicol 2016; 12:645-55. [PMID: 27111148 DOI: 10.1080/17425255.2016.1181752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Despite the increased availability of systemic antifungal agents in recent years, the management of invasive fungal disease is still associated with significant morbidity and mortality. Knowledge of a drug's pharmacokinetic behavior is critical for optimizing existing treatment strategies. AREAS COVERED This review examines the pharmacokinetics of the major drug classes used to treat invasive mycoses including the echinocandins, imidazoles, triazoles, nucleoside analogs, and polyenes. It examines the mechanisms behind dose-exposure profiles that differ in children as compared with adults and explores the utility of pharmacogenetic testing and therapeutic drug monitoring. EXPERT OPINION Lifesaving medical advances for oncologic and autoimmune conditions have resulted in a significant increase in the frequency of opportunistic fungal infections. Owing to the high rate of treatment failures observed when managing invasive fungal infections, strategies to optimize antifungal therapy are critical when caring for these complex patients. Opportunities to maximize positive outcomes include dose refinement based on age or genetic status, formulation selection, co-administration of interacting medications, and administration with regard to food. The application of therapeutic drug monitoring for dose individualization is a valuable strategy to achieve pharmacodynamic targets.
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Affiliation(s)
- Jennifer L Goldman
- a Department of Pediatrics , UMKC School of Medicine , Kansas City , MO , USA.,b Drug Safety Service Children's Mercy Hospital , Kansas City , MO , USA.,c Antimicrobial Stewardship Program Children's Mercy Hospital , Kansas City , MO , USA.,d Divisions Pediatric Infectious Diseases & Clinical Pharmacology , Toxicology, and Therapeutic Innovation Children's Mercy Hospital , Kansas City , MO , USA
| | - Susan M Abdel-Rahman
- a Department of Pediatrics , UMKC School of Medicine , Kansas City , MO , USA.,d Divisions Pediatric Infectious Diseases & Clinical Pharmacology , Toxicology, and Therapeutic Innovation Children's Mercy Hospital , Kansas City , MO , USA
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Srinivas NR. Prediction of area under the curve for a p-glycoprotein, a CYP3A4 and a CYP2C9 substrate using a single time point strategy: assessment using fexofenadine, itraconazole and losartan and metabolites. Drug Dev Ind Pharm 2015; 42:945-57. [DOI: 10.3109/03639045.2015.1096278] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Population pharmacokinetic modeling of itraconazole and hydroxyitraconazole for oral SUBA-itraconazole and sporanox capsule formulations in healthy subjects in fed and fasted states. Antimicrob Agents Chemother 2015; 59:5681-96. [PMID: 26149987 DOI: 10.1128/aac.00973-15] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 06/28/2015] [Indexed: 01/21/2023] Open
Abstract
Itraconazole is an orally active antifungal agent that has complex and highly variable absorption kinetics that is highly affected by food. This study aimed to develop a population pharmacokinetic model for itraconazole and the active metabolite hydroxyitraconazole, in particular, quantifying the effects of food and formulation on oral absorption. Plasma pharmacokinetic data were collected from seven phase I crossover trials comparing the SUBA-itraconazole and Sporanox formulations of itraconazole. First, a model of single-dose itraconazole data was developed, which was then extended to the multidose data. Covariate effects on itraconazole were then examined before extending the model to describe hydroxyitraconazole. The final itraconazole model was a 2-compartment model with oral absorption described by 4-transit compartments. Multidose kinetics was described by total effective daily dose- and time-dependent changes in clearance and bioavailability. Hydroxyitraconazole was best described by a 1-compartment model with mixed first-order and Michaelis-Menten elimination for the single-dose data and a time-dependent clearance for the multidose data. The relative bioavailability of SUBA-itraconazole compared to that of Sporanox was 173% and was 21% less variable between subjects. Food resulted in a 27% reduction in bioavailability and 58% reduction in the transit absorption rate constant compared to that with the fasted state, irrespective of the formulation. This analysis presents the most extensive population pharmacokinetic model of itraconazole and hydroxyitraconazole in the literature performed in healthy subjects. The presented model can be used for simulating food effects on itraconazole exposure and for performing prestudy power analysis and sample size estimation, which are important aspects of clinical trial design of bioequivalence studies.
