1
|
Wang X, Hu X, Ye C, Zhao J, Tan SC, Zhou L, Zhao C, Wu KH, Yang X, Wei J, Yang M. Astragalus Polysaccharide Enhances Voriconazole Metabolism under Inflammatory Conditions through the Gut Microbiota. J Clin Transl Hepatol 2024; 12:481-495. [PMID: 38779521 PMCID: PMC11106349 DOI: 10.14218/jcth.2024.00024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/03/2024] [Accepted: 04/08/2024] [Indexed: 05/25/2024] Open
Abstract
Background and Aims Voriconazole (VRC), a widely used antifungal drug, often causes hepatotoxicity, which presents a significant clinical challenge. Previous studies demonstrated that Astragalus polysaccharide (APS) can regulate VRC metabolism, thereby potentially mitigating its hepatotoxic effects. In this study, we aimed to explore the mechanism by which APS regulates VRC metabolism. Methods First, we assessed the association of abnormal VRC metabolism with hepatotoxicity using the Roussel Uclaf Causality Assessment Method scale. Second, we conducted a series of basic experiments to verify the promotive effect of APS on VRC metabolism. Various in vitro and in vivo assays, including cytokine profiling, immunohistochemistry, quantitative polymerase chain reaction, metabolite analysis, and drug concentration measurements, were performed using a lipopolysaccharide-induced rat inflammation model. Finally, experiments such as intestinal biodiversity analysis, intestinal clearance assessments, and Bifidobacterium bifidum replenishment were performed to examine the ability of B. bifidum to regulate the expression of the VRC-metabolizing enzyme CYP2C19 through the gut-liver axis. Results The results indicated that APS does not have a direct effect on hepatocytes. However, the assessment of gut microbiota function revealed that APS significantly increases the abundance of B. bifidum, which could lead to an anti-inflammatory response in the liver and indirectly enhance VRC metabolism. The dual-luciferase reporter gene assay revealed that APS can hinder the secretion of pro-inflammatory mediators and reduce the inhibitory effect on CYP2C19 transcription through the nuclear factor-κB signaling pathway. Conclusions The study offers valuable insights into the mechanism by which APS alleviates VRC-induced liver damage, highlighting its immunomodulatory influence on hepatic tissues and its indirect regulatory control of VRC-metabolizing enzymes within hepatocytes.
Collapse
Affiliation(s)
- Xiaokang Wang
- The Marine Biomedical Research Institute of Guangdong Zhanjiang, Zhanjiang, Guangdong, China
- Guangdong Provincial Key Laboratory of Research and Development of Natural Drugs, Guangdong Medical University, Dongguan, Guangdong, China
- Department of Pharmacy, Shenzhen Longhua District Central Hospital, Shenzhen, Guangdong, China
| | - Xianjing Hu
- Guangdong Provincial Key Laboratory of Research and Development of Natural Drugs, Guangdong Medical University, Dongguan, Guangdong, China
- Dongguan Key Laboratory of Chronic Inflammatory Diseases, The First Dongguan Affiliated Hospital, Guangdong Medical University, Dongguan, Guangdong, China
| | - Chunxiao Ye
- Department of Pharmacy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jingqian Zhao
- Department of Pharmacy, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong, China
| | - Shing Cheng Tan
- UKM Medical Molecular Biology Institute, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Liangbin Zhou
- Department of Biomedical Engineering, Faculty of Engineering, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Chenyu Zhao
- Department of Pharmacy, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong, China
| | - Kit Hang Wu
- Department of Pharmacy, Nossa Senhora do Carmo-Lago Health Centre, Health Bureau, Macau, China
| | - Xixiao Yang
- Department of Pharmacy, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong, China
| | - Jinbin Wei
- Pharmaceutical College, Guangxi Medical University, Nanning, Guangxi, China
| | - Maoxun Yang
- The Marine Biomedical Research Institute of Guangdong Zhanjiang, Zhanjiang, Guangdong, China
- Guangdong Provincial Key Laboratory of Research and Development of Natural Drugs, Guangdong Medical University, Dongguan, Guangdong, China
- Dongguan Key Laboratory of Chronic Inflammatory Diseases, The First Dongguan Affiliated Hospital, Guangdong Medical University, Dongguan, Guangdong, China
| |
Collapse
|
2
|
Kato H, Umemura T, Hagihara M, Shiota A, Asai N, Hamada Y, Mikamo H, Iwamoto T. Development of a therapeutic drug-monitoring algorithm for outpatients receiving voriconazole: A multicentre retrospective study. Br J Clin Pharmacol 2024; 90:1222-1230. [PMID: 38320604 DOI: 10.1111/bcp.16004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 12/27/2023] [Accepted: 01/04/2024] [Indexed: 02/08/2024] Open
Abstract
AIMS Although therapeutic drug monitoring (TDM) of voriconazole is performed in outpatients to prevent treatment failure and toxicity, whether TDM should be performed in all or only selected patients remains controversial. This study evaluated the association between voriconazole trough concentrations and clinical events. METHODS We investigated the aggravation of clinical symptoms, incidence of hepatotoxicity and visual disturbances, change in co-medications and interaction between voriconazole and co-medications in outpatients receiving voriconazole between 2017 and 2021 in three facilities. Abnormal trough concentrations were defined as <1.0 mg/L (low group) and >4.0 mg/L (high group). RESULTS A total of 141 outpatients (578 concentration measurements) met the inclusion criteria (treatment, 37 patients, 131 values; prophylaxis, 104 patients, 447 values). The percentages of patients with abnormal concentrations were 29.0% and 31.5% in the treatment and prophylaxis groups, respectively. Abnormal concentrations showed 50% of the concentrations at the first measurement in both therapies. Aggravation of clinical symptoms was most frequently observed in the low treatment group (18.2%). Adverse events were most common in the high group for both therapies (treatment, hepatotoxicity 6.3%, visual disturbance 18.8%; prophylaxis, hepatotoxicity 27.9%). No differences were found in changes to co-medications and drug interactions. In the prophylaxis group, prescription duration in the presence of clinical events tended to be longer than in their absence (47.4 ± 23.4 days vs 39.7 ± 21.9 days, P = .1132). CONCLUSIONS We developed an algorithm based on clinical events for appropriate implementation of TDM in outpatients. However, future interventions based on this algorithm should be validated.
