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Fernández-Ruiz M. Pharmacological management of invasive mold infections in solid organ transplant recipients. Expert Opin Pharmacother 2024; 25:239-254. [PMID: 38436619 DOI: 10.1080/14656566.2024.2326507] [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: 11/09/2023] [Accepted: 02/29/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Solid organ transplant (SOT) recipients face an increased susceptibility to invasive fungal infection (IFI) due to filamentous fungi. Post-transplant invasive aspergillosis (IA) and mucormycosis are related to exceedingly high mortality rates and graft loss risk, and its management involve a unique range of clinical challenges. AREAS COVERED First, the current treatment recommendations for IA and mucormycosis among SOT recipients are critically reviewed, including the supporting evidence. Next, we discussed particular concerns in this patient population, such as drug-drug interactions (DDIs) between triazoles and post-transplant immunosuppression or treatment-related toxicity. The role for immunomodulatory and host-targeted therapies is also considered, as well as the theoretical impact of the intrinsic antifungal activity of calcineurin inhibitors. Finally, a personal opinion is made on future directions in the pharmacological approach to post-transplant IFI. EXPERT OPINION Despite relevant advances in the treatment of mold IFIs in the SOT setting, such as the incorporation of isavuconazole (with lower incidence of DDIs and better tolerability than voriconazole), there remains a large room for improvement in areas such as the position of combination therapy or the optimal strategy for the reduction of baseline immunosuppression. Importantly, future studies should define the specific contribution of newer antifungal agents and classes.
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Affiliation(s)
- Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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Liu T, Gao P, Xie C, Zhang H, Shi Z, Chen R. Study on the daily dose and serum concentration of clozapine in psychiatric patients and possible influencing factors of serum concentration. BMC Psychiatry 2023; 23:596. [PMID: 37582705 PMCID: PMC10428656 DOI: 10.1186/s12888-023-05078-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/02/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND Clozapine is the most effective drug for treatment-resistant schizophrenia, and the dosage and concentration of clozapine in the treatment of mental illness vary greatly in different populations and are affected by many factors. METHODS The serum clozapine concentration of 3734 psychiatric patients was detected, and data on daily dose, sex, age and other medical records were collected for statistical analysis. RESULTS The mean daily dose, mean serum concentration and mean C/D (concentration/dose) ratio of clozapine were 191.02 ± 113.47 mg/day, 326.15 ± 235.66 ng/mL and 1.94 ± 1.25 ng/mL per mg/day, respectively. There was difference in daily dose between sexes, and females had higher daily dose (p <0.01), higher serum clozapine concentrations (p < 0.01) and higher C/D ratios (p < 0.01). There were significant differences in daily dose (p < 0.001), serum drug concentration (p < 0.001) and C/D ratio (p < 0.001) among different age groups. The daily dose decreased with age (p for trend < 0.001), and the C/D ratio increased with age (p for trend < 0.001). Inpatients and outpatients had no difference in daily dose, but inpatients had higher serum concentration (p < 0.001) and C/D ratio (p < 0.001). There was no difference in daily dose among different occupations, but there were significant differences in serum concentration (p < 0.001) and C/D ratio (p < 0.001), and unemployed patients may have higher serum concentration and C/D ratio. Duration of disease, comorbidity, marital status, and psychotic type may influence the daily dose and serum concentration. CONCLUSIONS The effective daily dose and serum concentration of clozapine in the study area may be lower than recommended levels, and women have higher serum concentrations and slower metabolic rates. With increasing age, the daily dose decreases, and the metabolic rate slows. Inpatient status and occupation of patients may influence the serum concentration and metabolic rate of clozapine.
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Affiliation(s)
- Taixiu Liu
- Department of Clinical Laboratory, Shandong Daizhuang Hospital, Jining, 272051, China
| | - Peng Gao
- Department of Clinical Laboratory, Shandong Daizhuang Hospital, Jining, 272051, China.
| | - Chuange Xie
- Department of Clinical Laboratory, Shandong Daizhuang Hospital, Jining, 272051, China
| | - Heng Zhang
- Department of Clinical Laboratory, Shandong Daizhuang Hospital, Jining, 272051, China
| | - Zheng Shi
- Department of Clinical Laboratory, Shandong Daizhuang Hospital, Jining, 272051, China
| | - Ruirui Chen
- Department of Clinical Laboratory, Shandong Daizhuang Hospital, Jining, 272051, China
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The Effect of Voriconazole on Tacrolimus in Kidney Transplantation Recipients: A Real-World Study. Pharmaceutics 2022; 14:pharmaceutics14122739. [PMID: 36559231 PMCID: PMC9785881 DOI: 10.3390/pharmaceutics14122739] [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: 10/31/2022] [Revised: 11/25/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
Abstract
Tacrolimus is an immunosuppressant with a narrow therapeutic window. Tacrolimus exposure increased significantly during voriconazole co-therapy. The magnitude of this interaction is highly variable, but it is hard to predict quantitatively. We conducted a study on 91 kidney transplantation recipients with voriconazole co-therapy. Furthermore, 1701 tacrolimus concentration data were collected. Standard concentration adjusted by tacrolimus daily dose (C/D) and weight-adjusted standard concentration (CDW) increased to 6 times higher during voriconazole co-therapy. C/D and CDW increased with voriconazole concentration. Patients with the genotype of CYP3A5 *3/*3 and CYP2C19 *2/*2 or *2/*3 were more variable at the same voriconazole concentration level. The final prediction model could explain 54.27% of the variation in C/D and 51.11% of the variation in CDW. In conclusion, voriconazole was the main factor causing C/D and CDW variation, and the effect intensity should be quantitative by its concentration. Kidney transplant recipients with CYP3A5 genotype of *3/*3 and CYP2C19 genotype of *2/*2 and *2/*3 should be given more attention during voriconazole co-therapy. The prediction model established in this study may help to reduce the occurrence of rejection.
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Lu Y, Li WJ, Gao SY, Wang XX, Yang K, Hu W, Wu DF, Jiang QL, Cheng H. Voriconazole-induced severe skin allergy and neurological adverse event in a liver failure patient: A case report. J Clin Pharm Ther 2022; 47:1725-1728. [PMID: 36097367 DOI: 10.1111/jcpt.13774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/22/2022] [Accepted: 08/18/2022] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Triazole antifungal-associated severe skin allergy has received little attention. Here we report a case of an acute-on-chronic liver failure (ACLF) patient with diffused skin allergy pervading from the chest, abdomen, back, knees to perineum, with red colour and partially desquamation as well as a neurological adverse (insomnia) event after voriconazole treatment. CASE SUMMARY A 40-year-old man with liver failure in our hospital had received voriconazole for invasive fungal infection therapy, and while waiting for liver transplantation exhibited a severe diffuse rash and a neurological adverse event. WHAT IS NEW AND CONCLUSION To the best of our knowledge, this is the first report of a liver failure patient who suffered a severe allergy accompanied with a neurological adverse event after voriconazole administration.
