1
|
Weerdenburg H, Walker H, Curtis N, Duffull S, Haeusler G, Cole T, Gwee A. Posaconazole in paediatric malignancy and haematopoietic stem cell transplant: dosing to achieve therapeutic concentration. J Antimicrob Chemother 2024; 79:1493-1507. [PMID: 38637310 DOI: 10.1093/jac/dkae099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/05/2024] [Indexed: 04/20/2024] Open
Abstract
OBJECTIVES Posaconazole is increasingly used for the treatment and prophylaxis of invasive fungal infections in immunocompromised children. We aimed to review evidence for paediatric posaconazole dosing regimens focusing on attainment of target concentrations and frequency of adverse effects. METHODS In May 2023, the Cochrane, Embase, MEDLINE and PubMed databases were searched for articles reporting posaconazole dosing in children with malignancy or post-haematopoietic stem cell transplantation. Studies reporting the attainment of target serum concentrations were included. RESULTS Overall, 24 studies were included. Eighteen studies of the oral suspension consistently reported poor attainment of target concentrations for prophylaxis (≥0.7 µg/mL, 12%-78%) despite high daily doses of 14-23 mg/kg/day (max. 1200 mg/day). Target attainment was significantly affected by gastric pH and food intake. Six studies of the delayed-release tablet (DRT) reported 58%-94% achieved concentrations ≥0.7 µg/mL, with the majority using lower doses of 4-12 mg/kg/day (max. 300 mg/day). Similarly, one study of powder for oral suspension found 67%-100% achieved target concentrations with a dose of 6 mg/kg/day (max. 300 mg/day). As expected, the IV formulation had high attainment of prophylaxis targets (81%-90%) with 6-10 mg/kg/day (max. 400 mg/day). All formulations were well tolerated, and no relationship between adverse effects and posaconazole concentrations was identified. CONCLUSIONS The required posaconazole dose in immunocompromised children varies depending on the formulation. The IV infusion had the highest attainment of therapeutic concentration followed by the DRT and powder for suspension. By contrast, the oral suspension had low attainment of target concentrations despite higher daily doses.
Collapse
Affiliation(s)
- Heather Weerdenburg
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Hannah Walker
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nigel Curtis
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Gabrielle Haeusler
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- The Victorian Paediatric Integrated Cancer Service, Victoria State Government, Melbourne, Victoria, Australia
| | - Theresa Cole
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Amanda Gwee
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
2
|
Castro-Balado A, Varela-Rey I, Mejuto B, Mondelo-García C, Zarra-Ferro I, Rodríguez-Jato T, Fernández-Ferreiro A. Updated antimicrobial dosing recommendations for obese patients. Antimicrob Agents Chemother 2024; 68:e0171923. [PMID: 38526051 PMCID: PMC11064535 DOI: 10.1128/aac.01719-23] [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] [Indexed: 03/26/2024] Open
Abstract
The prevalence of obesity has increased considerably in the last few decades. Pathophysiological changes in obese patients lead to pharmacokinetic (PK) and pharmacodynamic (PD) alterations that can condition the correct exposure to antimicrobials if standard dosages are used. Inadequate dosing in obese patients can lead to toxicity or therapeutic failure. In recent years, additional antimicrobial PK/PD data, extended infusion strategies, and studies in critically ill patients have made it possible to obtain data to provide a better dosage in obese patients. Despite this, it is usually difficult to find information on drug dosing in this population, which is sometimes contradictory. This is a comprehensive review of the dosing of different types of antimicrobials (antibiotics, antifungals, antivirals, and antituberculosis drugs) in obese patients, where the literature on PK and possible dosing strategies in obese adults was critically assessed.
Collapse
Affiliation(s)
- Ana Castro-Balado
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Iria Varela-Rey
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Beatriz Mejuto
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
| | - Cristina Mondelo-García
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Irene Zarra-Ferro
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Teresa Rodríguez-Jato
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Anxo Fernández-Ferreiro
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| |
Collapse
|
3
|
Patel K, Kevlani V, Shah S. A novel Posaconazole oral formulation using spray dried solid dispersion technology: in-vitro and in-vivo study. Drug Deliv Transl Res 2024; 14:1253-1276. [PMID: 37952081 DOI: 10.1007/s13346-023-01461-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2023] [Indexed: 11/14/2023]
Abstract
SD (solid dispersion) technology is one of the well-recognized solubility enhancement methods; but the use of versatile carriers in ASD (amorphous SD) to achieve the added advantage of modified release along with solubility improvement is an emerging area of exploration. Spray drying is a widely used technology with excellent scalability and product attributes. The SD carriers explored were Soluplus®, possessing excellent solubilization properties that may enhance bioavailability and is suitable for innovative processing, and Gelucire 43/01, a lipid polymer utilized in a non-effervescent-based floating gastro-retentive DDS for the modified release of API. The CPPs of spray drying were screened during preliminary trials, and the formulation variables were optimized using a 32 Full Factorial Design. All nine batches were evaluated for % yield, % drug content, flow properties, floating behavior, saturation solubility, and in-vitro drug release in 0.1 N HCl. The optimized batch characterized based on DSC (differential scanning calorimetry) and PXRD (powder X-ray diffraction) confirmed the amorphous nature of entrapped drug in SDD (spray-dried dispersion). Particle size analysis and SEM (scanning electron microscopy) demonstrated micron size irregular shaped particles. Residual solvent analysis by GCMS-HS confirmed the elimination of organic solvents from SDD. The optimized batch was found stable after 6 months stability study as per ICH guidelines. In-vivo roentgenography study in New Zealand white rabbit showed the residence of SDD in gastric environment for sufficient time. The pharmacokinetic study was performed in male Sprague-Dawley rats to determine the bioavailability of developed SDD based product in fasting and fed conditions, and to compare the data with marketed Noxafil formulation. The current research is focused on the development of a novel ternary SDD (spray-dried dispersion)-based gastro-retentive formulation for an anti-fungal drug Posaconazole.
Collapse
Affiliation(s)
- Kaushika Patel
- Department of Pharmaceutical Technology, L. J. Institute of Pharmacy, L J University, Ahmedabad, 382 210, India
- Gujarat Technological University, Ahmedabad, India
| | - Vijay Kevlani
- Department of Pharmacology, L. J. Institute of Pharmacy, L J University, Ahmedabad, 382 210, India
| | - Shreeraj Shah
- Department of Pharmaceutical Technology, L. J. Institute of Pharmacy, L J University, Ahmedabad, 382 210, India.
| |
Collapse
|
4
|
Muehlberg L, Pabst T, Largiadèr C, Aebi Y, Hayoz M, Muehlethaler K, Zimmerli S, Hirzel C. Evaluation of Posaconazole Serum Concentrations Achieved With Delayed-release Tablets and Oral Suspension in Patients Undergoing Intensive Chemotherapy for Acute Myeloid Leukemia and Myelodysplastic Syndrome. Open Forum Infect Dis 2024; 11:ofae263. [PMID: 38798896 PMCID: PMC11127630 DOI: 10.1093/ofid/ofae263] [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: 02/23/2024] [Accepted: 05/03/2024] [Indexed: 05/29/2024] Open
Abstract
Data on posaconazole serum levels of patients on prophylaxis with delayed-release tablets or oral suspension during intensive chemotherapy for acute myeloid leukemia and myelodysplastic syndrome are scarce. In this analysis, the proportion of patients with acute myeloid leukemia/myelodysplastic syndrome achieving posaconazole target concentrations with delayed-release tablets was higher than with oral suspension.
Collapse
Affiliation(s)
- Leonora Muehlberg
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Carlo Largiadèr
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Yolanda Aebi
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Michael Hayoz
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Konrad Muehlethaler
- Department of Clinical Microbiology, Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Stefan Zimmerli
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Cédric Hirzel
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
5
|
Sugimoto M, Yonezawa A, Kanda J, Itohara K, Hira D, Yamagiwa T, Taniguchi R, Hanyu Y, Watanabe M, Arai Y, Mizumoto C, Kitawaki T, Kondo T, Yamashita K, Takaori-Kondo A, Terada T. Population Pharmacokinetic Modeling of Posaconazole in Japanese Patients Receiving Fungal Prophylaxis. Ther Drug Monit 2024:00007691-990000000-00207. [PMID: 38648638 DOI: 10.1097/ftd.0000000000001198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 01/26/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Posaconazole is a vital drug to treat and prevent invasive fungal infections. Several factors, such as sex, body weight, total serum proteins, dietary intake, and severe mucositis, affect posaconazole pharmacokinetics (PKs). However, the relevance of other factors that affect the PKs of posaconazole in hematopoietic stem cell transplantation (HSCT) is unknown. This study explored factors influencing the PKs of posaconazole in HSCT recipients and nontransplant patients with hematological diseases. METHODS The authors conducted a single-institution, retrospective study. Forty-two Japanese inpatients receiving oral posaconazole tablets as prophylaxis for fungal infections were enrolled in this study. A one-compartment model with first-order absorption was used as the structural pharmacokinetic model. A population PK (PopPK) analysis was performed using a nonlinear mixed-effects modeling program, using a first-order conditional estimation method with interactions. Perl-speaks-NONMEM and R were used to evaluate the goodness of fit and visualize the output. RESULTS In 29% of the enrolled patients, the serum concentration of posaconazole was <0.5 mcg/mL, considered the effective range. PopPK analysis revealed that the patient had undergone HSCT within 1 year, diarrhea occurred more than 5 times a day, and aspartate aminotransferase were covariates that influenced apparent clearance (CL/F). The CL/F of posaconazole was 1.43-fold higher after HSCT and 1.26-fold higher during diarrhea. CONCLUSIONS PopPK analysis revealed that HSCT, diarrhea, and aspartate aminotransferase were factors associated with the CL/F of posaconazole. The trough concentration of posaconazole may be below the therapeutic range in a few patients with diarrhea and/or after HSCT. As invasive fungal infections in patients with hematologic diseases can be life-threatening, therapeutic drug monitoring of posaconazole is strongly recommended, and patients should be carefully monitored.
Collapse
Affiliation(s)
- Mitsuhiro Sugimoto
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
- Division of Integrative Clinical Pharmacology, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Kotaro Itohara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Daiki Hira
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Takeo Yamagiwa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Risa Taniguchi
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Yuta Hanyu
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Mizuki Watanabe
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Chisaki Mizumoto
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Toshio Kitawaki
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kouhei Yamashita
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Tomohiro Terada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| |
Collapse
|
6
|
Yamada T, Belabbas T, Suetsugu K, Hirota T, Mori Y, Kato K, Akashi K, Egashira N, Ieiri I. Factors Influencing Serum Posaconazole Concentrations in Patients with Hematologic Malignancies Receiving Delayed-Release Tablets. Ther Drug Monit 2024:00007691-990000000-00205. [PMID: 38648660 DOI: 10.1097/ftd.0000000000001196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/30/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Posaconazole (PCZ) plays a crucial role in the prophylaxis and treatment of invasive fungal infections in hematologic malignancies. PCZ concentrations reportedly vary among patients receiving delayed-release tablets (DRT). However, the factors influencing these concentrations remain insufficiently elucidated. Therefore, this study aimed to evaluate the factors influencing PCZ concentrations and their effect on the probability of target attainment (PTA) using a population pharmacokinetic (PPK) approach. We also explored the relationship between PCZ exposure and hepatotoxicity. METHODS This retrospective study included adult patients with hematologic malignancies who received PCZ DRT. A PPK model was developed based on observational data for 130 concentrations in 28 patients. Simulation analyses were performed to assess the PTA at standard doses of 0.7 and 1.0 mg/L for prophylaxis and treatment, respectively. Estimated concentrations were used to evaluate the correlation between PCZ exposure and hepatotoxicity. RESULTS Significant factors influencing PCZ concentrations included body weight, serum total protein levels, and diarrhea. Diarrhea correlated with decreased PCZ concentrations resulting in up to 26% lower PTA compared with that without diarrhea. Moreover, PTA declined markedly as the total protein levels decreased from 6.6 g/dL to 4.4 g/dL. The incidence of hepatotoxicity was 17.4% (4/23); no significant relationship could be established between the PCZ concentrations and hepatotoxicity (P = 0.188). CONCLUSIONS We identified the factors affecting PCZ exposure, which could not be detected by PPK analysis using data from clinical trials. Our results suggest that the generally recommended dose of PCZ causes underexposure in patients with hematologic malignancies characterized by high body weight, hypoproteinemia, or concurrent diarrhea. Therapeutic drug monitoring for DRT may be recommended, especially in patients with these risk factors.
