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Bewersdorf TN, Hofmann J, Findeisen S, Schamberger C, Lingner T, Sommer U, Schmidmaier G, Grossner T. Impact of Anti-Mycotic Drugs on the Osteogenic Response of Bone Marrow Mesenchymal Stem Cells In Vitro. Antibiotics (Basel) 2024; 13:186. [PMID: 38391572 PMCID: PMC10886247 DOI: 10.3390/antibiotics13020186] [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: 12/28/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
The treatment of fungal bone infections and infected non-unions is a huge challenge in modern trauma and orthopedics, which normally contain the local and systemic administration of anti-fungal drugs. Although frequently used, little is known about the impact of systemic and locally administered fungicides on the osteogenic regenerative capabilities of infected bone tissue, especially upon the osteogenesis of human bone marrow mesenchymal stem cells (BM-hMSCs). This study evaluates the effects of the three most common fungicides for the systemic treatment of bone infections, Voriconazole (VOR), liposomal Amphotericin B (LAMB), and Fluconazole (FLU), as well as the effects of VOR and LAMB-loaded Polymethylmethacrylate (PMMA) cement chips in different concentrations upon the osteogenic response of BM-hMSCs in vitro. Within this study, we compared the ability of BM-hMSC to differentiate into osteoblast-like cells and synthesize hydroxyapatite as assessed by radioactive 99mTechnetium-Hydroxydiphosphonate (99mTc-HDP) labeling, cell proliferation, and analyses of supernatants upon various osteogenic parameters. Our results revealed that VOR added to the cell culture medium affects the osteogenic potential of BM-hMSC negatively, while there were no detectable effects of LAMB and FLU. Moreover, we showed dose-dependent negative effects of high- and extended-dose fungicide-loaded PMMA cement due to cytotoxicity, with a higher cytotoxic potential of VOR than LAMB, while low-dose fungicide-loaded PMMA had no significant effect on the osteogenic potential of BM-hMSC in vitro.
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Affiliation(s)
- Tim Niklas Bewersdorf
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Jakob Hofmann
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Sebastian Findeisen
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Christian Schamberger
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Thomas Lingner
- Genevention GmbH, Rudolf-Wissell-Str. 28A, 37079 Göttingen, Germany
| | - Ulrike Sommer
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Gerhard Schmidmaier
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Tobias Grossner
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
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Ezquer-Garin C, Aguilar G, Ferriols-Lisart R, Alos-Almiñana M. Validated HPLC-UV method for amphotericin B quantification in a critical patient receiving AmBisome and treated with extracorporeal replacement therapies. Biomed Chromatogr 2023; 37:e5749. [PMID: 37727118 DOI: 10.1002/bmc.5749] [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: 03/27/2023] [Revised: 07/11/2023] [Accepted: 09/05/2023] [Indexed: 09/21/2023]
Abstract
Amphotericin B (AMB) is a polyene macrolide antifungal agent used for treating invasive fungal infections. Liposomal AMB is a lipid dosage form, available as AmBisome, which reduces the toxicity of the drug. A simple HPLC-UV method was developed for the determination of AMB in plasma to study its pharmacokinetic profile in a critical patient receiving AmBisome and treated with extracorporeal replacement therapies. Sample preparation was performed using plasma deproteinization and drug release from liposome by the addition of acetonitrile (ACN)/zinc sulfate and ultrasonication. Chromatographic separation was performed using a C18 column and a mobile phase consisting of phosphate buffer (pH 3.0)/ACN (65/35, v/v). The UV detector was set at 407 nm. The total run time analysis was 23 min. The method was validated according to the standard guidelines and applied to study the pharmacokinetics of AMB in a critical patient. The total run time analysis obtained was shorter than that of the previously reported methods, being useful for therapeutic drug monitoring or pharmacokinetic profile research.
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Affiliation(s)
- Carlos Ezquer-Garin
- INCLIVA, Valencia, Spain
- Department of Pharmacy, University Clinical Hospital of Valencia, Valencia, Spain
| | - Gerardo Aguilar
- INCLIVA, Valencia, Spain
- Department of Anaesthesiology and Intensive Care, University Clinical Hospital of Valencia, Valencia, Spain
| | - Rafael Ferriols-Lisart
- INCLIVA, Valencia, Spain
- Department of Pharmacy, University Clinical Hospital of Valencia, Valencia, Spain
| | - Manuel Alos-Almiñana
- INCLIVA, Valencia, Spain
- Department of Pharmacy, University Clinical Hospital of Valencia, Valencia, Spain
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Novy E, Roger C, Roberts JA, Cotta MO. Pharmacokinetic and pharmacodynamic considerations for antifungal therapy optimisation in the treatment of intra-abdominal candidiasis. Crit Care 2023; 27:449. [PMID: 37981676 PMCID: PMC10659066 DOI: 10.1186/s13054-023-04742-w] [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: 09/13/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023] Open
Abstract
Intra-abdominal candidiasis (IAC) is one of the most common of invasive candidiasis observed in critically ill patients. It is associated with high mortality, with up to 50% of deaths attributable to delays in source control and/or the introduction of antifungal therapy. Currently, there is no comprehensive guidance on optimising antifungal dosing in the treatment of IAC among the critically ill. However, this form of abdominal sepsis presents specific pharmacokinetic (PK) alterations and pharmacodynamic (PD) challenges that risk suboptimal antifungal exposure at the site of infection in critically ill patients. This review aims to describe the peculiarities of IAC from both PK and PD perspectives, advocating an individualized approach to antifungal dosing. Additionally, all current PK/PD studies relating to IAC are reviewed in terms of strength and limitations, so that core elements for the basis of future research can be provided.
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Affiliation(s)
- Emmanuel Novy
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane & Women's Hospital Campus Herston, Brisbane, QLD, 4029, Australia
- Department of Anaesthesiology, Critical Care and Peri-Operative Medicine, University Hospital of Nancy, Nancy, France
- Université de Lorraine, SIMPA, 54500, Nancy, France
| | - Claire Roger
- Department of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nimes University Hospital, Place du Professeur Robert Debré, 30029, Nîmes Cedex 9, France
- UR UM103 IMAGINE, Univ Montpellier, Montpellier, France
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane & Women's Hospital Campus Herston, Brisbane, QLD, 4029, Australia.
- Department of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nimes University Hospital, Place du Professeur Robert Debré, 30029, Nîmes Cedex 9, France.
- Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia.
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane & Women's Hospital Campus Herston, Brisbane, QLD, 4029, Australia
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Maseda E, Martín-Loeches I, Zaragoza R, Pemán J, Fortún J, Grau S, Aguilar G, Varela M, Borges M, Giménez MJ, Rodríguez A. Critical appraisal beyond clinical guidelines for intraabdominal candidiasis. Crit Care 2023; 27:382. [PMID: 37789338 PMCID: PMC10546659 DOI: 10.1186/s13054-023-04673-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/28/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Regardless of the available antifungals, intraabdominal candidiasis (IAC) mortality continues to be high and represents a challenge for clinicians. MAIN BODY This opinion paper discusses alternative antifungal options for treating IAC. This clinical entity should be addressed separately from candidemia due to the peculiarity of the required penetration of antifungals into the peritoneal cavity. Intraabdominal concentrations may be further restricted in critically ill patients where pathophysiological facts alter normal drug distribution. Echinocandins are recommended as first-line treatment in guidelines for invasive candidiasis. However, considering published data, our pharmacodynamic analysis suggests the required increase of doses, postulated by some authors, to attain adequate pharmacokinetic (PK) levels in peritoneal fluid. Given the limited evidence in the literature on PK/PD-based treatments of IAC, an algorithm is proposed to guide antifungal treatment. Liposomal amphotericin B is advocated as first-line therapy in patients with sepsis/septic shock presenting candidemia or endophthalmitis, or with prior exposure to echinocandins and/or fluconazole, or with infections by Candida glabrata. Other situations and alternatives, such as new compounds or combination therapy, are also analysed. CONCLUSION There is a critical need for more robust clinical trials, studies examining patient heterogeneity and surveillance of antifungal resistance to enhance patient care and optimise treatment outcomes. Such evidence will help refine the existing guidelines and contribute to a more personalised and effective approach to treating this serious medical condition. Meanwhile, it is suggested to broaden the consideration of other options, such as liposomal amphotericin B, as first-line treatment until the results of the fungogram are available and antifungal stewardship could be implemented to prevent the development of resistance.