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Affiliation(s)
- Yun Lu
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wen-Jing Li
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Su-Yu Gao
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xuan-Xuan Wang
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Kun Yang
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wen Hu
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Dong-Fang Wu
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Qiao-Li Jiang
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Hong Cheng
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
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Xie Y, Zhou X, Zhang J, Yu H, Song Z. Immunomodulatory responses of differentially polarized macrophages to fungal infections. Int Immunopharmacol 2022; 111:109089. [PMID: 35964406 DOI: 10.1016/j.intimp.2022.109089] [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: 04/18/2022] [Revised: 07/16/2022] [Accepted: 07/22/2022] [Indexed: 11/05/2022]
Abstract
Macrophages, the first line of defense against invasive fungi in the innate immune system, are widely distributed in the blood and tissues of the body. In response to various internal and external stimulators, macrophages can polarize into classically activated macrophages (M1) and alternatively activated macrophages (M2). These two types of polarized macrophages play different roles in antifungal activity and in maintaining the steady-state balance between inflammation and tissue repair. However, the antifungal mechanisms of M1- and M2-type macrophages have not been fully described. In this review, the immune regulatory mechanisms against pathogenic fungi of these two classical types of macrophages in various tissues are summarized. The effects of antifungal factors on macrophage differentiation are also highlighted. The description of these data, on the one hand provides valuable insight for future investigations and also highlights new strategies for the treatment of pathogenic fungal infections.
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Affiliation(s)
- Yuxin Xie
- School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, PR China.
| | - Xue Zhou
- School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, PR China.
| | - Jinping Zhang
- School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, PR China; The Public Platform of Molecular Biotechnology, Public Center of Experimental Technology, Southwest Medical University, Luzhou 646000, People's Republic of China.
| | - Hong Yu
- School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, PR China; The Public Platform of Cell Biotechnology, Public Center of Experimental Technology, Southwest Medical University, Luzhou 646000, PR China.
| | - Zhangyong Song
- School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, PR China; The Public Platform of Molecular Biotechnology, Public Center of Experimental Technology, Southwest Medical University, Luzhou 646000, People's Republic of China.
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Zhang SF, Tang BH, An-Hua W, Du Y, Guan ZW, Li Y. Effect of drug combination on tacrolimus target dose in renal transplant patients with different CYP3A5 genotypes. Xenobiotica 2022; 52:312-321. [PMID: 35395919 DOI: 10.1080/00498254.2022.2064252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Various factors, including genetic polymorphisms, drug-drug interactions, and patient characteristics influence the blood concentrations of tacrolimus in renal transplant patients. In the present study, we established a population pharmacokinetic model to explore the effect of combined use of Wuzhi capsules/echinocandins and the patients' biochemical parameters such as hematocrit on blood concentrations and target doses of tacrolimus in renal transplant patients with different CYP3A5 genotypes. The aim of the study was to propose an individualized tacrolimus administration regimen for early renal transplant recipients.In this retrospective cohort study, we included 240 renal transplant recipients within 21 days of surgery (174 males and 66 females, mean age 39.4 years), who received tacrolimus alone (n = 54), in combination with Wuzhi capsules (99) or caspofungin (57) or micafungin (30). We collected demographic characteristics, clinical indicators, CYP3A5 genotypes, and 1950 steady-state trough concentrations of tacrolimus and included them in population pharmacokinetic model. An additional 110 renal transplant recipients and 625 steady-state trough concentrations of tacrolimus were included for external validation of the model. The population pharmacokinetic model was established and Monte Carlo was used to simulate probabilities for achieving the target concentration for individual tacrolimus administration.A two-compartment model of first-order absorption and elimination was developed to describe the population pharmacokinetics of tacrolimus. CYP3A5 genotypes and co-administration of Wuzhi capsules, as well as time after renal transplantation and hematocrit, were important factors affecting the clearance of tacrolimus. We found no obvious change in trend in the scatter plot of tacrolimus clearance rate vs. hematocrit. The Monte Carlo simulation indicated the following recommended doses of tacrolimus alone: 0.14 mg·kg-1·d-1 for genotype CYP3A5*1*1, 0.12 mg·kg-1·d-1 for CYP3A5*1*3, and 0.10 mg·kg-1·d-1 for CYP3A5*3*3. For patients receiving the combination with Wuzhi capsules, the recommended doses of tacrolimus were 0.10 mg·kg-1·d-1 for CYP3A5*1*1, 0.08 mg·kg-1·d-1 for CYP3A5*1*3, and 0.06 mg·kg-1·d-1 for CYP3A5*3*3 genotypes. Caspofungin or micafungin had no effect on the clearance of tacrolimus in renal transplant recipients.The population pharmacokinetics of tacrolimus in renal transplant patients was evaluated and the individual administration regimen of tacrolimus was simulated. For early kidney transplant recipients receiving tacrolimus treatment, not only body weight, but also CYP3A5 genotypes and drugs used in combination should be considered when determining the target dose of tacrolimus.
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Affiliation(s)
- Shu-Fang Zhang
- School of Pharmacy, Shandong First Medical University, Tai'an, China.,Department of Pharmacy, Tai'an City Central Hospital, Tai'an, China
| | - Bo-Hao Tang
- School of Pharmaceutical Science, Shandong University, Ji'nan, China
| | - Wei An-Hua
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue Du
- School of Pharmacy, Shandong First Medical University, Tai'an, China
| | - Zi-Wan Guan
- School of Pharmaceutical Science, Shandong University, Ji'nan, China
| | - Yan Li
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University, Ji'nan, China
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Chen J, Cai S, Li R, Xie J, Yang F, Liu T. Blockade of Cycloxygenase-2 ameliorates sepsis induced immune-suppression by regulating myeloid-derived suppressor cells. Int Immunopharmacol 2022; 104:108506. [PMID: 35008007 DOI: 10.1016/j.intimp.2021.108506] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/27/2021] [Accepted: 12/27/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Myeloid-derived suppressor cells (MDSCs) and cyclooxy-genase-2 (COX-2)/Prostaglandin E2 (PGE2) axis are important contributors to sepsis-induced immune-suppression. The purpose of present study is to explore whether COX-2 inhibitor can improve immunological disorder after sepsis via regulating MDSCs. METHODS A ''two-hit'' model reflecting clinical sepsis development was performed. Cecal ligation and puncture (CLP) and Legionella pneumophila infection were used as the first and the second hit, respectively. NS398, a selective COX-2 inhibitor, was utilized to treat septic mice. The motality, bacterial counts in the lung, systematic inflammatory reaction and CD4 + T cells response after sepsis were assessed, so as the frequency and function of MDSCs. In some experiments, the number of MDSCs was manipulated by adoptive transfer or neutralizing antibody before induction of secondary infection. RESULTS Mice surviving CLP showed a marked expansion and activation of MDSCs in spleen, accompanied by suppressed proliferating capability, impaired secreting functionand increased apoptosis of CD4 + T cells. Majority of CLP survivors became succumbed to L. pneumophila invasion, associated with defective bacteria elimination ability. NS398 treatment was found to ameliorate these adverse outcomes significantly. CONCLUSION MDSCs contribute greatly to the sepsis-induced immune dysfunction. Inhibiting COX-2 may become a promising therapy that targets MDSCs-induced immunosuppression.
