1
|
Interaction of Antifungal Drugs with CYP3A- and OATP1B-Mediated Venetoclax Elimination. Pharmaceutics 2022; 14:pharmaceutics14040694. [PMID: 35456528 PMCID: PMC9025810 DOI: 10.3390/pharmaceutics14040694] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/09/2022] [Accepted: 03/21/2022] [Indexed: 12/17/2022] Open
Abstract
Venetoclax, a BCL-2 inhibitor used to treat certain hematological cancers, exhibits low oral bioavailability and high interpatient pharmacokinetic variability. Venetoclax is commonly administered with prophylactic antifungal drugs that may result in drug interactions, of which the underlying mechanisms remain poorly understood. We hypothesized that antifungal drugs may increase venetoclax exposure through inhibition of both CYP3A-mediated metabolism and OATP1B-mediated transport. Pharmacokinetic studies were performed in wild-type mice and mice genetically engineered to lack all CYP3A isoforms, or OATP1B2 that received venetoclax alone or in combination with ketoconazole or micafungin. In mice lacking all CYP3A isoforms, venetoclax AUC was increased by 1.8-fold, and pretreatment with the antifungal ketoconazole further increased venetoclax exposure by 1.6-fold, despite the absence of CYP3A. Ensuing experiments demonstrated that the deficiency of OATP1B-type transporters is also associated with increases in venetoclax exposure, and that many antifungal drugs, including micafungin, posaconazole, and isavuconazole, are inhibitors of this transport mechanism both in vitro and in vivo. These studies have identified OATP1B-mediated transport as a previously unrecognized contributor to the elimination of venetoclax that is sensitive to inhibition by various clinically-relevant antifungal drugs. Additional consideration is warranted when venetoclax is administered together with agents that inhibit both CYP3A-mediated metabolism and OATP1B-mediated transport.
Collapse
|
2
|
Khanina A, Tio SY, Ananda‐Rajah MR, Kidd SE, Williams E, Chee L, Urbancic K, Thursky KA. Consensus guidelines for antifungal stewardship, surveillance and infection prevention, 2021. Intern Med J 2021; 51 Suppl 7:18-36. [DOI: 10.1111/imj.15586] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Anna Khanina
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology The University of Melbourne Melbourne Victoria Australia
| | - Shio Yen Tio
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology The University of Melbourne Melbourne Victoria Australia
| | - Michelle R. Ananda‐Rajah
- Department of General Medicine Alfred Health Melbourne Victoria Australia
- Department of Infectious Diseases Alfred Health Melbourne Victoria Australia
| | - Sarah E. Kidd
- National Mycology Reference Centre Microbiology and Infectious Diseases, SA Pathology Adelaide South Australia Australia
- School of Biological Sciences University of Adelaide Adelaide South Australia Australia
| | - Eloise Williams
- Department of Microbiology Royal Melbourne Hospital Melbourne Victoria Australia
- Department of Microbiology and Immunology The Peter Doherty Institute for Immunity and Infection, The University of Melbourne Melbourne Parkville Victoria Australia
| | - Lynette Chee
- Department of Clinical Haematology Peter MacCallum Cancer Centre and Royal Melbourne Hospital Melbourne Victoria Australia
- Department of Medicine The University of Melbourne Melbourne Victoria Australia
| | - Karen Urbancic
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Medicine The University of Melbourne Melbourne Victoria Australia
- Pharmacy Department Austin Health Melbourne Victoria Australia
- National Centre for Antimicrobial Stewardship Melbourne Victoria Australia
| | - Karin A. Thursky
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Medicine The University of Melbourne Melbourne Victoria Australia
- National Centre for Antimicrobial Stewardship Melbourne Victoria Australia
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Victorian Infectious Diseases Service The Peter Doherty Institute for Immunity and Infection, Royal Melbourne Hospital Melbourne Victoria Australia
| | | |
Collapse
|
3
|