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Affiliation(s)
- Emilio Maseda
- Service of Anesthesia, Hospital Quirónsalud Valle del Henares, Av. de La Constitución, 249, 28850, Torrejón de Ardoz, Madrid, Spain.
| | - Ignacio Martín-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, James Street, Leinster, Dublin 8, D08 NHY1, Ireland.
- Pulmonary Intensive Care Unit, Respiratory Institute, Hospital Clinic of Barcelona, IDIBAPS (Institut d'Investigacions Biomèdiques August Pi I Sunyer), University of Barcelona, CIBERes, Barcelona, Spain.
| | | | - Javier Pemán
- Microbiology Department, Hospital Universitari I Politecnic La Fe, Valencia, Spain
- Fundación Micellium, La Eliana, Valencia, Spain
| | - Jesús Fortún
- Infectious Diseases Service, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Santiago Grau
- Service of Pharmacy, Hospital del Mar, Barcelona, Spain
| | - Gerardo Aguilar
- Service of Anesthesia, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Marina Varela
- Service of Anesthesia, Área Sanitaria de Pontevedra, Pontevedra, Spain
| | - Marcio Borges
- ICU, Hospital Universitario Son Llátzer, Palma, Spain
| | - María-José Giménez
- Faculty of Sports Sciences and Physiotherapy, Universidad Europea de Madrid, Madrid, Spain
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Marx R, Lee J, Svirkin Y, Yoon S, Landrau N, Abul Kaisar M, Qin B, Park JH, Alam K, Kozak D, Wang Y, Xu X, Zheng J, Rivnay B. Physicochemical surrogates for in vitro toxicity assessment of liposomal amphotericin B. Int J Pharm 2022; 628:122273. [DOI: 10.1016/j.ijpharm.2022.122273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/30/2022]
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Qiu C, Wu Y, Guo Q, Shi Q, Zhang J, Meng Y, Xia F, Wang J. Preparation and application of calcium phosphate nanocarriers in drug delivery. Mater Today Bio 2022; 17:100501. [DOI: 10.1016/j.mtbio.2022.100501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/05/2022] [Accepted: 11/20/2022] [Indexed: 11/24/2022] Open
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Haro-Reyes T, Díaz-Peralta L, Galván-Hernández A, Rodríguez-López A, Rodríguez-Fragoso L, Ortega-Blake I. Polyene Antibiotics Physical Chemistry and Their Effect on Lipid Membranes; Impacting Biological Processes and Medical Applications. MEMBRANES 2022; 12:681. [PMID: 35877884 PMCID: PMC9316096 DOI: 10.3390/membranes12070681] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 01/27/2023]
Abstract
This review examined a collection of studies regarding the molecular properties of some polyene antibiotic molecules as well as their properties in solution and in particular environmental conditions. We also looked into the proposed mechanism of action of polyenes, where membrane properties play a crucial role. Given the interest in polyene antibiotics as therapeutic agents, we looked into alternative ways of reducing their collateral toxicity, including semi-synthesis of derivatives and new formulations. We follow with studies on the role of membrane structure and, finally, recent developments regarding the most important clinical applications of these compounds.
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Affiliation(s)
- Tammy Haro-Reyes
- Instituto de Ciencias Físicas, Universidad Nacional Autónoma de México, Av. Universidad s/n, Col. Chamilpa, Cuernavaca 62210, Morelos, Mexico; (T.H.-R.); (L.D.-P.); (A.G.-H.)
| | - Lucero Díaz-Peralta
- Instituto de Ciencias Físicas, Universidad Nacional Autónoma de México, Av. Universidad s/n, Col. Chamilpa, Cuernavaca 62210, Morelos, Mexico; (T.H.-R.); (L.D.-P.); (A.G.-H.)
| | - Arturo Galván-Hernández
- Instituto de Ciencias Físicas, Universidad Nacional Autónoma de México, Av. Universidad s/n, Col. Chamilpa, Cuernavaca 62210, Morelos, Mexico; (T.H.-R.); (L.D.-P.); (A.G.-H.)
| | - Anahi Rodríguez-López
- Facultad de Farmacia, Universidad Autónoma del Estado de Morelos, Cuernavaca 62210, Morelos, Mexico; (A.R.-L.); (L.R.-F.)
| | - Lourdes Rodríguez-Fragoso
- Facultad de Farmacia, Universidad Autónoma del Estado de Morelos, Cuernavaca 62210, Morelos, Mexico; (A.R.-L.); (L.R.-F.)
| | - Iván Ortega-Blake
- Instituto de Ciencias Físicas, Universidad Nacional Autónoma de México, Av. Universidad s/n, Col. Chamilpa, Cuernavaca 62210, Morelos, Mexico; (T.H.-R.); (L.D.-P.); (A.G.-H.)
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Rubey KM, Brenner JS. Nanomedicine to fight infectious disease. Adv Drug Deliv Rev 2021; 179:113996. [PMID: 34634395 PMCID: PMC8665093 DOI: 10.1016/j.addr.2021.113996] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 09/09/2021] [Accepted: 10/04/2021] [Indexed: 12/11/2022]
Abstract
The ubiquity and potency of antibiotics may give the false impression that infection is a solved problem. Unfortunately, even bacterial infections, the target of antibiotics, remain a major cause of illness and death. Several major unmet needs persist: biofilms, such as those on implanted hardware, largely resist antibiotics; the inflammatory host response to infection often produces more damage than the infection itself; and systemic antibiotics often decimate the gut microbiome, which can predispose to additional infections and even predispose to non-infectious diseases. Additionally, there is an increasing threat from multi-drug resistant microorganisms, though market forces may continue to inhibit innovation in this realm. These numerous unmet infection-related needs provide attractive goals for innovation of targeted drug delivery technologies, especially those of nanomedicine. Here we review several of those innovations in pre-clinical development, the two such therapies which have made it to clinical use, and the opportunities for further technology development for treating infections.
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Affiliation(s)
- Kathryn M Rubey
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Jacob S Brenner
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Yu X, Chu Z, Li J, He R, Wang Y, Cheng C. Pharmacokinetic Drug-drug Interaction of Antibiotics Used in Sepsis Care in China. Curr Drug Metab 2021; 22:5-23. [PMID: 32990533 DOI: 10.2174/1389200221666200929115117] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/17/2020] [Accepted: 07/07/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Many antibiotics have a high potential for interactions with drugs, as a perpetrator and/or victim, in critically ill patients, and particularly in sepsis patients. METHODS The aim of this review is to summarize the pharmacokinetic drug-drug interaction (DDI) of 45 antibiotics commonly used in sepsis care in China. Literature search was conducted to obtain human pharmacokinetics/ dispositions of the antibiotics, their interactions with drug-metabolizing enzymes or transporters, and their associated clinical drug interactions. Potential DDI is indicated by a DDI index ≥ 0.1 for inhibition or a treatedcell/ untreated-cell ratio of enzyme activity being ≥ 2 for induction. RESULTS The literature-mined information on human pharmacokinetics of the identified antibiotics and their potential drug interactions is summarized. CONCLUSION Antibiotic-perpetrated drug interactions, involving P450 enzyme inhibition, have been reported for four lipophilic antibacterials (ciprofloxacin, erythromycin, trimethoprim, and trimethoprim-sulfamethoxazole) and three antifungals (fluconazole, itraconazole, and voriconazole). In addition, seven hydrophilic antibacterials (ceftriaxone, cefamandole, piperacillin, penicillin G, amikacin, metronidazole, and linezolid) inhibit drug transporters in vitro. Despite no clinical PK drug interactions with the transporters, caution is advised in the use of these antibacterials. Eight hydrophilic antibiotics (all β-lactams; meropenem, cefotaxime, cefazolin, piperacillin, ticarcillin, penicillin G, ampicillin, and flucloxacillin), are potential victims of drug interactions due to transporter inhibition. Rifampin is reported to perpetrate drug interactions by inducing CYP3A or inhibiting OATP1B; it is also reported to be a victim of drug interactions, due to the dual inhibition of CYP3A4 and OATP1B by indinavir. In addition, three antifungals (caspofungin, itraconazole, and voriconazole) are reported to be victims of drug interactions because of P450 enzyme induction. Reports for other antibiotics acting as victims in drug interactions are scarce.