Collapse
Affiliation(s)
- Takaaki Yamada
- Department of Pharmacy, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
- Department of Clinical Pharmacology and Therapeutics, School of Pharmaceutical Sciences, Wakayama Medical University, Wakayama-shi, Wakayama, Japan
| | - Tassadit Belabbas
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan; and
| | - Kimitaka Suetsugu
- Department of Pharmacy, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
| | - Takeshi Hirota
- Department of Pharmacy, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan; and
| | - Yasuo Mori
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Koji Kato
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Nobuaki Egashira
- Department of Pharmacy, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
- Department of Clinical Pharmacology and Therapeutics, School of Pharmaceutical Sciences, Wakayama Medical University, Wakayama-shi, Wakayama, Japan
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan; and
| | - Ichiro Ieiri
- Department of Pharmacy, Kyushu University Hospital, Higashi-ku, Fukuoka, Japan
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan; and
| |
Collapse
|
7
|
Muhammad HJ, Shimada T, Fujita A, Sai Y. Sodium citrate buffer improves pazopanib solubility and absorption in gastric acid-suppressed rat model. Drug Metab Pharmacokinet 2024; 55:100995. [PMID: 38447327 DOI: 10.1016/j.dmpk.2024.100995] [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: 09/01/2023] [Revised: 11/24/2023] [Accepted: 12/29/2023] [Indexed: 03/08/2024]
Abstract
Pazopanib exhibits pH-dependent solubility and its absorption depends primarily on the stomach pH. Significant decrease of pazopanib absorption by coadministration with proton pump inhibitors in clinical situation need to be overcome. Thus, the purpose of this study is firstly to investigate the effect of acidic beverages and sodium citrate buffer on the solubility of pazopanib and secondly to examine the effect of sodium citrate buffer on pazopanib absorption in a rat model with esomeprazole-mediated gastric acid suppression. Pazopanib solubility decreased with increasing pH of sodium citrate buffer in vitro. Interestingly, its solubility in some acidic beverages was significantly lower than that in sodium citrate buffer of the same pH. The AUC0-24h of pazopanib administered in tap water to rats treated with esomeprazole (ESP rats) was 66 % lower than that in the control rats treated with saline. However, AUC0-24h was 4.8 times higher in ESP rats that received pazopanib with sodium citrate buffer (pH 2.3) compared to ESP rats that received pazopanib with tap water. Our results indicate that the drug-drug interactions between pazopanib and proton pump inhibitors can be overcome, at least in part, by suspending pazopanib in sodium citrate buffer.
Collapse
Affiliation(s)
- Huda Jassim Muhammad
- Department of Clinical Pharmacokinetics, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan; Department of Clinical Pharmacy, College of Pharmacy, Karbala University, Karbala, 56001, Iraq.
| | - Tsutomu Shimada
- Department of Clinical Pharmacokinetics, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan; Department of Hospital Pharmacy, University Hospital, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan.
| | - Arimi Fujita
- Department of Clinical Pharmacokinetics, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan; Department of Hospital Pharmacy, University Hospital, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan.
| | - Yoshimichi Sai
- Department of Clinical Pharmacokinetics, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan; Department of Hospital Pharmacy, University Hospital, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan.
| |
Collapse
|
8
|
Boppana M, Sengar M, Jain H, Gurjar M, Ambotkar M, Gota V, Bonda A, Bagal B, Thorat J, Gokarn A, Nayak L, Shetty N, Baheti A, Mokal S, Kannan S, Shetty A, Eipe T. A Prospective Study to Evaluate the Effect of Therapeutic Drug Monitoring-Based Posaconazole Prophylaxis on Invasive Fungal Infection Rate During Acute Myeloid Leukemia Induction Therapy. Indian J Hematol Blood Transfus 2024; 40:204-212. [PMID: 38708158 PMCID: PMC11065854 DOI: 10.1007/s12288-023-01709-3] [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: 05/13/2023] [Accepted: 10/04/2023] [Indexed: 05/07/2024] Open
Abstract
Invasive fungal infections (IFIs) are a significant cause of morbidity and mortality in de-novo acute myeloid leukemia patients receiving induction chemotherapy. Despite using posaconazole, a broad-spectrum antifungal, for IFI prophylaxis, the breakthrough IFI rate is high in the real-world setting. One of the reasons could be frequent suboptimal plasma posaconazole levels. In the present study, we evaluated if therapeutic drug monitoring (TDM) guided posaconazole prophylaxis can reduce the IFI rates in comparison to a historical cohort. We enrolled 90 patients, > / = 16 years of age, without baseline IFIs, planned for remission induction therapy. All patients were started on posaconazole suspension 200 mg TDS and the dose was increased in a stepwise manner if trough levels were found to be suboptimal (< 350 ng/ml for day 2 or < 700 ng/ml subsequently). The TDM based approach resulted in a significant decline in breakthrough IFI rates (18% versus 52%, P < 0.0001) A total of 69 patients (78%) required dose escalation. Thirty-one patients required change in antifungals due to either suboptimal levels, persistent fever, diarrhoea or vomiting. We could not demonstrate an exposure-response relationship but the difference in IFI rates in patients with a median posaconazole level > / = 700 ng/ml (0%) and < 700 ng/ml (21.6%) was clinically meaningful. Posaconazole levels were found to be significantly lower in patients on antacids and prokinetics. The incidence of posaconazole-related grade 3 toxicity was low (2.3%). Thus TDM-based dosing of posaconazole helps reduce breakthrough IFI rate and should be a part of posaconazole prophylaxis. Supplementary Information The online version contains supplementary material available at 10.1007/s12288-023-01709-3.
Collapse
Affiliation(s)
- Mounika Boppana
- Department of Medical Oncology, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
- Present Address: Department of Medical Oncology, Krishna Institute of Medical Sciences, Minister Road, Secunderabad, Telangana 500003, India
| | - Manju Sengar
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National University, Earnest Borges Road, Parel, Mumbai 400012 India
| | - Hasmukh Jain
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Murari Gurjar
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Madhavi Ambotkar
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Vikram Gota
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Avinash Bonda
- Department of Medical Oncology, Asian Institute of Gastroenterology (AIG) Hospitals, Mindspace Road, P Janardhan Reddy Nagar, Gachibowli, Hyderabad, Telangana 500032, India
| | - Bhausaheb Bagal
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Jayashree Thorat
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Anant Gokarn
- Adult Hematolymphoid Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Lingaraj Nayak
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Nitin Shetty
- Department of Radiodiagnosis, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Akshay Baheti
- Department of Radiodiagnosis, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Smruti Mokal
- Clinical Research Secretariat, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Sadhana Kannan
- Clinical Research Secretariat, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Alok Shetty
- Department of Medical Oncology, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Thomas Eipe
- Department of Medical Oncology, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| |
Collapse
|
9
|
König C, Göpfert M, Kluge S, Wichmann D. Posaconazole exposure in critically ill ICU patients: a need for action. Infection 2023; 51:1767-1772. [PMID: 37498488 PMCID: PMC10665255 DOI: 10.1007/s15010-023-02078-9] [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: 01/13/2023] [Accepted: 07/16/2023] [Indexed: 07/28/2023]
Abstract
PURPOSE Posaconazole is an antifungal drug currently being used for prophylaxis and treatment of invasive fungal infections such as aspergillosis. To date, therapeutic drug monitoring (TDM) of posaconazole is recommended with the use of oral suspension, but the potential need of TDM with the use of IV formulations is rising. Therefore, we aimed to investigate the pharmacokinetics of IV posaconazole in critically ill patients. METHODS In a prospective study, we analysed 168 consecutivelly collected posaconazole levels from 10 critically ill patients drawn during a 7 day curse. Posaconazole concentrations were measured using a chromatographic method. Demographic and laboratory data were collected, and the data was analysed using descriptive statistics. RESULTS We included 168 posaconazole levels, resulting in a median trough of 0.62 [0.29-1.05] mg/L with 58% not reaching the suggested target of 0.5 mg/L for fungal prophylaxis. Moreover, 74% of the trough levels were under the target of 1 mg/L which is proposed for the treatment of aspergillosis. CONCLUSION Posaconazole exposure is highly variable in critically ill patients resulting in potentially insufficient drug concentrations in many cases. TDM is highly recommended to identify and avoid underexposure. TRIAL REGISTRATION NUMBER NCT05275179, March 11, 2022.
Collapse
Affiliation(s)
- Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 42, 20251, Hamburg, Germany
| | - Melanie Göpfert
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 42, 20251, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 42, 20251, Hamburg, Germany
| | - Dominic Wichmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 42, 20251, Hamburg, Germany.
| |
Collapse
|
10
|
Dayan N, Oğralı E, Kirişçioğlu C, Dude UK, Erşahin R. Single-Dose Crossover Comparative Bioavailability Study of Two Different Posaconazole 100 mg Gastro-Resistant Tablets Under Fasted and Fed Conditions in Healthy Volunteers. INFECTIOUS DISEASES & CLINICAL MICROBIOLOGY 2023; 5:341-352. [PMID: 38633861 PMCID: PMC10986696 DOI: 10.36519/idcm.2023.277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/09/2023] [Indexed: 04/19/2024]
Abstract
Objective This study aimed to compare the bioavailability of two different gastro-resistant oral tablet formulations of posaconazole under fasted and fed conditions and to evaluate a potential food effect on the bioavailability of each formulation. Materials and Methods Healthy volunteers randomly assigned to receive a test product (Posagil® 100 mg gastro-resistant tablet) or reference product (Noxafil® 100 mg gastro-resistant tablet) were included in this single-center, randomized, four-period (days 1, 15, 29 and 43), four-sequence crossover comparative bioavailability study. Data on posaconazole plasma concentrations and related pharmacokinetic profile (the maximum observed plasma concentration [Cmax] from time 0 to the time of last observed quantifiable plasma concentration [AUC0-T] and from time zero to infinity [AUC0-∞]) were recorded to evaluate efficacy of the test product in relation to the reference product under both fasted and fed conditions, based on bioequivalence (T-fasted vs. R-fasted and T-fed vs. R-fed) and food effect (T-fasted vs. T-fed and R-fasted vs. R-fed) assessments. Safety was evaluated through assessment of adverse events (AEs), standard laboratory evaluations, and vital signs. Results The bioequivalence criteria were met under fed conditions (T-fed vs. R-fed: geometric LSMean ratios of Cmax, AUC0-T, and AUC0-∞ of posaconazole were 97.41%, 97.45%, and 97.08%, respectively; all within the range of 80% to 125%) but not under fasted conditions. There was a food effect on the reference product (R-fed vs. R-fasted: geometric LSMean ratios of Cmax, AUC0-T, and AUC0-∞ of posaconazole were 145.32%, 138.84%, and 138.46%, respectively) but not on the test product. No safety concerns were identified. Conclusions Our findings suggest that the pharmacokinetic profile of Posagil® is similar to the pharmacokinetic profile of Noxafil®. The generic Posagil® seems to have similarly high bioavailability under fed and fasted conditions, offering a higher posaconazole exposure than the original Noxafil® in the fasted state. Hence, Posagil® may be considered a value-added generic product that offers adequate posaconazole exposure under fasted state and fed state, regardless of the concomitant high-fat meal intake.
Collapse
Affiliation(s)
- Nilden Dayan
- Abdi İbrahim Pharmaceuticals Inc., İstanbul, Türkiye
| | - Elif Oğralı
- Abdi İbrahim Pharmaceuticals Inc., İstanbul, Türkiye
| | | | | | - Recep Erşahin
- Abdi İbrahim Pharmaceuticals Inc., İstanbul, Türkiye
| |
Collapse
|
11
|
Kane Z, Cheng I, McGarrity O, Chiesa R, Klein N, Cortina-Borja M, Standing JF, Gastine S. Model Based Estimation of Posaconazole Tablet and Suspension Bioavailability in Hospitalized Children Using Real-World Therapeutic Drug Monitoring Data in Patients Receiving Intravenous and Oral Dosing. Antimicrob Agents Chemother 2023; 67:e0007723. [PMID: 37260401 PMCID: PMC10353366 DOI: 10.1128/aac.00077-23] [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: 01/16/2023] [Accepted: 04/18/2023] [Indexed: 06/02/2023] Open
Abstract
Invasive fungal infections are a major cause of morbidity and mortality for immunocompromised patients. Posaconazole is approved for treatment and prophylaxis of invasive fungal infection in adult patients, with intravenous, oral suspension, and gastroresistant/delayed-released tablet formulations available. In Europe, until very recently, posaconazole was used off-label in children, although a new delayed-release suspension approved for pediatric use is expected to become available soon. A population pharmacokinetic model was developed which uses posaconazole therapeutic drug monitoring data following intravenous and oral dosing in hospitalized children, thus enabling estimation of pediatric suspension and tablet oral bioavailability. In total, 297 therapeutic drug monitoring plasma levels from 104 children were included in this analysis. The final model was a one-compartment model with first-order absorption and nonlinear elimination. Allometric scaling on clearance and volume of distribution was included a priori. Tablet bioavailability was estimated to be 66%. Suspension bioavailability was estimated to decrease with increasing doses, ranging from 3.8% to 32.2% in this study population. Additionally, concomitant use of proton pump-inhibitors was detected as a significant covariate, reducing suspension bioavailability by 41.0%. This is the first population pharmacokinetic study to model posaconazole data from hospitalized children following intravenous, tablet, and suspension dosing simultaneously. The incorporation of saturable posaconazole clearance into the model has been key to the credible joint estimation of tablet and suspension bioavailability. To aid rational posaconazole dosing in children, this model was used alongside published pharmacodynamic targets to predict the probability of target attainment using typical pediatric dosing regimen.