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Kumar N, Shishu. D-optimal experimental approach for designing topical microemulsion of itraconazole: Characterization and evaluation of antifungal efficacy against a standardized Tinea pedis infection model in Wistar rats. Eur J Pharm Sci 2015; 67:97-112. [DOI: 10.1016/j.ejps.2014.10.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 09/03/2014] [Accepted: 10/17/2014] [Indexed: 11/26/2022]
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Farzanegan B, Alehashem M, Bastani M, Baniasadi S. Potential drug-drug interactions in cardiothoracic intensive care unit of a pulmonary teaching hospital. J Clin Pharmacol 2014; 55:132-6. [DOI: 10.1002/jcph.421] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 11/02/2014] [Indexed: 11/12/2022]
Affiliation(s)
- Behrooz Farzanegan
- Tracheal Diseases Research Center; National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences; Tehran Iran
| | - Maryam Alehashem
- Tracheal Diseases Research Center; National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences; Tehran Iran
| | - Marjan Bastani
- Pharmaceutical Sciences Branch; Islamic Azad University; Tehran Iran
| | - Shadi Baniasadi
- Virology Research Center; National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences; Tehran Iran
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Glotzbecker B, Duncan C, Alyea E, Campbell B, Soiffer R. Important Drug Interactions in Hematopoietic Stem Cell Transplantation: What Every Physician Should Know. Biol Blood Marrow Transplant 2012; 18:989-1006. [DOI: 10.1016/j.bbmt.2011.11.029] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Accepted: 11/23/2011] [Indexed: 10/14/2022]
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Azole interactions with multidrug therapy in pediatric oncology. Eur J Clin Pharmacol 2012; 69:1-10. [PMID: 22660443 DOI: 10.1007/s00228-012-1310-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Accepted: 05/08/2012] [Indexed: 10/28/2022]
Abstract
Patients with cancer receive multidrug therapy. Antineoplastic agents and supportive care drugs are often administered together, leading to potential drug-drug interactions. These interactions may have significant clinical implications in terms of toxicity or a decrease in the efficacy of the treatment administered. Here, we focus on the role of azoles and their main pharmacokinetic interactions with the principal classes of drugs used in pediatric oncology. The co-administration of azoles and antineoplastic agents, corticosteroids, immunosuppressants, antacids, antiemetics, antiepileptic drugs and analgesics was investigated, and a practical guide on the management of these drugs when administered together is provided.
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Abstract
One may consider that drug-drug interactions (DDIs) associated with antacids is an obsolete topic because they are prescribed less frequently by medical professionals due to the advent of drugs that more effectively suppress gastric acidity (i.e. histamine H(2)-receptor antagonists [H2RAs] and proton pump inhibitors [PPIs]). Nevertheless, the use of antacids by ambulant patients may be ever increasing, because they are freely available as over-the-counter (OTC) drugs. Antacids consisting of weak basic substances coupled with polyvalent cations may alter the rate and/or the extent of absorption of concomitantly administered drugs via different mechanisms. Polyvalent cations in antacid formulations may form insoluble chelate complexes with drugs and substantially reduce their bioavailability. Clinical studies demonstrated that two classes of antibacterials (tetracyclines and fluoroquinolones) are susceptible to clinically relevant DDIs with antacids through this mechanism. Countermeasures against this type of DDI include spacing out the dosing interval - taking antacid either 4 hours before or 2 hours after administration of these antibacterials. Bisphosphonates may be susceptible to DDIs with antacids by the same mechanism, as described in the prescription information of most bisphosphonates, but no quantitative data about the DDIs are available. For drugs with solubility critically dependent on pH, neutralization of gastric fluid by antacids may alter the dissolution of these drugs and the rate and/or extent of their absorption. However, the magnitude of DDIs elicited by antacids through this mechanism is less than that produced by H2RAs or PPIs; therefore, the clinical relevance of such DDIs is often obscure. Magnesium ions contained in some antacid formulas may increase gastric emptying, thereby accelerating the rate of absorption of some drugs. However, the clinical relevance of this is unclear in most cases because the difference in plasma drug concentration observed after dosing shortly disappears. Recent reports have indicated that some of the molecular-targeting agents such as the tyrosine kinase inhibitors dasatinib and imatinib, and the thrombopoietin receptor agonist eltrombopag may be susceptible to DDIs with antacids. Finally, the recent trend of developing OTC drugs as combination formulations of an antacid and an H2RA is a concern because these drugs will increase the risk of DDIs by dual mechanisms, i.e. a gastric pH-dependent mechanism by H2RAs and a cation-mediated chelation mechanism by antacids.