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Affiliation(s)
- Xuan Yu
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Zixuan Chu
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Jian Li
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Rongrong He
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Yaya Wang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Chen Cheng
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
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Voriconazole- induced severe hypokalemic rhabdomyolysis: A case report. Int J Pediatr Adolesc Med 2021; 9:66-68. [PMID: 35573070 PMCID: PMC9072235 DOI: 10.1016/j.ijpam.2021.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/16/2021] [Indexed: 11/23/2022]
Abstract
We report a child who presented with lower limb weakness and inability to walk, laboratory confirmed severe hypokalemia with typical electrocardiogram changes, and evidence of rhabdomyolysis while on voriconazole treatment for Pseudallescheria boydii soft tissue infection. Although voriconazole is a well-tolerated antifungal agent, hypokalemia is a well-known, yet uncommon side effect associated with its use. Furthermore, hypokalemic-rhabdomyolysis has not been reported with voriconazole use alone. Maintaining the clinical suspicion about the potential association between voriconazole and hypokalemic-rhabdomyolysis can lead to prompt recognition and intervention.
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Sixty years of Amphotericin B: An Overview of the Main Antifungal Agent Used to Treat Invasive Fungal Infections. Infect Dis Ther 2021; 10:115-147. [PMID: 33523419 PMCID: PMC7954977 DOI: 10.1007/s40121-020-00382-7] [Citation(s) in RCA: 122] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/04/2020] [Indexed: 12/29/2022] Open
Abstract
Introduced in the late 1950s, polyenes represent the oldest family of antifungal drugs. The discovery of amphotericin B and its therapeutic uses is considered one of the most important scientific milestones of the twentieth century . Despite its toxic potential, it remains useful in the treatment of invasive fungal diseases owing to its broad spectrum of activity, low resistance rate, and excellent clinical and pharmacological action. The well-reported and defined toxicity of the conventional drug has meant that much attention has been paid to the development of new products that could minimize this effect. As a result, lipid-based formulations of amphotericin B have emerged and, even keeping the active principle in common, present distinct characteristics that may influence therapeutic results. This study presents an overview of the pharmacological properties of the different formulations for systemic use of amphotericin B available for the treatment of invasive fungal infections, highlighting the characteristics related to their chemical, pharmacokinetic structures, drug–target interactions, stability, and others, and points out the most relevant aspects for clinical practice.
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12
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Schiave LA, Nascimento E, Gaspar GG, Vilar FC, Martinez EZ, Gaitani CMD, Martinez R. Minimum concentration of Amphotericin B in serum according to the formulation, dose, and daily or prolonged intermittent therapeutic regimen. Rev Soc Bras Med Trop 2020; 53:e20180463. [PMID: 32049198 PMCID: PMC7083383 DOI: 10.1590/0037-8682-0463-2018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 12/16/2019] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION: The therapeutic efficacy of daily amphotericin B infusion is related to its
maximum concentration in blood; however, trough levels may be useful in
intermittent regimens of this antifungal drug. METHODS: High performance liquid chromatography (HPLC) was used to determine the
minimum concentration (Cmin) of amphotericin B in the serum of patients
receiving deoxycholate (D-Amph) or liposomal amphotericin B (L-AmB) for the
treatment of cryptococcal meningitis (n=28), histoplasmosis (n=8),
paracoccidioidomycosis (n=1), and leishmaniasis (n=1). RESULTS: Daily use of D-Amph 30 to 50 mg or L-AmB 50 mg resulted in a similar Cmin,
but a significant increase ocurred with L-AmB 100 mg/day. The geometric mean
Cmin tended to decrease with a reduction in the dose and frequency of
intermittent L-AmB infusions: 357 ng/mL (100 mg 4 to 5 times/week) > 263
ng/mL (50 mg 4 to 5 times/week) > 227 ng/mL (50 mg 1 to 3 times/week).
The impact on Cmin was variable in patients whose dose or therapeutic scheme
was changed, especially when administered the intermittent infusion of
amphotericin B. The mean Cmin for each L-AmB schedule of intermittent
therapy was equal or higher than the minimum inhibitory concentration of
amphotericin B against Cryptococcus isolates from 10/12
patients. The Cmin of amphotericin B in patients with cryptococcal
meningitis was comparable between those that survived or died. CONCLUSIONS: By evaluating the Cmin of amphotericin B, we demonstrated the therapeutic
potential of its intermittent use including in the consolidation phase of
neurocryptococcosis treatment, despite the great variability in serum levels
among patients.
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Affiliation(s)
- Leticia Aparecida Schiave
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Clínica Médica, Ribeirão Preto, SP, Brasil
| | - Erika Nascimento
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Clínica Médica, Ribeirão Preto, SP, Brasil
| | - Gilberto Gambero Gaspar
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Clínica Médica, Ribeirão Preto, SP, Brasil
| | - Fernando Crivelenti Vilar
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Clínica Médica, Ribeirão Preto, SP, Brasil
| | - Edson Zangiacomi Martinez
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Medicina Social, Ribeirão Preto, SP, Brasil
| | | | - Roberto Martinez
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Clínica Médica, Ribeirão Preto, SP, Brasil
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Branick K, Taylor MJ, Trump MW, Wall GC. Apparent interference with extracorporeal membrane oxygenation by liposomal amphotericin B in a patient with disseminated blastomycosis receiving continuous renal replacement therapy. Am J Health Syst Pharm 2020; 76:810-813. [PMID: 30994894 DOI: 10.1093/ajhp/zxz054] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Indexed: 11/13/2022] Open
Abstract
PURPOSE We describe the use of liposomal amphotericin B and amphotericin B deoxycholate in a critically ill patient with pulmonary blastomycosis receiving both venovenous extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). SUMMARY A 50-year-old African American man presented for dyspnea and cough and was noted to have blastomycosis on bronchoscopy. He developed respiratory failure and acute kidney injury, requiring mechanical ventilation, ECMO, and CRRT. After 4 days of liposomal amphotericin, the transmembrane pressure gradient on the membrane oxygenator increased dramatically without visualization of a clot, requiring a circuit exchange. A trough amphotericin B level taken the day before the exchange was undetectable for amphotericin B. After the circuit exchange, the patient was switched to amphotericin B deoxycholate. A subsequent trough level was 3.8 μg/mL. The patient improved and was able to be decannulated. However, he did require tracheostomy and long-term hemodialysis. CONCLUSION In our case we believe that liposomal amphotericin B was significantly removed by ECMO and was responsible for the failure of the ECMO circuit. We would suggest amphotericin B deoxycholate be used in such patients preferentially and that serum levels of the drug be assessed when possible.
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Affiliation(s)
- Kaitlin Branick
- Department of Internal Medicine, Iowa Methodist Medical Center, Des Moines, IA
| | - Matthew J Taylor
- Department of Internal Medicine, Iowa Methodist Medical Center, Des Moines, IA
| | - Matthew W Trump
- Department of Pulmonary and Critical Care Medicine, The Iowa Clinic PC, and Department of Pulmonary and Critical Care Medicine-Unity Point Health, Des Moines, IA
| | - Geoffrey C Wall
- Drake University College of Pharmacy and Health Sciences, Des Moines, IA
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14
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Faustino C, Pinheiro L. Lipid Systems for the Delivery of Amphotericin B in Antifungal Therapy. Pharmaceutics 2020; 12:pharmaceutics12010029. [PMID: 31906268 PMCID: PMC7023008 DOI: 10.3390/pharmaceutics12010029] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/17/2019] [Accepted: 12/19/2019] [Indexed: 12/31/2022] Open
Abstract
Amphotericin B (AmB), a broad-spectrum polyene antibiotic in the clinic for more than fifty years, remains the gold standard in the treatment of life-threatening invasive fungal infections and visceral leishmaniasis. Due to its poor water solubility and membrane permeability, AmB is conventionally formulated with deoxycholate as a micellar suspension for intravenous administration, but severe infusion-related side effects and nephrotoxicity hamper its therapeutic potential. Lipid-based formulations, such as liposomal AmB, have been developed which significantly reduce the toxic side effects of the drug. However, their high cost and the need for parenteral administration limit their widespread use. Therefore, delivery systems that can retain or even enhance antimicrobial efficacy while simultaneously reducing AmB adverse events are an active area of research. Among those, lipid systems have been extensively investigated due to the high affinity of AmB for binding lipids. The development of a safe and cost-effective oral formulation able to improve drug accessibility would be a major breakthrough, and several lipid systems for the oral delivery of AmB are currently under development. This review summarizes recent advances in lipid-based systems for targeted delivery of AmB focusing on non-parenteral nanoparticulate formulations mainly investigated over the last five years and highlighting those that are currently in clinical trials.