Collapse
Affiliation(s)
- Zoe Kane
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Iek Cheng
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Department of Pharmacy, Great Ormond Street Hospital, London, United Kingdom
| | - Orlagh McGarrity
- Department of Pharmacy, Great Ormond Street Hospital, London, United Kingdom
| | - Robert Chiesa
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital, London, United Kingdom
| | - Nigel Klein
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Mario Cortina-Borja
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Joseph F. Standing
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Department of Pharmacy, Great Ormond Street Hospital, London, United Kingdom
| | - Silke Gastine
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| |
Collapse
|
12
|
McCann S, Sinha J, Wilson WS, McKinzie CJ, Garner LM, Gonzalez D. Population Pharmacokinetics of Posaconazole in Immune-Compromised Children and Assessment of Target Attainment in Invasive Fungal Disease. Clin Pharmacokinet 2023; 62:997-1009. [PMID: 37179512 PMCID: PMC10338595 DOI: 10.1007/s40262-023-01254-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND AND OBJECTIVE Posaconazole (PSZ) is a triazole antifungal for the management of invasive fungal disease (IFD) in adults and children. Although PSZ is available as an intravenous (IV) solution, oral suspension (OS) and delayed-release tablets (DRTs), OS is the preferred formulation for pediatric use because of potential safety concerns associated with an excipient in the IV formulation and difficulty in swallowing intact tablets by children. However, poor biopharmaceutical characteristics of the OS formulation leads to an unpredictable dose-exposure profile of PSZ in children, potentially risking therapeutic failure. The goal of this study was to characterize the population pharmacokinetics (PK) of PSZ in immunocompromised children and assess therapeutic target attainment. METHODS Serum concentrations of PSZ were collected retrospectively from records of hospitalized patients. A population PK analysis was performed in a nonlinear mixed-effects modeling framework with NONMEM (v7.4). The PK parameters were scaled to body weight, then potential covariate effects were assessed. The final PK model was used to evaluate recommended dosing schemes through simulation of target attainment (as a percentage of the population having steady-state trough concentrations above the recommended target) using Simulx (v2021R1). RESULTS Repeated measurement data of 202 serum concentrations of total PSZ were acquired from 47 immunocompromised patients between 1 and 21 years of age receiving PSZ either intravenously or orally, or both. A one-compartment PK model with first-order absorption and linear elimination best fit the data. The estimated absolute bioavailability (95% confidence interval) for suspension (Fs) was 16% (8-27%), which was significantly lower than the reported tablet bioavailability (Ft) [67%]. Fs was reduced by 62% and 75% upon concomitant administration with pantoprazole (PAN) and omeprazole (OME), respectively. Famotidine resulted in a reduction of Fs by only 22%. Both fixed dosing and weight-based adaptive dosing provided adequate target attainment when PAN or OME were not coadministered with the suspension. CONCLUSIONS The results of this study revealed that both fixed and weight-based adaptive dosing schemes can be appropriate for target attainment across all PSZ formulations, including suspension. Additionally, covariate analysis suggests that concomitant proton pump inhibitors should be contraindicated during PSZ suspension dosing.
Collapse
Affiliation(s)
- Sean McCann
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA
| | - Jaydeep Sinha
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA
- Department of Pediatrics, UNC School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William S Wilson
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Cameron J McKinzie
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Lauren M Garner
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA.
| |
Collapse
|
13
|
Sengar M, Jain H, D’souza S, Kannan S, Mokal S, Gurjar M, Ambotkar M, Sharma N, Boppanna M, Gota V. Exposure-Response Relationship of Posaconazole Suspension in Theprophylaxis of Invasive Fungal Infections in Patients with Acute Myeloid Leukemia. Indian J Hematol Blood Transfus 2023; 39:200-207. [PMID: 37006974 PMCID: PMC10064351 DOI: 10.1007/s12288-022-01568-4] [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: 04/06/2022] [Accepted: 08/10/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Antifungal prophylaxis with posaconazole has demonstrated a reduction in the risk of death due to Invasive fungal infections (IFI)in patients with acute myeloid leukemia (AML) during induction therapy. However, various factors affect the plasma levels of posaconazole and can potentially limit its efficacy. Therapeutic drug monitoring (TDM) can help optimize the dose, but literature is scant from centers with a high IFI burden. This study aimed to evaluate the proportion of de-novo AML patients on induction who could achieve the target level of 700ng/mL with posaconazole prophylaxis,factors that can influence the plasma levels, and the impact of plasma posaconazole levels on incidence of IFI. Methods Patients with AML on induction therapy with no baseline IFI were enrolled at our tertiary cancer center which has high prevalence of IFI. These patients received posaconazole suspension as prophylaxis. Daily plasma levels were measured from Day 4 till Day 12 of posaconazole prophylaxis. All patients were monitored for the development of IFI. The data on adverse events, concomitant drugs, mucositis, vomiting, and diarrhea were recorded. Results A total of 411 samples from fifty patients were collected. Only 177 out of 411 samples had levels > 700 ng/mL. The median trough level was 610 ng/mL (range30-3000 ng/mL). The median time to achieve target trough concentration was four days (range 4-12 days) from the start of induction.Thirty-eight (76%) patients achieved target plasma levels by day 12 of induction.The median plasma level on day 12 was 690 ng/mL (range,30-1270) in patients who achieved target levels as compared to 340 (50-560) ng/mL in those who did not. Twenty-six (52%) patients had IFI in our study, and the median time to develop breakthrough IFI was 14 days (range 4-24 days). Median and range of plasma levels were 690 ng/ml (30-2410; n = 22) in those who developed IFI, while 590 ng/mL (50-2300 n = 24) in those who did not. The odds of developing IFI in patients who did not achieve the threshold trough concentration of 700 ng/mL was 7.14 (95% CI; 1.35-37.75, p = 0.0206). Occurrence of vomiting (p = 0.02), diarrhea (p = 0.0008), mucositis (p = 0.003) had adverse impact on achievement of target plasma posaconazole levels. Conclusion A significant proportion of patients receiving posaconazole prophylaxis fail to achieve target plasma levels which can result in high risk of development of IFI. Occurrence of diarrhea, vomiting and mucositis can adversely affect the achievement target plasma levels.
Collapse
Affiliation(s)
- Manju Sengar
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National University, Dr. E. Borges Road, Parel, 400012 Mumbai, Maharashtra India
| | - Hasmukh Jain
- Kasturba Medical College, Manipal University, 203, Light House Hill Rd, 575001 Mangalore, Hampankatta, Mangalore, Karnataka India
| | - Sanyo D’souza
- Tata Memorial Centre, Homi Bhabha National University, Dr.E Borges Road, Parel, 400 012 Mumbai, India
| | - Sadhana Kannan
- Tata Memorial Centre, Homi Bhabha National University, Dr.E Borges Road, Parel, 400 012 Mumbai, India
| | - Smruti Mokal
- Tata Memorial Centre, Homi Bhabha National University, Dr.E Borges Road, Parel, 400 012 Mumbai, India
| | - Murari Gurjar
- ACTREC, Tata Memorial Centre, 410210 Kharghar, Navi Mumbai, Maharashtra India
| | - Madhavi Ambotkar
- ACTREC, Tata Memorial Centre, 410210 Kharghar, Navi Mumbai, Maharashtra India
| | - Neha Sharma
- Tata Memorial Centre, Dr. E Borges Road, Parel, 400 012 Mumbai, India
| | - Mounika Boppanna
- Department of Medical Oncology, Krishna Institute of Medical Sciences, Hyderabad, India
| | - Vikram Gota
- Clinical Pharmacology, ACTREC, Tata Memorial Centre, Homi Bhabha National University, Kharghar, Navi Mumbai, 410210 Mumbai, Maharashtra India
| |
Collapse
|
14
|
Shah H, Shah K, Gajera B, Dave RH, Taft DR. Developing a Formulation Strategy Coupled with PBPK Modeling and Simulation for the Weakly Basic Drug Albendazole. Pharmaceutics 2023; 15:pharmaceutics15041040. [PMID: 37111526 PMCID: PMC10145446 DOI: 10.3390/pharmaceutics15041040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/11/2023] [Accepted: 03/17/2023] [Indexed: 04/29/2023] Open
Abstract
Albendazole (ABZ) is a weakly basic drug that undergoes extensive presystemic metabolism after oral administration and converts to its active form albendazole sulfoxide (ABZ_SO). The absorption of albendazole is limited by poor aqueous solubility, and dissolution is the rate-limiting step in the overall exposure of ABZ_SO. In this study, PBPK modeling was used to identify formulation-specific parameters that impact the oral bioavailability of ABZ_SO. In vitro experiments were carried out to determine pH solubility, precipitation kinetics, particle size distribution, and biorelevant solubility. A transfer experiment was conducted to determine the precipitation kinetics. A PBPK model for ABZ and ABZ_SO was developed using the Simcyp™ Simulator based on parameter estimates from in vitro experiments. Sensitivity analyses were performed to assess the impact of physiological parameters and formulation-related parameters on the systemic exposure of ABZ_SO. Model simulations predicted that increased gastric pH significantly reduced ABZ absorption and, subsequently, ABZ_SO systemic exposure. Reducing the particle size below 50 µm did not improve the bioavailability of ABZ. Modeling results illustrated that systemic exposure of ABZ_SO was enhanced by increasing solubility or supersaturation and decreasing the drug precipitation of ABZ at the intestinal pH level. These results were used to identify potential formulation strategies to enhance the oral bioavailability of ABZ_SO.
Collapse
Affiliation(s)
- Harsh Shah
- Invagen, A Cipla Subsidiary, Hauppauge, NY 11788, USA
| | - Kushal Shah
- Takeda Pharmaceuticals International Inc., Cambridge, MA 02139, USA
| | | | - Rutesh H Dave
- Division of Pharmaceutical Sciences, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY 11201, USA
| | - David R Taft
- Samuel J. and Joan B. Williamson Institute for Pharmacometrics, Division of Pharmaceutical Sciences, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY 11201, USA
| |
Collapse
|
15
|
Franco YL, Da Silva L, Charbe N, Kinvig H, Kim S, Cristofoletti R. Integrating Forward and Reverse Translation in PBPK Modeling to Predict Food Effect on Oral Absorption of Weakly Basic Drugs. Pharm Res 2023; 40:405-418. [PMID: 36788156 DOI: 10.1007/s11095-023-03478-0] [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: 10/10/2022] [Accepted: 01/28/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION Ketoconazole and posaconazole are two weakly basic broad-spectrum antifungals classified as Biopharmaceutics Classification System class II drugs, indicating that they are highly permeable, but exhibit poor solubility. As a result, oral bioavailability and clinical efficacy can be impacted by the formulation performance in the gastrointestinal system. In this work, we have leveraged in vitro biopharmaceutics and clinical data available in the literature to build physiologically based pharmacokinetic (PBPK) models for ketoconazole and posaconazole, to determine the suitability of forward in vitro-in vivo translation for characterization of in vivo drug precipitation, and to predict food effect. METHODS A stepwise modeling approach was utilized to derive key parameters related to absorption, such as drug solubility, dissolution, and precipitation kinetics from in vitro data. These parameters were then integrated into PBPK models for the simulation of ketoconazole and posaconazole plasma concentrations in the fasted and fed states. RESULTS Forward in vitro-in vivo translation of intestinal precipitation kinetics for both model drugs resulted in poor predictions of PK profiles. Therefore, a reverse translation approach was applied, based on limited fitting of precipitation-related parameters to clinical data. Subsequent simulations for ketoconazole and posaconazole demonstrated that fasted and fed state PK profiles for both drugs were adequately recapitulated. CONCLUSION The two examples presented in this paper show how middle-out modeling approaches can be used to predict the magnitude and direction of food effects provided the model is verified on fasted state PK data.
Collapse
Affiliation(s)
- Yesenia L Franco
- Center for Pharmacometrics & Systems Pharmacology, Department of Pharmaceutics (Lake Nona), University of Florida, Orlando, FL, USA
| | - Lais Da Silva
- Center for Pharmacometrics & Systems Pharmacology, Department of Pharmaceutics (Lake Nona), University of Florida, Orlando, FL, USA
| | - Nitin Charbe
- Center for Pharmacometrics & Systems Pharmacology, Department of Pharmaceutics (Lake Nona), University of Florida, Orlando, FL, USA
| | - Hannah Kinvig
- Center for Pharmacometrics & Systems Pharmacology, Department of Pharmaceutics (Lake Nona), University of Florida, Orlando, FL, USA
| | - Soyoung Kim
- Center for Pharmacometrics & Systems Pharmacology, Department of Pharmaceutics (Lake Nona), University of Florida, Orlando, FL, USA
| | - Rodrigo Cristofoletti
- Center for Pharmacometrics & Systems Pharmacology, Department of Pharmaceutics (Lake Nona), University of Florida, Orlando, FL, USA.
| |
Collapse
|
16
|
Systemic Antifungal Therapy for Invasive Pulmonary Infections. J Fungi (Basel) 2023; 9:jof9020144. [PMID: 36836260 PMCID: PMC9966409 DOI: 10.3390/jof9020144] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/13/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
Antifungal therapy for pulmonary fungal diseases is in a state of flux. Amphotericin B, the time-honored standard of care for many years, has been replaced by agents demonstrating superior efficacy and safety, including extended-spectrum triazoles and liposomal amphotericin B. Voriconazole, which became the treatment of choice for most pulmonary mold diseases, has been compared with posaconazole and itraconazole, both of which have shown clinical efficacy similar to that of voriconazole, with fewer adverse events. With the worldwide expansion of azole-resistant Aspergillus fumigatus and infections with intrinsically resistant non-Aspergillus molds, the need for newer antifungals with novel mechanisms of action becomes ever more pressing.