Collapse
Affiliation(s)
- Hideo Kato
- Department of Pharmacy, Mie University Hospital, Tsu, Mie, Japan
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Tsu, Mie, Japan
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takumi Umemura
- Department of Pharmacy, Tosei General Hospital, Seto, Aichi, Japan
| | - Mao Hagihara
- Department of Molecular Epidemiology and Biomedical Sciences, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Arifumi Shiota
- Department of Pharmacy, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Nobuhiro Asai
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan
| | - Yukihiro Hamada
- Department of Pharmacy, Kochi Medical School Hospital, Nankoku, Kochi, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takuya Iwamoto
- Department of Pharmacy, Mie University Hospital, Tsu, Mie, Japan
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| |
Collapse
|
3
|
Chen C, Xu T, Zhou K, Zhu S. Factors affecting voriconazole concentration to dose ratio changes according to route of administration. Eur J Hosp Pharm 2023; 31:31-35. [PMID: 35273002 PMCID: PMC10800250 DOI: 10.1136/ejhpharm-2021-003173] [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: 11/28/2021] [Accepted: 02/22/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Voriconazole (VRCZ) is commonly used as oral and intravenous (IV) formulations. Few studies have comprehensively analysed the variation factors for the weight-corrected VRCZ serum concentration/dose (C/D) ratio based on the administration route. We retrospectively investigated the risk factors that influence the VRCZ C/D ratio in patients treated with oral or IV formulations. METHODS A total of 325 patients were divided into two groups (IV and oral groups). Propensity score matching was performed and linear regression analyses were used to identify the risk factors that affect the VRCZ C/D ratio according to the administration route. Receiver operating characteristic (ROC) curves were also used to assess the predictive potential for VRCZ trough concentration >5 µg/mL. RESULTS The VRCZ C/D ratio in the oral group was significantly lower than that in the IV group (p<0.001). Propensity score matching resulted in 65 in the IV group matched with 65 in the oral group. Multivariate analysis showed that age (p=0.039), aspartate aminotransferase (AST) (p=0.016) and total bilirubin (TBIL) (p=0.041) levels were independent influencing factors of the VRCZ C/D ratio in the oral group. ROC curves showed that the predicted probability of combined age, AST and TBIL had maximal area under the curve (AUC) of 0.901 for VRCZ trough level >5 µg/mL. Meanwhile, the ratio of TBIL (p=0.005) and single dose (p=0.015) were independent factors in the IV group with ROCAUC of 0.781. CONCLUSIONS To obtain optimal VRCZ efficacy and safety, dose adjustment is required based on multiple factors that may cause the observed difference in the VRCZ C/D ratio and trough levels between oral and IV administration.
Collapse
Affiliation(s)
- Chunyan Chen
- Department of Pharmacy, Ningbo First Hospital, Ningbo, Zhejiang, P.R. China
| | - Tao Xu
- Department of Pharmacy, Ningbo First Hospital, Ningbo, Zhejiang, P.R. China
| | - Keting Zhou
- Department of Pharmacy, Ningbo First Hospital, Ningbo, Zhejiang, P.R. China
| | - Suyan Zhu
- Department of Pharmacy, Ningbo First Hospital, Ningbo, Zhejiang, P.R. China
| |
Collapse
|
4
|
Hanai Y, Ueda T, Hamada Y, Oda K, Takahashi Y, Nakajima K, Miyazaki Y, Kiriyama M, Uekusa S, Matsuo K, Matsumoto K, Kimura T, Takesue Y. Optimal timing for therapeutic drug monitoring of voriconazole to prevent adverse effects in Japanese patients. Mycoses 2023; 66:1035-1044. [PMID: 37584173 DOI: 10.1111/myc.13639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/22/2023] [Accepted: 07/26/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND The optimal timing for therapeutic drug monitoring (TDM) of voriconazole in Asians, who have higher rates of poor metabolisers than non-Asians, is unclear. This can cause unexpectedly high concentrations and delays in reaching steady-state levels. OBJECTIVES To determine the appropriate timing of TDM in Japanese patients receiving voriconazole. PATIENTS/METHODS Trough levels (Cmin ) were measured on days 3-5 (recommended timing, RT) and days 6-14 (delayed timing, DT) after starting voriconazole in patients receiving an appropriate dosage. Considering bioavailability, Cmin was only compared in patients receiving oral voriconazole. RESULTS A total of 289 and 186 patients were included in the safety and pharmacokinetic analyses, respectively. There was a significant difference in Cmin measured no later than and after day 5 (3.59 ± 2.12 [RT] vs. 4.77 ± 3.88 μg/mL [DT], p = .023), whereas no significant difference was observed on cutoff day 6 (3.91 ± 2.60 vs. 4.40 ± 3.94 μg/mL, p = .465), suggesting that Cmin close to the steady-state was achieved after day 5. DT causes a delay in achieving the therapeutic range. The hepatotoxicity rates were 21.5% and 36.8% in the RT and DT groups, respectively (p = .004); DT was an independent risk factor for hepatotoxicity. CONCLUSION Although steady-state concentrations may not be achieved by day 5, early dose optimisation using RT can prevent hepatotoxicity in Japanese patients. TDM should be performed on days 3-5 to ensure safety. However, subsequent TDM may be necessary due to a possible further increase in Cmin .
Collapse
Affiliation(s)
- Yuki Hanai
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Toho University, Chiba, Japan
| | - Takashi Ueda
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yukihiro Hamada
- Department of Pharmacy, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Kazutaka Oda
- Department of Pharmacy, Kumamoto University Hospital, Kumamoto, Japan
| | - Yoshiko Takahashi
- Department of Pharmacy, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazuhiko Nakajima
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshitsugu Miyazaki
- Department of Chemotherapy and Mycoses, National Institute of Infectious Diseases, Tokyo, Japan
| | - Mone Kiriyama
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Toho University, Chiba, Japan
| | - Shusuke Uekusa
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Toho University, Chiba, Japan
| | - Kazuhiro Matsuo
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Toho University, Chiba, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Toshimi Kimura
- Department of Pharmacy, Juntendo University Hospital, Tokyo, Japan
| | - Yoshio Takesue
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
- Department of Clinical Infectious Diseases, Tokoname City Hospital, Tokoname, Japan
| |
Collapse
|
5
|
Gu L, Ai T, Pang L, Xu D, Wang H. Voriconazole-Induced Hepatotoxicity in a Patient with Pulmonary Aspergillosis: A Case Report. Infect Drug Resist 2023; 16:5405-5411. [PMID: 37614681 PMCID: PMC10443690 DOI: 10.2147/idr.s419382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 08/01/2023] [Indexed: 08/25/2023] Open
Abstract
Voriconazole is the therapy of choice for aspergillosis. However, hepatotoxicity is the most common reason for the discontinuation of voriconazole. In contrast, posaconazole is well tolerated, with a low incidence of hepatotoxicity. In most cases, hepatotoxicity is associated with high voriconazole trough concentration influenced mainly by cytochrome P450 (CYP) 2C19 gene polymorphism. Compared with normal metabolizers, intermediate and poor metabolizers generally have higher voriconazole trough concentrations with an increased risk of hepatotoxicity. Here, we describe changes in hepatotoxicity throughout azole therapy in a patient with pulmonary aspergillosis (PA). Nevertheless, the patient with the normal metabolism genotype of CYP2C19 developed severe hepatotoxicity caused by voriconazole but tolerated posaconazole well, with a lack of direct cross-hepatotoxicity between the both. Interestingly, the patient had a high risk of hepatotoxicity at a low voriconazole trough concentration. Fortunately, elevated liver enzymes declined to the baselines with posaconazole treatment.
