1
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Wei XC, Zhao MF, Xiao X. Supratherapeutic posaconazole concentrations associated with hyperlipidemia in a patient with HSCT. J Infect Chemother 2024; 30:255-257. [PMID: 37832823 DOI: 10.1016/j.jiac.2023.10.008] [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: 08/17/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 10/15/2023]
Abstract
Posaconazole is a potent, extended-spectrum triazole antifungal used for the treatment and prophylaxis of serious fungal infections. Previous reports have demonstrated hyperlipidemia resulted in significant changes in posaconazole pharmacokinetics and tissue distribution in rats. However, the effect of hyperlipidemia on the pharmacokinetics of posaconazole in patients has not yet been reported. We report a case of a 34-year-old woman who experienced a supratherapeutic posaconazole trough concentration (PTC) associated with hyperlipidemia after haploidentical hematopoietic stem cell transplantation (HSCT). The patient was admitted 13 months after HSCT for recurrent cough and sputum. She was treated with caspofungin due to developing invasive fungal infection of Candida tropicalis. After 10 days, caspofungin was discontinued due to the poor therapeutic efficacy and replaced with amphotericin B. Afterwards, the condition of the patient improved significantly and she was switched to daily oral posaconazole tablet. Therapeutic drug monitoring (TDM) of posaconazole showed a PTC was 3.2 mg/L. After discharge, she continued to receive posaconazole tablet as antifungal treatment. Two months later, laboratory tests at outpatient showed her blood lipid levels were significantly elevated and PTC was increased to 9.38 mg/L. Therefore, the posaconazole tablet was discontinued and she received lipid-lowering therapy. A few days later, the PTC was down to 5.22 mg/L. No medication errors and significant drug interactions were found. Hence, supratherapeutic PTC for this patient may be caused by hyperlipidemia which altered pharmacokinetics of posaconazole. Our findings highlight the need for close TDM in order to avoid supratherapeutic PTC if hyperlipidimia occurs during posaconazole use.
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Affiliation(s)
- Xiao-Chen Wei
- Department of Pharmacy, Tianjin First Central Hospital, Tianjin, PR China.
| | - Ming-Feng Zhao
- Department of Hematology, Tianjin First Central Hospital, Tianjin, PR China
| | - Xia Xiao
- Department of Hematology, Tianjin First Central Hospital, Tianjin, PR China
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2
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Jensen K, Saleh OA, Chesdachai S, Jannetto PJ, Mara KC, Yetmar ZA, Rivera CG. Association of adverse effects with high serum posaconazole concentrations. Med Mycol 2023; 61:myad079. [PMID: 37537152 PMCID: PMC10414342 DOI: 10.1093/mmy/myad079] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/13/2023] [Accepted: 08/01/2023] [Indexed: 08/05/2023] Open
Abstract
Posaconazole therapeutic drug monitoring (TDM) is widely utilized to assess therapeutic efficacy and safety; however, clinical effects of very high serum concentrations are unknown. A retrospective review of 90 patients receiving posaconazole for treatment or prophylaxis of invasive fungal infections with serum concentrations ≥3000 ng/mL from 1/1/2019 to 4/30/2021 evaluated the incidence and type of adverse drug reactions (ADRs). Symptomatic ADRs were very common in patients with posaconazole concentrations of ≥5000 ng/mL and 3000-4999 ng/mL (80% vs. 58.8%; P = 0.31). Posaconazole TDM should be performed for both treatment and prophylaxis indications and dose decrease for serum concentrations >3000 ng/mL should be considered.