Desai PM, Brown J, Gill S, Solh MM, Akard LP, Hsu JW, Ustun C, Andreadis C, Frankfurt O, Foran JM, Lister J, Schiller GJ, Wieduwilt MJ, Pagel JM, Stiff PJ, Liu D, Khan I, Stock W, Kambhampati S, Tallman MS, Morris L, Edwards J, Pusic I, Kantarjian HM, Mamelok R, Wong A, Van Syoc R, Kellerman L, Panuganti S, Mandalam R, Abboud CN, Ravandi F. Open-Label Phase II Prospective, Randomized, Controlled Study of Romyelocel-L Myeloid Progenitor Cells to Reduce Infection During Induction Chemotherapy for Acute Myeloid Leukemia. J Clin Oncol 2021; 39:3261-3272. [PMID: 34156898 PMCID: PMC8500663 DOI: 10.1200/jco.20.01739] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Standard cytotoxic induction chemotherapy for acute myeloid leukemia (AML) results in prolonged neutropenia and risk of infection. Romyelocel-L is a universal, allogeneic myeloid progenitor cell product being studied to reduce infection during induction chemotherapy. PATIENTS AND METHODS One hundred sixty-three patients with de novo AML (age ≥ 55 years) receiving induction chemotherapy were randomly assigned on day 0 (d0), of whom 120 were evaluable. Subjects received either romyelocel-L infusion on d9 with granulocyte colony-stimulating factor (G-CSF) starting daily d14 (treatment group) or G-CSF daily alone on d14 (control) until absolute neutrophil count recovery to 500/µL. End points included days in febrile episode, microbiologically defined infections, clinically diagnosed infection, and days in hospital. RESULTS Mean days in febrile episode was shorter in the treatment arm from d15 through d28 (2.36 v 3.90; P = .02). Similarly, a trend toward decreased microbiologically defined infections and clinically diagnosed infection in the treatment arm was observed from d9 to d28 (35.6% v 47.5%; P = .09), reaching a statistically significant difference from d15 to d28 (6.8% v 27.9%; P = .002). Because of this, antibacterial or antifungal use for treatment of an infection was significantly less in the treatment group (d9-d28: 44.1% v 63.9%; P = .01). Significantly fewer patients in the treatment arm received empiric antifungals from d9 tod28 (42.4% v 63.9%; P = .02) and d15-d28 (42.4% v 62.3%; P = .02). Patients in the treatment arm also had 3.2 fewer hospital days compared with control (25.5 v 28.7; P = .001). Remission rates and days to absolute neutrophil count recovery were similar in the two groups. No patients in the romyelocel-L plus G-CSF group died because of infection compared with two patients in the control arm. No graft-versus-host disease was observed. CONCLUSION Subjects receiving romyelocel-L showed a decreased incidence of infections, antimicrobial use, and hospitalization, suggesting that romyelocel-L may provide a new option to reduce infections in patients with AML undergoing induction therapy.
Collapse
Affiliation(s)
| | - Janice Brown
- Stanford University Medical Center, Stanford, CA
| | - Saar Gill
- University of Pennsylvania, Philadelphia, PA
| | | | - Luke P Akard
- Indiana Blood and Marrow Transplantation, Indianapolis, IN
| | | | | | | | | | | | | | | | | | | | | | | | - Irum Khan
- University of Illinois Cancer Center, Chicago, IL
| | | | | | | | | | - John Edwards
- Indiana Blood and Marrow Transplantation, Indianapolis, IN
| | | | | | | | | | | | | | | | | | | | - Farhad Ravandi
- The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
4
|
Khanina A, Cairns KA, Kong DCM, Thursky KA, Slavin MA, Roberts JA. The impact of pharmacist‐led antifungal stewardship interventions in the hospital setting: a systematic review. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2021. [DOI: 10.1002/jppr.1721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Anna Khanina
- Peter MacCallum Cancer Centre The National Centre for Infections in Cancer Melbourne Australia
- Sir Peter MacCallum Department of Oncology The University of Melbourne Melbourne Australia
| | | | - David C. M. Kong
- The National Centre for Antimicrobial Stewardship The Peter Doherty Institute for Infection and Immunity Melbourne Australia
- Centre for Medicine Use and Safety Monash Institute of Pharmaceutical SciencesMonash University Parkville Australia
- Ballarat Health Services Parkville Australia
| | - Karin A. Thursky
- Peter MacCallum Cancer Centre The National Centre for Infections in Cancer Melbourne Australia