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Affiliation(s)
- Ryuichi Ogawa
- Department of Pharmacotherapy, Meiji Pharmaceutical University, Kiyose, Tokyo, Japan.
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Miller MA, DiNunzio J, Matteucci ME, Ludher BS, Williams RO, Johnston KP. Flocculated amorphous itraconazole nanoparticles for enhancedin vitrosupersaturation andin vivobioavailability. Drug Dev Ind Pharm 2011; 38:557-70. [DOI: 10.3109/03639045.2011.616513] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Gubbins PO, Heldenbrand S. Clinically relevant drug interactions of current antifungal agents. Mycoses 2010; 53:95-113. [DOI: 10.1111/j.1439-0507.2009.01820.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cronin S, Chandrasekar PH. Safety of triazole antifungal drugs in patients with cancer. J Antimicrob Chemother 2009; 65:410-6. [PMID: 20035021 DOI: 10.1093/jac/dkp464] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Triazole drugs are widely used in cancer patients for prophylaxis and treatment of life-threatening invasive fungal infections. Fluconazole, available for over two decades, is safe and effective in patients with cancer; however, the excellent safety profile of fluconazole may not be applicable to the newer triazoles. Itraconazole, voriconazole and posaconazole are associated with adverse events, and drug interactions frequently occur, particularly in cancer patients, since the triazoles and many drugs used in cancer chemotherapy are metabolized via a common metabolic pathway, the hepatic cytochrome P450 system. Close monitoring for drug interactions is needed when triazoles are used with anti-neoplastic drugs and dosage modification of the triazole or its discontinuation may be required. Monitoring of triazole serum concentrations is becoming an important aspect of management to minimize toxicity and ensure efficacy.
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Affiliation(s)
- Simon Cronin
- Department of Pharmacy, Karmanos Cancer Institute, Detroit, MI, USA
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Mycoses in the elderly. Eur J Clin Microbiol Infect Dis 2009; 29:5-13. [DOI: 10.1007/s10096-009-0822-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Accepted: 09/24/2009] [Indexed: 12/19/2022]
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DiNunzio JC, Miller DA, Yang W, McGinity JW, Williams RO. Amorphous compositions using concentration enhancing polymers for improved bioavailability of itraconazole. Mol Pharm 2009; 5:968-80. [PMID: 19434851 DOI: 10.1021/mp800042d] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Amorphous engineered particle compositions of itraconazole (ITZ) and potential concentration enhancing polymers, cellulose acetate phthalate (CAP) and polyvinyl acetate phthalate (PVAP), were produced by ultra-rapid freezing to investigate the effect of these polymers on the bioavailability of ITZ solid dispersions. X-ray diffraction analyses of engineered particle compositions were shown to be amorphous. Modulated differential scanning calorimetry demonstrated that ITZ:CAP engineered particle compositions exhibited a strong correlation with the Gordon-Taylor relationship while ITZ:PVAP formulations exhibited positive deviations from predicted values attributed to hydrogen bonding interactions between the drug and polymer. Energy dispersive spectroscopy mapping demonstrated that the drug was homogenously distributed within all compositions, supporting the miscibility of the drug with the polymers. Scanning electron microscopy imaging of the particles demonstrated that the material existed in two general forms, discrete particles of approximately 5 microm and larger aggregates in excess of 30 microm, with engineered particle compositions having approximately 15 times higher measured specific surfaces areas compared to micronized ITZ. In vitro supersaturated dissolution results showed that all compositions provided significantly lower levels of supersaturation in acidic media and greater extents of supersaturation in neutral media compared to Sporanox pellets. ITZ: CAP formulations provided the greatest degree and extent of supersaturation in neutral media. Dissolution data were fitted to an exponential relationship based on a simplified model of particle growth, allowing for the determination of drug half-life in solution for evaluation of stabilization behavior. 1:2 ITZ:CAP showed superior in vitro performance compared to all other engineered particle compositions and was selected for in vivo testing. Although not fully elucidated, data indicated that the stabilization mechanism was due to interactions between the drug and polymer, primarily attributed to steric hindrance resulting from the molecular weight of the polymer chain and chemical composition of the polymer backbone relative to position of hydrogen bonding sites. In vivo testing conducted in Sprague-Dawley rats (n = 6) demonstrated a significant improvement in oral bioavailability from the 1:2 ITZ:CAP (AUC = 4,516 +/- 1,949 ng x h/mL) compared to the Sporanox pellets (AUC = 2,132 +/- 1,273 ng x h/mL) (p < or = 0.05). Additionally, the more rapid onset of action indicated superior targeting of the upper small intestines, and the prolonged half-life suggested the utility of CAP to maintain supersaturated concentrations, in vivo. These results demonstrated that amorphous compositions of ITZ and enteric concentration enhancing polymers provided improved bioavailability due to enhanced intestinal targeting and increased durations of supersaturation.