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Affiliation(s)
| | - Lídia Pinheiro
- Correspondence: ; Tel.: +351-21-7946-400; Fax: +351-21-7946-470
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15
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Zhao Y, Seelhammer TG, Barreto EF, Wilson JW. Altered Pharmacokinetics and Dosing of Liposomal Amphotericin B and Isavuconazole during Extracorporeal Membrane Oxygenation. Pharmacotherapy 2019; 40:89-95. [PMID: 31742741 DOI: 10.1002/phar.2348] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Drug pharmacokinetics may be significantly altered in patients receiving extracorporeal membrane oxygenation (ECMO). Ensuring the optimized effective dosing of antimicrobials on ECMO remains a challenge. To date, limited data are available regarding the optimal use of amphotericin and triazoles during ECMO. We report a case of altered pharmacokinetics, insufficient liposomal amphotericin B and isavuconazole levels, and the need for escalated doses during ECMO in a patient with severe acute respiratory distress syndrome secondary to pulmonary blastomycosis. A 2-fold increase in the standard total daily dose of both drugs was necessary to overcome low serum concentrations thought to be secondary to drug loss from ECMO circuit sequestration. These findings have important implications for optimizing antimicrobial therapy in patients receiving ECMO to maximize therapeutic efficacy. The use of therapeutic drug monitoring for patients receiving antimicrobial therapy with concurrent ECMO may facilitate appropriate drug dosing to achieve adequate serum concentrations and optimize favorable patient outcomes. Further studies exploring antimicrobial pharmacokinetics during ECMO are needed to inform dosing recommendations in critically ill patients.
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Affiliation(s)
- Yanjun Zhao
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | - Troy G Seelhammer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - John W Wilson
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
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16
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John J, Loo A, Mazur S, Walsh TJ. Therapeutic drug monitoring of systemic antifungal agents: a pragmatic approach for adult and pediatric patients. Expert Opin Drug Metab Toxicol 2019; 15:881-895. [PMID: 31550939 DOI: 10.1080/17425255.2019.1671971] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Introduction: Therapeutic drug monitoring (TDM) has been shown to optimize the management of invasive fungal infections (IFIs), particularly for select antifungal agents with a well-defined exposure-response relationship and an unpredictable pharmacokinetic profile or a narrow therapeutic index. Select triazoles (itraconazole, voriconazole, and posaconazole) and flucytosine fulfill these criteria, while the echinocandins, fluconazole, isavuconazole, and amphotericin B generally do not do so. Given the morbidity and mortality associated with IFIs and the challenges surrounding the use of currently available antifungal agents, TDM plays an important role in therapy.Areas covered: This review seeks to describe the rationale for TDM of antifungal agents, summarize their pharmacokinetic and pharmacodynamic properties, identify treatment goals for efficacy and safety, and provide recommendations for optimal dosing and therapeutic monitoring strategies.Expert opinion: Several new antifungal agents are currently in development, including compounds from existing antifungal classes with enhanced pharmacokinetic or safety profiles as well as agents with novel targets for the treatment of IFIs. Given the predictable pharmacokinetics of these newly developed agents, use of routine TDM is not anticipated. However, expanded knowledge of exposure-response relationships of these compounds may yield a role for TDM to improve outcomes for adult and pediatric patients.
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Affiliation(s)
- Jamie John
- Department of Pharmacy, New York-Presbyterian Hospital, New York, NY, USA
| | - Angela Loo
- Department of Pharmacy, New York-Presbyterian Hospital, New York, NY, USA
| | - Shawn Mazur
- Department of Pharmacy, New York-Presbyterian Hospital, New York, NY, USA
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
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17
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Cornely OA, Hoenigl M, Lass-Flörl C, Chen SCA, Kontoyiannis DP, Morrissey CO, Thompson GR. Defining breakthrough invasive fungal infection-Position paper of the mycoses study group education and research consortium and the European Confederation of Medical Mycology. Mycoses 2019; 62:716-729. [PMID: 31254420 PMCID: PMC6692208 DOI: 10.1111/myc.12960] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 12/14/2022]
Abstract
Breakthrough invasive fungal infections (IFIs) have emerged as a significant problem in patients receiving systemic antifungals; however, consensus criteria for defining breakthrough IFI are missing. This position paper establishes broadly applicable definitions of breakthrough IFI for clinical research. Representatives of the Mycoses Study Group Education and Research Consortium (MSG-ERC) and the European Confederation of Medical Mycology (ECMM) reviewed the relevant English literature for definitions applied and published through 2018. A draft proposal for definitions was developed and circulated to all members of the two organisations for comment and suggestions. The authors addressed comments received and circulated the updated document for approval. Breakthrough IFI was defined as any IFI occurring during exposure to an antifungal drug, including fungi outside the spectrum of activity of an antifungal. The time of breakthrough IFI was defined as the first attributable clinical sign or symptom, mycological finding or radiological feature. The period defining breakthrough IFI depends on pharmacokinetic properties and extends at least until one dosing interval after drug discontinuation. Persistent IFI describes IFI that is unchanged/stable since treatment initiation with ongoing need for antifungal therapy. It is distinct from refractory IFI, defined as progression of disease and therefore similar to non-response to treatment. Relapsed IFI occurs after treatment and is caused by the same pathogen at the same site, although dissemination can occur. These proposed definitions are intended to support the design of future clinical trials and epidemiological research in clinical mycology, with the ultimate goal of increasing the comparability of clinical trial results.
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Affiliation(s)
- Oliver A Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- Department I of Internal Medicine, ECMM Center of Excellence for Medical Mycology, German Centre for Infection Research, Partner Site Bonn-Cologne (DZIF), University of Cologne, Cologne, Germany
- Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | - Martin Hoenigl
- Division of Infectious Diseases, University of California San Diego, San Diego, CA, USA
- Division of Pulmonology and Section of Infectious Diseases, Medical University of Graz, Graz, Austria
| | - Cornelia Lass-Flörl
- Division of Hygiene and Microbiology, ECMM Excellence Center for Medical Mycology, Medical University Innsbruck, Innsbruck, Austria
| | - Sharon C-A Chen
- Centre for Infectious Diseases and Microbiology, Laboratory Services, ICPMR, New South Wales Health Pathology, Westmead Hospital, Centre for Infectious Diseases and Microbiology, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control, and Employee Health, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - C Orla Morrissey
- Infectious Diseases, Alfred Health and Monash University, Melbourne, VIC, Australia
| | - George R Thompson
- Departments of Medical Microbiology and Immunology and Internal Medicine Division of Infectious Diseases, UC-Davis Medical Center, Sacramento, CA, USA
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18
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Van Haute D, Jiang W, Mudalige T. Evaluation of size-based distribution of drug and excipient in amphotericin B liposomal formulation. Int J Pharm 2019; 569:118603. [PMID: 31401296 DOI: 10.1016/j.ijpharm.2019.118603] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/10/2019] [Accepted: 08/05/2019] [Indexed: 12/15/2022]
Abstract
Conventional quantitation of drug content in the liposome formulation involves the breakdown of bulk liposomes, which ignores details on the distribution of the active pharmaceutical ingredient (API) and excipients in liposomes of different sizes. The objective of this study is to develop an analytical method which can separate the liposomes into different sizes and obtain information of the drug and excipient distribution in the different sized liposomes. We developed an asymmetric flow field-flow fractionation (AF4) method for size-based separation of AmBisome, an amphotericin B liposomal formulation, and a high-performance liquid chromatography ultraviolet-visible and charged aerosol detection (HPLC-UV-CAD) method for simultaneous quantitation of the API (Amphotericin B) and the lipid excipients [1,2-Distearoyl-sn-glycero-3-phosphoglycerol (DSPG), hydrogenated soy phosphatidylcholine (HSPC), and cholesterol]. The measured drug content in the bulk liposome formulation was consistent with the drug product labeling. Liposomes were separated using AF4 into eleven size fractions and the liposomes particles sizes of each fraction were measured with nanoparticle tracking analysis. The drug to total lipid ratios in fractionated liposomes increased from 0.1 to 0.45 when the liposome size increased from 75 nm to 124 nm, while the lipid composition remained constant throughout the fractioned size range (cholesterol:DSPG, 0.7 and HSPC:DSPG, 0.3). These study results suggest that, for liposomal formulations of Amphotericin B in liposomes, the drug to lipid ratio increases with the size of the liposomes. This new analytical method provided a more in-depth characterization of liposomes, i.e., determining drug and excipient distributions in different sizes of liposomes, in a more efficient manner with more specific size-based composition information.