- Sir Peter MacCallum Department of Oncology The University of Melbourne Melbourne Australia
- The National Centre for Antimicrobial Stewardship The Peter Doherty Institute for Infection and Immunity Melbourne Australia
- Department of Medicine University of Melbourne Parkville Australia
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Australia
| | - Monica A. Slavin
- Peter MacCallum Cancer Centre The National Centre for Infections in Cancer Melbourne Australia
- Sir Peter MacCallum Department of Oncology The University of Melbourne Melbourne Australia
- Department of Medicine University of Melbourne Parkville Australia
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Australia
| | - Jason A. Roberts
- Faculty of Medicine The University of Queensland University of Queensland Centre for Clinical Research Brisbane Australia
- Departments of Pharmacy and Intensive Care Medicine Royal Brisbane and Women’s Hospital Brisbane Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine Nîmes University Hospital University of Montpellier Nîmes France
| |
Collapse
|
5
|
Khanina A, Douglas AP, Thursky KA. Implementation of Effective Antifungal Stewardship in Cancer Patients—A Review of Current Evidence. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00408-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
6
|
Reslan Z, Lindsay J, Kerridge I, Gellatly R. Pharmacist review of high-risk haematology outpatients to improve appropriateness of antifungal prophylaxis. Int J Clin Pharm 2020; 42:1412-1418. [PMID: 33009604 DOI: 10.1007/s11096-020-01090-5] [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: 02/16/2020] [Accepted: 06/23/2020] [Indexed: 11/29/2022]
Abstract
Background Patients with haematological malignancies are at high risk of invasive fungal infections. However, there is a lack of information about the utilisation of the recommended Australian antifungal prophylaxis guidelines in haematology outpatients. Objective To assess the impact of a weekly pharmacist review of high-risk adult haematology outpatients on the utilisation of appropriate antifungal prophylaxis. Setting Outpatient cancer centre, tertiary referral hospital in Sydney, Australia. Method A 3-month pre-and post-interventional study was conducted. A retrospective audit was conducted to obtain baseline utilisation of antifungal guidelines in adult haematology outpatients with acute myeloid leukemia, acute lymphoblastic leukemia and myelodysplastic syndrome receiving chemotherapy. This was followed by a weekly pharmacist review over a 3-month period of all eligible outpatients assessing the appropriateness of antifungal agent, dose, use of therapeutic drug monitoring and presence of drug-interactions/contraindications. Recommendations to physicians were conveyed weekly and outcomes recorded. Main outcome measure Appropriate utilisation of antifungal prophylaxis guidelines in outpatient haematology patients before and after implementation of a 3-month weekly pharmacist review service. Results Forty patients were included in the retrospective group, equating to 348 reviews, while 42 patients equating to 269 reviews were included in the prospective group. Appropriate utilisation of antifungal prophylaxis guidelines increased from 31 to 54% post implementation of a pharmacist review (Odds Ratio = 2.44, 95% Confidence Interval: 1.07-5.58, p = 0.0344). The most common reason for nonadherence to guidelines in both groups was lack of therapeutic drug monitoring and failure to prescribe antifungal prophylaxis where indicated. The percentage of appropriate use of antifungal prophylaxis in patients with acute myeloid leukemia increased from 13 to 46% (p value < 0.01) after pharmacist intervention. The pharmacist made 153 recommendations from 269 reviews, with a percentage uptake of 40%. Moderate to severe drug interactions were identified in 19 reviews from 10 patients. One major azole antifungal-chemotherapy interaction was avoided. Conclusions Appropriate utilisation of antifungal prophylaxis guidelines can be improved through a regular pharmacist review. Future studies should identify whether improving adherence to antifungal guidelines leads to improved patient outcomes.