Collapse
Affiliation(s)
- Li Gu
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College and State Key Laboratory for Diagnosis and Treatment of Severe Zoonostic Infectious Disease, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Tao Ai
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Ling Pang
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College and State Key Laboratory for Diagnosis and Treatment of Severe Zoonostic Infectious Disease, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Dong Xu
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College and State Key Laboratory for Diagnosis and Treatment of Severe Zoonostic Infectious Disease, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Han Wang
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| |
Collapse
|
6
|
Xiao G, Liu Y, Chen Y, He Z, Wen Y, Hu M. The Development and Validation of a Predictive Model for Voriconazole-Related Liver Injury in Hospitalized Patients in China. J Clin Med 2023; 12:4254. [PMID: 37445289 DOI: 10.3390/jcm12134254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Voriconazole is widely used in the treatment and prevention of invasive fungal diseases. Common drug-induced liver injuries increase the economic burdens and the risks of premature drug withdrawal and disease recurrence. This study estimated the disposal cost of voriconazole-related liver injury, explored the risk factors of voriconazole-related liver injury in hospitalized patients, and established a predictive model of liver injury to assist clinicians and pharmacists in estimating the probability or risk of liver injury after voriconazole administration to allow for early identification and intervention in patients at high risk of liver injury. A retrospective study was conducted on the selected inpatients whose blood concentration of voriconazole was measured in the West China Hospital of Sichuan University from September 2016 to June 2020. The incidence and disposal cost of voriconazole-related liver injuries were calculated. The incidence of voriconazole-related liver injury was 15.82% (217/1372). The disposal cost has been converted to 2023 at a discount rate of 5%. The median (P25, P75) disposal cost of severe liver injury (n = 42), general liver injury (n = 175), and non-liver injury (n = 1155) was 993.59 (361.70, 1451.76) Chinese yuan, 0.00 (0.00, 410.48) yuan, and 0.00 (0.00, 0.00) yuan, respectively, with a statistically significant difference (p < 0.001). Single factor analysis and multiple factor logistic regression were used to analyze the risk factors of voriconazole-related liver injury. The voriconazole-related liver injury was related to the trough concentration (Cmin, OR 1.099, 95% CI 1.058-1.140), hypoproteinemia (OR 1.723, 95% CI 1.126-2.636), and transplantation status (OR 0.555, 95% CI 0.325-0.948). The prediction model of liver injury was Logit (P)= -2.219 + 0.094 × Cmin + 0.544 × Hydroproteinemia - 0.589 × Transplantation, and the prediction model nomogram was established. The model validation results showed that the C-index of the derivation set and validation set was 0.706 and 0.733, respectively. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve was 0.705 and 0.733, respectively, indicating that the model had good prediction ability. The prediction model will be helpful to develop clinical individualized medication of voriconazole and to identify and intervene in the cases of patients at high risk of voriconazole-related liver injury early on, in order to reduce the incidence of voriconazole-related liver injuries and the cost of treatment.
Collapse
Affiliation(s)
- Guirong Xiao
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yiyao Liu
- West China School of Pharmacy, Sichuan University, Chengdu 610041, China
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yanhua Chen
- Department of Pharmacy, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu 610072, China
| | - Zhiyao He
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yan Wen
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Ming Hu
- West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| |
Collapse
|
7
|
Cheng L, Liang Z, Liu F, Lin L, Zhang J, Xie L, Yu M, Sun F. Factors influencing plasma concentration of voriconazole and voriconazole- N-oxide in younger adult and elderly patients. Front Pharmacol 2023; 14:1126580. [PMID: 36860301 PMCID: PMC9969092 DOI: 10.3389/fphar.2023.1126580] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 02/03/2023] [Indexed: 02/15/2023] Open
Abstract
Background: Voriconazole (VCZ) metabolism is influenced by many factors. Identifying independent influencing factors helps optimize VCZ dosing regimens and maintain its trough concentration (C0) in the therapeutic window. Methods: We conducted a prospective study investigating independent factors influencing VCZ C0 and the VCZ C0 to VCZ N-oxide concentration ratio (C0/CN) in younger adults and elderly patients. A stepwise multivariate linear regression model, including the IL-6 inflammatory marker, was used. The receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive effect of the indicator. Results: A total of 463 VCZ C0 were analyzed from 304 patients. In younger adult patients, the independent factors that influenced VCZ C0 were the levels of total bile acid (TBA) and glutamic-pyruvic transaminase (ALT) and the use of proton-pump inhibitors. The independent factors influencing VCZ C0/CN were IL-6, age, direct bilirubin, and TBA. The TBA level was positively associated with VCZ C0 (ρ = 0.176, p = 0.019). VCZ C0 increased significantly when the TBA levels were higher than 10 μmol/L (p = 0.027). ROC curve analysis indicated that when the TBA level ≥4.05 μmol/L, the incidence of a VCZ C0 greater than 5 μg/ml (95% CI = 0.54-0.74) (p = 0.007) increased. In elderly patients, the influencing factors of VCZ C0 were DBIL, albumin, and estimated glomerular filtration rate (eGFR). The independent factors that affected VCZ C0/CN were eGFR, ALT, γ-glutamyl transferase, TBA, and platelet count. TBA levels showed a positive association with VCZ C0 (ρ = 0.204, p = 0.006) and C0/CN (ρ = 0.342, p < 0.001). VCZ C0/CN increased significantly when TBA levels were greater than 10 μmol/L (p = 0.025). ROC curve analysis indicated that when the TBA level ≥14.55 μmol/L, the incidence of a VCZ C0 greater than 5 μg/ml (95% CI = 0.52-0.71) (p = 0.048) increased. Conclusion: TBA level may serve as a novel marker for VCZ metabolism. eGFR and platelet count should also be considered when using VCZ, especially in elderly patients.