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Affiliation(s)
- Kelsey Jensen
- Department of Pharmacy, Mayo Clinic Health System, Austin, MN, USA
| | - Omar Abu Saleh
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Supavit Chesdachai
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paul J Jannetto
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Zachary A Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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3
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Almeida MA, Bernardes-Engemann AR, Coelho RA, Lugones CJG, de Andrade IB, Corrêa-Junior D, de Oliveira SSC, Dos Santos ALS, Frases S, Rodrigues ML, Valente RH, Zancopé-Oliveira RM, Almeida-Paes R. Mebendazole Inhibits Histoplasma capsulatum In Vitro Growth and Decreases Mitochondrion and Cytoskeleton Protein Levels. J Fungi (Basel) 2023; 9:jof9030385. [PMID: 36983553 PMCID: PMC10051957 DOI: 10.3390/jof9030385] [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: 01/26/2023] [Revised: 03/13/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Histoplasmosis is a frequent mycosis in people living with HIV/AIDS and other immunocompromised hosts. Histoplasmosis has high rates of mortality in these patients if treatment is unsuccessful. Itraconazole and amphotericin B are used to treat histoplasmosis; however, both antifungals have potentially severe pharmacokinetic drug interactions and toxicity. The present study determined the minimal inhibitory and fungicidal concentrations of mebendazole, a drug present in the NIH Clinical Collection, to establish whether it has fungicidal or fungistatic activity against Histoplasma capsulatum. Protein extracts from H. capsulatum yeasts, treated or not with mebendazole, were analyzed by proteomics to understand the metabolic changes driven by this benzimidazole. Mebendazole inhibited the growth of 10 H. capsulatum strains, presenting minimal inhibitory concentrations ranging from 5.0 to 0.08 µM. Proteomics revealed 30 and 18 proteins exclusively detected in untreated and mebendazole-treated H. capsulatum yeast cells, respectively. Proteins related to the tricarboxylic acid cycle, cytoskeleton, and ribosomes were highly abundant in untreated cells. Proteins related to the nitrogen, sulfur, and pyrimidine metabolisms were enriched in mebendazole-treated cells. Furthermore, mebendazole was able to inhibit the oxidative metabolism, disrupt the cytoskeleton, and decrease ribosomal proteins in H. capsulatum. These results suggest mebendazole as a drug to be repurposed for histoplasmosis treatment.
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Affiliation(s)
- Marcos Abreu Almeida
- Laboratório de Micologia, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil
| | - Andrea Reis Bernardes-Engemann
- Laboratório de Micologia, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil
| | - Rowena Alves Coelho
- Laboratório de Micologia, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil
| | - Camila Jantoro Guzman Lugones
- Laboratório de Micologia, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil
| | - Iara Bastos de Andrade
- Laboratório de Biofísica de Fungos, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, Brazil
| | - Dario Corrêa-Junior
- Laboratório de Biofísica de Fungos, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, Brazil
| | - Simone Santiago Carvalho de Oliveira
- Laboratório de Estudos Avançados de Microrganismos Emergentes e Resistentes, Departamento de Microbiologia Geral, Instituto de Microbiologia Paulo de Goés, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, Brazil
| | - André Luis Souza Dos Santos
- Laboratório de Estudos Avançados de Microrganismos Emergentes e Resistentes, Departamento de Microbiologia Geral, Instituto de Microbiologia Paulo de Goés, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, Brazil
- Rede Micologia RJ, Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), Rio de Janeiro 21941-901, Brazil
| | - Susana Frases
- Laboratório de Biofísica de Fungos, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, Brazil
- Rede Micologia RJ, Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), Rio de Janeiro 21941-901, Brazil
| | | | - Richard Hemmi Valente
- Laboratório de Toxinologia, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil
| | - Rosely Maria Zancopé-Oliveira
- Laboratório de Micologia, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil
| | - Rodrigo Almeida-Paes
- Laboratório de Micologia, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil
- Rede Micologia RJ, Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), Rio de Janeiro 21941-901, Brazil
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4
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Ji HH, Tang XW, Zhang N, Huo BN, Liu Y, Song L, Jia YT. Antifungal Therapy with Azoles Induced the Syndrome of Acquired Apparent Mineralocorticoid Excess: a Literature and Database Analysis. Antimicrob Agents Chemother 2022; 66:e0166821. [PMID: 34662186 PMCID: PMC8765306 DOI: 10.1128/aac.01668-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/02/2021] [Indexed: 11/20/2022] Open
Abstract
We aimed to estimate the risk of varied antifungal therapy with azoles causing the syndrome of acquired apparent mineralocorticoid excess (AME) in real-world practice. First, we conducted a disproportionality analysis based on data from the FDA Adverse Event Reporting System (FAERS) database to characterize the signal differences of triazoles-related AME. Second, a systematic review was conducted, and clinical features of AME cases reported in clinical practice were described. In the FAERS database, we identified 27 cases of triazoles-AME, posaconazole [ROR = 865.37; 95%CI (464.14; 1613.45)], and itraconazole [ROR = 556.21; 95% (303.05; 1020.85)] significantly increased the risk of AME events, while fluconazole, voriconazole, and isavuconazole did not affect any of the mineralocorticoid excess targets. Eighteen studies with 39 cases raised evidence of AME following posaconazole and itraconazole treatment, and another 27 cases were identified by analysis of the description of clinical features in the FAERS database. The average age of 66 patients was 55.5 years (6-87 years). AME mainly occurs in patients with posaconazole concentrations above 3 μg/mL (mean = 4.4 μg/mL, range 1.8∼9.5 μg/mL), and is less likely to occur when levels are below 2 μg/mL (6%). The median time to event onset was 11.5 weeks, and 50% of the adverse events occurred within 3 months for posaconazole. The presented study supports very recent findings that posaconazole and itraconazole, but not the other three azole antifungals investigated, are associated with AME and that the effects are dose-dependent, which allows for a dose de-escalation strategy and for substitution with fluconazole, isavuconazole, or voriconazole to resolve the adverse effects.