Collapse
|
17
|
Rakhshan A, Rahmati Kamel B, Saffaei A, Tavakoli-Ardakani M. Hepatotoxicity Induced by Azole Antifungal Agents: A Review Study. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2023; 22:e130336. [PMID: 38116543 PMCID: PMC10728840 DOI: 10.5812/ijpr-130336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/31/2023] [Accepted: 02/21/2023] [Indexed: 12/21/2023]
Abstract
Context Fungal infections are very common, and several medications are used to treat them. Azoles are prescribed widely to treat fungal infections. In addition to therapeutic effects, any drug can be accompanied by side effects in patients. One of the most important complications in this regard is liver injury. Therefore, hepatotoxicity induced by azole antifungal drugs were reviewed in this study. Evidence Acquisition English scientific papers were evaluated to review the effects of hepatotoxicity by azole antifungal agents, and the related studies' results were summarized using a table. The systematic search was implemented on electronic databases, including PubMed, Google Scholar, and Science Direct. Original articles and review articles that were published before April 1, 2022, were included in the study. Those articles without available full text or non-English articles were excluded. Also, articles that reported pediatric data were excluded. Results Most studies have reported the effects of hepatotoxicity by azole antifungal agents, and their mechanisms have been described. Conclusions Clinical evaluations regarding the hepatotoxicity of antifungal agents provided in the literature were reviewed. Therefore, it is recommended to prescribe these drugs with caution in high-risk patients suffering from liver diseases, and patients should be monitored for hepatotoxicity. However, more research is needed to evaluate the hepatotoxicity of azole antifungal agents and select appropriate drugs according to cost-effectiveness and the side effects' profiles, relying on lower incidence of this liver complication.
Collapse
Affiliation(s)
- Amin Rakhshan
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Bardia Rahmati Kamel
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Saffaei
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maria Tavakoli-Ardakani
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Pharmaceutical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| |
Collapse
|
18
|
An Integrated Population Pharmacokinetic Analysis for Posaconazole Oral Suspension, Delayed-Release Tablet, and Intravenous Infusion in Healthy Volunteers. Drugs 2023; 83:75-86. [PMID: 36607589 DOI: 10.1007/s40265-022-01819-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Posaconazole is widely used for the prophylaxis and treatment of invasive fungal diseases. Because of the limited and variable absorption of the initially available oral suspension, a delayed-release tablet and intravenous formulation were developed. OBJECTIVE This study aimed to characterize the pharmacokinetics, including the absolute oral bioavailability, of all posaconazole formulations in healthy volunteers. METHODS Data from 182 healthy volunteers with 3898 densely sampled posaconazole concentrations were pooled from eight phase I clinical studies on the three formulations of various single and multiple dosage regimens between 50 and 400 mg. Analysis and simulations were performed using NONMEM 7.5.0. In the covariate analysis, the influence of food (fed vs fasted), nonlinearity, and for the delayed-release tablet, comedication (antacid, ranitidine, esomeprazole, and metoclopramide) were tested. RESULTS A two-compartment model with respectively, four and eight absorption transit compartments, best described the profiles of the oral suspension and delayed-release tablet. For the suspension, both a food effect and a dose-dependent nonlinear bioavailability were quantified, resulting in lower bioavailability when fasted or at a higher dose. The typical bioavailability of the suspension at 100 mg and 400 mg was derived to be respectively, 17.1% and 10.1% under fasted conditions and 59.1% and 49.2% under fed conditions. The absolute bioavailability of the delayed-release tablet was 58.8% (95% confidence interval 33.2-80.4) under fasted conditions and approached complete absorption under fed conditions for dosages up to 300 mg. Food intake reduced the absorption rate constant of the suspension by 52.2% (confidence interval 45.2-59.2). The impact of comedication on the absorption of the delayed-release tablet was not statistically significant. Model-based simulations indicate that under fed conditions, the licensed dosages of the three formulations yield a steady-state trough concentration ≥ 0.7 mg/L in over 90% of healthy volunteers. About 35% of healthy volunteers who receive the licensed 300-mg delayed-release tablet under fasted conditions do not achieve this target, while for the suspension this percentage varies between 55 and 85%, depending on the dose. CONCLUSIONS For both oral posaconazole formulations, we quantified bioavailability and absorption rate, including food effects, in healthy volunteers. The pharmacokinetic superiority of the delayed-release tablet was demonstrated under both fed and fasted conditions, compared with the oral suspension. The impact of food on the bioavailability of the delayed-release tablet was larger than anticipated, suggesting that administering the delayed-release tablet with food enhances absorption.
Collapse
|
19
|
Lamoth F, Calandra T. Pulmonary aspergillosis: diagnosis and treatment. Eur Respir Rev 2022; 31:31/166/220114. [DOI: 10.1183/16000617.0114-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/18/2022] [Indexed: 12/05/2022] Open
Abstract
Aspergillusspecies are the most frequent cause of fungal infections of the lungs with a broad spectrum of clinical presentations including invasive pulmonary aspergillosis (IPA) and chronic pulmonary aspergillosis (CPA). IPA affects immunocompromised populations, which are increasing in number and diversity with the advent of novel anti-cancer therapies. Moreover, IPA has emerged as a complication of severe influenza and coronavirus disease 2019 in apparently immunocompetent hosts. CPA mainly affects patients with pre-existing lung lesions and is recognised increasingly frequently among patients with long-term survival following cure of tuberculosis or lung cancer. The diagnosis of pulmonary aspergillosis is complex as it relies on the presence of clinical, radiological and microbiological criteria, which differ according to the type of pulmonary aspergillosis (IPA or CPA) and the type of patient population. The management of pulmonary aspergillosis is complicated by the limited number of treatment options, drug interactions, adverse events and the emergence of antifungal resistance.
Collapse
|
20
|
Bui J, Gellatly R, Othman J, Lindsay J. Subtherapeutic concentrations of posaconazole tablet: determining risk factors and effectiveness of a standardized dose adjustment in hematology inpatients. Leuk Lymphoma 2022; 63:3418-3425. [PMID: 36175159 DOI: 10.1080/10428194.2022.2126282] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Posaconazole is indicated for antifungal prophylaxis in hematology patients at high-risk of invasive fungal infections (IFI). Consensus guidelines recommend maintaining steady-state trough concentrations above 0.7 mg/L; however, upto one-third of patients return subtherapeutic concentrations which is associated with breakthrough IFI. This retrospective observational study of 496 concentrations from 90 hematology inpatients prescribed posaconazole tablet (PCZ-tab) between May 2017 and May 2019 identified 24% (n = 121) of posaconazole concentrations were subtherapeutic after the dosage of 300 mg daily. On multivariable analyses, diarrhea (p = 0.002), male gender (p = 0.018), and concurrent regular metoclopramide (p = 0.002) were significantly associated with subtherapeutic posaconazole concentrations. Eighty-nine percent of patients (n = 16) who underwent dose adjustment to 200 mg twice daily successfully achieved target posaconazole concentrations at first steady-state measurement. This study confirms that therapeutic drug monitoring of posaconazole remains necessary as subtherapeutic posaconazole concentrations are relatively common, and that dose adjustment of 200 mg twice daily, safely enabled achievement of therapeutic concentrations.
Collapse
Affiliation(s)
- Jessica Bui
- Clinical Pharmacy Department, Royal North Shore Hospital, Sydney, Australia.,Department of Infectious Diseases, Royal North Shore Hospital, Sydney, Australia
| | - Rochelle Gellatly
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia.,Pharmacy Department, Surrey Memorial Hospital, Surrey, Canada
| | - Jad Othman
- Haematology Department, Royal North Shore Hospital, Sydney, Australia
| | - Julian Lindsay
- Haematology Department, Royal North Shore Hospital, Sydney, Australia.,National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia.,Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Research Center, SE, USA
| |
Collapse
|
21
|
Ding Q, Huang S, Sun Z, Chen K, Li X, Pei Q. A Review of Population Pharmacokinetic Models of Posaconazole. Drug Des Devel Ther 2022; 16:3691-3709. [PMID: 36277600 PMCID: PMC9584355 DOI: 10.2147/dddt.s384637] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/22/2022] [Indexed: 11/05/2022] Open
Abstract
Posaconazole is often used for the prophylaxis and treatment of invasive fungal infections (IFI). However, intra- and inter-individual differences and drug interactions affect the efficacy and safety of posaconazole. Precision dosing of posaconazole based on the population pharmacokinetic (PopPK) model may assist in making significant clinical decisions. This review aimed to comprehensively summarize the published PopPK models of posaconazole and analyze covariates that significantly influence posaconazole exposure. Articles published until May 2022 for PopPK analysis of posaconazole were searched in PubMed and EMBASE databases. Demographic characteristics, model characteristics, and results of PopPK analysis were extracted from the selected articles. In addition, the steady-state pharmacokinetic profiles of posaconazole were simulated at different covariate levels and dosing regimens. Out of the 13 studies included in our review, nine studies included adults, three included children, and one included both adults and children. All oral administration models were one-compartment models, and all intravenous administration models were two-compartment models. Body weight, proton pump inhibitors, and incidence of diarrhea were found to be important covariates. Clinically, the potential impact of factors such as patient physiopathologic characteristics and comorbid medications on posaconazole pharmacokinetics should be considered. Dose adjustment in combination with TDM or replacement with a tablet or intravenous formulation with higher exposure may be an effective way to ensure drug efficacy as well as to reduce fungal resistance. Meanwhile, published models require further external evaluation to examine extrapolation.
Collapse
Affiliation(s)
- Qin Ding
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Shuqi Huang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Zexu Sun
- Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, People’s Republic of China
| | - Kaifeng Chen
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Xin Li
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China,Xin Li, Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, 410013, People’s Republic of China, Email
| | - Qi Pei
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China,Correspondence: Qi Pei, Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, People’s Republic of China, Tel +86 1 317 041 9804, Email
| |
Collapse
|
22
|
Huang S, Ding Q, Yang N, Sun Z, Cheng Q, Liu W, Li Y, Chen X, Wu C, Pei Q. External evaluation of published population pharmacokinetic models of posaconazole. Front Pharmacol 2022; 13:1005348. [PMID: 36249756 PMCID: PMC9561726 DOI: 10.3389/fphar.2022.1005348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
Population pharmacokinetic (PopPK) models of posaconazole have been established to promote the precision dosing. However, the performance of these models extrapolated to other centers has not been evaluated. This study aimed to conduct an external evaluation of published posaconazole PopPK models to evaluate their predictive performance. Posaconazole PopPK models screened from the PubMed and MEDLINE databases were evaluated using an external dataset of 213 trough concentration samples collected from 97 patients. Their predictive performance was evaluated by prediction-based diagnosis (prediction error), simulation-based diagnosis (visual predictive check), and Bayesian forecasting. In addition, external cohorts with and without proton pump inhibitor were used to evaluate the models respectively. Ten models suitable for the external dataset were finally included into the study. In prediction-based diagnostics, none of the models met pre-determined criteria for predictive indexes. Only M4, M6, and M10 demonstrated favorable simulations in visual predictive check. The prediction performance of M5, M7, M8, and M9 evaluated using the cohort without proton pump inhibitor showed a significant improvement compared to that evaluated using the whole cohort. Consistent with our expectations, Bayesian forecasting significantly improved the predictive per-formance of the models with two or three prior observations. In general, the applicability of these published posaconazole PopPK models extrapolated to our center was unsatisfactory. Prospective studies combined with therapeutic drug monitoring are needed to establish a PopPK model for posaconazole in the Chinese population to promote individualized dosing.
Collapse
Affiliation(s)
- Shuqi Huang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Qin Ding
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Nan Yang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Zexu Sun
- Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, China
| | - Qian Cheng
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Wei Liu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yejun Li
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xin Chen
- Department of Pharmacy, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Cuifang Wu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Cuifang Wu, ; Qi Pei,
| | - Qi Pei
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Cuifang Wu, ; Qi Pei,
| |
Collapse
|
23
|
Lin D, Yu L, Shang D, Huang L, Wu L, Liao X, Zhang Y, Zi J, Zhang J, Zeng Y, Wang X, Yang L. Population pharmacokinetics of posaconazole in Chinese pediatric patients with acute leukaemia: effect of food on bioavailability and dose optimization. Eur J Pharm Sci 2022; 178:106289. [PMID: 36041707 DOI: 10.1016/j.ejps.2022.106289] [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: 05/04/2022] [Revised: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 11/03/2022]
Abstract
This study aimed to investigate the effect of food on the pharmacokinetics of posaconazole suspension in pediatric patients with acute leukaemia and to recommend optimal dosing strategies. This single-site, prospective, open-label, observational study was conducted in 42 patients and included 186 plasma concentrations of posaconazole. Sparse data were analyzed using population pharmacokinetic modeling. Monte Carlo simulations were conducted to predict the morning trough concentrations at steady-state with the proposed dose of 2-7 mg/kg three times daily (tid) or four times daily (qid) for bodyweights of 10-36 kg. The target concentrations were 700 ng/mL for prophylaxis and 1000 ng/mL for treatment. Dosage regimens with percentage of target attainment (PTA) ≥70% were recommended. A one-compartment model with allometric scaling adequately described the pharmacokinetic profile. The apparent clearance was 9.05 L/h (95% confidence interval [CI] 7.14-11.09) and the apparent volume of distribution was 283 L (95% CI 168-491) for a typical individual of 17.5 kg. The relative bioavailability with high-fat diet was as high as 1.95-fold compared with regular food. Following the intake of regular meals, 4 mg/kg qid was adequate with a PTA ≥ 71.8% for prophylaxis. A dosage of 6 mg/kg qid under a regular diet reached a PTA ≥ 73.4% for treatment. The recommended dosage of posaconazole for prophylaxis and treatment could be predicted by the pharmacokinetic model based on bodyweight and diet type in pediatric patients.