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Affiliation(s)
- Desiree Van Haute
- Arkansas Laboratory, Office of Regulatory Science, Office of Regulatory Affairs, US Food and Drug Administration, Jefferson, AR 72079, United States
| | - Wenlei Jiang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD 20993, United States.
| | - Thilak Mudalige
- Arkansas Laboratory, Office of Regulatory Science, Office of Regulatory Affairs, US Food and Drug Administration, Jefferson, AR 72079, United States.
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Kip AE, Schellens JHM, Beijnen JH, Dorlo TPC. Clinical Pharmacokinetics of Systemically Administered Antileishmanial Drugs. Clin Pharmacokinet 2019; 57:151-176. [PMID: 28756612 PMCID: PMC5784002 DOI: 10.1007/s40262-017-0570-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This review describes the pharmacokinetic properties of the systemically administered antileishmanial drugs pentavalent antimony, paromomycin, pentamidine, miltefosine and amphotericin B (AMB), including their absorption, distribution, metabolism and excretion and potential drug–drug interactions. This overview provides an understanding of their clinical pharmacokinetics, which could assist in rationalising and optimising treatment regimens, especially in combining multiple antileishmanial drugs in an attempt to increase efficacy and shorten treatment duration. Pentavalent antimony pharmacokinetics are characterised by rapid renal excretion of unchanged drug and a long terminal half-life, potentially due to intracellular conversion to trivalent antimony. Pentamidine is the only antileishmanial drug metabolised by cytochrome P450 enzymes. Paromomycin is excreted by the kidneys unchanged and is eliminated fastest of all antileishmanial drugs. Miltefosine pharmacokinetics are characterized by a long terminal half-life and extensive accumulation during treatment. AMB pharmacokinetics differ per drug formulation, with a fast renal and faecal excretion of AMB deoxylate but a much slower clearance of liposomal AMB resulting in an approximately ten-fold higher exposure. AMB and pentamidine pharmacokinetics have never been evaluated in leishmaniasis patients. Studies linking exposure to effect would be required to define target exposure levels in dose optimisation but have only been performed for miltefosine. Limited research has been conducted on exposure at the drug’s site of action, such as skin exposure in cutaneous leishmaniasis patients after systemic administration. Pharmacokinetic data on special patient populations such as HIV co-infected patients are mostly lacking. More research in these areas will help improve clinical outcomes by informed dosing and combination of drugs.
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Affiliation(s)
- Anke E Kip
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital/MC Slotervaart, Amsterdam, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Jan H M Schellens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
- Department of Clinical Pharmacology, Antoni van Leeuwenhoek Hospital/The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital/MC Slotervaart, Amsterdam, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
- Department of Clinical Pharmacology, Antoni van Leeuwenhoek Hospital/The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas P C Dorlo
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital/MC Slotervaart, Amsterdam, The Netherlands.
- Pharmacometrics Research Group, Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden.
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20
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Groll AH, Rijnders BJA, Walsh TJ, Adler-Moore J, Lewis RE, Brüggemann RJM. Clinical Pharmacokinetics, Pharmacodynamics, Safety and Efficacy of Liposomal Amphotericin B. Clin Infect Dis 2019; 68:S260-S274. [PMID: 31222253 PMCID: PMC6495018 DOI: 10.1093/cid/ciz076] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Since its introduction in the 1990s, liposomal amphotericin B (LAmB) continues to be an important agent for the treatment of invasive fungal diseases caused by a wide variety of yeasts and molds. This liposomal formulation was developed to improve the tolerability of intravenous amphotericin B, while optimizing its clinical efficacy. Since then, numerous clinical studies have been conducted, collecting a comprehensive body of evidence on its efficacy, safety, and tolerability in the preclinical and clinical setting. Nevertheless, insights into the pharmacokinetics and pharmacodynamics of LAmB continue to evolve and can be utilized to develop strategies that optimize efficacy while maintaining the compound's safety. In this article, we review the clinical pharmacokinetics, pharmacodynamics, safety, and efficacy of LAmB in a wide variety of patient populations and in different indications, and provide an assessment of areas with a need for further clinical research.
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Affiliation(s)
- Andreas H Groll
- Infectious Disease Research Program, Department of Pediatric Hematology and Oncology and Center for Bone Marrow Transplantation, University Children’s Hospital Muenster, Germany
| | - Bart J A Rijnders
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Thomas J Walsh
- Departments of Medicine, Pediatrics, and Microbiology & Immunology, Weill Cornell Medicine of Cornell University, New York, New York
| | - Jill Adler-Moore
- Department of Biological Sciences, California State Polytechnic University, Pomona
| | - Russell E Lewis
- Unit of Infectious Diseases, Policlinico Sant’Orsola-Malpighi, Department of Medical Sciences and Surgery, University of Bologna, Italy
| | - Roger J M Brüggemann
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
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21
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Foulquier J, Berneau P, Frérou A, Verdier M, Saint-Marcoux F, Petitcollin A, Tron C, Bellissant E, Lemaitre F. Liposomal amphotericin B pharmacokinetics in a patient treated with extracorporeal membrane oxygenation. Med Mal Infect 2019; 49:69-71. [DOI: 10.1016/j.medmal.2018.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 10/18/2018] [Indexed: 10/27/2022]
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22
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Nieto J, Alvar J, Rodríguez C, San Andrés M, San Andrés M, González F. Comparison of conventional and lipid emulsion formulations of amphotericin B: Pharmacokinetics and toxicokinetics in dogs. Res Vet Sci 2018; 117:125-132. [DOI: 10.1016/j.rvsc.2017.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/17/2017] [Accepted: 12/14/2017] [Indexed: 10/18/2022]
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23
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Bellmann R, Smuszkiewicz P. Pharmacokinetics of antifungal drugs: practical implications for optimized treatment of patients. Infection 2017; 45:737-779. [PMID: 28702763 PMCID: PMC5696449 DOI: 10.1007/s15010-017-1042-z] [Citation(s) in RCA: 203] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 06/25/2017] [Indexed: 02/08/2023]
Abstract
Introduction Because of the high mortality of invasive fungal infections (IFIs), appropriate exposure to antifungals appears to be crucial for therapeutic efficacy and safety. Materials and methods This review summarises published pharmacokinetic data on systemically administered antifungals focusing on co-morbidities, target-site penetration, and combination antifungal therapy. Conclusions and discussion Amphotericin B is eliminated unchanged via urine and faeces. Flucytosine and fluconazole display low protein binding and are eliminated by the kidney. Itraconazole, voriconazole, posaconazole and isavuconazole are metabolised in the liver. Azoles are substrates and inhibitors of cytochrome P450 (CYP) isoenzymes and are therefore involved in numerous drug–drug interactions. Anidulafungin is spontaneously degraded in the plasma. Caspofungin and micafungin undergo enzymatic metabolism in the liver, which is independent of CYP. Although several drug–drug interactions occur during caspofungin and micafungin treatment, echinocandins display a lower potential for drug–drug interactions. Flucytosine and azoles penetrate into most of relevant tissues. Amphotericin B accumulates in the liver and in the spleen. Its concentrations in lung and kidney are intermediate and relatively low myocardium and brain. Tissue distribution of echinocandins is similar to that of amphotericin. Combination antifungal therapy is established for cryptococcosis but controversial in other IFIs such as invasive aspergillosis and mucormycosis.