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Affiliation(s)
- Huan-huan Ji
- Department of Pharmacy, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xue-wen Tang
- Chengdu Shuchuang Linyan Technology Co., Ltd, Chengdu, China
| | - Ni Zhang
- Department of Pharmacy, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Ben-nian Huo
- Department of Pharmacy, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Ying Liu
- Department of Pharmacy, National Center for Children‘s Health, Beijing Children’s Hospital, Capital Medical University, Beijing, China
| | - Lin Song
- Department of Pharmacy, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yun-tao Jia
- Department of Pharmacy, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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5
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Davis MR, Nguyen MVH, Gintjee TJ, Odermatt A, Young BY, Thompson GR. Management of posaconazole-induced pseudohyperaldosteronism. J Antimicrob Chemother 2021; 75:3688-3693. [PMID: 32830274 DOI: 10.1093/jac/dkaa366] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/25/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Posaconazole-induced pseudohyperaldosteronism (PIPH) has been associated with elevated posaconazole serum concentrations. Clinicians are faced with the difficult task of managing patients with PIPH while maintaining the efficacy of antifungal therapy. Commonly, modifications to posaconazole therapy are utilized in managing PIPH, including dosage reduction of posaconazole or switch to an alternative antifungal. OBJECTIVES To characterize the management of patients diagnosed with PIPH and their response to various therapeutic interventions. METHODS We retrospectively reviewed 20 consecutive adult patients diagnosed with PIPH. Patient data collected included blood pressure, electrolytes, endocrine laboratory values and posaconazole serum concentrations collected before and after therapeutic intervention. RESULTS Of 20 patients included, 17 patients (85%) underwent therapeutic modification, with posaconazole dose reduction (n = 11) as the most common change. Other modifications included discontinuation (n = 3), switch to an alternative antifungal (n = 2) and addition of spironolactone (n = 1). Clinical improvement (decrease in systolic blood pressure and increase in serum potassium) was observed in 9 of 17 patients (52.9%). An average decrease in systolic blood pressure of 7.1 mmHg and increase in serum potassium of 0.22 mmol/L was observed following therapeutic modification. CONCLUSIONS We report our experience with PIPH management, for which there is no universally effective strategy. We utilized a stepwise approach for management, starting with posaconazole dose reduction and repeat assessment of clinical and laboratory parameters. If resolution of PIPH is not achieved, an alternative triazole antifungal or the addition of an aldosterone antagonist are additional potential interventions. It is possible for PIPH to persist after therapeutic modification despite these interventions. Thus, early diagnosis and continuous monitoring is warranted.