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Affiliation(s)
- Jiajun Chen
- Department of Trauma Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, Hubei, PR China
| | - Shiqi Cai
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, Hubei, PR China
| | - Renjie Li
- Department of Emergency Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, Hubei, PR China
| | - Jie Xie
- Department of Trauma Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, Hubei, PR China
| | - Fan Yang
- Department of Trauma Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, Hubei, PR China
| | - Tao Liu
- Department of Trauma Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, Hubei, PR China.
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Cheng F, Li Q, Wang J, Zeng F, Zhang Y. Effects and safety evaluation of Wuzhi Capsules combined with tacrolimus for the treatment of kidney transplantation recipients. J Clin Pharm Ther 2021; 46:1636-1649. [PMID: 34342024 DOI: 10.1111/jcpt.13493] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 01/06/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Tacrolimus (FK506), an effective and potent calcineurin inhibitor, is the cornerstone of immunosuppression after kidney transplantation. Wuzhi capsule (WZC), a prescribed ethanol extract of Nan-Wuweizi (Schisandra sphenanthera), is widely prescribed for kidney transplant recipients for the maintenance of tacrolimus concentration in clinical settings. Previous studies have demonstrated that WZC can increase the blood concentration of tacrolimus. However, it remains controversial whether to use WZC can be used to increase tacrolimus concentration in clinical practice. Our study aimed to evaluate the efficacy and safety of WZC combined with tacrolimus in the treatment of kidney transplant recipients. METHODS One hundred and ninety four Chinese kidney transplant recipients were included in this retrospective study. The recipients were divided into two groups (non-WZC group and WZC group). We investigated the effects of WZC on tacrolimus in terms of tacrolimus metabolism, laboratory tests, pharmacogenomics, renal function and adverse reactions. RESULTS AND DISCUSSION The concentration/dose (C0 /D) of tacrolimus was significantly higher in the WZC group than the non-WZC group. The laboratory findings of blood routine tests, liver and kidney function were not significantly different between the two groups. The CYP3A5 genotype showed clearly associated with tacrolimus C0 /D, whereas no significant difference was observed in patients with CYP3A4*1B, CYP3A4*22, ABCB1, ABCC2, POR*28 or PXR alleles. The improvement of C0 /D by administration of WZC was significant in CYP3A5 expressers compared to non-expressers. Furthermore, the WZC group had a remarkably higher proportion of subjects who reached the target tacrolimus concentration than the non-WZC group. No significant differences in renal function and adverse reactions were observed between the groups. WHAT IS NEW AND CONCLUSION Wuzhi capsule can increase tacrolimus concentration without negative effects on renal function and adverse reactions, especially in CYP3A5 expressers. Efficient and economical synergistic effects can be achieved by the combined administration of WZC in kidney transplant recipients.
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Affiliation(s)
- Fang Cheng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Qiang Li
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Jinglin Wang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Fang Zeng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Yu Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
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Hannachi I, Ben Fredj N, Chadli Z, Ben Fadhel N, Ben Romdhane H, Touitou Y, Boughattas NA, Chaabane A, Aouam K. Effect of CYP3A4*22 and CYP3A4*1B but not CYP3A5*3 polymorphisms on tacrolimus pharmacokinetic model in Tunisian kidney transplant. Toxicol Appl Pharmacol 2020; 396:115000. [DOI: 10.1016/j.taap.2020.115000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 03/18/2020] [Accepted: 04/05/2020] [Indexed: 12/16/2022]
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10
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Cheng L, Xiang R, Liu F, Li Y, Chen H, Yao P, Sun F, Xia P. Therapeutic drug monitoring and safety of voriconazole in elderly patients. Int Immunopharmacol 2020; 78:106078. [DOI: 10.1016/j.intimp.2019.106078] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/22/2019] [Accepted: 11/22/2019] [Indexed: 02/08/2023]
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Li M, Zhu L, Chen L, Li N, Qi F. Assessment of drug–drug interactions between voriconazole and glucocorticoids. J Chemother 2019; 30:296-303. [PMID: 30843777 DOI: 10.1080/1120009x.2018.1506693] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- MengXue Li
- Pharmaceutical College, Tianjin Medical University, Tianjin, China
| | - LiQin Zhu
- Pharmaceutical College, Tianjin Medical University, Tianjin, China
- Department of Pharmacy, Tianjin First Central Hospital, Tianjin, China
| | - Lu Chen
- Pharmaceutical College, Tianjin Medical University, Tianjin, China
| | - Na Li
- Pharmaceutical College, Tianjin Medical University, Tianjin, China
| | - Fang Qi
- Pharmaceutical College, Tianjin Medical University, Tianjin, China
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Peluso G, Incollingo P, Carlomagno N, D'Alessandro V, Tammaro V, Caggiano M, Sandoval Sotelo ML, Rupealta N, Candida M, Mazzoni G, Campanile S, Chiacchio G, Scotti A, Santangelo ML. Our Timing to Remove Peritoneal Catheter Dialysis After Kidney Transplant. Transplant Proc 2018; 51:160-163. [PMID: 30655154 DOI: 10.1016/j.transproceed.2018.04.075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 04/13/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients on peritoneal dialysis treatment represent 15% of the global dialysis population. The major complication of peritoneal dialysis is catheter and peritoneal infection. Peritoneal dialysis patients who receive kidney transplants are at increased risk of infection because of immunosuppressive therapy. AIM The purpose of this study is to show our ideal timing to remove peritoneal catheter after kidney transplant, which gives adequate security on renal function recovery and reduction of septic risk. METHOD OF STUDY We analyzed the outcomes of 65 patients on peritoneal dialysis who underwent kidney transplant between 2000 and 2016. RESULTS In 61 cases there was an immediate graft functional recovery. In 4 cases there was a delayed graft function (DGF), and we performed a hemodialysis with temporary placement of a venous catheter. In all patients we removed peritoneal dialysis catheter 30 to 45 days after transplant. There has been 1 case of catheter infection, which was treated with antibiotic therapy. DISCUSSION Our average time to remove the peritoneal dialysis catheter was shorter than times in previous studies, between the 30th and 45th postoperative day. In the 4 cases in which there has been a DGF, we performed hemodialysis treatment to avoid, in the immediate postoperative period, direct insults to the peritoneum by local dialysis procedures. CONCLUSION Our experience show that the 30th to 45th postoperative day is a good time frame, better yet a good watershed between the safe removal of peritoneal catheter when patients have a stabilized renal function and the possibility of leaving it in situ, to resume peritoneal dialysis in case of persistent DGF.