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Affiliation(s)
- James C DiNunzio
- Division of Pharmaceutics, The University of Texas at Austin, 1 University Station A1920, Austin, Texas 78712, USA.
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Ghazal HS, Dyas AM, Ford JL, Hutcheon GA. In vitro evaluation of the dissolution behaviour of itraconazole in bio-relevant media. Int J Pharm 2008; 366:117-23. [PMID: 18832020 DOI: 10.1016/j.ijpharm.2008.09.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Revised: 08/21/2008] [Accepted: 09/04/2008] [Indexed: 12/21/2022]
Abstract
Drugs in the gastrointestinal tract are exposed to a medium of partially digested food, comprising mixtures of fat, protein and carbohydrate. The dissolution behaviour of itraconazole was evaluated in bio-relevant media which were developed to take this into account. Media containing milk with different fat contents, protein (albumin, casein, gluten and gelatin), carbohydrates (glucose, lactose and starch) and amino acids (lysine, glycine, alanine and aspartic acid) to mimic a digested meal and bile components (sodium taurocholate and lecithin) to represent a key endogenous digestive material were investigated. The effect of medium composition on the intrinsic dissolution rate of itraconazole was evaluated as this drug has extremely poor solubility and its bioavailability is affected by food. Dissolution tests were carried out in simple compendial media based on dilute solutions of hydrochloric acid or neutral solutions of phosphate buffer and in more complex media containing the dietary components. The data obtained showed that most of the dietary components enhanced the solubility compared to simulated gastric fluid (SGF) but to differing extents. The greatest increase in dissolution was observed with the addition of milk and albumin although an increase was also seen with other proteins, amino acids and simulated gastrointestinal fluids.
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Affiliation(s)
- Heba S Ghazal
- School of Pharmacy and Chemistry, Liverpool John Moores University, Liverpool, UK
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Mould-active azoles: pharmacokinetics, drug interactions in neutropenic patients. Curr Opin Infect Dis 2007; 20:579-86. [DOI: 10.1097/qco.0b013e3282f1be91] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Azole antifungals have different pharmacokinetic characteristics: complete oral absorption for Voriconazole, and to a lesser extent for fluconazole. The absorption of posaconazole and itraconazole increases with food intake. All of them have high tissue distribution with low plasma concentrations, especially low in the case of posaconazole and itraconazole. Posaconazole and itraconazole have high plasmatic protein binding and consequently both have a very low free fraction. Elimination of azole antifungals is through a metabolic pathway with CYP450 isoenzymes, and has a non linear pharmacokinetics with a high risk of interation with other drugs since azoles have the ability of CYP450 isoenzymes inhibition. Possibly the parameter that defines more precisely their efficacy is AUIC with an optimum value near 20, although cut-off values must be defined since some azoles may have difficulty to reach this value.
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Affiliation(s)
- José Ramón Azanza
- Servicio de Farmacología Clínica, Clínica Universitaria de Navarra, Facultad de Medicina Universidad de Navarra, Pamplona, Navarra, Spain.
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Nassr N, Lahu G, Hünnemeyer A, von Richter O, Knoerzer D, Reutter F, Zech K, Hermann R. Magnesium hydroxide/aluminium hydroxide-containing antacid does not affect the pharmacokinetics of the targeted phosphodiesterase 4 inhibitor roflumilast. J Clin Pharmacol 2007; 47:660-6. [PMID: 17374735 DOI: 10.1177/0091270006297920] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nassr Nassr
- Department of Exploratory Medicine, ALTANA Pharma AG, Byk-Gulden-Str. 2, 78467 Konstanz, Germany
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Domínguez-Gil Hurlé A, Sánchez Navarro A, García Sánchez M. Therapeutic drug monitoring of itraconazole and the relevance of pharmacokinetic interactions. Clin Microbiol Infect 2006. [DOI: 10.1111/j.1469-0691.2006.01611.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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