Collapse
Affiliation(s)
| | | | - Fang Liu
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Third Military Medical University, Chongqing, China
| | - Ling Lin
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Third Military Medical University, Chongqing, China
| | - Jiao Zhang
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Third Military Medical University, Chongqing, China
| | - Linli Xie
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Third Military Medical University, Chongqing, China
| | - Mingjie Yu
- *Correspondence: Mingjie Yu, ; Fengjun Sun,
| | | |
Collapse
|
8
|
Gong Y, Zhang L, Liu S, Zhang H, Peng L, Li H, Dai S, Chen B. Continuous voriconazole lavage in managing moderate and severe fungal keratitis: a randomized controlled trial. Graefes Arch Clin Exp Ophthalmol 2023; 261:1639-1649. [PMID: 36642766 DOI: 10.1007/s00417-022-05969-z] [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: 09/15/2022] [Revised: 11/30/2022] [Accepted: 12/28/2022] [Indexed: 01/17/2023] Open
Abstract
PURPOSE To assess the effectiveness and safety of continuous lavage with 1% voriconazole (CL) for moderate and severe fungal keratitis. METHODS Thirty-one patients were randomized to receive topical eye drops either alone (T) or combined with continuous 1% voriconazole lavage (CL-T). The primary outcome was the cure rate at 3 months. The secondary outcomes were the 6-day efficacy, 3-day infiltration size and depth, hypopyon height, central corneal thickness (CCT), epithelial defect size, and subject feelings and clinical signs assessment scores. RESULTS At 3 months, the cure rate was comparable between the groups in patients with moderate fungal keratitis (66.7% vs. 62.5%, P = 0.60). However, among severe cases, 4 cases (44.4%) in the CL-T group healed successfully, while none in the T group; this difference was not significant (P = 0.08), although it was very close to 0.05. This may be related to the small sample size. After 6 days, the percentage of patients with "worsened" ulcers in the CL-T group was lower than that in the T group (0% vs. 31%, P = 0.043). The infiltration size, infiltration depth, and hypopyon height in the CL-T group were smaller than those in the T group after 3 days (all P < 0.05). There was no difference in CCT, epithelial defect size, subject feelings scores, or clinical signs scores between groups. CONCLUSION These outcomes suggest that CL is an effective and safe adjuvant method for controlling the progression of moderate and severe fungal keratitis. TRIAL REGISTRATION NUMBER ChiCTR2100050565.
Collapse
Affiliation(s)
- Yujia Gong
- Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Hunan Clinical Research Center of Ophthalmic Disease, Changsha, 410011, China
| | - Liwei Zhang
- Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Hunan Clinical Research Center of Ophthalmic Disease, Changsha, 410011, China
| | - Shaohua Liu
- Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Hunan Clinical Research Center of Ophthalmic Disease, Changsha, 410011, China
| | - Hongyan Zhang
- Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Hunan Clinical Research Center of Ophthalmic Disease, Changsha, 410011, China
| | - Li Peng
- Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Hunan Clinical Research Center of Ophthalmic Disease, Changsha, 410011, China
| | - Haoyu Li
- Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Hunan Clinical Research Center of Ophthalmic Disease, Changsha, 410011, China
| | - Shirui Dai
- Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Hunan Clinical Research Center of Ophthalmic Disease, Changsha, 410011, China
| | - Baihua Chen
- Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China. .,Hunan Clinical Research Center of Ophthalmic Disease, Changsha, 410011, China.
| |
Collapse
|
9
|
Inose R, Goto R, Shimoki M, Ohmagari N, Muraki Y. Trends in Implementation of Loading Dose of Voriconazole from 2010 to 2019 and Influencing Factors of Loading Dose Based on a Japanese Administrative Claim Database: A Retrospective Cohort Study. Biol Pharm Bull 2023; 46:1838-1841. [PMID: 38044104 DOI: 10.1248/bpb.b23-00524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
A loading dose of voriconazole (VRCZ) is recommended to increase its blood concentration at an early stage. However, the trends in the implementation of the loading dose in VRCZ in Japan has not yet been clarified. In addition, although pharmacists play many important roles in antimicrobial stewardship, the effect of pharmacist intervention on the implementation of a loading dose of VRCZ has not yet been reported. Therefore, this study aimed to clarify the implementation of loading dose of VRCZ and the influencing factors of loading dose. This study used an administrative claims database that included patients who received injectable VRCZ between 2010 and 2019. The implementation of loading doses in the VRCZ was evaluated annually. Multivariate logistic regression analysis was performed to identify the factors influencing loading dose. Overall, 2197 patients were included. The implementation rate of the loading dose remained below 65% throughout the study period. Among medical fees that can be calculated through pharmacist intervention, only the infection prevention and control premium significantly increased the implementation of loading dose of VRCZ (odds ratio: 1.587, 95% confidence interval: 1.053-2.392). In conclusion, antifungal stewardship may have been promoted at medical institutions that established infection prevention and control. In the future, pharmacists will need to intervene more actively from the beginning of VRCZ administration.
Collapse
Affiliation(s)
- Ryo Inose
- Laboratory of Clinical Pharmacoepidemiology, Kyoto Pharmaceutical University
| | - Ryota Goto
- Laboratory of Clinical Pharmacoepidemiology, Kyoto Pharmaceutical University
| | - Misato Shimoki
- Laboratory of Clinical Pharmacoepidemiology, Kyoto Pharmaceutical University
| | - Norio Ohmagari
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine
| | - Yuichi Muraki
- Laboratory of Clinical Pharmacoepidemiology, Kyoto Pharmaceutical University
| |
Collapse
|
10
|
Yang L, Wang C, Zhang Y, Wang Q, Qiu Y, Li S, Yang B, Du Q, Chen J, Teng M, Wang T, Dong Y. Central Nervous System Toxicity of Voriconazole: Risk Factors and Threshold - A Retrospective Cohort Study. Infect Drug Resist 2022; 15:7475-7484. [PMID: 36561883 PMCID: PMC9766498 DOI: 10.2147/idr.s391022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose Voriconazole (VRC) is an antifungal agent which is used for treatment and prophylaxis of invasive fungal infections. The common clinical adverse reactions mainly include central nervous system (CNS) toxicity and abnormal liver function. These adverse reactions limit the clinical use of voriconazole to a certain extent. Therefore, the aim of this study was to analyze the risk factors of voriconazole neurotoxic side effects and to determine the plasma trough concentration (C min) threshold of voriconazole-induced CNS toxicity, so as to improve the safety of voriconazole treatment. Patients and Methods This study retrospectively collected the clinical data of 165 patients who received voriconazole and underwent therapeutic drug monitoring (TDM). CNS toxicity was defined using the National Cancer Institute (NCI) criteria, logistic regression was used to analyze the risk factors of CNS toxicity, classification and Regression tree (CART) model was used to determine the C min threshold for CNS toxicity. Results Voriconazole-related CNS toxicity occurred during treatment in 34 of 165 patients (20.6%) and the median time from administration to onset of CNS toxicity was 6 days (range, 2-19 days). The overall incidence of CNS toxicity was 20.6% (34/165), including visual disturbances in 4.8% (8/165) and nervous system disorders in 15.8% (26/165). C min significantly affects the occurrence of CNS toxicity and the threshold of C min for voriconazole CNS toxicity was determined to be 4.85 mg/L, when C min >4.85 mg/L and ≤4.85 mg/L, the incidence of CNS was 32.9% and 11.6%, respectively. Conclusion Voriconazole trough concentration of C min is an independent risk factor for CNS toxicity, and the threshold of C min for CNS toxicity is 4.85mg/L. TDM should be routinely performed in patients with clinical use of voriconazole to reduce the occurrence of CNS toxicity of voriconazole.