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Affiliation(s)
- G Peluso
- Operative Unit of General Surgery and Kidney Transplantation, Advanced Biomedical Science Department, University Federico II of Naples, Naples, Italy.
| | - P Incollingo
- Operative Unit of General Surgery and Kidney Transplantation, Advanced Biomedical Science Department, University Federico II of Naples, Naples, Italy
| | - N Carlomagno
- Operative Unit of General Surgery and Kidney Transplantation, Advanced Biomedical Science Department, University Federico II of Naples, Naples, Italy
| | - V D'Alessandro
- Kidney Transplantation Center and Retroperitoneal Surgery, University Hospital Federico II of Naples, Naples, Italy
| | - V Tammaro
- Operative Unit of General Surgery and Kidney Transplantation, Advanced Biomedical Science Department, University Federico II of Naples, Naples, Italy
| | - M Caggiano
- Operative Unit of General Surgery and Kidney Transplantation, Advanced Biomedical Science Department, University Federico II of Naples, Naples, Italy
| | - M L Sandoval Sotelo
- Operative Unit of General Surgery and Kidney Transplantation, Advanced Biomedical Science Department, University Federico II of Naples, Naples, Italy
| | - N Rupealta
- Operative Unit of General Surgery and Kidney Transplantation, Advanced Biomedical Science Department, University Federico II of Naples, Naples, Italy
| | - M Candida
- Operative Unit of General Surgery and Kidney Transplantation, Advanced Biomedical Science Department, University Federico II of Naples, Naples, Italy
| | - G Mazzoni
- Operative Unit of General Surgery and Kidney Transplantation, Advanced Biomedical Science Department, University Federico II of Naples, Naples, Italy
| | - S Campanile
- Operative Unit of General Surgery and Kidney Transplantation, Advanced Biomedical Science Department, University Federico II of Naples, Naples, Italy
| | - G Chiacchio
- Operative Unit of General Surgery and Kidney Transplantation, Advanced Biomedical Science Department, University Federico II of Naples, Naples, Italy
| | - A Scotti
- Operative Unit of General Surgery and Kidney Transplantation, Advanced Biomedical Science Department, University Federico II of Naples, Naples, Italy
| | - M L Santangelo
- Operative Unit of General Surgery and Kidney Transplantation, Advanced Biomedical Science Department, University Federico II of Naples, Naples, Italy
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Impact of CYP2C19 Genotype and Liver Function on Voriconazole Pharmacokinetics in Renal Transplant Recipients. Ther Drug Monit 2018; 39:422-428. [PMID: 28604474 PMCID: PMC5538305 DOI: 10.1097/ftd.0000000000000425] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Invasive fungal infection (IFI) is one of the leading causes of early death after renal transplantation. Voriconazole (VRC) is the first-line drug of IFI. Because of the large inter- and intraindividual variability in VRC plasma concentrations and the narrow therapeutic window for treating patients with IFIs, it is crucial to study the factors which could influence pharmacokinetic variability. We performed a population pharmacokinetics (PPK) study of VRC for personalized medicine. METHODS A total of 125 trough concentrations (Cmin) from 56 patients were evaluated, retrospectively. Nonlinear mixed effect model was used to describe a PPK model that was internally validated by bootstrap method. Potential covariates included demographic characteristics, physiological and pathological data, concomitant medications, and CYP2C19 genotype. RESULTS A 1-compartment model with first-order absorption and elimination was fit to characterize the VRC pharmacokinetics in renal transplant recipients (RTRs). Aspartate aminotransferase (AST) had a significant influence on clearance (CL) while CYP2C19 genotype had a major impact on the volume of distribution (V). The parameters of CL and V were 4.76 L/h and 22.47 L, respectively. The final model was V (L) = 22.47 × [1 + 2.21 × (EM = 1)] × [1 + 4.67 × (IM = 1)] × [1 + 3.30 × (PM = 1)] × exp (0.96); CL (L/h) = 4.76 × (AST/33)^(-0.23) × exp (0.14). VRC Cmin in intermediate metabolizers was significantly higher than in extensive metabolizers. CONCLUSIONS Liver function and CYP2C19 polymorphism are major determinants of VRC pharmacokinetic variability in RTRs. Genotypes and clinical biomarkers can determine the initial scheme. Subsequently, therapeutic drug monitoring can optimize clinical efficacy and minimize toxicity. Hence, this is a feasible way to facilitate personalized medicine in RTRs. In addition, it is the first report about PPK of VRC in RTRs.
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Alves IA, Staudt KJ, Silva CDM, Lock GDA, Dalla Costa T, de Araujo BV. Influence of Experimental Cryptococcal Meningitis in Wistar Rats on Voriconazole Brain Penetration Assessed by Microdialysis. Antimicrob Agents Chemother 2017; 61:e00321-17. [PMID: 28483963 PMCID: PMC5487622 DOI: 10.1128/aac.00321-17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 04/28/2017] [Indexed: 12/24/2022] Open
Abstract
To make advances in the treatment of cryptococcal meningitis, it is crucial to know a given drug's free fraction that reaches the biophase. In the present study, we applied microdialysis (μD) as a tool to determine the free levels reached by voriconazole (VRC) in the brains of healthy and Cryptococcus neoformans-infected rats. The infection was induced by the intravenous (i.v.) administration of 1 × 105 CFU of yeast. The dose administered was 5 mg/kg (of body weight) of VRC, given i.v. Plasma and microdialysate samples were analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS) and LC-UV methods. The free brain/free plasma ratio (fT) and population pharmacokinetic (popPK) analyses were performed to evaluate the impact of infection on PK parameters of the drug. The brain penetration ratio showed an increase on brain exposure in infected animals (fThealthy = 0.85 versus fTinfected = 1.86). The structural PK model with two compartments and Michaelis-Menten (MM) elimination describes the VRC concentration-time profile in plasma and tissue simultaneously. The covariate infection was included in volume of distribution in the peripheral compartment in healthy animals (V2) and maximum rate of metabolism (VM ). The levels reached in infected tissues were higher than the values described for MIC of VRC for Cryptococccus neoformans (0.03 to 0.5 μg ml-1), indicating its great potential to treat meningitis associated with C. neoformans.
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Affiliation(s)
- Izabel Almeida Alves
- Pharmaceutical Sciences Graduate Program of Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Keli Jaqueline Staudt
- Medical Sciences Graduate Program of Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Carolina de Miranda Silva
- Pharmaceutical Sciences Graduate Program of Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Graziela de Araujo Lock
- Pharmaceutical Sciences Graduate Program of Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Teresa Dalla Costa
- Pharmaceutical Sciences Graduate Program of Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Bibiana Verlindo de Araujo
- Pharmaceutical Sciences Graduate Program of Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Medical Sciences Graduate Program of Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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Wang Y, Cui J, Dai Y, Wu Y, Huang W, Qian H, Ge L. Reversal of P-glycoprotein-mediated multidrug resistance and pharmacokinetics study in rats by WYX-5. Can J Physiol Pharmacol 2016; 95:580-585. [PMID: 28177682 DOI: 10.1139/cjpp-2016-0518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Multidrug resistance (MDR) is one of the major obstacles confronted in cancer chemotherapy; this obstacle is mainly due to the overexpression of P-glycoprotein (P-gp). Co-administration of anticancer drugs and P-gp inhibitors is a promising approach to overcome MDR. WYX-5, a novel P-gp inhibitor, shows a notable reversal effect with low cytotoxicity in vitro. In this paper, the reversal mechanism and safety of the MDR modulator WYX-5 were explored in vitro, and evaluated for its pharmacokinetics and effects on adriamycin (ADM) metabolism in vivo. The results suggest that WYX-5 is a potent P-gp inhibitor with EC50 in nanomole range (EC50 = 204.3 ± 20.2 nmol·L-1), relative safety (therapeutic index = 446.4), which performs as a substrate of P-gp and retrains its function. Further, WYX-5 (5 mg·kg-1) had relatively ideal pharmacokinetic properties (T1/2 = 6.448 h, F = 96.05%) without interactions with ADM metabolism in vivo. In conclusion, WYX-5 may be a promising candidate for MDR cancer combined-chemotherapy research.