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Affiliation(s)
- Matthew R Davis
- Department of Pharmacy, University of California Los Angeles Ronald Reagan Medical Center, Los Angeles, CA, USA
| | - Minh-Vu H Nguyen
- Department of Internal Medicine, Division of Infectious Diseases, University of California-Davis Health, Sacramento, CA, USA
| | - Thomas J Gintjee
- Department of Pharmacy, University of California-Davis Health, Sacramento, CA, USA
| | - Alex Odermatt
- Swiss Centre for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Brian Y Young
- Department of Internal Medicine, Division of Nephrology, University of California-Davis Health, Sacramento, CA, USA
| | - George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases, University of California-Davis Health, Sacramento, CA, USA.,Department of Medical Microbiology and Immunology, University of California-Davis Health, Sacramento, CA, USA.,University of California-Davis Center for Valley Fever, Davis, CA, USA
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6
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Beck KR, Odermatt A. Antifungal therapy with azoles and the syndrome of acquired mineralocorticoid excess. Mol Cell Endocrinol 2021; 524:111168. [PMID: 33484741 DOI: 10.1016/j.mce.2021.111168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 12/31/2020] [Accepted: 01/06/2021] [Indexed: 10/22/2022]
Abstract
The syndromes of mineralocorticoid excess describe a heterogeneous group of clinical manifestations leading to endocrine hypertension, typically either through direct activation of mineralocorticoid receptors or indirectly by impaired pre-receptor enzymatic regulation or through disturbed renal sodium homeostasis. The phenotypes of these disorders can be caused by inherited gene variants and somatic mutations or may be acquired upon exposures to exogenous substances. Regarding the latter, the symptoms of an acquired mineralocorticoid excess have been reported during treatment with azole antifungal drugs. The current review describes the occurrence of mineralocorticoid excess particularly during the therapy with posaconazole and itraconazole, addresses the underlying mechanisms as well as inter- and intra-individual differences, and proposes a therapeutic drug monitoring strategy for these two azole antifungals. Moreover, other therapeutically used azole antifungals and ongoing efforts to avoid adverse mineralocorticoid effects of azole compounds are shortly discussed.
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Affiliation(s)
- Katharina R Beck
- Swiss Centre for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Alex Odermatt
- Swiss Centre for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland.
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7
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Nguyen MVH, Davis MR, Wittenberg R, Mchardy I, Baddley JW, Young BY, Odermatt A, Thompson GR. Posaconazole Serum Drug Levels Associated With Pseudohyperaldosteronism. Clin Infect Dis 2021; 70:2593-2598. [PMID: 31403165 DOI: 10.1093/cid/ciz741] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 08/01/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Posaconazole tablets are well tolerated and efficacious in the prophylaxis and treatment of aspergillosis, mucormycosis, and other invasive fungal infections. There have been case reports of posaconazole-induced pseudohyperaldosteronism (PIPH); however, its occurrence and association with serum posaconazole drug levels have not previously been investigated. METHODS In this single-center, retrospective, observational study, we examined the occurrence of PIPH in outpatients newly starting posaconazole and evaluated differences in serum posaconazole concentrations and clinical characteristics between those with and without this syndrome. RESULTS Sixty-nine patients receiving posaconazole were included, of whom 16 (23.2%) met the definition of PIPH. Patients with PIPH were significantly older (61.1 vs 44.7 years, P = .007) and more frequently had hypertension prior to starting posaconazole (68.8% vs 32.1%, P = .009). Patients with PIPH had a significantly higher median serum posaconazole level than those without PIPH (3.0 vs 1.2 µg/mL, P ≤ .0001). There was a positive correlation between serum posaconazole levels and changes in systolic blood pressure (r = .37, P = .01), a negative correlation between serum posaconazole levels and changes in serum potassium (r = -.39, P = .006), and a positive correlation between serum posaconazole levels and serum 11-deoxycortisol (r = .69, P < .0001). CONCLUSIONS Posaconazole is associated with secondary hypertension and hypokalemia, consistent with pseudohyperaldosteronism, and development is associated with higher serum posaconazole concentrations, older age, and baseline hypertension.
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Affiliation(s)
- Minh-Vu H Nguyen
- Department of Internal Medicine, University of California-Davis Health, Sacramento, California, USA; , Basel, Switzerland
| | - Matthew R Davis
- Department of Pharmacy, University of California-Davis Health, Sacramento, California, USA; , Basel, Switzerland
| | - Rebecca Wittenberg
- Department of Pharmacy, University of California-Davis Health, Sacramento, California, USA; , Basel, Switzerland
| | - Ian Mchardy
- Department of Medical Microbiology and Immunology, University of California-Davis Health, Sacramento, California, USA, Basel, Switzerland
| | - John W Baddley
- Department of Internal Medicine, Division of Infectious Diseases, University of Alabama-Birmingham, Birmingham, Alabama, USA, Basel, Switzerland
| | - Brian Y Young
- Department of Internal Medicine, Division of Nephrology, University of California-Davis Health, Sacramento, California, USA; , Basel, Switzerland
| | - Alex Odermatt
- Swiss Centre for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - George R Thompson
- Department of Medical Microbiology and Immunology, University of California-Davis Health, Sacramento, California, USA, Basel, Switzerland.,Department of Internal Medicine, Division of Infectious Diseases, University of California-Davis Health, Sacramento, California, USA
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8
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Beck KR, Thompson GR, Odermatt A. Drug-induced endocrine blood pressure elevation. Pharmacol Res 2019; 154:104311. [PMID: 31212012 DOI: 10.1016/j.phrs.2019.104311] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 06/08/2019] [Accepted: 06/10/2019] [Indexed: 11/16/2022]
Abstract
Patients with uncontrolled hypertension are at risk for cardiovascular complications. The majority of them suffers from unidentified forms of hypertension and a fraction has so-called secondary hypertension with an identifiable cause. The patient's medications, its use of certain herbal supplements and over-the-counter agents represent potential causal factors for secondary hypertension that are often overlooked. The current review focuses on drugs that are likely to elevate blood pressure by affecting the human endocrine system at the level of steroid synthesis or metabolism, mineralocorticoid receptor activity, or by affecting the catecholaminergic system. Drugs with known adverse effects but where benefits outweigh their risks, drug candidates and market withdrawals are reviewed. Finally, potential therapeutic strategies are discussed.