Collapse
Affiliation(s)
- Luting Yang
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Chuhui Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Yijing Zhang
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Quanfang Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Yulan Qiu
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Sihan Li
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Bo Yang
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Qian Du
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Jiaojiao Chen
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Mengmeng Teng
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Taotao Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China,Correspondence: Yalin Dong; Taotao Wang, Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China, Tel +86-29-85323241; Tel/Fax +86-29-85323243, Fax +86-29-85323240, Email ;
| |
Collapse
|
11
|
Takesue Y, Hanai Y, Oda K, Hamada Y, Ueda T, Mayumi T, Matsumoto K, Fujii S, Takahashi Y, Miyazaki Y, Kimura T. Clinical Practice Guideline for the Therapeutic Drug Monitoring of Voriconazole in Non-Asian and Asian Adult Patients: Consensus Review by the Japanese Society of Chemotherapy and the Japanese Society of Therapeutic Drug Monitoring. Clin Ther 2022; 44:1604-1623. [DOI: 10.1016/j.clinthera.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/18/2022] [Accepted: 10/28/2022] [Indexed: 11/23/2022]
|
12
|
Ebihara F, Maruyama T, Kikuchi K, Kimura T, Hamada Y. Antifungal Stewardship Task Shifting Required of Pharmacists. Med Mycol J 2022; 63:109-117. [DOI: 10.3314/mmj.22.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Affiliation(s)
- Fumiya Ebihara
- Department of Pharmacy, Tokyo Women's Medical University Hospital
| | - Takumi Maruyama
- Department of Pharmacy, Tokyo Women's Medical University Hospital
| | - Ken Kikuchi
- Department of Pharmacy, Department of Infectious Disease, Tokyo Women's Medical University Hospital
| | | | - Yukihiro Hamada
- Department of Pharmacy, Tokyo Women's Medical University Hospital
| |
Collapse
|
13
|
Hou J, Marriott D, Cattaneo D, Stocker S, Stojanova J, Alffenaar JW, Xiao C, Zhao Y, Gong H, Yan M. Therapeutic drug monitoring practices of anti-infectives: An Asia-wide cross-sectional survey. Front Pharmacol 2022; 13:992354. [PMID: 36299881 PMCID: PMC9589087 DOI: 10.3389/fphar.2022.992354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/13/2022] [Indexed: 11/30/2023] Open
Abstract
Objectives: The current practice of therapeutic drug monitoring (TDM) in Asia is poorly documented. Our aim was to capture and describe TDM services delivered in hospitals across Asia, including aspects such as assay availability, interpretation of results and clinical decision-making. Methods: An online survey about anti-infective TDM practices, available in English and involving 50 questions, was promoted to people involved in TDM in Asia. The survey was open for responses from September to November 2021. Results: Of 207 responses from participants working in 14 Asian countries, 150 responses from 10 countries could be included. TDM services are available for many anti-infectives, providing assays based on chromatographic assays (100.0%) or immunoassays (39.3%). Clinicians (82.6%) and pharmacists (86.8%) were responsible for ordering and interpreting TDM. Most services provided reference targets and dose recommendations. Interpretative support was available to a varying degree. Assay results were available and clinical decision-making could be completed within 24 h in most hospitals (87.9% and 88.9% respectively). As the turnaround time of assay results decreased, the proportion of clinical decision-making completed within 8 h increased. Barriers to implementation of TDM included lack of funding or equipment (71.1%), lack of clinician interest or cooperation (47.0%), and lack of expertise (42.3%). Lack of expertise was the primary barrier for using precision dosing software (50.5%). Conclusion: There are significant differences and challenges in the development and practice of anti-infective TDM in Asian countries.
Collapse
Affiliation(s)
- Jingjing Hou
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- International Research Center for Precision Medicine, Transformative Technology and Software Services, Changsha, China
| | - Debbie Marriott
- Department of Microbiology and Infectious Diseases, St. Vincent’s Hospital, Sydney, NSW, Australia
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, ASST FBF Sacco University Hospital, Milan, Italy
| | - Sophie Stocker
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- UNSW Sydney, St Vincent’s Clinical School, Sydney, Australia
- Department of Clinical Pharmacology and Toxicology, St Vincent’s Hospital Sydney, Sydney, NSW, Australia
| | - Jana Stojanova
- Department of Clinical Pharmacology and Toxicology, St Vincent’s Hospital Sydney, Sydney, NSW, Australia
| | - Jan-Willem Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Westmead Hospital, Sydney, NSW, Australia
- Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW, Australia
| | - Chenlin Xiao
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- International Research Center for Precision Medicine, Transformative Technology and Software Services, Changsha, China
| | - Yichang Zhao
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- International Research Center for Precision Medicine, Transformative Technology and Software Services, Changsha, China
| | - Hui Gong
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- International Research Center for Precision Medicine, Transformative Technology and Software Services, Changsha, China
| | - Miao Yan
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- International Research Center for Precision Medicine, Transformative Technology and Software Services, Changsha, China
| |
Collapse
|
14
|
Shen K, Gu Y, Wang Y, Lu Y, Ni Y, Zhong H, Shi Y, Su X. Therapeutic drug monitoring and safety evaluation of voriconazole in the treatment of pulmonary fungal diseases. Ther Adv Drug Saf 2022; 13:20420986221127503. [PMID: 36225945 PMCID: PMC9549188 DOI: 10.1177/20420986221127503] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 09/04/2022] [Indexed: 11/07/2022] Open
Abstract
Aims: The gene polymorphism of voriconazole metabolism–related liver enzyme is
notable in East Asia population. It casts a significant influence on the
rational use of voriconazole. We conducted this study to investigate the
relationship between steady-state voriconazole trough concentration
(Ctrough) and adverse effects (AEs), especially
hepatotoxicity. Methods: We conducted a real-world study in the Jinling Hospital from January 2015 to
June 2020. A total of 140 patients receiving voriconazole were enrolled in
this study. The determination and scoring of voriconazole-associated
hepatotoxicity were performed according to the Roussel Uclaf Causality
Assessment Method scoring scale and the severity of hepatotoxicity was
graded according to the Common Terminology Criteria for Adverse Events
(CTCAE). Results: Elevated steady-state voriconazole Ctrough with concomitant AEs
are the most common reason for dose adjustments during treatment. Compared
with the group without any AEs, voriconazole Ctrough was
significantly higher in the hepatotoxicity and neurotoxicity groups, and the
incidence of both events showed an overall increasing trend with increasing
voriconazole Ctrough. Hepatotoxicity occurred in 66.7% of
patients within 7 days of the first dose of voriconazole and 94.4% within
15 days of the dose. Steady-state voriconazole Ctrough
>3.61 mg/l was associated with an increased incidence of hepatotoxicity
(area under the curve = 0.645, p = 0.047). Logistic
regression analysis showed that timely voriconazole dose adjustment was a
predictor of attenuated hepatotoxicity after adjustment for confounders, but
hepatotoxicity was not associated with voriconazole Ctrough
measured at a single time point. Conclusion: Hepatotoxicity and neurotoxicity correlate with voriconazole
Ctrough, and dose reduction in patients with elevated