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Affiliation(s)
- Yuzhu Wang
- a Center for Drug Evaluation, CFDA, Beijing, PR China.,b Center of Drug Discovery, State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, PR China
| | - Jian Cui
- b Center of Drug Discovery, State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, PR China
| | - Yuxuan Dai
- b Center of Drug Discovery, State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, PR China
| | - Yuxiang Wu
- b Center of Drug Discovery, State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, PR China
| | - Wenlong Huang
- b Center of Drug Discovery, State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, PR China.,c Jiangsu Key Laboratory of Drug Discovery for Metabolic Disease, China Pharmaceutical University, Nanjing, PR China
| | - Hai Qian
- b Center of Drug Discovery, State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, PR China.,c Jiangsu Key Laboratory of Drug Discovery for Metabolic Disease, China Pharmaceutical University, Nanjing, PR China
| | - Liang Ge
- d School of Pharmacy, China Pharmaceutical University, Nanjing, PR China
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Ishiwata Y, Nagata M, Arai T, Makiishi M, Yoshikawa M, Takahashi H, Kohsaka H, Yasuhara M. Effects of Miconazole Oral Gel on Blood Concentrations of Tacrolimus and Cyclosporine: A Retrospective Observational Study. Ther Drug Monit 2016; 38:717-721. [PMID: 27559841 DOI: 10.1097/ftd.0000000000000335] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although azole antifungal agents have been shown to affect the pharmacokinetics of calcineurin inhibitors such as tacrolimus (TAC) and cyclosporine (CyA) by inhibiting drug metabolism, there are few clinical reports on drug interactions between miconazole (MCZ) oral gel and calcineurin inhibitors. In this study, the effects of MCZ oral gel on the blood concentrations of TAC and CyA were investigated. METHODS In this retrospective study, 18 patients concomitantly administered MCZ oral gel and TAC (9 for dermatomyositis, 3 for myasthenia gravis, 2 for systemic lupus erythematosus, 2 for rheumatoid arthritis, 1 for polymyositis, 1 for prevention of graft-versus-host disease after bone marrow transplantation), and 15 patients concomitantly administered MCZ oral gel and CyA (11 for interstitial pneumonia, 2 for pemphigus, 1 for eosinophilic granulomatosis with polyangiitis, 1 for systemic lupus erythematosus) were evaluated. The dose-adjusted blood concentrations of TAC or CyA were compared before and after the initiation of MCZ oral gel. RESULTS The trough blood concentration/dose (C/D) ratios of TAC and CyA increased significantly with the administration of MCZ oral gel. The median C/D ratios of TAC and CyA increased by 108% (range: -44% to 216%) and 44% (range: -34% to 195%), respectively. CONCLUSIONS These results suggest that MCZ oral gel affects the pharmacokinetics of TAC and CyA. Detailed monitoring of the blood concentrations of these drugs, followed by dose adjustments, is needed for each patient because of the difficulties associated with accurately predicting the degree of the effects of MCZ oral gel.
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Affiliation(s)
- Yasuyoshi Ishiwata
- *Department of Pharmacy, Medical Hospital, Tokyo Medical and Dental University (TMDU); Departments of †Rheumatology and ‡Pharmacokinetics and Pharmacodynamics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
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EXP CLIN TRANSPLANTExp Clin Transplant 2016; 14. [DOI: 10.6002/ect.2015.0273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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18
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Management of Everolimus and Voriconazole Interaction in Lung Transplant Patients. Ther Drug Monit 2016; 38:305-12. [DOI: 10.1097/ftd.0000000000000294] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Righi E, Ivaldi F, Carnelutti A, Tomkova L, Villa G, Sartor A, Soardo G, Baccarani U, Pea F, Bassetti M. Immunologic and Pharmacologic Aspects in an Elderly Recipient of Liver Transplant With Pulmonary Aspergillosis and Multiple Comorbidities. EXP CLIN TRANSPLANT 2016; 14:567-570. [PMID: 26742489 DOI: 10.6002/ect.2014.0127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The net state of immunosuppression, the occurrence of infections, drug-drug interactions, and toxicity can compromise the outcome of liver transplant recipients with multiple comorbidities. We present a 67-year-old man who developed early posttransplant severe chronic obstructive pulmonary disease exacerbation, pulmonary aspergillosis, and cytomegalovirus reactivation. Drug-drug interactions between azoles and cyclosporine, along with renal and liver toxicity, required adjustments in dosage. Interferon-gamma production from antigen-stimulated T cells was recorded. Early diagnosis and treatment, along with therapeutic drug monitoring and recovery of T-cell immunity, were key factors for a positive outcome.
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Affiliation(s)
- Elda Righi
- From the Infectious Diseases Division, Santa Maria della Misericordia University Hospital, Italy
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20
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Imamura CK, Furihata K, Okamoto S, Tanigawara Y. Impact of cytochrome P450 2C19 polymorphisms on the pharmacokinetics of tacrolimus when coadministered with voriconazole. J Clin Pharmacol 2015; 56:408-13. [PMID: 26239045 PMCID: PMC5057355 DOI: 10.1002/jcph.605] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 07/30/2015] [Indexed: 01/21/2023]
Abstract
This study evaluated the effects of cytochrome P450 (CYP) 2C19 polymorphisms on tacrolimus pharmacokinetics when coadministered with voriconazole. Eighteen healthy volunteers, including 6 individuals in each CYP2C19 genotype (extensive metabolizers [EMs], intermediate metabolizers [IMs], and poor metabolizers [PMs]), received a single oral dose of 3 mg tacrolimus alone or in combination with 200 mg voriconazole twice daily at steady state. When tacrolimus was coadministered with voriconazole, a significant increase in area under its concentration‐time curve (AUC0‐24) was observed for all genotypes. AUC0‐12 of voriconazole in IMs and PMs were significantly higher than that in EMs (P < .05 and P < .01, respectively). Consequently, AUC0‐24 of tacrolimus in combination with voriconazole in IMs and PMs were also significantly higher than that in EMs (P < .05). These results demonstrate that CYP2C19 genotypes influenced the exposure of tacrolimus when coadministered with voriconazole, although tacrolimus is mainly metabolized by CYP3A.