Collapse
Affiliation(s)
- Danna Lin
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Lihua Yu
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Dewei Shang
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China.
| | - Lulu Huang
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Li Wu
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Xu Liao
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Yajie Zhang
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Juan Zi
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Jingxin Zhang
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Yinghua Zeng
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Xipei Wang
- Medical Research Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China; Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
| | - Lihua Yang
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| |
Collapse
|
24
|
Challenges in the Treatment of Invasive Aspergillosis in Immunocompromised Children. Antimicrob Agents Chemother 2022; 66:e0215621. [PMID: 35766509 PMCID: PMC9295552 DOI: 10.1128/aac.02156-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Invasive aspergillosis (IA) is associated with significant morbidity and mortality. Voriconazole remains the drug of choice for the treatment of IA in children; however, the complex kinetics of voriconazole in children make dosing challenging and therapeutic drug monitoring (TDM) essential for treatment success. The overarching goal of this review is to discuss the role of voriconazole, posaconazole, isavuconazole, liposomal amphotericin B, echinocandins, and combination antifungal therapy for the treatment of IA in children. We also provide a detailed discussion of antifungal TDM in children.
Collapse
|
25
|
Perveen S, Gauhar S, Yousuf RI, Ali H, Zafar F, Sheikh AF. Evaluation of pharmacokinetic interactions of amoxicillin with ranitidine in healthy human volunteers of Karachi, Pakistan. PLoS One 2022; 17:e0267791. [PMID: 35609024 PMCID: PMC9128966 DOI: 10.1371/journal.pone.0267791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 04/18/2022] [Indexed: 11/18/2022] Open
Abstract
Polypharmacy may be considered as the customary practice to provide optimum care services to patients but inter resulted in augmented probability of multiple drug interaction. Keeping in view the importance of drug interaction possibility, this study was designed to evaluate the effect of ranitidine on pharmacokinetics of amoxicillin in the local population of Karachi, Pakistan. Amoxicillin and ranitidine are the most commonly prescribed drugs to treat duodenal ulcer caused by Helicobacter pylori. The current investigation was carried out as a single center, open label, two phase, single dose, randomized way in cross over manner to evaluate the potential of pharmacokinetic interaction among amoxicillin formulation and ranitidine in adult healthy male volunteers. Post dosing blood samples were collected at multiple time points that are 0.5, 1, 1.5, 2, 3, 4, 6, 8 and 10 hours after administering amoxicillin 250mg capsule with and without ranitidine. For estimation of amoxicillin concentration in plasma, an HPLC method was developed and validated. The solvent system consisted of 0.025M phosphate buffer: acetonitrile (94:6 v/v). C18 column was employed with a flow rate of 1.0 ml/minute and at 230nm. A linear pattern with a correlation coefficient of 0.999 in the concentration ranges of 25μg/mL to 0.097μg/mL for amoxicillin and 25μg/mL to 0.048μg/mL for ranitidine was observed. Amoxicillin retention time was about 8 minutes and ranitidine retention time was around 12 minutes. Amoxicillin levels were computed and the concentrations were applied to calculate the pharmacokinetic parameters. Pharmacokinetic parameters were estimated by Kinetica TM 4.4.1 (Thermo Electron Corp. USA). The analysis of variance (two way) and t test (two one sided) were applied on log transformed pharmacokinetic parameters of amoxicillin. The Tmax was determined between amoxicillin alone and amoxicillin with ranitidine by Friedman test. The 90% confidence interval values for Cmax(calc) (0.687–0.743) and Tmax(calc) (1.148–1.742) for amoxicillin with or without ranitidine were not found within the FDA acceptable limits of 0.8–1.25. Study demonstrated the significant reduction in peak plasma levels of amoxicillin in presence of ranitidine. It is advisable to administer both drugs with time interval to avoid such interactions and increases in the bactericidal efficacy of amoxicillin.
Collapse
Affiliation(s)
- Shaheen Perveen
- Faculty of Pharmacy, Department of Pharmaceutics, University of Karachi, Karachi, Pakistan
- Department of Pharmaceutics, Institute of Pharmaceutical Sciences, Jinnah Sindh Medical University, Karachi, Pakistan
- * E-mail:
| | - Shahnaz Gauhar
- RAK College of Pharmaceutical Sciences, RAK MHSU, Ras Al Khaimah, UAE
| | - Rabia Ismail Yousuf
- Faculty of Pharmacy, Department of Pharmaceutics, University of Karachi, Karachi, Pakistan
| | - Huma Ali
- Department of Pharmaceutics, Institute of Pharmaceutical Sciences, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Farya Zafar
- Faculty of Pharmacy, Department of Pharmaceutics, University of Karachi, Karachi, Pakistan
| | - Anab Fatima Sheikh
- College of Pharmacy, Dow University of Health Sciences, Karachi, Pakistan
| |
Collapse
|
26
|
Jia M, Zhang Q, Qin Z, Wang D, Liu P, Yang J, Zhang X. Dose Optimisation of Posaconazole and Therapeutic Drug Monitoring in Pediatric Patients. Front Pharmacol 2022; 13:833303. [PMID: 35517786 PMCID: PMC9061949 DOI: 10.3389/fphar.2022.833303] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Experience in the clinical use of posaconazole (PCZ) in pediatric patients is limited, and no specific dose recommendations exist. This study aimed to investigate an appropriate dosing regimen, and assess the exposure-response relationships of PCZ in children. We reviewed the medical records of inpatients aged <18 years who subjected to PCZ concentrations monitoring. Clinical data, PCZ dosing and monitoring data were collected. A total of 375 PCZ trough concentrations (C min) from 105 pediatric patients were included. For children receiving PCZ for prophylaxis, the median doses required to achieve the therapeutic range at the ages of <6, 6-12 and >12 years were 14.80, 14.52 and 12.90 mg/kg/day, respectively (p = 0.001); and for those receiving PCZ for treatment, the median doses were 23.50, 20.96 and 15.38 mg/kg/day, respectively (p = 0.001). Among children taking PCZ for prophylaxis, 12% developed a proven or probable breakthrough IFIs; the median PCZ concentrations were significantly lower than those children with successful treatment response (0.43 versus 1.20 μg mL-1; p < 0.001). 79.2% patients taking PCZ for treatment had a positive clinical response, and the median PCZ concentrations were significantly higher than those children with disease progression (1.06 versus 0.53 μg mL-1; p = 0.024). No association between C min values and hepatotoxicity was observed. Factors such as age, CRP, ALT and co-administration with proton pump inhibitors exhibited significant effects on PCZ C min. It is necessary to adjust the dosing regimens based on PCZ C min to individualize antifungal therapy and provide guidelines for dose adjustment in children.
Collapse
Affiliation(s)
- Mengmeng Jia
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Qiwen Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Zifei Qin
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Dao Wang
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peng Liu
- Pediatric Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Yang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Xiaojian Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| |
Collapse
|
27
|
Wu D, Mi Y, Weng J, Zhuang J, Ke X, Wang C, Liu K, Martinho M, Winchell GA, Zang Y, Xu L. Phase 1b/3 Pharmacokinetics and Safety Study of Intravenous Posaconazole in Adult Asian Participants at High Risk for Invasive Fungal Infections. Adv Ther 2022; 39:1697-1710. [PMID: 35167031 PMCID: PMC8989837 DOI: 10.1007/s12325-021-02012-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 12/01/2021] [Indexed: 01/01/2023]
Abstract
Introduction Antifungal prophylaxis in patients at high risk for invasive fungal infections (IFIs), such as those with acute myeloid leukemia or myelodysplastic syndromes, continues to be underused in Asia, despite the fact that it reduces IFI-related death and increases IFI-free survival. We characterized the pharmacokinetics (PK) and safety of the intravenous (IV) formulation of posaconazole in adult Asian participants at high risk for IFI. Methods Participants received posaconazole IV 300 mg twice on day 1, posaconazole IV 300 mg once daily on days 2–10, and posaconazole IV 300 mg once daily or oral suspension 200 mg 3 times daily for up to 18 days for a maximum of 28 days. There were two PK sampling groups: intensive and sparse. Sparse trough PK sampling was collected from all participants on days 3, 6, 10, 15, 22, and 28/end of treatment. The intensive PK group had additional sampling performed over 24 h on day 10. Primary end points were steady state average concentration (Cavg,ss) and percentage of participants with Cavg,ss ≥ 500 ng/mL. Safety was assessed up to day 30/end of treatment. Results Seventy participants with acute myelogenous leukemia were enrolled, 30 in the intensive PK group and 40 in the sparse PK group; 57 participants completed the study, 26 in the intensive PK group and 31 in the sparse PK group. On day 10, arithmetic mean Cavg,ss was 2986 ng/mL [coefficient of variation (%CV), 36%; range, 1409–5930 ng/mL]; 100% of participants in the intensive PK group (n/N = 27/27) had Cavg,ss ≥ 500 ng/mL. Arithmetic mean (%CV) Cmin was 2474 (50.4%) and 2466 ng/mL (42.4%) in the intensive and sparse PK groups on day 10, respectively. Safety was similar to that of previous posaconazole formulations. Conclusion In Asian participants at high risk for IFIs, IV posaconazole achieved the target exposure associated with efficacy that was previously established for supporting global registration of posaconazole for IV administration and was generally well tolerated. Clinical trial registration ClinicalTrials.gov, NCT03336502. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-02012-1.
Collapse
Affiliation(s)
- Depei Wu
- Hematology Department, The First Affiliated Hospital of Soochow University, 296 Shizi Street, Cang Lang Qu, Suzhou, 215006, Jiangsu, China.
| | - Yingchang Mi
- Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, 30020, China
| | - Jianyu Weng
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Science, Guangzhou, 510080, China
| | | | - Xiaoyan Ke
- Peking University Third Hospital, Beijing, China
| | - Chun Wang
- Shanghai General Hospital, Shanghai, China
| | - Kaiyan Liu
- Peking University People's Hospital, Beijing, China
| | | | | | | | - Lianzhe Xu
- Merck & Co., Inc, Kenilworth, NJ, 07033, USA
| |
Collapse
|
28
|
Ashok A, Mangalore RP, Morrissey CO. Azole Therapeutic Drug Monitoring and its Use in the Management of Invasive Fungal Disease. CURRENT FUNGAL INFECTION REPORTS 2022. [DOI: 10.1007/s12281-022-00430-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
29
|
Darwish RM, AlMasri M, Al‐Masri MM. Mucormycosis: The Hidden and Forgotten Disease. J Appl Microbiol 2022; 132:4042-4057. [DOI: 10.1111/jam.15487] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/14/2022] [Accepted: 02/08/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Rula M. Darwish
- Department of Pharmaceutics and Pharmaceutical Technology, School of Pharmacy The University of Jordan Amman Jordan
| | | | | |
Collapse
|
30
|
Dental and Oral Manifestations of COVID-19 Related Mucormycosis: Diagnoses, Management Strategies and Outcomes. J Fungi (Basel) 2021; 8:jof8010044. [PMID: 35049983 PMCID: PMC8781413 DOI: 10.3390/jof8010044] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 12/14/2022] Open
Abstract
It has been nearly two years since the pandemic caused by the novel coronavirus disease (COVID-19) has affected the world. Several innovations and discoveries related to COVID-19 are surfacing every day and new problems associated with the COVID-19 virus are also coming to light. A similar situation is with the emergence of deep invasive fungal infections associated with severe acute respiratory syndrome 2 (SARS-CoV-2). Recent literature reported the cases of pulmonary and rhino-cerebral fungal infections appearing in patients previously infected by COVID-19. Histopathological analysis of these cases has shown that most of such infections are diagnosed as mucormycosis or aspergillosis. Rhino-orbital-cerebral mucormycosis usually affects the maxillary sinus with involvement of maxillary teeth, orbits, and ethmoidal sinuses. Diabetes mellitus is an independent risk factor for both COVID-19 as well as mucormycosis. At this point, there is scanty data on the subject and most of the published literature comprises of either case reports or case series with no long-term data available. The aim of this review paper is to present the characteristics of COVID-19 related mucormycosis and associated clinical features, outcome, diagnostic and management strategies. A prompt diagnosis and aggressive treatment planning can surely benefit these patients.
Collapse
|
31
|
Chau MM, Daveson K, Alffenaar JWC, Gwee A, Ho SA, Marriott DJE, Trubiano JA, Zhao J, Roberts JA. Consensus guidelines for optimising antifungal drug delivery and monitoring to avoid toxicity and improve outcomes in patients with haematological malignancy and haemopoietic stem cell transplant recipients, 2021. Intern Med J 2021; 51 Suppl 7:37-66. [PMID: 34937141 DOI: 10.1111/imj.15587] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Antifungal agents can have complex dosing and the potential for drug interaction, both of which can lead to subtherapeutic antifungal drug concentrations and poorer clinical outcomes for patients with haematological malignancy and haemopoietic stem cell transplant recipients. Antifungal agents can also be associated with significant toxicities when drug concentrations are too high. Suboptimal dosing can be minimised by clinical assessment, laboratory monitoring, avoidance of interacting drugs, and dose modification. Therapeutic drug monitoring (TDM) plays an increasingly important role in antifungal therapy, particularly for antifungal agents that have an established exposure-response relationship with either a narrow therapeutic window, large dose-exposure variability, cytochrome P450 gene polymorphism affecting drug metabolism, the presence of antifungal drug interactions or unexpected toxicity, and/or concerns for non-compliance or inadequate absorption of oral antifungals. These guidelines provide recommendations on antifungal drug monitoring and TDM-guided dosing adjustment for selected antifungal agents, and include suggested resources for identifying and analysing antifungal drug interactions. Recommended competencies for optimal interpretation of antifungal TDM and dose recommendations are also provided.