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Affiliation(s)
- Katharina R Beck
- Swiss Centre for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases and the Department of Medical Microbiology and Immunology, University of California Davis Medical Center, Davis, California, USA
| | - Alex Odermatt
- Swiss Centre for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland.
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9
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Thompson GR, Beck KR, Patt M, Kratschmar DV, Odermatt A. Posaconazole-Induced Hypertension Due to Inhibition of 11 β-Hydroxylase and 11 β-Hydroxysteroid Dehydrogenase 2. J Endocr Soc 2019; 3:1361-1366. [PMID: 31286100 PMCID: PMC6608555 DOI: 10.1210/js.2019-00189] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 05/31/2019] [Indexed: 11/29/2022] Open
Abstract
We describe two cases of hypertension and hypokalemia due to mineralocorticoid excess caused by posaconazole treatment of coccidioidomycosis and rhinocerebral mucormycosis infections, respectively. Clinical laboratory evaluations, including a comprehensive analysis of blood and urine steroid profiles, revealed low renin and aldosterone and indicated as the underlying mechanism primarily a block of 11β-hydroxylase activity in patient 1, whereas patient 2 displayed weaker 11β-hydroxylase but more pronounced 11β-hydroxysteroid dehydrogenase 2 inhibition. The results show that both previously suggested mechanisms must be considered and emphasize significant interindividual differences in the contribution of each enzyme to the observed mineralocorticoid excess phenotype. The mineralocorticoid symptoms of patient 1 resolved after replacement of posaconazole therapy by isavoconazole, and posaconazole dosage de-escalation ameliorated the effects in patient 2. By providing a thorough analysis of the patients’ blood and urine steroid metabolites, this report adds further evidence for two individually pronounced mechanisms of posaconazole-induced hypertension and hypokalemia. The elucidation of the factors responsible for the individual phenotype warrants further research.
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Affiliation(s)
- George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases and the Department of Medical Microbiology and Immunology, University of California Davis Medical Center, Davis, California
| | - Katharina R Beck
- Swiss Centre for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Melanie Patt
- Swiss Centre for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Denise V Kratschmar
- Swiss Centre for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Alex Odermatt
- Swiss Centre for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
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10
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Leelawattanachai P, Montakantikul P, Nosoongnoen W, Chayakulkeeree M. Pharmacokinetic/pharmacodynamic study of posaconazole delayed-release tablet in a patient with coexisting invasive aspergillosis and mucormycosis. Ther Clin Risk Manag 2019; 15:589-595. [PMID: 31114213 PMCID: PMC6497849 DOI: 10.2147/tcrm.s203625] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/30/2019] [Indexed: 11/24/2022] Open
Abstract
Limited information exists regarding the optimal dose of posaconazole delayed-release tablet for the treatment of invasive mold infection. Here, we report the case of a previously healthy 44-year-old Thai man who developed coexisting invasive pulmonary aspergillosis and mucormycosis following a car accident. He was treated with posaconazole delayed-release tablet. This report describes the pharmacokinetic/pharmacodynamic study, safety profile, and determination of the appropriate dosage of posaconazole delayed-release tablet in a patient with coexisting invasive aspergillosis and mucormycosis. Posaconazole exposure was analyzed by noncompartmental model. Ratio of area under the plasma concentration-time curve over the minimum inhibitory concentration (AUC/MIC) was applied to maximize the efficacy of posaconazole. The loading dose of 300 mg q 12 hrs was found to be potentially insufficient for achieving the AUC/MIC target for treatment of invasive mold infection with minimum inhibitory concentrations >0.01 mg/L. Early therapeutic drug monitoring to detect the drug concentration of posaconazole delayed-release tablet is necessary so that dosing adjustments can be made, as needed. In addition, a maintenance dose of either 400 or 300 mg once daily could achieve the AUC/MIC targets. These maintenance dosing regimens effectuated a successful clinical outcome with minimal adverse events.