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Affiliation(s)
- Chiyo K Imamura
- Department of Clinical Pharmacokinetics and Pharmacodynamics, School of Medicine, Keio University, Tokyo, Japan
| | - Kenichi Furihata
- P-One Clinic, Keikokai Medical Corporation, Hachioji, Tokyo, Japan.,Department of Clinical Pharmacology, School of Medicine, Tokai University, Isehara, Kanagawa, Japan
| | - Shinichiro Okamoto
- Division of Hematology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Yusuke Tanigawara
- Department of Clinical Pharmacokinetics and Pharmacodynamics, School of Medicine, Keio University, Tokyo, Japan
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Scotti A, Santangelo M, Federico S, Carrano R, La Tessa C, Carlomagno N, Palmieri DG, Calogero A, Piantadosi M, Renda A. Complicated diverticulitis in kidney transplanted patients: analysis of 717 cases. Transplant Proc 2015; 46:2247-50. [PMID: 25242762 DOI: 10.1016/j.transproceed.2014.07.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION This study aims to investigate possible risk factors for diverticulitis in kidney transplant recipients affected by colonic diverticulosis. METHODS AND RESULTS We investigated 717 patients transplanted between 2000 and 2010. Diverticular disease was endoscopically diagnosed in 17 of 717 examined patients. Eight patients were diagnosed with autosomal dominant polycystic kidney disease (ADPKD); 9 of 17 patients underwent emergency surgery. We performed Hartmann's procedure on all patients, with a second stage performed at least 6 months later. DISCUSSION Although the incidence of colonic diverticular perforation in kidney transplanted patients is similar to that observed in the general population, perforation in immunosuppressed patients is associated with a higher morbidity/mortality rate. In our study, the incidence of perforation is 1.25% (9 of 717), with almost half of the cases observed in patients with ADPKD (4 of 9). Such an observation is consistent with published data, in which patients with ADPKD are reported to more frequently develop colonic diverticulosis and its complications. One possible explanation might be related to a belated diagnosis of diverticulitis, which could initially simulate an inflammatory disease as a consequence of renal cysts. Also, steroids seem to be a predisposing factor for colonic perforation in these patients. CONCLUSIONS A timely surgery can significantly reduce mortality. In cases of elective surgery, mortality and morbidity are similar to those of immunocompetent patients; accordingly, this is the goal to be pursued. Early signs and symptoms are often masked by immunosuppressive therapy. In these patients, surgeons should always perform (1) abdominal computed tomography scanning and, in the presence of diverticulitis, reduce or withdraw immunosuppressive therapy; and (2) early surgery, with Hartmann's procedure being, in our opinion, the best choice. Before transplantation, elective surgery for colonic resection should be considered in patients with ADPKD or with a history of 1 or more episodes of acute diverticulitis who then regressed with medical therapy.
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Affiliation(s)
- A Scotti
- Department of Surgical Sciences and Nephrology; University Federico II of Naples, Naples, Italy.
| | - M Santangelo
- Department of Surgical Sciences and Nephrology; University Federico II of Naples, Naples, Italy
| | - S Federico
- Department of Surgical Sciences and Nephrology; University Federico II of Naples, Naples, Italy
| | - R Carrano
- Department of Surgical Sciences and Nephrology; University Federico II of Naples, Naples, Italy
| | - C La Tessa
- Department of Surgical Sciences and Nephrology; University Federico II of Naples, Naples, Italy
| | - N Carlomagno
- Department of Surgical Sciences and Nephrology; University Federico II of Naples, Naples, Italy
| | - D G Palmieri
- Department of Surgical Sciences and Nephrology; University Federico II of Naples, Naples, Italy
| | - A Calogero
- Department of Surgical Sciences and Nephrology; University Federico II of Naples, Naples, Italy
| | - M Piantadosi
- Department of Surgical Sciences and Nephrology; University Federico II of Naples, Naples, Italy
| | - A Renda
- Department of Surgical Sciences and Nephrology; University Federico II of Naples, Naples, Italy
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Hoyo I, Sanclemente G, de la Bellacasa JP, Cofán F, Ricart M, Cardona M, Colmenero J, Fernández J, Escorsell A, Navasa M, Moreno A, Cervera C. Epidemiology, clinical characteristics, and outcome of invasive aspergillosis in renal transplant patients. Transpl Infect Dis 2014; 16:951-957. [DOI: 10.1111/tid.12301] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- I. Hoyo
- Department of Infectious Diseases; Hospital Clinic of Barcelona - Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona; Barcelona Spain
| | - G. Sanclemente
- Department of Infectious Diseases; Hospital Clinic of Barcelona - Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona; Barcelona Spain
| | - J. Puig de la Bellacasa
- Microbiology, “Centre Diagnòstic Biomèdic” (CDB); Centre for International Health Research (CRESIB); Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - F. Cofán
- Renal Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - M.J. Ricart
- Renal Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - M. Cardona
- Heart Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - J. Colmenero
- Liver Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - J. Fernández
- Liver Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - A. Escorsell
- Liver Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - M. Navasa
- Liver Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - A. Moreno
- Department of Infectious Diseases; Hospital Clinic of Barcelona - Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona; Barcelona Spain
| | - C. Cervera
- Department of Infectious Diseases; Hospital Clinic of Barcelona - Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona; Barcelona Spain
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Ostermann H, Solano C, Jarque I, Garcia-Vidal C, Gao X, Barrueta JA, De Salas-Cansado M, Stephens J, Xue M, Weber B, Charbonneau C. Cost analysis of voriconazole versus liposomal amphotericin B for primary therapy of invasive aspergillosis among patients with haematological disorders in Germany and Spain. BMC Pharmacol Toxicol 2014; 15:52. [PMID: 25253630 PMCID: PMC4183350 DOI: 10.1186/2050-6511-15-52] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 09/16/2014] [Indexed: 11/15/2022] Open
Abstract
Background The current healthcare climate demands pharmacoeconomic evaluations for different treatment strategies incorporating drug acquisition costs, costs incurred for hospitalisation, drug administration and preparation, diagnostic and laboratory testing and drug-related adverse events (AEs). Here we evaluate the pharmacoeconomics of voriconazole versus liposomal amphotericin B as first-line therapies for invasive aspergillosis (IA) in patients with haematological malignancy and prolonged neutropenia or who were undergoing haematopoietic stem-cell transplantation in Germany or Spain. Methods A decision analytic model based on a decision tree was constructed to estimate the potential treatment costs of voriconazole versus liposomal amphotericin B. Each model pathway was defined by the probability of an event occurring and the costs of clinical outcomes. Outcome probabilities and cost inputs were derived from the published literature, clinical trials, expert panels and local database costs. In the base case, patients who failed to respond to first-line therapy were assumed to experience a single switch between comparator drugs or the other drug was added as second-line treatment. Base-case evaluation included only drug-management costs and additional hospitalisation costs due to severe AEs associated with first- and second-line therapies. Sensitivity analyses were conducted to assess the robustness of the results. Cost estimates were inflated to 2011 euros (€). Results Based on clinical trial success rates of 52.8% (voriconazole) and 50.0% (liposomal amphotericin B), voriconazole had lower total treatment costs compared with liposomal amphotericin B in both Germany (€12,256 versus €18,133; length of therapy [LOT] = 10-day intravenous [IV] + 5-day oral voriconazole and 15-day IV liposomal amphotericin B) and Spain (€8,032 versus €10,516; LOT = 7-day IV + 8-day oral voriconazole and 15-day IV liposomal amphotericin B). Assuming the same efficacy (50.0%) in first-line therapy, voriconazole maintained a lower total treatment cost compared with liposomal amphotericin B. Cost savings were primarily due to the lower drug acquisition costs and shorter IV LOT associated with voriconazole. Sensitivity analyses showed that the results were sensitive to drug price, particularly the cost of liposomal amphotericin B. Conclusions Voriconazole is likely to be cost-saving compared with liposomal amphotericin B when used as a first-line treatment for IA in Germany and Spain.