Collapse
Affiliation(s)
- Zainab Reslan
- Pharmacy Department, Royal North Shore Hospital, Level 1 ASB, Reserve Road, Sydney, NSW, Australia. .,Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia.
| | - Julian Lindsay
- Hematology and Bone Marrow Transplant Unit, Royal North Shore Hospital, Sydney, NSW, Australia.,National Centre for Infection in Cancer (NCIC), Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Ian Kerridge
- Hematology and Bone Marrow Transplant Unit, Royal North Shore Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health Science, University of Sydney, Sydney, NSW, Australia
| | - Rochelle Gellatly
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| |
Collapse
|
7
|
Economic analysis of oral posaconazole prophylaxis in acute myeloid leukemia during remission induction in Turkey. North Clin Istanb 2020; 7:222-225. [PMID: 32478292 PMCID: PMC7251278 DOI: 10.14744/nci.2019.89896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 08/01/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Invasive fungal infections (IFI) are important and trending causes of mortality in patients with acute leukemia, especially during the remission induction. METHODS In this study, 225 patients who were diagnosed with acute myeloid leukemia (AML) and undergoing intensive treatment for remission induction were enrolled in a retrospective manner. RESULTS Within the whole group, which consisted of 225 patients, 90 patients received prophylactic antifungal treatment (PAT) (40%), while 135 patients did not (60%) receive. The mean cost of hospitalization was 9.151,6 (2.872,6-20.483,3) US dollars. Gender distribution and mean ages of groups were similar. One hundred fourteen patients not on PAT (84.4%) and five patients on PAT (5.5%) received intravenous antifungal treatment. Thirty-two of the patients who were not on PAT (23.7%) and 11 of the patients on PAT died during remission induction (12.22%). The mean day of the hospitalization was 22.61 days for the patients on PAT and 33.89 days for the patients who were not on PAT. In patients on PAT, the mean number of transfused platelet units was six (0-9), while 12.51 (4-43) units for patients who were not on PAT. CONCLUSION In our study, the oral suspension form of posaconazole was observed to be cost-effective to prevent IFI with a significant decrease in mortality during remission induction treatment.
Collapse
|
8
|
Reslan Z, Lindsay J, Kerridge I, Gellatly R. Adherence to Antifungal Guidelines in Malignant Hematology Patients: A Review of the Literature. J Pharm Technol 2019; 35:270-280. [PMID: 34753155 DOI: 10.1177/8755122519859976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective: To review the published literature assessing adherence rates to antifungal guidelines and reasons for nonadherence in the adult malignant hematology inpatient setting. Data sources: The databases Embase, MEDLINE, and PubMed (from data inception to May 2019) were searched using the terms hematology, oncology, antifungal, guidelines, adherence, and stewardship with the search limited to adult human subjects and published in English. This yielded 123 articles. From this list, studies that were published in peer-reviewed journals were extracted, leaving 10 citations that met the final inclusion criteria. Study Selection and Data Extraction: Ten studies were selected assessing adherence to consensus antifungal guidelines in the malignant hematology setting. These included studies investigating the introduction of antifungal stewardship programs in tertiary hospitals. Data Synthesis: Although the studies were heterogeneous, all focused on appropriateness of antifungal therapy in the inpatient setting. Adherence to antifungal guidelines for optimal antifungal prophylaxis and treatment was low in most studies, with rates of inappropriate antifungal therapy ranging from 25% to 70% of fungal prescriptions. Relevance to Patient Care and Clinical Practice: Adherence rates with guidelines for antifungal therapy are low in the hematology inpatient setting. This may affect infection rates influencing morbidity and mortality in this high-risk population. Conclusion: Given the prevalence of invasive fungal infections in malignant hematology inpatients, suboptimal adherence with antifungal guidelines is concerning. This demands a focus on education, antifungal stewardship, and updating guidelines to meet real-world scenarios. Adherence with antifungal guidelines in the outpatient hematology setting is unknown and requires further research.