steady-state voriconazole Ctrough may prevent hepatotoxicity. In
patients with early occurrence of hepatotoxicity, initial therapeutic drug
monitoring (TDM) might predict the risk of hepatotoxicity. Follow-up TDM may
be necessary to predict late onset hepatotoxicity. Plain Language Summary Safety of voriconazole for the treatment of pulmonary fungal
diseases Introduction: Several studies have suggested an association
between the concentration of voriconazole in the blood and liver damage, but
the evidence is weak. This study aimed to investigate relationships between
voriconazole drug concentration and side effects and to analyze the factors
affecting liver damage caused by voriconazole. Methods: We conducted a study at the Jinling Hospital from
January 2015 to June 2020, in which a total of 140 patients were finally
enrolled. Results: Voriconazole doses were adjusted in 44 patients due to
abnormal voriconazole drug concentration or side effects, 32 patients
reduced the dose and 8 patients increased the dose. An elevated liver enzyme
level was the most common cause for dose adjustment. After the first dose
adjustment, most patients achieved the target drug concentration. A total of
18 patients were determined as probable or highly probable to have
drug-induced liver injury from voriconazole. Voriconazole drug concentration
was significantly higher in the liver damage and nervous system damage
groups as compared with the group without any side effects, and most liver
damage events occurred within 14 days of the first dose. Voriconazole drug
concentration >3.61 mg/l was associated with an increased incidence of
liver damage. Conclusion: In this study, approximately one-third of patients
with pulmonary fungal disease needed to adjust their dose after the standard
dose of voriconazole treatment. The incidence of liver damage and nervous
system damage showed an overall increasing trend with increasing
voriconazole baseline concentrations. Initial therapeutic drug monitoring
may be predictive of liver damage. Follow-up monitoring of liver enzymes may
be needed.
Collapse
Affiliation(s)
- Kunlu Shen
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, The First School of Clinical Medicine, Southern
Medical University, Nanjing, China
| | - Yu Gu
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Yu Wang
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing,
China
| | - Yajie Lu
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing,
China
| | - Yueyan Ni
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Huanhiuan Zhong
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing,
China
| | - Yi Shi
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing,
China
| | | |
Collapse
|
15
|
Current Aspects of Pediatric Pharmacokinetics and Pharmacodynamics of Antimicrobials in Japan: Importance of the Promotion of Population PK/PD Analysis. Pediatr Infect Dis J 2022; 41:e418-e423. [PMID: 35763684 DOI: 10.1097/inf.0000000000003622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pharmacologic knowledge is important for pediatricians conducting feasible pharmacokinetic or pharmacodynamic (PK/PD) studies or applying effective antimicrobial therapies in children. Because of the difficulties in conducting PK/PD studies in children, antimicrobial PK/PD data in children are still limited. To fill in the lack of knowledge, promotion of population PK/PD analysis, which allows us to handle sparse sampling data from individual patients, is important because it is considered a suitable methodology to conduct PK/PD studies in children with limited blood drug concentration data for PK/PD analysis. Population PK/PD analysis is also useful in the clinical setting to provide individualized optimal dosage for each patient with various conditions. Here we summarized the current aspects of pediatric PK/PD studies of antimicrobials in Japan from clinical and research perspectives, specifically focusing on the importance of population PK/PD analysis.
Collapse
|
16
|
High-Performance Liquid Chromatography for Ultra-Simple Determination of Plasma Voriconazole Concentration. J Fungi (Basel) 2022; 8:jof8101035. [PMID: 36294600 PMCID: PMC9604553 DOI: 10.3390/jof8101035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Voriconazole is an antifungal drug used to treat invasive aspergillosis. Voriconazole exhibits nonlinear behavior and considerable individual variability in its pharmacokinetic profile. Invasive aspergillosis has a poor prognosis, and failure of treatment owing to low voriconazole blood levels is undesirable. Thus, therapeutic drug monitoring (TDM) of voriconazole is recommended. However, plasma voriconazole concentration is rarely measured in hospitals, and the TDM of voriconazole is not widely practiced in Japan. We aimed to develop an ultra-simple method to measure plasma voriconazole concentration. Ten microliters of plasma sample was extracted, and proteins were precipitated using methanol extraction. Voriconazole and ketoconazole (internal standard) were separated using high-performance liquid chromatography. A calibration curve was prepared, which was linear over plasma voriconazole concentrations of 0.125−12.5 µg/mL, with a coefficient of determination of 0.9999. The intra-day and inter-day validation coefficients were 0.9−2.2% and 1.3−6.1%, respectively. The assay accuracy was −4.2% to 1.6%, and recovery was >97.8%. Our ultra-simple, sensitive, and inexpensive high-performance liquid chromatography ultraviolet method to determine plasma voriconazole concentration will help improve the voriconazole TDM implementation rate and contribute to effective and safe voriconazole use.
Collapse
|
17
|
Kably B, Launay M, Derobertmasure A, Lefeuvre S, Dannaoui E, Billaud EM. Antifungal Drugs TDM: Trends and Update. Ther Drug Monit 2022; 44:166-197. [PMID: 34923544 DOI: 10.1097/ftd.0000000000000952] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/09/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The increasing burden of invasive fungal infections results in growing challenges to antifungal (AF) therapeutic drug monitoring (TDM). This review aims to provide an overview of recent advances in AF TDM. METHODS We conducted a PubMed search for articles during 2016-2020 using "TDM" or "pharmacokinetics" or "drug-drug-interaction" with "antifungal," consolidated for each AF. Selection was limited to English language articles with human data on drug exposure. RESULTS More than 1000 articles matched the search terms. We selected 566 publications. The latest findings tend to confirm previous observations in real-life clinical settings. The pharmacokinetic variability related to special populations is not specific but must be considered. AF benefit-to-risk ratio, drug-drug interaction (DDI) profiles, and minimal inhibitory concentrations for pathogens must be known to manage at-risk situations and patients. Itraconazole has replaced ketoconazole in healthy volunteers DDI studies. Physiologically based pharmacokinetic modeling is widely used to assess metabolic azole DDI. AF prophylactic use was studied more for Aspergillus spp. and Mucorales in oncohematology and solid organ transplantation than for Candida (already studied). Emergence of central nervous system infection and severe infections in immunocompetent individuals both merit special attention. TDM is more challenging for azoles than amphotericin B and echinocandins. Fewer TDM requirements exist for fluconazole and isavuconazole (ISZ); however, ISZ is frequently used in clinical situations in which TDM is recommended. Voriconazole remains the most challenging of the AF, with toxicity limiting high-dose treatments. Moreover, alternative treatments (posaconazole tablets, ISZ) are now available. CONCLUSIONS TDM seems to be crucial for curative and/or long-term maintenance treatment in highly variable patients. TDM poses fewer cost issues than the drugs themselves or subsequent treatment issues. The integration of clinical pharmacology into multidisciplinary management is now increasingly seen as a part of patient care.