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Abstract
The enduring success of lung transplantation is built on the use of immunosuppressive drugs to stop the immune system from rejecting the newly transplanted lung allograft. Most patients receive a triple-drug maintenance immunosuppressive regimen consisting of a calcineurin inhibitor, an antiproliferative and corticosteroids. Induction therapy with either an antilymphocyte monoclonal or an interleukin-2 receptor antagonist are prescribed by many centres aiming to achieve rapid inhibition of recently activated and potentially alloreactive T lymphocytes. Despite this generic approach acute rejection episodes remain common, mandating further fine-tuning and augmentation of the immunosuppressive regimen. While there has been a trend away from cyclosporine and azathioprine towards a preference for tacrolimus and mycophenolate mofetil, this has not translated into significant protection from the development of chronic lung allograft dysfunction, the main barrier to the long-term success of lung transplantation. This article reviews the problem of lung allograft rejection and the evidence for immunosuppressive regimens used both in the short- and long-term in patients undergoing lung transplantation.
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Cariello PF, Wickes BL, Sutton DA, Castlebury LA, Levitz SM, Finberg RW, Thompson EH, Daly JS. Phomopsis bougainvilleicola prepatellar bursitis in a renal transplant recipient. J Clin Microbiol 2013; 51:692-5. [PMID: 23196359 PMCID: PMC3553907 DOI: 10.1128/jcm.02674-12] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 11/21/2012] [Indexed: 11/20/2022] Open
Abstract
Prepatellar bursitis is typically a monomicrobial bacterial infection. A fungal cause is rarely identified. We describe a 61-year-old man who had received a renal transplant 21 months prior to presentation whose synovial fluid and surgical specimens grew Phomopsis bougainvilleicola, a pycnidial coelomycete.
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Affiliation(s)
- Paloma F Cariello
- Division of Infectious Diseases and Immunology, Department of Medicine, University of Massachusetts, Worcester, Massachusetts, USA.
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Invasive aspergillosis in a renal transplant recipient successfully treated with interferon-gamma. Case Rep Transplant 2012; 2012:493758. [PMID: 23259133 PMCID: PMC3504275 DOI: 10.1155/2012/493758] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 08/27/2012] [Indexed: 12/04/2022] Open
Abstract
Invasive aspergillosis is a serious complication of solid organ transplantation. An early diagnosis is hampered by the lack of reliable serum markers and, even if appropriately diagnosed and treated with current antifungal agents, has a high mortality rate. We report a case of invasive pulmonary and cerebral aspergillosis in a renal transplant patient treated with IFN-γ in conjunction with combination anti-fungal therapy for six weeks in whom complete resolution of the fungal infection was achieved. Renal function remained intact throughout the treatment period. Surveillance CT scans of the chest and head showed resolution of prior disease but revealed a new left upper lobe mass four months after completion of treatment with IFN-γ. Biopsy of the lesion was positive for primary lung adenocarcinoma, for which she underwent left upper lobe resection. The pathology report confirmed clear surgical margins and lymph nodes and no evidence of fungal hyphae. IFN-γ should be considered early in the management of invasive aspergillosis in renal transplant patients. To date, allograft rejection has not been encountered.
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Fujita Y, Araki T, Okada Y, Aomori T, Shimizu R, Tomizawa T, Hiromura K, Nojima Y, Nakamura T, Yamamoto K. Analysis of cytochrome P450 gene polymorphism in a lupus nephritis patient in whom tacrolimus blood concentration was markedly elevated after administration of azole antifungal agents. J Clin Pharm Ther 2012; 38:74-6. [PMID: 22971159 DOI: 10.1111/jcpt.12004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Both itraconazole (ITCZ) and voriconazole (VCZ) are potent inhibitors of cytochrome P450 (CYP) 3A, and their effects have been reported to be equal. However, ITCZ is metabolized by CYP3A, whereas VCZ is mainly metabolized by CYP2C9 and CYP2C19 and only partially by CYP3A. We experienced the case of a patient who showed a 5-fold increase in trough levels of tacrolimus (FK) level after switching from ITCZ to VCZ. Our objective is to discuss the mechanism of the increase drug-drug interaction in terms of serum concentration of the azole drugs and patient pharmacogenomics. CASE SUMMARY A 53-year-old woman was treated with FK (1 mg/day) for lupus nephritis. Because fungal infection was suspected, she received ITCZ (100 mg/day). When ITCZ was replaced with VCZ (400 mg/day), the blood concentration of FK increased markedly from 6·1 to 34·2 ng/mL. During coadministration with FK, the levels of ITCZ and VCZ were 135·5 ng/mL and 5·5 μg/mL, respectively, with the VCZ level around 3-fold higher than the previously reported level (1·4-1·8 μg/mL). Her CYP genotypes were CYP2C19*1/*2, CYP3A4*1/*1 and CYP3A5*3/*3. WHAT IS NEW AND CONCLUSION The patient was a CYP2C19 intermediate metabolizer (IM) and deficient in CYP3A5. The increase in plasma VCZ level appears to have been at least in part, associated with the CYP2C19 IM phenotype. One possible explanation for the marked increase in blood FK concentration was increased inhibition of CYP3A because of the impaired metabolism and subsequent increased plasma concentration of VCZ. This case shows that the severity of drug interactions may be influenced by metabolic gene polymorphism.
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Affiliation(s)
- Y Fujita
- Department of Pharmacy, Gunma University Hospital, Maebashi, Japan
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Wu X, Wang J, Tan L, Bui J, Gjerstad E, McMillan K, Zhang W. In vitro ADME profiling using high-throughput rapidfire mass spectrometry: cytochrome p450 inhibition and metabolic stability assays. ACTA ACUST UNITED AC 2012; 17:761-72. [PMID: 22460176 DOI: 10.1177/1087057112441013] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Early assessment of absorption, distribution, metabolism, and excretion (ADME) properties of drug candidates has become an essential component of modern drug discovery. ADME characterization is important in identifying compounds early that are likely to fail in later clinical development because of suboptimal pharmacokinetic properties or undesirable drug-drug interactions. Proper utilization of ADME results, meanwhile, can prioritize candidates that are more likely to have good pharmacokinetic properties and also minimize potential drug-drug interactions. By integrating a RapidFire system with an API4000 mass spectrometer (RF-MS), we have established a high-throughput capability to profile compounds (>100 compounds/wk) in a panel of ADME assays in parallel with biochemical and cellular characterizations. Cytochrome P450 inhibition and time-dependent inhibition assays and microsomal stability assays were developed and fully optimized on the system. Compared with the classic liquid chromatography-mass spectrometry method, the RF-MS system generates consistent data with approximately 20-fold increase in throughput. The lack of chromatographic separation of compounds, substrates, and metabolites can complicate data interpretation, but this occurs in a small number of cases that are readily identifiable. Overall, this system has enabled a real-time and quantitative measurement of a large number of ADME samples, providing a rapid evaluation of clinically important drug-drug interaction potential and drug metabolic stability.