Collapse
Affiliation(s)
- Maggie M Chau
- Pharmacy Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Kathryn Daveson
- Department of Infectious Diseases and Microbiology, The Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - Jan-Willem C Alffenaar
- Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Camperdown, New South Wales, Australia.,Pharmacy Department, Westmead Hospital, Westmead, New South Wales, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Camperdown, New South Wales, Australia
| | - Amanda Gwee
- Infectious Diseases Unit, The Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Infectious Diseases Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Su Ann Ho
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Deborah J E Marriott
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Darlinghurst, New South Wales, Australia.,Faculty of Science, University of Technology, Ultimo, New South Wales, Australia.,Faculty of Medicine, The University of New South Wales, Kensington, New South Wales, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Jessie Zhao
- Department of Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason A Roberts
- The University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | |
Collapse
|
32
|
Czyrski A, Resztak M, Świderski P, Brylak J, Główka FK. The Overview on the Pharmacokinetic and Pharmacodynamic Interactions of Triazoles. Pharmaceutics 2021; 13:pharmaceutics13111961. [PMID: 34834376 PMCID: PMC8620887 DOI: 10.3390/pharmaceutics13111961] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/09/2021] [Accepted: 11/15/2021] [Indexed: 12/24/2022] Open
Abstract
Second generation triazoles are widely used as first-line drugs for the treatment of invasive fungal infections, including aspergillosis and candidiasis. This class, along with itraconazole, voriconazole, posaconazole, and isavuconazole, is characterized by a broad range of activity, however, individual drugs vary considerably in safety, tolerability, pharmacokinetics profiles, and interactions with concomitant medications. The interaction may be encountered on the absorption, distribution, metabolism, and elimination (ADME) step. All triazoles as inhibitors or substrates of CYP isoenzymes can often interact with many drugs, which may result in the change of the activity of the drug and cause serious side effects. Drugs of this class should be used with caution with other agents, and an understanding of their pharmacokinetic profile, safety, and drug-drug interaction profiles is important to provide effective antifungal therapy. The manuscript reviews significant drug interactions of azoles with other medications, as well as with food. The PubMed and Google Scholar bases were searched to collect the literature data. The interactions with anticonvulsants, antibiotics, statins, kinase inhibitors, proton pump inhibitors, non-nucleoside reverse transcriptase inhibitors, opioid analgesics, benzodiazepines, cardiac glycosides, nonsteroidal anti-inflammatory drugs, immunosuppressants, antipsychotics, corticosteroids, biguanides, and anticoagulants are presented. We also paid attention to possible interactions with drugs during experimental therapies for the treatment of COVID-19.
Collapse
Affiliation(s)
- Andrzej Czyrski
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland; (M.R.); (F.K.G.)
- Correspondence: ; Tel.: +48-61-854-64-33
| | - Matylda Resztak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland; (M.R.); (F.K.G.)
| | - Paweł Świderski
- Department of Forensic Medicine, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland;
| | - Jan Brylak
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, 27/33 Szpitalna Street, 60-572 Poznań, Poland;
| | - Franciszek K. Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland; (M.R.); (F.K.G.)
| |
Collapse
|
33
|
Osae SP, Chastain DB, Young HN. Pharmacists role in addressing health disparities—Part 1: Social determinants of health and their intersectionality with medication use, health care utilization, and health outcomes. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1565] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sharmon P. Osae
- College of Pharmacy University of Georgia Albany Georgia USA
| | | | - Henry N. Young
- College of Pharmacy University of Georgia Athens Georgia USA
| |
Collapse
|
34
|
Panagopoulou P, Roilides E. Evaluating posaconazole, its pharmacology, efficacy and safety for the prophylaxis and treatment of fungal infections. Expert Opin Pharmacother 2021; 23:175-199. [PMID: 34758695 DOI: 10.1080/14656566.2021.1996562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Invasive fungal diseases (IFDs) are a significant cause of morbidity and mortality among immunocompromised patients. Safe and effective antifungal medications used for prophylaxis and treatment are pivotal in their management. Posaconazole is a promising triazole antifungal agent. AREAS COVERED The authors discuss the pharmacological properties of posaconazole, including pharmacokinetics/pharmacodynamics, safety and tolerability profile, together with efficacy data for prophylaxis and treatment as well as its use in special populations based on current literature. EXPERT OPINION Posaconazole has a favorable safety and tolerability profile; however, caution is advised when co-administered with agents that are CYP3A4 inhibitors, because their concentration may significantly increase, and their levels should be closely monitored. It has an extended spectrum of activity against yeasts and filamentous fungi. It is successfully used as prophylaxis for patients with acute myeloid leukemia (AML)/myelodysplastic syndrome (MDS) and post-hematopoietic cell transplantation (HCT) with graft-versus-host disease (GVHD). It is the first line treatment for oropharyngeal candidiasis and is also used as a salvage treatment for refractory IFDs. Currently available formulations include the oral suspension, delayed-release tablets and solution for intravenous infusion, all with different PK/PD properties and indications. Its use in children and adolescents is currently being examined in Phase-II clinical trials.
Collapse
Affiliation(s)
- Paraskevi Panagopoulou
- 4th Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Papageorgiou General Hospital, Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Hippokration General Hospital, Thessaloniki, Greece.,Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
35
|
Kataoka M, Minami K, Takagi T, Amidon GE, Yamashita S. In Vitro-In Vivo Correlation in Cocrystal Dissolution: Consideration of Drug Release Profiles Based on Coformer Dissolution and Absorption Behavior. Mol Pharm 2021; 18:4122-4130. [PMID: 34618448 DOI: 10.1021/acs.molpharmaceut.1c00537] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This study assessed the in vitro-in vivo correlation in cocrystal dissolution based on the coformer behavior. 4-Aminobenzoic acid (4ABA) was used as a coformer. Cocrystals of poorly water-soluble drugs with 4ABA, ketoconazole cocrystal (KTZ-4ABA), posaconazole cocrystal (PSZ-4ABA), and itraconazole cocrystal (ITZ-4ABA) were used. These three cocrystals generated supersaturated solutions in fasted state simulated intestinal fluid (FaSSIF) in a small-scale, 8 mL dissolution vessel. The time profile of the dissolved amount of 4ABA, an indicator of cocrystal dissolution, was significantly different among the three cocrystals. Under the conditions utilized, half of the KTZ-4ABA cocrystal solid rapidly dissolved within 5 min and the dissolved amount (% of applied amount) of KTZ and 4ABA was the same. Then, even though the residual solid cocrystal gradually dissolved, KTZ precipitated with time. The PSZ-4ABA cocrystal dissolved in a linear fashion with time but the dissolved concentration of PSZ reached a plateau in the supersaturated state and was maintained for at least 2 h. The dissolution rate of ITZ-4ABA was very slow compared to those of the other cocrystals, but a similar tendency was observed between cocrystal dissolution and the dissolved amount of ITZ. The rank order of the cocrystal dissolution rate based on the conformer concentration was KTZ-4ABA > PSZ-4ABA > ITZ-4ABA. Furthermore, cocrystallization of the three drugs with 4ABA significantly enhanced the oral drug absorption in rats. The rank order of the in vivo cocrystal dissolution rate by a deconvolution analysis with the plasma concentration-time profile of 4ABA was KTZ-4ABA > PSZ-4ABA > ITZ-4ABA, which corresponded well with the in vitro dissolution profiles of the cocrystals. These results indicate that analysis of cocrystal dissolution based on the coformer behavior may be useful to evaluate the in vitro and in vivo cocrystal dissolution.
Collapse
Affiliation(s)
- Makoto Kataoka
- Faculty of Pharmaceutical Sciences, Setsunan University, Hirakata, Osaka 573-0101, Japan.,College of Pharmacy, University of Michigan, Ann Arbor, Michigan 498109-1065, United States
| | - Keiko Minami
- Faculty of Pharmaceutical Sciences, Setsunan University, Hirakata, Osaka 573-0101, Japan
| | - Toshihide Takagi
- Faculty of Pharmaceutical Sciences, Setsunan University, Hirakata, Osaka 573-0101, Japan
| | - Gregory E Amidon
- College of Pharmacy, University of Michigan, Ann Arbor, Michigan 498109-1065, United States
| | - Shinji Yamashita
- Faculty of Pharmaceutical Sciences, Setsunan University, Hirakata, Osaka 573-0101, Japan
| |
Collapse
|
36
|
Population pharmacokinetics of a posaconazole tablet formulation in transplant adult allogeneic stem cell recipients. Eur J Pharm Sci 2021; 168:106049. [PMID: 34699939 DOI: 10.1016/j.ejps.2021.106049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/05/2021] [Accepted: 10/21/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Posaconazole is an antifungal agent extensively used as a prophylaxis for invasive fungal infections (IFIs) in allogeneic stem cell transplant (SCT) recipients. Low posaconazole concentrations have been associated with reduced clinical response. The aim of this study was to develop a population pharmacokinetic (popPK) model of a posaconazole tablet formulation in allogeneic SCT adult recipients for supporting model-informed precision dosing (MIPD). MATERIALS AND METHOD Prospective observational study performed in adult allogeneic SCT recipients receiving posaconazole as prophylaxis for IFIs and followed up by a therapeutic drug monitoring (TDM) program. Posaconazole plasma concentrations were quantified using an ultra-high-performance liquid chromatography (UPLC) with UV detector. A popPK model was developed using NONMEM v.7.4.0. Deterministic and stochastic simulations were carried out with the final model to evaluate the differences across physiological variables with impact on drug exposure. RESULTS A one-compartment model with sequential absorption (zero and first order) and first order elimination described adequately 55 posaconazole concentrations from 36 patients. Higher doses of posaconazole were found to be required by males and patients with lower values of total serum proteins. A nomogram to estimate the posaconazole daily dose based on pharmacokinetic/pharmacodynamic (PKPD) criterion for males and females for different values of total proteins was developed. CONCLUSIONS Gender and total serum proteins have been identified as covariates influencing posaconazole CL/F in adult allogeneic SCT recipients receiving the delay-released tablet formulation. Additional studies are required to better characterize the absorption of posaconazole and implications on dosage recommendations together with potential safety concerns.
Collapse
|
37
|
Musick KL, Jones SL, Norris AM, Hochstetler LJ, Williams FN, McKinzie BP. Evaluation of Voriconazole and Posaconazole Dosing in Patients with Thermal Burn Injuries. J Burn Care Res 2021; 43:802-807. [PMID: 34672325 DOI: 10.1093/jbcr/irab200] [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] [Indexed: 11/14/2022]
Abstract
Fungal infections are a recognized cause of increased morbidity and mortality in thermal burn patients. Adequate treatment regimens remain a challenge due to unpredictable pharmacokinetic/pharmacodynamic changes caused by a hypermetabolic state and individual patient factors. A retrospective evaluation of adult thermal burn patients from April 2014 to April 2020 was conducted to assess voriconazole and posaconazole antifungal dosing regimens. The primary outcome was the incidence of attaining a therapeutic steady-state trough level on the patient's initial voriconazole or posaconazole regimen. Of the 35 patients analyzed, 28 (80.0%) patients achieved a therapeutic level during azole therapy. However, only 13 (46.4%) patients achieved a therapeutic level on their first azole regimen. The median time to therapeutic level was 8.0 + 21.1 days from the start of azole therapy. Optimal dosing strategies for azole therapy in patients with thermal burns remains undefined. Further assessment is needed to delineate patient-specific factors that can contribute to subtherapeutic azole levels in thermal burn patients and the overall clinical impact of population-specific dosing regimens.