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Affiliation(s)
- Romuald Bellmann
- Clinical Pharmacokinetics Unit, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Piotr Smuszkiewicz
- Department of Anesthesiology, Intensive Therapy and Pain Treatment, University Hospital, Poznań, Poland
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Stone NRH, Bicanic T, Salim R, Hope W. Liposomal Amphotericin B (AmBisome(®)): A Review of the Pharmacokinetics, Pharmacodynamics, Clinical Experience and Future Directions. Drugs 2016; 76:485-500. [PMID: 26818726 DOI: 10.1007/s40265-016-0538-7] [Citation(s) in RCA: 280] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Liposomal amphotericin B (AmBisome(®); LAmB) is a unique lipid formulation of amphotericin B. LAmB is a standard of care for a wide range of medically important opportunistic fungal pathogens. LAmB has a significantly improved toxicity profile compared with conventional amphotericin B deoxycholate (DAmB). Despite nearly 20 years of clinical use, the pharmacokinetics and pharmacodynamics of this agent, which differ considerably from DAmB, remain relatively poorly understood and underutilized in the clinical setting. The molecular pharmacology, preclinical and clinical pharmacokinetics, and clinical experience with LAmB for the most commonly encountered fungal pathogens are reviewed. In vitro, experimental animal models and human clinical trial data are summarized, and novel routes of administration and dosing schedules are discussed. LAmB is a formulation that results in reduced toxicity as compared with DAmB while retaining the antifungal effect of the active agent. Its long terminal half-life and retention in tissues suggest that single or intermittent dosing regimens are feasible, and these should be actively investigated in both preclinical models and in clinical trials. Significant gaps remain in knowledge of pharmacokinetics and pharmacodynamics in special populations such as neonates and children, pregnant women and obese patients.
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Affiliation(s)
- Neil R H Stone
- Institute for Infection and Immunity, St. George's University of London, London, UK.
| | - Tihana Bicanic
- Institute for Infection and Immunity, St. George's University of London, London, UK
| | - Rahuman Salim
- Department of Haematology, Royal Liverpool University Hospital, Liverpool, UK
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, 1.09 Sherrington Building, University of Liverpool, Liverpool, UK
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25
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Takemoto K, Kanazawa K. AmBisome: relationship between the pharmacokinetic characteristics acquired by liposomal formulation and safety/efficacy. J Liposome Res 2016; 27:186-194. [DOI: 10.1080/08982104.2016.1205087] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Koji Takemoto
- Pharmacology Research Laboratories, Sumitomo Dainippon Pharma Co., Ltd., Osaka, Japan and
| | - Katsunori Kanazawa
- Product Management & Promotion Planning, Sumitomo Dainippon Pharma Co., Ltd., Tokyo, Japan
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26
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Affiliation(s)
- Yuanzeng Min
- Laboratory of Nano- and Translational Medicine, Carolina Institute of Nanomedicine, Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill , Chapel Hill, North Carolina 27599, United States
| | - Joseph M Caster
- Laboratory of Nano- and Translational Medicine, Carolina Institute of Nanomedicine, Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill , Chapel Hill, North Carolina 27599, United States
| | - Michael J Eblan
- Laboratory of Nano- and Translational Medicine, Carolina Institute of Nanomedicine, Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill , Chapel Hill, North Carolina 27599, United States
| | - Andrew Z Wang
- Laboratory of Nano- and Translational Medicine, Carolina Institute of Nanomedicine, Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill , Chapel Hill, North Carolina 27599, United States
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27
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Olson JA, Schwartz JA, Hahka D, Nguyen N, Bunch T, Jensen GM, Adler-Moore JP. Toxicity and efficacy differences between liposomal amphotericin B formulations in uninfected and Aspergillus fumigatus infected mice. Med Mycol 2014; 53:107-18. [DOI: 10.1093/mmy/myu070] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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28
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Dézsi L, Fülöp T, Mészáros T, Szénási G, Urbanics R, Vázsonyi C, Őrfi E, Rosivall L, Nemes R, Kok RJ, Metselaar JM, Storm G, Szebeni J. Features of complement activation-related pseudoallergy to liposomes with different surface charge and PEGylation: Comparison of the porcine and rat responses. J Control Release 2014; 195:2-10. [DOI: 10.1016/j.jconrel.2014.08.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 08/07/2014] [Accepted: 08/08/2014] [Indexed: 12/21/2022]
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29
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Gupta PK, Jaiswal AK, Asthana S, Verma A, Kumar V, Shukla P, Dwivedi P, Dube A, Mishra PR. Self Assembled Ionically Sodium Alginate Cross-Linked Amphotericin B Encapsulated Glycol Chitosan Stearate Nanoparticles: Applicability in Better Chemotherapy and Non-Toxic Delivery in Visceral Leishmaniasis. Pharm Res 2014; 32:1727-40. [DOI: 10.1007/s11095-014-1571-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 11/10/2014] [Indexed: 01/09/2023]
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30
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Pastor FJ, Guarro J. Treatment of Aspergillus terreus infections: a clinical problem not yet resolved. Int J Antimicrob Agents 2014; 44:281-9. [PMID: 25190543 DOI: 10.1016/j.ijantimicag.2014.07.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 07/03/2014] [Accepted: 07/10/2014] [Indexed: 10/24/2022]
Abstract
Despite the use of recommended therapies, invasive infections by Aspergillus terreus show a poor response. For years, investigative studies on the failure of therapy of fungal infections have focused on in vitro susceptibility data. However, it is well known that low minimum inhibitory concentrations (MICs) are not always predictive of response to therapy despite a correct dosage schedule. Many experimental and clinical studies have tried to establish a relationship between MICs and outcome in serious fungal infections but have come to contradictory and even surprising conclusions. The success or failure of treatment is determined by many factors, including the in vitro susceptibility of the causative fungal isolate, the pharmacokinetics/pharmacodynamics of the drug used for treatment, pharmacokinetic variability in the population, and the underlying disease that patients suffer. To try to understand this poor response to treatment, available data on the in vitro susceptibility of A. terreus, the experimental and clinical response to amphotericin B, triazoles and echinocandins, and the pharmacokinetics/pharmacodynamics of these antifungals have been reviewed. Of special interest are the fungistatic activites of these drugs against A. terreus and the high interpatient variability of serum drug levels observed in therapy based on triazoles, which make monitoring of infected patients necessary.
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Affiliation(s)
- F Javier Pastor
- Unitat de Microbiologia, Facultat de Medicina i Ciències de la Salut, IISPV, Universitat Rovira i Virgili, Sant Llorenç 21, 43201 Reus, Spain
| | - Josep Guarro
- Unitat de Microbiologia, Facultat de Medicina i Ciències de la Salut, IISPV, Universitat Rovira i Virgili, Sant Llorenç 21, 43201 Reus, Spain.
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31
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Norvaisas P, Ziemys A. The role of payload hydrophobicity in nanotherapeutic pharmacokinetics. J Pharm Sci 2014; 103:2147-2156. [PMID: 24801583 DOI: 10.1002/jps.23996] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 03/26/2014] [Accepted: 04/07/2014] [Indexed: 12/23/2022]
Abstract
Although drug delivery with nanovectors is regarded as one of the paradigm-shifting advances in modern medicine, the compatibility and performance of drug-vector formulations have not been systematically studied in terms of their physicochemistry and pharmacokinetics (PKs). The drug delivery systems (DDSs), currently available in clinics or trials, were analyzed based on hydrophobicity and anatomical therapeutic chemical (ATC) classification of drug payloads. Four major types of DDSs differentiated based on DDS structure and drug hydrophobicity, where payload hydrophobicity decreased: micelles, serum albumin, liposome membrane, and liposome interior. A strong relationship between the increase in half-life in DDS formulation and drug hydrophobicity was found with up to 200-fold greater increase for hydrophilic drugs. The analysis results seemingly integrated PKs, ATC, and hydrophobicity to reinforce the development or optimization of drug delivery vectors and their formulations.