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Affiliation(s)
- Xiang Wu
- New Lead Discovery, Exelixis, Inc., South San Francisco, CA, USA
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Passey C, Birnbaum AK, Brundage RC, Oetting WS, Israni AK, Jacobson PA. Dosing equation for tacrolimus using genetic variants and clinical factors. Br J Clin Pharmacol 2012; 72:948-57. [PMID: 21671989 DOI: 10.1111/j.1365-2125.2011.04039.x] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
AIM To develop a dosing equation for tacrolimus, using genetic and clinical factors from a large cohort of kidney transplant recipients. Clinical factors and six genetic variants were screened for importance towards tacrolimus clearance (CL/F). METHODS Clinical data, tacrolimus troughs and corresponding doses were collected from 681 kidney transplant recipients in a multicentre observational study in the USA and Canada for the first 6 months post transplant. The patients were genotyped for 2,724 single nucleotide polymorphisms using a customized Affymetrix SNP chip. Clinical factors and the most important SNPs (rs776746, rs12114000, rs3734354, rs4926, rs3135506 and rs2608555) were analysed for their influence on tacrolimus CL/F. RESULTS The CYP3A5*1 genotype, days post transplant, age, transplant at a steroid sparing centre and calcium channel blocker (CCB) use significantly influenced tacrolimus CL/F. The final model describing CL/F (l h(-1)) was: 38.4 ×[(0.86, if days 6-10) or (0.71, if days 11-180)]×[(1.69, if CYP3A5*1/*3 genotype) or (2.00, if CYP3A5*1/*1 genotype)]× (0.70, if receiving a transplant at a steroid sparing centre) × ([age in years/50](-0.4)) × (0.94, if CCB is present). The dose to achieve the desired trough is then prospectively determined using the individuals CL/F estimate. CONCLUSIONS The CYP3A5*1 genotype and four clinical factors were important for tacrolimus CL/F. An individualized dose is easily determined from the predicted CL/F. This study is important towards individualization of dosing in the clinical setting and may increase the number of patients achieving the target concentration. This equation requires validation in an independent cohort of kidney transplant recipients.
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Affiliation(s)
- Chaitali Passey
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN 55455, USA
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Gaïes E, Salouage I, Sahnoun R, Trabelsi S, Jebabli N, Lakhal M, Klouz A. Interaction médicamenteuse entre des antifongiques azolés et le tacrolimus chez quatre greffés rénaux. J Mycol Med 2011; 21:46-50. [DOI: 10.1016/j.mycmed.2010.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 11/02/2010] [Accepted: 11/16/2010] [Indexed: 10/18/2022]
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Vethe N, Midtvedt K, Åsberg A, Amundsen R, Bergan S. Legemiddelinteraksjoner og immunsuppresjon hos organtransplanterte. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2011; 131:2000-3. [DOI: 10.4045/tidsskr.11.0138] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Onizuka M, Kunii N, Toyosaki M, Machida S, Ohgiya D, Ogawa Y, Kawada H, Inoko H, Ando K. Cytochrome P450 genetic polymorphisms influence the serum concentration of calcineurin inhibitors in allogeneic hematopoietic SCT recipients. Bone Marrow Transplant 2010; 46:1113-7. [PMID: 21102498 DOI: 10.1038/bmt.2010.273] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Calcineurin inhibitors are necessary as immunosuppressants during hematopoietic SCT (HSCT) to prevent alloreactivity, but have unfortunate toxicities. So, we investigated the association of gene polymorphisms with the initial calcineurin inhibitor concentration and the subsequent drug dose from day 1 to day 28 among patients who underwent HSCT at a single institution. We analyzed 58 serial cases of Japanese patients receiving GVHD prophylaxis with CsA (21 cases) or tacrolimus (37 cases). We investigated eight single-nucleotide polymorphisms: rs4244285 (CYP2C19), rs15524, rs4646450, rs3800959, rs776746 (CYP3A5), rs1128503, rs2032582 and rs1045642 (MDR1). The CsA concentration was significantly higher when the genotype of CYP3A5 rs15524 was T/T (P=0.044) or rs776746 was G/G (P=0.027). The CYP3A5 rs776746 and rs4646450 genotypes were also associated with tacrolimus concentration (P=0.013 and P=0.0058, respectively). The dosage of tacrolimus was remarkably reduced from day -1 to day 28 when the patient had the CYP3A5 rs4646450 C/C and/or rs776746 G/G genotype (P=0.0010 and P=0.0021, respectively). In this study, we show that genetic variation has a predictable effect on the pharmacological responses to calcineurin inhibitors in HSCT patients.
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Affiliation(s)
- M Onizuka
- Department of Hematology and Oncology, Tokai University School of Medicine, Kanagawa, Japan.
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Abstract
Objective: To report the case of a kidney allograft recipient on a stable regimen of tacrolimus who exhibited increased tacrolimus concentrations within 24 hours of initiating ranolazine. Case Summary: A 64-year-old kidney allograft recipient on a stable dose of tacrolimus (10 mg twice daily) was admitted for recent worsening of her chronic anginal pain. The patient was initiated on ranolazine 500 mg twice daily on hospital day 2. Tacrolimus concentrations rose from 7.0-10.1 ng/mL preadmission to 17.8 ng/mL within 24 hours of ranolazine initiation. Ranolazine therapy was continued due to the patient's beneficial response; therefore, the tacrolimus dose was eventually decreased by 70% to 3 mg twice daily to maintain steady-state trough concentrations between 6.6 and 7.9 ng/mL with ranolazine therapy. Ranolazine dechallenge on a subsequent admission produced subtherapeutic tacrolimus concentrations requiring dosage increases. Discussion: Ranolazine, an antianginal agent, is both a substrate and a weak inhibitor of CYP3A as well as a substrate and moderate inhibitor of the P-glycoprotein (P-GP) efflux transport system. Tacrolimus, an immunosuppressant, is also a substrate of CYP3A and P-GP. Through possible inhibition of both P-GP– and CYP3A-mediated first-pass metabolism and CYP3A systemic metabolism, ranolazine may have significantly increased serum concentrations of tacrolimus necessitating an eventual 70% decrease in the tacrolimus dose. Based on the Horn Drug Interaction Probability Scale, this interaction is possible. Conclusions: We suggest that the eventual 70% decrease in tacrolimus dose after ranolazine initiation may indicate that ranolazine decreases the metabolism and clearance of tacrolimus, causing an elevation in tacrolimus concentrations and the potential for tacrolimus toxicity. Clinicians should be aware of this possible interaction when initiating ranolazine in patients on tacrolimus.
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Affiliation(s)
- Dwayne A Pierce
- Pharmacy Specialist-Nephrology/Hemodialysis, Department of Pharmacy, Wake Forest University Baptist Medical Center, Winston-Salem, NC
| | - Amber M Reeves-Daniel
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine
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