Collapse
Affiliation(s)
- Benjamin Kably
- Laboratoire de Pharmacologie-Toxicologie, Hôpital Européen Georges Pompidou, AP-HP Centre
- Faculté de Médecine, Université de Paris, Paris, France
| | - Manon Launay
- Laboratoire de Pharmacologie-Toxicologie-Gaz du sang, Hôpital Nord-CHU Saint Etienne, Saint-Etienne
| | - Audrey Derobertmasure
- Laboratoire de Pharmacologie-Toxicologie, Hôpital Européen Georges Pompidou, AP-HP Centre
| | - Sandrine Lefeuvre
- Laboratoire de Toxicologie et Pharmacocinétique, CHU de Poitiers, Poitiers; and
| | - Eric Dannaoui
- Faculté de Médecine, Université de Paris, Paris, France
- Unité de Parasitologie-Mycologie, Laboratoire de Microbiologie, Hôpital Européen Georges Pompidou, Paris, France
| | - Eliane M Billaud
- Laboratoire de Pharmacologie-Toxicologie, Hôpital Européen Georges Pompidou, AP-HP Centre
- Faculté de Médecine, Université de Paris, Paris, France
| |
Collapse
|
18
|
Association between voriconazole exposure and Sequential Organ Failure Assessment (SOFA) score in critically ill patients. PLoS One 2021; 16:e0260656. [PMID: 34818379 PMCID: PMC8612507 DOI: 10.1371/journal.pone.0260656] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/07/2021] [Indexed: 12/01/2022] Open
Abstract
Therapeutic drug monitoring (TDM) is essential for voriconazole to ensure optimal drug exposure, mainly in critically ill patients for whom voriconazole demonstrated a large variability. The study aimed at describing factors associated with trough voriconazole concentrations in critically ill patients and evaluating the impact of voriconazole concentrations on adverse effects. A 2-year retrospective multicenter cohort study (NCT04502771) was conducted in six intensive care units. Adult patients who had at least one voriconazole TDM were included. Univariable and multivariable linear regression analyses were performed to identify predictors of voriconazole concentrations, and univariable logistic regression analysis, to study the relationship between voriconazole concentrations and adverse effects. During the 2-year study period, 70 patients were included. Optimal trough voriconazole concentrations were reported in 37 patients (52.8%), subtherapeutic in 20 (28.6%), and supratherapeutic in 13 (18.6%). Adverse effects were reported in six (8.6%) patients. SOFA score was identified as a factor associated with an increase in voriconazole concentration (p = 0.025), mainly in the group of patients who had SOFA score ≥ 10. Moreover, an increase in voriconazole concentration was shown to be a risk factor for occurrence of adverse effects (p = 0.011). In that respect, critically ill patients who received voriconazole treatment must benefit from a TDM, particularly if they have a SOFA score ≥ 10. Indeed, identifying patients who are overdosed will help to prevent voriconazole related adverse effects. This result is of utmost importance given the recognized COVID-19-associated pulmonary aspergillosis in ICU patients for whom voriconazole is among the recommended first-line treatment.
Collapse
|
19
|
Hamada Y, Ebihara F, Kikuchi K. A Strategy for Hospital Pharmacists to Control Antimicrobial Resistance (AMR) in Japan. Antibiotics (Basel) 2021; 10:1284. [PMID: 34827222 PMCID: PMC8614892 DOI: 10.3390/antibiotics10111284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 10/19/2021] [Accepted: 10/19/2021] [Indexed: 12/21/2022] Open
Abstract
In Japan, there is concern regarding the relation between the inappropriate use of antibiotics and antibiotic resistance (AMR). Increased bacterial resistance is due in part to the inappropriate use of antimicrobial agents. The support of the pharmacist becomes important, and there is growing interest in antimicrobial stewardship to promote the appropriate and safe use of antimicrobials needed for the optimal selection of drugs, doses, durations of therapy, therapeutic drug monitoring (TDM), and implementations of cost containment strategies in Japan. Pharmacists should strive to disseminate the concept of "choosing wisely" in relation to all medicines, implement further interventions, and put them into practice. In this article, we present data for antimicrobial stewardship and Japan's AMR action plan, focusing on how pharmacists should be involved in enabling physicians to choose antimicrobials wisely.
Collapse
Affiliation(s)
- Yukihiro Hamada
- Department of Pharmacy, Tokyo Women’s Medical University Hospital, Tokyo 162-8666, Japan;
| | - Fumiya Ebihara
- Department of Pharmacy, Tokyo Women’s Medical University Hospital, Tokyo 162-8666, Japan;
| | - Ken Kikuchi
- Department of Infectious Disease, Tokyo Women’s Medical University Hospital, Tokyo 162-8666, Japan;
| |
Collapse
|
20
|
Impact of CYP2C19 Phenotype and Drug-Drug Interactions on Voriconazole Concentration in Pediatric Patients. Antimicrob Agents Chemother 2021; 65:e0020721. [PMID: 34152823 DOI: 10.1128/aac.00207-21] [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] [Indexed: 12/24/2022] Open
Abstract
Voriconazole (VRC), a first-line agent for the treatment of invasive fungal infections, is mainly metabolized by human cytochrome P450 (CYP) 2C19. In this study, a retrospective analysis was performed to investigate the key factors that influence the plasma trough concentration (Cmin) of VRC, and an appropriate dosing regimen for pediatric patients was drafted subsequently. Overall, factors such as age, CYP2C19 phenotype, and combination medication with proton pump inhibitors accounted for 23.4% of variability in dose-normalized Cmin values of VRC by a multiple linear regression analysis. Dose-normalized Cmin values in the poor metabolizers (PMs) and intermediate metabolizers (IMs) were significantly higher than those in extensive metabolizers (EMs) (P < 0.001). To achieve therapeutic Cmin for CYP2C19 ultrarapid metabolizers (UMs) or EMs, patients aged no more than 12 and more than 12 years required doses of 6.53 ± 2.08 and 3.95 ± 0.85 mg/kg of body weight twice daily (P = 0.007). For CYP2C19 PMs or IMs, patients aged under 12 and over 12 years required doses of 5.75 ± 1.73 and 4.23 ± 0.76 mg/kg twice daily, respectively (P = 0.019). Furthermore, coadministration of rifamycin sodium or omeprazole exhibited significant effects on VRC Cmin. Taken together, it is necessary to pay attention to the impact of CYP2C19 phenotype and drug-drug interactions to achieve optimal therapy.