Collapse
Affiliation(s)
- Kaitlin L Musick
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, USA
| | - Savannah L Jones
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, USA
| | - Ashlyn M Norris
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, USA
| | - Lauren J Hochstetler
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, USA
| | - Felicia N Williams
- Jaycee Burn Center, University of North Carolina Medical Center, Chapel Hill, USA
| | - Brian P McKinzie
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, USA
| |
Collapse
|
38
|
Scardina T, Oikonomopoulou Z, Sun S, Muller WJ, Patel SJ. Opportunities for Antimicrobial Stewardship Among Pediatric Patients Prescribed Combination Antifungal Therapy. J Pediatr Pharmacol Ther 2021; 26:624-631. [PMID: 34421413 DOI: 10.5863/1551-6776-26.6.624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 01/13/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Combination antifungal therapy (CAF) may be prescribed to treat invasive fungal infections (IFIs). Data on the incidence of CAF among the pediatric population are limited. Antimicrobial stewardship for CAF includes therapeutic drug monitoring (TDM) and monitoring for adverse events. Primary outcome was to determine the incidence of CAF prescribed for documented proven, probable, and possible IFI. Secondary outcomes were to determine initial dose of antifungal therapy, determine incidence of adverse events, and evaluate our practice of TDM. METHODS Medical charts of patients who received CAF for proven, probable, or possible IFI within 6 years were reviewed. Patients age ≤18 years, prescribed CAF (defined as a second antifungal therapy started ≤72 hours of initial antifungal therapy) for at least 72 hours, and with normal liver function test results were included. RESULTS 57 patients received CAF for 72 separate episodes: 35 episodes were proven IFI, 11 were probable IFI, and 26 were possible IFI. Initial dose of antifungal therapy varied, and 29.1% received a loading dose. A total of 10 patients experienced 14 adverse events that were related to antifungal therapy. In 63.8% of CAF episodes, TDM was conducted. Target antifungal concentrations were documented for 10 CAF episodes. Reason for discontinued of CAF was documented for 35 episodes. Of these episodes, 74% were discontinued after therapeutic antifungal concentrations were achieved. CONCLUSIONS There are opportunities for antimicrobial stewardship interventions in the method of TDM and monitoring for adverse events that could aid in management of CAF.
Collapse
|
39
|
Elkayal O, Spriet I, Uyttebroeck A, Colita A, Annaert P, Allegaert K, Smits A, Van Daele R, Dreesen E. A Population Pharmacokinetic Modeling and Simulation Study of Posaconazole Oral Suspension in Immunocompromised Pediatric Patients: A Short Communication. Ther Drug Monit 2021; 43:512-518. [PMID: 33560094 DOI: 10.1097/ftd.0000000000000877] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Posaconazole oral suspension emerged as a promising candidate for prophylaxis of invasive fungal infections in immunocompromised children. Its pharmacodynamic advantages include a broad-spectrum activity and a favorable safety profile; however, they are overshadowed by its large pharmacokinetic (PK) variability, which might cause subtherapeutic exposure. The aim of this study was to develop a population (pop) PK model based on rich sampling data to better understand the PK of posaconazole oral suspension in pediatric patients. METHODS Data were obtained from a prospective interventional study involving hospitalized pediatric patients with a hematologic malignancy and prophylactically treated with posaconazole oral suspension. After constructing the popPK model, the probability of target attainment (PTA; 100% T ≥ 0.7 mg/L) for prophylaxis under fixed, body weight-based, and body surface area-based dosing was evaluated using Monte Carlo simulation. RESULTS Fourteen patients contributed 112 posaconazole plasma concentrations. The PK of posaconazole was adequately described by a 1-compartment model with lag time 2.71 hours [13%]; nonlinear bioavailability ED50 99.1 mg/m2 (fixed); first-order absorption rate constant 0.325 hour-1 [27%]; apparent volume of distribution 1150 L [34%]; and apparent clearance 15.4 L/h [24%] (∼70-kg individual). The bioavailability decreased in the presence of diarrhea and co-treatment with a proton pump inhibitor (PPI). The unexplained interindividual variability in posaconazole PK remained large. The PTA was <85%, irrespective of the simulated dosing strategy. Patients without diarrhea and not administered a PPI had the highest PTA (85% under the fixed 300-mg dosing 4 times per day). CONCLUSIONS Therapeutic drug monitoring is recommended during prophylactic posaconazole therapy in immunocompromised pediatric patients. Large-scale comparative studies are needed to characterize the PK variability between different posaconazole formulations in this cohort.
Collapse
Affiliation(s)
- Omar Elkayal
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
| | - Isabel Spriet
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
- Pharmacy Department, University Hospitals Leuven
| | - Anne Uyttebroeck
- Paediatric Oncology Unit, Department of Oncology, KU Leuven
- Pediatric Oncology and Hematology Department, University Hospitals Leuven, Leuven, Belgium
| | - Anca Colita
- Department of Pediatrics, Fundeni Clinical Institute
- Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Pieter Annaert
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
| | - Karel Allegaert
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
- Woman and Child Unit, Department of Development and Regeneration, KU Leuven
| | - Anne Smits
- Woman and Child Unit, Department of Development and Regeneration, KU Leuven
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium ; and
| | - Ruth Van Daele
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
- Pharmacy Department, University Hospitals Leuven
| | - Erwin Dreesen
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
- Pharmacometrics Research Group, Department of Pharmacy, Uppsala University, Uppsala, Sweden
| |
Collapse
|
40
|
Is Posaconazole Really Effective in Adolescent patients as a Prophylactic Agent: Experience of a Tertiary Care Center. J Pediatr Hematol Oncol 2021; 43:e613-e618. [PMID: 33560081 DOI: 10.1097/mph.0000000000002080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 12/20/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Invasive fungal infections (IFIs) are a leading cause of morbidity and death in immunocompromised patients. Data on efficacy and pharmacokinetics of posaconazole in pediatric patients are rare (1 to 5). Herein, we retrospectively analyzed adolescent patients who had received posaconazole as antifungal prophylaxis. METHODS We retrospectively analyzed patients who received posaconazole as primary or secondary antifungal prophylaxis. RESULTS A total of 34 adolescent patients, 19 men (55.9%) and 15 women (44.1%) with a mean age of 15.8±2.1 years were included. Twenty-five of 34 (73.5%) patients were on primary and nine of 34 (26.5%) patients were on secondary antifungal prophylaxis. Diagnosis of the patients receiving posaconazole as primary antifungal prophylaxis were acute myeloid leukemia (n=12, 48%), hematopoietic stem cell transplantation (n=7, 28%), acute lymphoblastic leukemia (n=5, 20%), and Fanconi aplastic anemia (n=1, 4%). Five patients (55.6%) with hematopoietic stem cell transplantation, 1 patient with acute myeloid leukemia (11.1%), 1 patient with Fanconi aplastic anemia (11.1%), and 2 (22.2%) patients with chronic granulomatous disease received posaconazole as secondary antifungal prophylaxis. Twelve of 25 (48%) patients receiving posaconazole as primary antifungal prophylaxis were complicated by IFI; 4 of them were proven, 6 probable, and 2 with possible IFI. Three of 9 patients (33.3%) receiving posaconazole as secondary antifungal prophylaxis was complicated by IFI (P=0.29), 2 of them were probable and 1 was possible IFI. Five of 25 patients (20%) receiving posaconazole as primary prophylaxis died because of IFI. CONCLUSION Improvement of antifungal prophylaxis in patients with high risk of invasive infections seems clearly necessary, and analyzing serum posaconazole levels and individualizing dosing may be 1 approach to improve outcomes.
Collapse
|
41
|
Lai T, Alffenaar JW, Kesson A, Bandodkar S, Roberts JA. Evaluation of target attainment of oral posaconazole suspension in immunocompromised children. J Antimicrob Chemother 2021; 75:726-729. [PMID: 31855264 DOI: 10.1093/jac/dkz481] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/16/2019] [Accepted: 10/21/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Posaconazole is a broad-spectrum antifungal that is not licensed for use in children <13 years of age. Despite this and by necessity, it is used extensively in paediatric hospitals for prophylaxis of invasive fungal disease. OBJECTIVES To determine whether initial prophylactic dosing recommendations attain a posaconazole plasma concentration of ≥700 ng/mL in immunocompromised children <13 years of age. PATIENTS AND METHODS We performed a retrospective study of immunocompromised children <13 years of age receiving posaconazole suspension prophylaxis at a starting dose of 5 mg/kg every 8 h for ≥7 days and who had a posaconazole concentration measured after ≥7 days. Posaconazole plasma concentrations and rate of breakthrough infection were recorded. RESULTS A total of 70 patients were included with a median age of 5 years (range 3 months to 12 years). The mean posaconazole plasma concentration was 783.4 ng/mL (IQR 428.3-980 ng/mL) and the percentage of patients with a posaconazole plasma concentration ≥700ng/mL was 47.9%. Patients who were on a proton pump inhibitor, a histamine H2 antagonist or metoclopramide, had mucositis or were enterally fed had a lower posaconazole plasma concentration compared with patients without these co-administered drugs/mucositis/enteral feeding (542.3 versus 1069.8 ng/mL; P<0.001). The breakthrough invasive fungal infection rate was 4.3% (3/70). CONCLUSIONS The studied 5 mg/kg posaconazole suspension every 8 h resulted in target concentrations in only 47.9% of patients and further studies looking at newer posaconazole formulations are needed.
Collapse
Affiliation(s)
- Tony Lai
- Department of Pharmacy, Westmead Children's Hospital, Sydney, Australia
| | - Jan-Willem Alffenaar
- Westmead Hospital, Sydney, Australia.,Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Sydney, Australia
| | - Alison Kesson
- Department of Infectious Diseases and Microbiology, Westmead Children's Hospital, Sydney, Australia
| | - Sushil Bandodkar
- Biochemistry Department, Westmead Children's Hospital, Sydney, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research and School of Pharmacy, The University of Queensland, Brisbane, Australia
| |
Collapse
|
42
|
Lambrix AA, Swanson HD, Pauley JL, Bragg AW, Carias DC, Bourque MS, Zhou Y, Cheng C, Greene WL, Maron G. Experience using intravenous posaconazole in paediatric and young adult oncology patients. J Antimicrob Chemother 2021; 75:3682-3687. [PMID: 32929484 DOI: 10.1093/jac/dkaa377] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/04/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Posaconazole exhibits broad-spectrum antifungal activity. An IV formulation became available in 2014. Few studies describing the use of this formulation exist in patients under the age of 18 years. This study describes our experience using IV posaconazole in paediatric and young adult cancer patients. METHODS This single-centre retrospective chart review evaluated patients who received IV posaconazole and had at least one posaconazole plasma concentration obtained after five or more days with a consistent dosage. Relationships between doses required to achieve a plasma concentration of ≥1 µg/mL and patient age, weight and body surface area (BSA) were evaluated. The clinical record was reviewed to identify descriptions of any adverse events. RESULTS Twenty-five patients were analysed, with a median age of 10.5 years (range 1.9-22.9 years; 92% were <18 years). All patients were able to achieve a posaconazole plasma concentration ≥1 µg/mL during their treatment course. The daily mg/kg/day dose required to achieve the target concentration decreased significantly with increasing age of the patient (P = 0.018). Assessment of dosage based on BSA suggested a requirement of 225 mg/m2/day across all age groups <18 years. Adverse events documented in the clinical record were consistent with those described with the oral formulations. No CNS toxicities were observed with use of IV posaconazole. CONCLUSIONS Concentrations ≥1 µg/mL are achievable and a BSA-based dosing approach may allow a consistent empirical dose for patients <18 years of age. Therapeutic drug monitoring is recommended to ensure patients achieve therapeutic concentrations.
Collapse
Affiliation(s)
- Arathi A Lambrix
- Department of Pharmacy, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Hope D Swanson
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jennifer L Pauley
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Allison W Bragg
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Delia C Carias
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Melissa S Bourque
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yinmei Zhou
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Cheng Cheng
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - William L Greene
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Gabriela Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
| |
Collapse
|
43
|
Abstract
Over the past 15 years, there has been an increase in the development and utilization of newer antifungal agents. The ideal antifungal, however, in regard to spectrum of activity, pharmacokinetic/pharmacodynamic properties, development of resistance, safety, and drug interaction profile remains elusive. This article reviews pharmacologic aspects of Food and Drug Administration-approved polyenes, flucytosine, azoles, and echinocandins as well as promising pipeline antifungal agents. Unique properties of these newer agents are highlighted. The clinical role of established and investigational antifungal agents as treatment and/or prevention of invasive fungal infections is discussed.
Collapse
Affiliation(s)
- Melissa D Johnson
- Duke University Medical Center, Box 102359 DUMC, Durham NC 27710, USA.
| |
Collapse
|
44
|
Yang E, Choi EJ, Park HS, Lee SO, Choi SH, Kim YS, Lee JH, Lee JH, Lee KH, Kim SH. Comparison of invasive fungal diseases between patients with acute myeloid leukemia receiving posaconazole prophylaxis and those not receiving prophylaxis: A single-center, observational, case-control study in South Korea. Medicine (Baltimore) 2021; 100:e25448. [PMID: 34011022 PMCID: PMC8137049 DOI: 10.1097/md.0000000000025448] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 03/17/2021] [Indexed: 01/05/2023] Open
Abstract
Posaconazole prophylaxis is effective in decreasing the incidence of invasive fungal diseases (IFDs) in patients with acute myeloid leukemia (AML). However, the use of antifungal prophylaxis varies in real-life practice, and only a small number of studies have compared the incidence of IFDs between those receiving posaconazole prophylaxis and those without prophylaxis. We compared the clinical characteristics and outcomes of IFDs between patients with AML who received posaconazole prophylaxis and those without antifungal prophylaxis.We reviewed the medical records of adult AML patients who underwent induction chemotherapy between June 2016 and October 2019 at Asan Medical Center (Seoul, South Korea), where posaconazole prophylaxis is not administered in patients with gastrointestinal symptoms that may hinder sufficient absorption of oral prophylactic agents, and in patients with abnormal liver functions considering the possible exacerbation of adverse events. Patients who received posaconazole prophylaxis for ≥7 days were included in the prophylaxis group. Clinical characteristics and outcomes including the incidence of IFDs were compared between the 2 groups.Of the 247 patients with AML who underwent induction chemotherapy, 162 (66%) received posaconazole prophylaxis and 85 (34%) did not receive any prophylaxis. The incidence of proven/probable IFD was significantly higher in the no prophylaxis group than in the prophylaxis group (9.4% [8/85] vs 2.5% [4/162], P = .03). Of the 8 cases of IFDs in the no prophylaxis group, 7 were mold infections and 1 was invasive candidiasis. Of the 4 cases of IFDs in the prophylaxis group, 3 were mold infections and 1 was invasive candidiasis. Patients with posaconazole prophylaxis less frequently received therapeutic antifungal therapy (2.5% vs 9.4%, P = .03) and had a longer median, duration from chemotherapy to antifungal therapy compared with the no prophylaxis group (18 vs 11 days, P < .01). The rate of IFD-related mortality was similar between the 2 groups (0.6% vs 0%, P > .99).Patients with AML who received posaconazole prophylaxis had a lower incidence of breakthrough IFDs compared with those who did not receive any prophylaxis. Invasive mold infection was the most common IFD regardless of antifungal prophylaxis.