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Affiliation(s)
- Povilas Norvaisas
- Houston Methodist Research Institute, Department of Nanomedicine, Houston, Texas, 77030
| | - Arturas Ziemys
- Houston Methodist Research Institute, Department of Nanomedicine, Houston, Texas, 77030.
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Therapeutic monitoring of amphotericin B in Saudi ICU patients using UPLC MS/MS assay. Biomed Chromatogr 2014; 28:1652-9. [DOI: 10.1002/bmc.3198] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 02/22/2014] [Accepted: 03/07/2014] [Indexed: 01/14/2023]
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Bedikian AY, Vardeleon A, Smith T, Campbell S, Namdari R. Pharmacokinetics and Urinary Excretion of Vincristine Sulfate Liposomes Injection in Metastatic Melanoma Patients. J Clin Pharmacol 2013; 46:727-37. [PMID: 16809798 DOI: 10.1177/0091270006288953] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Vincristine sulfate liposomes injection (VSLI) is a liposomal formulation of vincristine encapsulated in sphingosomes composed of sphinogomyelin and cholesterol (58/42; mol/mol). The pharmacokinetics and urinary excretion of VSLI were evaluated in 12 patients with metastatic melanoma after single-dose (2.0 mg/m2 every 2 weeks = 1 cycle) and multiple-dose (cycle 3, pharmacokinetics only) administrations (intravenous infusion over 1 hour). After VSLI infusion, total (released and encapsulated) vincristine concentrations in plasma remained relatively constant for 3 to 12 hours and thereafter declined, with interpatient variability seen in the rate of decline resulting in monoexponential or biexponential profiles. The area under the plasma concentration-time curve from time zero to infinity of total vincristine in plasma ranged from 4933 to 40495 h.ng/mL and total clearance ranged from 131 to 445 mL/h. The volume of distribution at steady state was 2650 +/- 731 mL, indicating VSLI was mainly confined within the plasma. The released vincristine concentrations in plasma were below the level of quantitation in 95% of samples. The pharmacokinetic parameters were similar between cycles 1 and 3, and trough plasma levels of total vincristine were below the level of quantitation of 1 ng/mL. Approximately 8% of the injected dose was excreted in the urine as unchanged vincristine (7%) or N-desformylvincristine (0.8%). Overall, VSLI exhibited a longer circulation half-life and higher area under the plasma concentration-time curve compared to conventional vincristine, whereas its route of elimination remained unchanged.
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Affiliation(s)
- Agop Y Bedikian
- Department of Melanoma Medical Oncology, The University of Texas, M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 430, Houston, TX 77030, USA.
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Devadasu VR, Bhardwaj V, Kumar MNVR. Can controversial nanotechnology promise drug delivery? Chem Rev 2012; 113:1686-735. [PMID: 23276295 DOI: 10.1021/cr300047q] [Citation(s) in RCA: 159] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Venkat Ratnam Devadasu
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow G4 0RE, United Kingdom
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Pharmacokinetics of amphotericin B colloidal dispersion in critically ill patients with cholestatic liver disease. Antimicrob Agents Chemother 2012; 56:5414-8. [PMID: 22850517 DOI: 10.1128/aac.00690-12] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
The pharmacokinetics of lipid-bound and liberated amphotericin B (AMB) was assessed in 11 critically ill patients with cholestatic liver disease (CSLD) and in 9 subjects with normal liver function treated with AMB colloidal dispersion (ABCD). Exposure to lipid-bound AMB was higher in patients with CSLD. Levels of liberated AMB were elevated by CSLD only after the first dose, whereas its pharmacokinetics was unaffected at steady state. The standard dosage of ABCD is probably adequate for patients with CSLD.
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Population pharmacokinetics of liposomal amphotericin B and caspofungin in allogeneic hematopoietic stem cell recipients. Antimicrob Agents Chemother 2011; 56:536-43. [PMID: 22083471 DOI: 10.1128/aac.00265-11] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Liposomal amphotericin B (LAMB) and caspofungin (CAS) are important antifungal agents in allogeneic hematopoietic stem cell transplant (aHSCT) recipients. Little is known, however, about the pharmacokinetics (PK) of both agents and their combination in this population. The PK of LAMB and CAS and the potential for PK interactions between both agents were investigated within a risk-stratified, randomized phase II clinical trial in 53 adult aHSCT recipients with granulocytopenia and refractory fever. Patients received either LAMB (n = 17; 3 mg/kg once a day [QD]), CAS (n = 19; 50 mg QD; day 1, 70 mg), or the combination of both (CAS-LAMB; n = 17) for a median duration of 10 to 13 days (range, 4 to 28 days) until defervescence and granulocyte recovery. PK sampling was performed on days 1 and 4. Drug concentrations in plasma (LAMB, 405 samples; CAS, 458 samples) were quantified by high-pressure liquid chromatography and were analyzed using population pharmacokinetic modeling. CAS concentration data best fitted a two-compartment model with a proportional error model and interindividual variability (IIV) for clearance (CL) and central volume of distribution (V(1)) (CL, 0.462 liter/h ± 25%; V(1), 8.33 liters ± 29%; intercompartmental clearance [Q], 1.25 liters/h; peripheral volume of distribution [V(2)], 3.59 liters). Concentration data for LAMB best fitted a two-compartment model with a proportional error model and IIV for all parameters (CL, 1.22 liters/h ± 64%; V(1), 19.2 liters ± 38%; Q, 2.18 liters/h ± 47%; V(2), 52.8 liters ± 84%). Internal model validation showed predictability and robustness of both models. None of the covariates tested (LAMB or CAS comedication, gender, body weight, age, body surface area, serum bilirubin, and creatinine clearance) further improved the models. In summary, the disposition of LAMB and CAS was best described by two-compartment models. Drug exposures in aHSCT patients were comparable to those in other populations, and no PK interactions were observed between the two compounds.
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Sinnollareddy M, Peake SL, Roberts MS, Lipman J, Roberts JA. Using pharmacokinetics and pharmacodynamics to optimise dosing of antifungal agents in critically ill patients: a systematic review. Int J Antimicrob Agents 2011; 39:1-10. [PMID: 21925845 DOI: 10.1016/j.ijantimicag.2011.07.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Accepted: 07/28/2011] [Indexed: 12/29/2022]
Abstract
The prevalence of invasive fungal infections (IFIs) caused by Candida spp. is increasing in critically ill patients. Recent development of new antifungal agents has significantly contributed to the successful treatment of IFIs. However, the pharmacokinetics of antifungal agents can be altered in a number of disease states, including critical illness. Therefore, doses established in healthy volunteers and other patient groups may not be appropriate for the critically ill. Moreover, inadequate dosing may contribute to treatment failure and the emergence of resistance. This systematic review provides a critical analysis of the pharmacokinetics of antifungal agents in the critically ill and their relevance to dosing requirements in clinical practice. Based on the limited data available, dosing of some antifungal agents may have to be adjusted in critically ill patients with conserved renal function as well as in those requiring renal replacement therapy. Further research to confirm the appropriateness of current dosing strategies to attain the appropriate pharmacodynamic targets is recommended.
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Affiliation(s)
- Mahipal Sinnollareddy
- Pharmacy Department, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, Adelaide, SA 5011, Australia.