Collapse
Affiliation(s)
- Zainab Reslan
- Royal North Shore Hospital, Sydney, New South Wales, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Julian Lindsay
- Royal North Shore Hospital, Sydney, New South Wales, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Ian Kerridge
- Royal North Shore Hospital, Sydney, New South Wales, Australia.,University of Sydney, New South Wales, Australia
| | | |
Collapse
|
9
|
Bui V, Walker SA, Elligsen M, Vyas A, Kiss A, Palmay L. Voriconazole prophylaxis in leukemic patients: A retrospective single-center study. J Oncol Pharm Pract 2019; 26:873-881. [PMID: 31566111 DOI: 10.1177/1078155219876683] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Invasive fungal infections commonly occur in acute myeloid and lymphoblastic leukemia patients receiving chemotherapy. In these patients with acute leukemia, posaconazole prophylaxis is recommended; however, voriconazole may be a less costly alternative. OBJECTIVES The objective of this study was to evaluate the efficacy and safety of voriconazole prophylaxis in acute leukemia patients. METHODS A retrospective chart review of inpatients at Sunnybrook Health Sciences Centre between 2005 and 2017 was completed. Hospitalized adult acute leukemia patients who received voriconazole prophylaxis (cases) were compared to patients who received fluconazole or no prophylaxis during chemotherapy (controls). Statistical analyses comparing baseline characteristics, safety, and efficacy outcomes between the study cohorts were completed. A posaconazole literature-based weighted mean risk was compared to the voriconazole risk of invasive fungal infection identified in this study. RESULTS Of 490 acute myeloid leukemia or acute lymphoblastic leukemia patients, 83 controls and 92 cases were eligible. Case patients received an average of 24.4 ± 10.8 days of voriconazole prophylaxis. The incidence of proven or probable invasive fungal infections with voriconazole was 3.3% (3/92) versus 7.2% (6/83) in the control cohort (p > 0.05) and was comparable to the literature reported weighted incidence of invasive fungal infection with posaconazole (2.4 ± 2.1%; 95% CI 1.3%-3.4%; p > 0.05). Voriconazole was well tolerated by patients (91%; 84/91; seven discontinued due to asymptomatic elevated liver function tests). CONCLUSIONS Voriconazole prophylaxis was found to be safe, effective, and comparable to literature-based efficacy data for risk of invasive fungal infection with posaconazole antifungal prophylaxis in patients with acute leukemia undergoing chemotherapy and could represent a significant cost advantage.
Collapse
Affiliation(s)
- Vivian Bui
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sandra An Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Anju Vyas
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alex Kiss
- Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lesley Palmay
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| |
Collapse
|
10
|
Girmenia C, Busca A, Candoni A, Cesaro S, Luppi M, Nosari AM, Pagano L, Rossi G, Venditti A, Aversa F. Breakthrough invasive fungal diseases in acute myeloid leukemia patients receiving mould active triazole primary prophylaxis after intensive chemotherapy: An Italian consensus agreement on definitions and management. Med Mycol 2019; 57:S127-S137. [PMID: 30816979 DOI: 10.1093/mmy/myy091] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 09/03/2018] [Accepted: 09/27/2018] [Indexed: 12/17/2022] Open
Abstract
In the attempt to establish definitions and provide shared approaches to breakthrough invasive fungal diseases (br-IFD) in acute myeloid leukemia (AML) patients submitted to intensive chemotherapy and receiving triazoles as mould active primary antifungal prophylaxis (MA-PAP), literature on br-IFD in AML patients receiving triazoles MA-PAP was reviewed and a Consensus Development Conference Project was convened. The following four candidate key-questions were generated and formed the set of questions of the present document: "definition of br-IFD," "diagnostic strategy during MA-PAP to detect br-IFD," "possible causes of MA-PAP failure," "management of br-IFD."