Collapse
Affiliation(s)
- Eunmi Yang
- Department of Infectious Diseases
- Present affiliation: Department of Infectious Diseases, Seoul Medical Center, Seoul, Republic of Korea
| | - Eun-Ji Choi
- Hematology, Asan Medical Center, University of Ulsan College of Medicine
| | - Han-Seung Park
- Hematology, Asan Medical Center, University of Ulsan College of Medicine
| | | | | | | | - Jung-Hee Lee
- Hematology, Asan Medical Center, University of Ulsan College of Medicine
| | - Je-Hwan Lee
- Hematology, Asan Medical Center, University of Ulsan College of Medicine
| | - Kyoo-Hyung Lee
- Hematology, Asan Medical Center, University of Ulsan College of Medicine
| | | |
Collapse
|
45
|
Renzi DF, de Almeida Campos L, Miranda EH, Mainardes RM, Abraham WR, Grigoletto DF, Khalil NM. Nanoparticles as a Tool for Broadening Antifungal Activities. Curr Med Chem 2021; 28:1841-1873. [PMID: 32223729 DOI: 10.2174/0929867327666200330143338] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/28/2020] [Accepted: 03/09/2020] [Indexed: 11/22/2022]
Abstract
Fungal infections are diseases that are considered neglected although their infection rates have increased worldwide in the last decades. Thus, since the antifungal arsenal is restricted and many strains have shown resistance, new therapeutic alternatives are necessary. Nanoparticles are considered important alternatives to promote drug delivery. In this sense, the objective of the present study was to evaluate the contributions of newly developed nanoparticles to the treatment of fungal infections. Studies have shown that nanoparticles generally improve the biopharmaceutical and pharmacokinetic characteristics of antifungals, which is reflected in a greater pharmacodynamic potential and lower toxicity, as well as the possibility of prolonged action. It also offers the proposition of new routes of administration. Nanotechnology is known to contribute to a new drug delivery system, not only for the control of infectious diseases but for various other diseases as well. In recent years, several studies have emphasized its application in infectious diseases, presenting better alternatives for the treatment of fungal infections.
Collapse
Affiliation(s)
- Daniele Fernanda Renzi
- Pharmaceutical Nanotechnology Laboratory, Universidade Estadual do Centro-Oeste, Alameda Élio Antonio Dalla Vecchia, 838 - CEP 85040-167, Guarapuava-PR, Brazil
| | - Laís de Almeida Campos
- Pharmaceutical Nanotechnology Laboratory, Universidade Estadual do Centro-Oeste, Alameda Élio Antonio Dalla Vecchia, 838 - CEP 85040-167, Guarapuava-PR, Brazil
| | - Eduardo Hösel Miranda
- Pharmaceutical Nanotechnology Laboratory, Universidade Estadual do Centro-Oeste, Alameda Élio Antonio Dalla Vecchia, 838 - CEP 85040-167, Guarapuava-PR, Brazil
| | - Rubiana Mara Mainardes
- Pharmaceutical Nanotechnology Laboratory, Universidade Estadual do Centro-Oeste, Alameda Élio Antonio Dalla Vecchia, 838 - CEP 85040-167, Guarapuava-PR, Brazil
| | - Wolf-Rainer Abraham
- Helmholtz Center for Infection Research, Chemical Microbiology, Inhoffenstraße 7, 38124 Braunschweig, Germany
| | - Diana Fortkamp Grigoletto
- Pharmaceutical Nanotechnology Laboratory, Universidade Estadual do Centro-Oeste, Alameda Élio Antonio Dalla Vecchia, 838 - CEP 85040-167, Guarapuava-PR, Brazil
| | - Najeh Maissar Khalil
- Pharmaceutical Nanotechnology Laboratory, Universidade Estadual do Centro-Oeste, Alameda Élio Antonio Dalla Vecchia, 838 - CEP 85040-167, Guarapuava-PR, Brazil
| |
Collapse
|
46
|
Kingma JS, Burgers DMT, Monpellier VM, Wiezer MJ, Blussé van Oud-Alblas HJ, Vaughns JD, Sherwin CMT, Knibbe CAJ. Oral drug dosing following bariatric surgery: General concepts and specific dosing advice. Br J Clin Pharmacol 2021; 87:4560-4576. [PMID: 33990981 PMCID: PMC9291886 DOI: 10.1111/bcp.14913] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 04/06/2021] [Accepted: 05/01/2021] [Indexed: 11/30/2022] Open
Abstract
Bariatric or weight‐loss surgery is a popular option for weight reduction. Depending on the surgical procedure, gastric changes like decreased transit time and volume and increased pH, decreased absorption surface in the small intestine, decreased exposure to bile acids and enterohepatic circulation, and decreased gastrointestinal transit time may be expected. In the years after bariatric surgery, patients will also substantially lose weight. As a result of these changes, the absorption, distribution, metabolism and/or elimination of drugs may be altered. The purpose of this article is to report the general influence of bariatric surgery on oral drug absorption, and to provide guidance for dosing of commonly used drugs in this special population. Upon oral drug administration, the time to maximum concentration is often earlier and this concentration may be higher with less consistent effects on trough concentrations and exposure. Additionally, prescription of liquid formulations to bariatric patients is supported by some reports, even though the high sugar load of these suspensions may be of concern. Studies on extended‐release medications result in an unaltered exposure for a substantial number of drugs. Also, studies evaluating the influence of timing after surgery show dynamic absorption profiles. Although for this group specific advice can be proposed for many drugs, we conclude that there is insufficient evidence for general advice for oral drug therapy after bariatric surgery, implying that a risk assessment on a case‐by‐case basis is required for each drug.
Collapse
Affiliation(s)
- Jurjen S Kingma
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Desirée M T Burgers
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Valerie M Monpellier
- Nederlandse Obesitas Kliniek (Dutch Obesity Clinic), Huis ter Heide, The Netherlands
| | - Marinus J Wiezer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Janelle D Vaughns
- Department of Anesthesia and Pain Medicine, Children's National Health System, Washington, DC, USA.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.,Division of Systems Biomedicine & Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands
| |
Collapse
|
47
|
Hens B, Augustijns P, Lennernäs H, McAllister M, Abrahamsson B. Leveraging Oral Drug Development to a Next Level: Impact of the IMI-Funded OrBiTo Project on Patient Healthcare. Front Med (Lausanne) 2021; 8:480706. [PMID: 33748152 PMCID: PMC7973356 DOI: 10.3389/fmed.2021.480706] [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: 06/25/2019] [Accepted: 02/12/2021] [Indexed: 11/13/2022] Open
Abstract
A thorough understanding of the behavior of drug formulations in the human gastrointestinal (GI) tract is essential when working in the field of oral drug development in a pharmaceutical company. For orally administered drug products, various GI processes, including disintegration of the drug formulation, drugrelease, dissolution, precipitation, degradation, dosage form transit and permeation, dictate absorption into the systemic circulation. These processes are not always fully captured in predictive in vitro and in silico tools, as commonly applied in the pre-clinical stage of formulation drug development. A collaborative initiative focused on the science of oral biopharmaceutics was established in 2012 between academic institutions and industrial companies to innovate, optimize and validate these in vitro and in silico biopharmaceutical tools. From that perspective, the predictive power of these models can be revised and, if necessary, optimized to improve the accuracy toward predictions of the in vivo performance of orally administered drug products in patients. The IMI/EFPIA-funded "Oral Bioavailability Tools (OrBiTo)" project aimed to improve our fundamental understanding of the GI absorption process. The gathered information was integrated into the development of new (or already existing) laboratory tests and computer-based methods in order to deliver more accurate predictions of drug product behavior in a real-life setting. These methods were validated with the use of industrial data. Crucially, the ultimate goal of the project was to set up a scientific framework (i.e., decision trees) to guide the use of these new tools in drug development. The project aimed to facilitate and accelerate the formulation development process and to significantly reduce the need for animal experiments in this area as well as for human clinical studies in the future. With respect to the positive outcome for patients, high-quality oral medicines will be developed where the required dose is well-calculated and consistently provides an optimal clinical effect. In a first step, this manuscript summarizes the setup of the project and how data were collected across the different work packages. In a second step, case studies of how this project contributed to improved knowledge of oral drug delivery which can be used to develop improved products for patients will be illustrated.
Collapse
Affiliation(s)
- Bart Hens
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Drug Product Design, Pfizer, Sandwich, United Kingdom
| | - Patrick Augustijns
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Hans Lennernäs
- Department of Pharmaceutical Biosciences and Technology, Uppsala University, Uppsala, Sweden
| | | | - Bertil Abrahamsson
- Oral Product Development, Pharmaceutical Technology and Development, Operations, AstraZeneca Gothenburg, Mölndal, Sweden
| |
Collapse
|
48
|
Review of Pharmacologic Considerations in the Use of Azole Antifungals in Lung Transplant Recipients. J Fungi (Basel) 2021; 7:jof7020076. [PMID: 33499209 PMCID: PMC7911495 DOI: 10.3390/jof7020076] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 12/15/2022] Open
Abstract
Mold-active azole antifungals are commonly prescribed for the prevention of invasive fungal infections in lung transplant recipients. Each agent exhibits a unique pharmacologic profile, an understanding of which is crucial for therapy selection and optimization. This article reviews pharmacologic considerations for three frequently-used azole antifungals in lung transplant recipients: voriconazole, posaconazole, and isavuconazole. Focus is drawn to analysis of drug-interactions, adverse drug reactions, pharmacokinetic considerations, and the role of therapeutic drug monitoring with special emphasis on data from the post-lung transplant population.
Collapse
|
49
|
Duehlmeyer S, Klockau C, Yu D, Rouch J. Characterization of Therapeutic Drug Monitoring Practices of Voriconazole and Posaconazole at a Pediatric Hospital. J Pediatr Pharmacol Ther 2021; 26:26-32. [PMID: 33424497 DOI: 10.5863/1551-6776-26.1.26] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 12/31/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To characterize the voriconazole and posaconazole serum trough ordering practices in patients receiving prophylactic and treatment antifungal therapy. METHODS A retrospective chart review over a 6-year period of pediatric patients who received voriconazole and/or posaconazole for >24 hours. RESULTS A total of 113 patients were included in this study and of these patients, 105 received voriconazole and 16 received posaconazole during the study period. Additionally, 167 trough levels were assessed in this study. Only 50% and 54% of levels were considered within goal recommendations for voriconazole and posaconazole, respectively. The median dose required to achieve goal trough concentration was dependent on drug, indication, and dosage form. Lastly, the most common adverse drug reactions (ADRs) were hepatoxicity, QTc prolongation, and CNS changes, which were in concordance with ADRs documented in the clinical trials for voriconazole and posaconazole. Approximately 20% of patients receiving either voriconazole or posaconazole died during the study period and the median trough in both groups was subtherapeutic. CONCLUSIONS Increased monitoring of trough concentrations may be warranted to prevent death or breakthrough invasive fungal infections. Further studies are warranted for assessing the relationship between trough concentrations and treatment outcomes as well as relationship between dosing and achieving goal trough concentrations.
Collapse
|
50
|
Abstract
Posaconazole is typically used for preventing invasive yeast and mold infections such as invasive aspergillosis in high-risk immunocompromised patients. The oral suspension was the first released formulation and many pharmacokinetic and pharmacodynamic studies of this formulation have been published. Erratic absorption profiles associated with this formulation were widely reported. Posaconazole exposure was found to be significantly influenced by food and many gastrointestinal conditions, including pH and motility. As a result, low posaconazole plasma concentrations were obtained in large groups of patients. These issues of erratic absorption urged the development of the subsequently marketed delayed-release tablet, which proved to be associated with higher and more stable exposure profiles. Shortly thereafter, an intravenous formulation was released for patients who are not able to take oral formulations. Both new formulations require a loading dose on day 1 to achieve high posaconazole concentrations more quickly, which was not possible with the oral suspension. So far, there appears to be no evidence of increased toxicity correlated to the higher posaconazole exposure achieved with the regimen for these formulations. The higher systemic availability of posaconazole for the delayed-release tablet and intravenous formulation have resulted in these two formulations being preferable for both prophylaxis and treatment of invasive fungal disease. This review aimed to integrate the current knowledge on posaconazole pharmacokinetics, pharmacodynamics, major toxicity, existing resistance, clinical experience in special populations, and new therapeutic strategies in order to get a clear understanding of the clinical use of this drug.
Collapse
|