Collapse
|
21
|
Aldossary S, Shah A. Healthcare Utilization and Impact of Antifungal Stewardships Within Respiratory Care Settings: A Systematic Literature Review. Mycopathologia 2021; 186:673-684. [PMID: 33991279 PMCID: PMC8536614 DOI: 10.1007/s11046-021-00547-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/17/2021] [Indexed: 12/27/2022]
Abstract
Introduction Fungal infection and sensitization are common in chronic respiratory patient populations such as bronchiectasis, chronic obstructive pulmonary disease (COPD), and cystic fibrosis (CF) and are often associated with prolonged antifungal therapy (Hohmann et al. in Clin Infect Dis 15:939–940, 2010; Vissichelli et al. in Infect Prev Pract 1:100029, 2019), morbidity, and mortality. Although the use of antifungal stewardship (AFS) is increasing within an invasive fungal disease setting, its use and impact within a chronic respiratory setting have not been defined. Methods A systematic literature review was conducted using PRISMA guidelines to evaluate the use of antifungal stewardship within a chronic respiratory care setting. Three databases have been searched, Medline via Ovid, Embase and GlobalHealth, for papers published between 1949 and 2020. Results The initial search identified 987 papers from Medline, 1761 papers from Embase, and 481 papers from GlobalHealth. Only 28 papers met the criteria for inclusion in this systematic literature review. The included studies were subjected to CASP and GRADE assessments to rank their quality and applicability. Only two studies were focussed on Aspergillus species infection. Conclusion Although antifungal stewardship is increasing, its applications are still limited in chronic respiratory care settings despite the prolonged requirement for antifungal therapy and high antimicrobial resistance. Supplementary Information The online version contains supplementary material available at 10.1007/s11046-021-00547-z.
Collapse
Affiliation(s)
- Salma Aldossary
- Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Anand Shah
- Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
- MRC Centre of Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK.
| |
Collapse
|
22
|
Favorable Effects of Voriconazole Trough Concentrations Exceeding 1 μg/mL on Treatment Success and All-Cause Mortality: A Systematic Review and Meta-Analysis. J Fungi (Basel) 2021; 7:jof7040306. [PMID: 33923727 PMCID: PMC8072959 DOI: 10.3390/jof7040306] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 12/23/2022] Open
Abstract
This systematic review and meta-analysis examined the optimal trough concentration of voriconazole for adult patients with invasive fungal infections. We used stepwise cutoffs of 0.5-2.0 μg/mL for efficacy and 3.0-6.0 μg/mL for safety. Studies were included if they reported the rates of all-cause mortality and/or treatment success, hepatotoxicity, and nephrotoxicity according to the trough concentration. Twenty-five studies involving 2554 patients were included. The probability of mortality was significantly decreased using a cutoff of ≥1.0 μg/mL (odds ratio (OR) = 0.34, 95% confidence interval (CI) = 0.15-0.80). Cutoffs of 0.5 (OR = 3.48, 95% CI = 1.45-8.34) and 1.0 μg/mL (OR = 3.35, 95% CI = 1.52-7.38) also increased the treatment success rate. Concerning safety, significantly higher risks of hepatotoxicity and neurotoxicity were demonstrated at higher concentrations for all cutoffs, and the highest ORs were recorded at 4.0 μg/mL (OR = 7.39, 95% CI = 3.81-14.36; OR = 5.76, 95% CI 3.14-10.57, respectively). Although further high-quality trials are needed, our findings suggest that the proper trough concentration for increasing clinical success while minimizing toxicity is 1.0-4.0 μg/mL for adult patients receiving voriconazole therapy.
Collapse
|
23
|
Hamada Y, Ueda T, Miyazaki Y, Nakajima K, Fukunaga K, Miyazaki T, Nakada-Motokawa N, Nagao M, Kawamura H, Shigemi A, Ebihara F, Kimura T, Ikegame K, Uchino M, Ikeuchi H, Takesue Y. Effects of antifungal stewardship using therapeutic drug monitoring in voriconazole therapy on the prevention and control of hepatotoxicity and visual symptoms: A multicentre study conducted in Japan. Mycoses 2020; 63:779-786. [PMID: 32510723 PMCID: PMC7496238 DOI: 10.1111/myc.13129] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/27/2020] [Accepted: 06/01/2020] [Indexed: 11/25/2022]
Abstract
Background Hepatotoxicity and visual symptoms are common adverse effects (AEs) of voriconazole therapy. Objective To retrospectively evaluate the effects of treatment modification based on therapeutic drug monitoring on AEs in patients undergoing voriconazole therapy. Methods The target voriconazole trough concentration (Cmin) was 1‐5 µg/mL. Receiver operating characteristic curves were used to determine Cmin cut‐offs for AEs. Results A total of 401 patients were included. Among 108 patients with high initial Cmin, voriconazole was discontinued in 32 and the dose was reduced in 71. Among 44 patients with low initial Cmin, voriconazole was discontinued in 4 and the dose was increased in 19. Hepatotoxicity occurred in 6.0% of patients, after a median of 10 days. Visual symptoms were evident in 9.5% of patients after a median of 4 days. Initial Cmin was significantly associated with visual symptoms but not hepatotoxicity, which suggested the effect of treatment modification on hepatotoxicity. However, both hepatotoxicity and visual symptoms were significantly correlated with Cmin at the onset of AEs, and the Cmin cut‐offs were 3.5 μg/mL for hepatotoxicity and 4.2 μg/mL for visual symptoms. Voriconazole was discontinued after the occurrence of AEs in 62.5% of patients with hepatotoxicity but only 26.3% of patients with visual symptoms. With dose adjustment, treatment was completed in 8/9 patients with hepatotoxicity and 27/28 patients with visual symptoms. Conclusions A significant preventive effect was demonstrated on hepatotoxicity, but not on visual symptoms because of earlier occurrence. With treatment modification after the occurrence of AEs, most patients completed therapy.
Collapse
Affiliation(s)
- Yukihiro Hamada
- Department of Pharmacy, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Takashi Ueda
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshitsugu Miyazaki
- Department of Chemotherapy and Mycoses, National Institute of Infectious Diseases, Tokyo, Japan
| | - Kazuhiko Nakajima
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Keiko Fukunaga
- Department of Hematology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Taiga Miyazaki
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Nana Nakada-Motokawa
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Miki Nagao
- Department of Infection Control and Prevention, Kyoto University Hospital, Kyoto, Japan
| | - Hideki Kawamura
- Division of Medical and Environmental Safety, Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan
| | - Akari Shigemi
- Division of Medical and Environmental Safety, Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan
| | - Fumiya Ebihara
- Department of Pharmacy, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Toshimi Kimura
- Department of Pharmacy, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Kazuhiro Ikegame
- Department of Hematology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Motoi Uchino
- Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroki Ikeuchi
- Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshio Takesue
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| |
Collapse
|