Collapse
Affiliation(s)
- Corrado Girmenia
- Dipartimento di Ematologia, Oncologia, e Dermatologia, Azienda Policlinico Umberto I, Rome
| | - Alessandro Busca
- A.O.U. Città della Salute e della Scienza, Dipartimento di Oncologia, SSD Trapianto allogenico di cellule staminali, Turin, Italy
| | - Anna Candoni
- Clinica Ematologica-Centro trapianti e Terapie Cellulari, Azienda Ospedaliero-Universitaria di Udine
| | - Simone Cesaro
- Oncoematologia Pediatrica, Azienda Ospedaliera Universitaria Integrata, Verona
| | - Mario Luppi
- Cattedra ed UO Ematologia. Dipartimento di Scienze Mediche e Chirurgiche Materno Infantile e dell' Adulto. AOU Modena. UNIMORE. Modena
| | - Anna Maria Nosari
- Divisione di Ematologia e Centro Trapianti Midollo ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Livio Pagano
- Istituto di Ematologia, Fondazione Policlinico A. Gemelli- IRCCS - Università Cattolica del Sacro Cuore, Rome
| | - Giuseppe Rossi
- S.C. Ematologia e Dipartimento Oncologia Medica Spedali Civili, Brescia
| | | | - Franco Aversa
- Haematology and BMT Unit, University of Parma, Parma, Italy
| |
Collapse
|
11
|
Özkocaman V, Özkalemkaş F, Seyhan S, Ener B, Ursavaş A, Ersal T, Kazak E, Demirdöğen E, Mıstık R, Akalın H. The Outcome of Antifungal Prophylaxis with Posaconazole in Patients with Acute Myeloid Leukemia: A Single-Center Study. Turk J Haematol 2018; 35:277-282. [PMID: 30047484 PMCID: PMC6256813 DOI: 10.4274/tjh.2017.0430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective Invasive fungal infections (IFIs) are a significant cause of morbidity and mortality among neutropenic patients undergoing chemotherapy for acute myeloid leukemia (AML) and stem cell transplantation. The aim of this study was to evaluate the real-life impact of posaconazole prophylaxis. Materials and Methods Eighty-four adult patients were included with AML under remission induction chemotherapy and posaconazole prophylaxis. The 34 patients in the control group did not receive primary antifungal prophylaxis. The period between June 2006 and January 2009, when antifungal prophylaxis was not administered (control group), was retrospectively compared to the period between December 2010 and May 2012 when primary oral posaconazole prophylaxis was administered in similar conditions (posaconazole group) according to the use of antifungal agents for treatment, breakthrough infections, galactomannan performance, and the necessity for performing bronchoalveolar lavage (BAL) procedures. Results The two groups were compared according to the use of antifungal agents; progression to a different antifungal agent was found in 34/34 patients (100%) in the control group and in 9/84 patients (11%) in the posaconazole group (p<0.001). There were four breakthrough IFIs (4/84, 4.8%) in the posaconazole group and 34 IFIs in the control group (p<0.001). In addition, 15/34 patients (44%) in the control group required BAL compared to 11/84 patients (13%) in the posaconazole group (p<0.001). Posaconazole treatment was discontinued within 7-14 days in 7/84 patients (8.3%) due to poor oral compliance related to mucositis after chemotherapy. Conclusion Posaconazole appears to be effective and well-tolerated protection against IFIs for AML patients.
Collapse
Affiliation(s)
- Vildan Özkocaman
- Uludağ University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Bursa, Turkey
| | - Fahir Özkalemkaş
- Uludağ University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Bursa, Turkey
| | - Serdar Seyhan
- Uludağ University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Bursa, Turkey
| | - Beyza Ener
- Uludağ University Faculty of Medicine, Department of Medical Microbiology, Bursa, Turkey
| | - Ahmet Ursavaş
- Uludağ University Faculty of Medicine, Department of Chest Disease and Tuberculosis, Bursa, Turkey
| | - Tuba Ersal
- Uludağ University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Bursa, Turkey
| | - Esra Kazak
- Uludağ University Faculty of Medicine, Department of Infectious Disease and Clinical Microbiology, Bursa, Turkey
| | - Ezgi Demirdöğen
- Uludağ University Faculty of Medicine, Department of Chest Disease and Tuberculosis, Bursa, Turkey
| | - Reşit Mıstık
- Uludağ University Faculty of Medicine, Department of Infectious Disease and Clinical Microbiology, Bursa, Turkey
| | - Halis Akalın
- Uludağ University Faculty of Medicine, Department of Infectious Disease and Clinical Microbiology, Bursa, Turkey
| |
Collapse
|
12
|
Clinical Outcomes of Oral Suspension versus Delayed-Release Tablet Formulations of Posaconazole for Prophylaxis of Invasive Fungal Infections. Antimicrob Agents Chemother 2018; 62:AAC.00893-18. [PMID: 30012757 PMCID: PMC6153813 DOI: 10.1128/aac.00893-18] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 06/21/2018] [Indexed: 02/06/2023] Open
Abstract