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Affiliation(s)
- Pannee Leelawattanachai
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand.,Department of Pharmacy, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Preecha Montakantikul
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Wichit Nosoongnoen
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Methee Chayakulkeeree
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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11
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12
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DiPippo AJ, Rausch CR, Kontoyiannis DP. Tolerability of isavuconazole after posaconazole toxicity in leukaemia patients. Mycoses 2018; 62:81-86. [PMID: 30230043 DOI: 10.1111/myc.12851] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/31/2018] [Accepted: 09/11/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Posaconazole (PCZ) is widely used for prophylaxis or treatment of invasive fungal infections (IFIs) in leukaemia patients. However, issues with PCZ tolerability can result in treatment interruption. Isavuconazole (ISA) has a similar broad spectrum of activity to PCZ; however, real-world data regarding the tolerability of ISA after PCZ toxicity are lacking. OBJECTIVES To describe the tolerability of ISA after PCZ toxicity in leukaemia patients. PATIENTS/METHODS We retrospectively assessed tolerability of ISA after PCZ toxicity in adult leukaemia patients (March 2015 to November 2017). We included all patients who received ≥7 days of ISA within 48 hours of PCZ discontinuation. Laboratory markers for liver toxicity were collected at three time points: prior to PCZ, at switch to ISA and after ISA therapy. RESULTS We identified 23 such patients. Increased liver function tests (LFTs) were noted in 20 patients on PCZ, while three patients had Grade 3/4 QTc prolongation. No patient discontinued subsequent ISA due to toxicity. Grade 3/4 elevations in LFTs were decreased after changing to ISA (30% after PCZ vs 5% after ISA). No patient had significant QTc prolongation after switching to ISA. CONCLUSIONS Isavuconazole was well-tolerated in patients discontinuing PCZ due to toxicity, with no patient discontinuing ISA due to toxicity.
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Affiliation(s)
- Adam J DiPippo
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Caitlin R Rausch
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, Texas
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Sanchez-Niño MD, Ortiz A. Unravelling drug-induced hypertension: molecular mechanisms of aldosterone-independent mineralocorticoid receptor activation by posaconazole. Clin Kidney J 2018; 11:688-690. [PMID: 30289131 PMCID: PMC6165746 DOI: 10.1093/ckj/sfy087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Indexed: 01/19/2023] Open
Abstract
Drug-induced hypertension offers the opportunity to further understand pathways involved in the regulation of blood pressure. Posaconazole is an antifungal agent known to induce hypertension and hypokalaemia. In recent months, a flurry of reports has unravelled the metabolic processes involved. In this issue of CKJ, Barton K, Davis TK, Marshall B et al. Posaconazole-induced hypertension and hypokalemia due to inhibition of the 11β-hydroxylase enzyme. Clin Kidney J 2018; 11: 691-693 present convincing evidence of 11β-hydroxylase inhibition resulting in a biochemical syndrome resembling genetic congenital adrenal hyperplasia and characterized by high 11-deoxycorticosterone and 11-deoxycortisol levels as well as androgen levels. This adds to prior evidence supporting inhibition of 11β-hydroxysteroid dehydrogenase 2, the enzyme that inactivates cortisol in aldosterone-sensitive tissues such as the kidneys, yielding a syndrome resembling genetic apparent mineralocorticoid excess or licorice toxicity, characterized by a high cortisol/cortisone ratio.