Posaconazole is used for prophylaxis for invasive fungal infections (IFIs) among patients with hematologic malignancies. We compared the incidence of breakthrough IFIs and early discontinuation between patients receiving delayed-release tablet and oral suspension formulations of posaconazole. Posaconazole is used for prophylaxis for invasive fungal infections (IFIs) among patients with hematologic malignancies. We compared the incidence of breakthrough IFIs and early discontinuation between patients receiving delayed-release tablet and oral suspension formulations of posaconazole. This was a retrospective cohort study of patients receiving posaconazole between 1 January 2010 and 30 June 2016. We defined probable or proven breakthrough IFIs using the European Organization for Research and Treatment of Cancer (EORTC) criteria. Overall, 547 patients received 860 courses of posaconazole (53% received the oral suspension and 48% received the tablet); primary indications for prophylaxis were acute myeloid leukemia (69%), graft-versus-host disease (18%), and myelodysplastic syndrome (3%). There were no significant differences in demographics or indications between patients receiving the different formulations. The incidence and incidence rate of probable or proven IFIs were 1.6% and 3.2 per 10,000 posaconazole days, respectively. There was no significant difference in the rate of IFIs between suspension courses (2.8 per 10,000 posaconazole days) and tablet courses (3.7 per 10,000 posaconazole days) (rate ratio = 0.8, 95% confidence interval [CI] = 0.3 to 2.3). Of the 14 proven or probable cases of IFI, 8/14 had posaconazole serum concentrations measured, and the concentrations in 7/8 were above 0.7 μg/ml. Posaconazole was discontinued early in 15.5% of courses; however, the frequency of discontinuation was also not significantly different between the tablet (16.5%) and oral suspension (14.6%) formulations (95% CI for difference = −0.13 to 0.06). In conclusion, the incidence of breakthrough IFIs was low among patients receiving posaconazole prophylaxis and not significantly different between patients receiving the tablet formulation and those receiving the oral suspension formulation.
Collapse
|
13
|
Lachenmayr SJ, Berking S, Horns H, Strobach D, Ostermann H, Berger K. Antifungal treatment in haematological and oncological patients: Need for quality assessment in routine care. Mycoses 2018; 61:464-471. [PMID: 29575106 DOI: 10.1111/myc.12768] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 02/27/2018] [Accepted: 03/11/2018] [Indexed: 11/30/2022]
Abstract
Invasive fungal infections in haematological and oncological patients have a major impact on morbidity, mortality and treatment costs. Therefore, rational use of antifungal agents is important for optimal patient care and resource use. The study's objective was to analyse antifungal usage in a German tertiary teaching hospital, department of haematology and oncology, to evaluate quality of antifungal treatment and to assess the need for an antifungal stewardship programme. This retrospective observational study included patients ≥18 years receiving systemic antifungals for prophylaxis or therapy of invasive fungal infection between January and June 2016. Appropriateness of antifungal prescriptions was evaluated in accordance with guidelines of the German Society of Haematology and Oncology (DGHO) and drug labelling. In total, 104/1278 (8.1%) patients received antifungals. One hundred seventy-one antifungals were prescribed: 48 for prophylaxis, 104 for empirical and 19 for targeted therapy. In 127 (74.3%) prescriptions, indication was appropriate, and in 132 (77.2%), choice of drug. Antifungals were correctly dosed in 131 prescriptions (76.6%). Thirty-four antifungals (20.0%) were co-administrated with interacting drugs (5 mild to moderate, 29 severe interactions). Results of this analysis demonstrate that use of systemic antifungals in routine care differs in a substantial number of patients from guideline and labelling recommendations. To optimise antifungal use, the implementation of antifungal stewardship programmes seems to be justified.
Collapse
Affiliation(s)
- Sarah J Lachenmayr
- Department of Haematology/Oncology, University Hospital of Munich, Munich, Germany.,Department of Pharmacy, University Hospital of Munich, Munich, Germany
| | - Sophie Berking
- Department of Haematology/Oncology, University Hospital of Munich, Munich, Germany
| | - Heidi Horns
- Department of Haematology/Oncology, University Hospital of Munich, Munich, Germany
| | - Dorothea Strobach
- Department of Pharmacy, University Hospital of Munich, Munich, Germany
| | - Helmut Ostermann
- Department of Haematology/Oncology, University Hospital of Munich, Munich, Germany
| | - Karin Berger
- Department of Haematology/Oncology, University Hospital of Munich, Munich, Germany
| |
Collapse
|