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Affiliation(s)
- Maria Dolores Sanchez-Niño
- IIS-Fundacion Jimenez Diaz, School of Medicine, Universidad Autonoma de Madrid; Fundacion Renal Iñigo Alvarez de Toledo-IRSIN and REDINREN, Madrid, Spain
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz, School of Medicine, Universidad Autonoma de Madrid; Fundacion Renal Iñigo Alvarez de Toledo-IRSIN and REDINREN, Madrid, Spain
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14
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Wassermann T, Reimer EK, McKinnon M, Stock W. Refractory Hypokalemia from Syndrome of Apparent Mineralocorticoid Excess on Low-Dose Posaconazole. Antimicrob Agents Chemother 2018; 62:e02605-17. [PMID: 29661880 PMCID: PMC6021675 DOI: 10.1128/aac.02605-17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Travis Wassermann
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Eleanor K Reimer
- Department of Internal Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Marie McKinnon
- Department of Internal Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Wendy Stock
- Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, Illinois, USA
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15
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Kuriakose K, Nesbitt WJ, Greene M, Harris B. Posaconazole-Induced Pseudohyperaldosteronism. Antimicrob Agents Chemother 2018; 62:e02130-17. [PMID: 29530850 PMCID: PMC5923153 DOI: 10.1128/aac.02130-17] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 03/02/2018] [Indexed: 12/27/2022] Open
Abstract
A woman in her late 60s with disseminated histoplasmosis was treated with posaconazole because first-line therapies were not tolerated. She subsequently presented with decompensated heart failure, hypertension, and hypokalemia. Laboratory tests revealed low renin and aldosterone levels. A potential mechanism is inhibition of the enzyme 11β-hydroxysteroid dehydrogenase 2, with resultant apparent mineralocorticoid excess.
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Affiliation(s)
- Kevin Kuriakose
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Whitney J Nesbitt
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew Greene
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bryan Harris
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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16
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Boughton C, Taylor D, Ghataore L, Taylor N, Whitelaw BC. Mineralocorticoid hypertension and hypokalaemia induced by posaconazole. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM-17-0157. [PMID: 29472988 PMCID: PMC5813713 DOI: 10.1530/edm-17-0157] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 01/11/2018] [Indexed: 11/08/2022] Open
Abstract
We describe severe hypokalaemia and hypertension due to a mineralocorticoid effect in a patient with myelodysplastic syndrome taking posaconazole as antifungal prophylaxis. Two distinct mechanisms due to posaconazole are identified: inhibition of 11β hydroxylase leading to the accumulation of the mineralocorticoid hormone 11-deoxycorticosterone (DOC) and secondly, inhibition of 11β hydroxysteroid dehydrogenase type 2 (11βHSD2), as demonstrated by an elevated serum cortisol-to-cortisone ratio. The effects were ameliorated by spironolactone. We also suggest that posaconazole may cause cortisol insufficiency. Patients taking posaconazole should therefore be monitored for hypokalaemia, hypertension and symptoms of hypocortisolaemia, at the onset of treatment and on a monthly basis. Treatment with mineralocorticoid antagonists (spironolactone or eplerenone), supplementation of glucocorticoids (e.g. hydrocortisone) or dose reduction or cessation of posaconazole should all be considered as management strategies.
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Affiliation(s)
- Charlotte Boughton
- Endocrinology Department of Clinical Biochemistry (Viapath), King's College Hospital NHS Foundation Trust, London, UK
| | - David Taylor
- Department of Clinical Biochemistry (Viapath), King's College Hospital NHS Foundation Trust, London, UK
| | - Lea Ghataore
- Department of Clinical Biochemistry (Viapath), King's College Hospital NHS Foundation Trust, London, UK
| | - Norman Taylor
- Department of Clinical Biochemistry (Viapath), King's College Hospital NHS Foundation Trust, London, UK
| | - Benjamin C Whitelaw
- Endocrinology Department of Clinical Biochemistry (Viapath), King's College Hospital NHS Foundation Trust, London, UK
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In Vivo 11β-Hydroxysteroid Dehydrogenase Inhibition in Posaconazole-Induced Hypertension and Hypokalemia. Antimicrob Agents Chemother 2017; 61:AAC.00760-17. [PMID: 28533238 DOI: 10.1128/aac.00760-17] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 05/14/2017] [Indexed: 11/20/2022] Open
Abstract
We describe a case of apparent mineralocorticoid excess (AME) secondary to posaconazole therapy and suggest the biochemical mechanism. Clinical and laboratory investigation confirmed 11β-hydroxysteroid dehydrogenase inhibition and withholding therapy led to a resolution of all clinical and laboratory abnormalities. Posaconazole was later restarted at a lower dose and prevented recurrence of this syndrome. Additional studies are necessary to determine the frequency of posaconazole-induced AME and whether other azole antifungals can be associated with this phenomenon.
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