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Formation of two different types of ion channels by amphotericin B in human erythrocyte membranes. J Membr Biol 2009; 230:69-81. [PMID: 19629570 DOI: 10.1007/s00232-009-9187-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Accepted: 06/17/2009] [Indexed: 10/20/2022]
Abstract
The polyene antibiotic amphotericin B (AmB) is known to form aqueous pores in lipid membranes and biological membranes. Here, membrane potential and ion permeability measurements were used to demonstrate that AmB can form two types of selective ion channels in human erythrocytes, differing in their interaction with cholesterol. We show that AmB induced a cation efflux (negative membrane polarization) across cholesterol-containing liposomes and erythrocytes at low concentrations (< or =1.0 x 10(-6) M), but a sharp reversal of such polarization was observed at concentrations greater than 1.0 x 10(-6) M AmB, an indication that aqueous pores are formed. Cation-selective AmB channels are also formed across sterol-free liposomes, but aqueous pores are only formed at AmB concentrations 10 times greater. The effect of temperature on the AmB-mediated K+ efflux across erythrocytes revealed that the energies of activation for channel formation are negative and positive at AmB concentrations that lead predominantly to the formation of cation-selective channels and aqueous pores, respectively. These findings support the conclusion that the two types of AmB channels formed in human erythrocytes differ in their interactions with cholesterol and other membrane components. In effect, a membrane lipid reorganization, as induced by incubation of erythrocytes with tetrathionate, a cross-linking agent of the lipid raft-associated protein spectrin, led to differential changes in the activation parameters for the formation of both types of channels, reflecting the different lipid environments in which such structures are formed.
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Lane JW, Rehak NN, Hortin GL, Zaoutis T, Krause PR, Walsh TJ. Pseudohyperphosphatemia associated with high-dose liposomal amphotericin B therapy. Clin Chim Acta 2007; 387:145-9. [PMID: 17936740 DOI: 10.1016/j.cca.2007.08.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Revised: 08/22/2007] [Accepted: 08/23/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND Acute increases in serum inorganic phosphorus (Pi) up to 4.75 mmol/l in the absence of hypocalcemia and tissue deposition of calcium phosphate were noted in 3 patients receiving liposomal amphotericin B (L-AMB). We investigated L-AMB as a possible cause of pseudohyperphosphatemia. METHODS Serum samples from the index patient were analyzed for Pi content by our laboratory's primary analyzer (Synchron LX20) and by an alternate analyzer (Vitros). Clear and lipemic serum pools, and normal saline, were spiked with L-AMB and analyzed by the LX20 Pi method. Ultrafiltration studies were performed on patient and spiked sera. RESULTS Increased Pi values were obtained only from the LX20 analyzer. There was a direct linear relationship between the concentration of L-AMB in the spiked samples and the LX20 Pi results, indicating a 0.9 mmol/l Pi increase for every 100 mg/l increase in L-AMB. Ultrafiltration normalized the Pi results. CONCLUSION Serum Pi results may be falsely increased in patients receiving L-AMB when measured by the LX20 analyzer. This novel cause of pseudohyperphosphatemia is due to interference of L-AMB with the method and is corrected by ultrafiltration of the specimen. Since the LX20 analyzer is widely used by the clinical laboratories clinicians and laboratory personnel should recognize this interference in order to avoid unnecessary diagnostic procedures and interventions.
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Affiliation(s)
- Jason W Lane
- Microbiology Service, Department of Laboratory Medicine, W. G. Magnuson Clinical Center, NIH, Bethesda, Maryland, USA
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41
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Song KY, Kang WK, Park CW, Choi YJ, Rha SE, Park CH. Mucormycosis Resulting in Gastric Perforation in a Patient with Acute Myelogenous Leukemia: Report of a Case. Surg Today 2006; 36:831-4. [PMID: 16937290 DOI: 10.1007/s00595-006-3246-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2005] [Accepted: 03/14/2006] [Indexed: 10/24/2022]
Abstract
Mucormycosis is an uncommon opportunistic fungal infection that may develop in immunocompromised patients with conditions such as diabetes mellitus, leukemia, lymphoma, or human immunodeficiency virus (HIV), or after transplantation with immunosupperessive therapy. We report a case of gastric perforation caused by a mucormycosis infection in a patient with acute myelogenous leukemia (AML). The patient was treated successfully with gastrectomy and the aggressive use of intravenous amphotericin B. He is still alive 1 year after his operation.
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Affiliation(s)
- Kyo Young Song
- Department of Surgery, The Catholic University of Korea, Seoul, Korea
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42
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Antony SJ, Jurczyk P, Brumble L. Successful use of combination antifungal therapy in the treatment of coccidioides meningitis. J Natl Med Assoc 2006; 98:940-2. [PMID: 16775917 PMCID: PMC2569371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Coccidioidal meningitis is a highly lethal condition with a high morbidity and relapse rate caused by Coccidioides immitis. This case report highlights the difficulty in diagnosing and treating coccidioidal meningitis, and discusses a novel combination antifungal therapy (voriconazole and liposomal amphotericin B), which was used to treat this patient.
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Fohrer C, Nivoix Y, Moulin JC, Marçais A, Herbrecht R. Apports des dérivés lipidiques de l’amphotéricine B dans la prise en charge des infections fongiques. Therapie 2006; 61:235-42. [PMID: 16989124 DOI: 10.2515/therapie:2006047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Three lipid formulations of amphotericin B have been developed: amphotericin B colloidal dispersion, amphotericin B lipid complex, and liposomal amphotericin B. These three compounds differ by their lipid composition and therefore by their physical characteristics, their pharmacokinetics, and their safety and efficacy profile. There is a consensus to accept reduced toxicity of these formulations, especially reduced, but not absence of, renal toxicity as compared to amphotericin B deoxycholate. Few well-designed studies have been conducted and none of them demonstrated convincingly superiority in term of efficacy of any of the lipid preparations over amphotericin B deoxycholate. Recently a double blind randomized study compared a standard dose of 3 mg/kg/d of liposomal amphotericin B and a loading dose (10 mg/kg/d for 14 days and then the standard dose) in primary therapy of invasive filamentous fungal infections, mainly aspergillosis. Response rate at end of randomized therapy as well as survival at 12 weeks was numerically superior in the standard dose arm but this difference was not statistically significant. Lack of benefit of high dose liposomal amphotericin B in aspergillosis cannot yet be extrapolated to other filamentous fungal infections. Nephrotoxicity was substantially higher in the loading dose arm and this contraindicates its use in clinical practice.
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Affiliation(s)
- Cécile Fohrer
- Département d'Hématologie et d'Oncologie, Hôpital de Hautepierre, Strasbourg, France
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Gibbs WJ, Drew RH, Perfect JR. Liposomal amphotericin B: clinical experience and perspectives. Expert Rev Anti Infect Ther 2006; 3:167-81. [PMID: 15918775 DOI: 10.1586/14787210.3.2.167] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
While amphotericin B deoxycholate (Fungizone, Apothecon Pharmaceuticals) has been considered by many to be the gold standard for the treatment for numerous invasive fungal infections for over 45 years, toxicities associated with its use often necessitate treatment modification or discontinuation. Lipid-based formulations, including liposomal amphotericin B (AmBisome, Fujisawa Healthcare, Inc.), were developed to decrease many of these toxicities while retaining broad antifungal spectrum and potency of amphotericin B. In clinical trials, liposomal amphotericin B has demonstrated efficacy comparable to that of amphotericin B deoxycholate while reducing the incidence of treatment-related nephrotoxicity, electrolyte-wasting, and infusion-related reactions. In addition, recent clinical trials have also compared liposomal amphotericin B with other antifungal classes. Acquisition costs of liposomal amphotericin B are substantially higher than those of amphotericin B deoxycholate and other antifungals. While pharmacoeconomic analyses consider outcomes and other treatment-related costs, they have yet to clearly demonstrate the cost-effectiveness of liposomal amphotericin B when compared with amphotericin B deoxycholate or other antifungal agents. This review will focus primarily on recent liposomal amphotericin B experience and attempt to put its use into perspective considering other available antifungal agents.
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Affiliation(s)
- Winter J Gibbs
- Department of Pharmacy practice, Campbell University School of Pharmacy, Buies Creek.
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Gavaldà J, Martín T, López P, Gomis X, Ramírez JL, Rodríguez D, Len O, Puigfel Y, Ruiz I, Pahissa A. Efficacy of high loading doses of liposomal amphotericin B in the treatment of experimental invasive pulmonary aspergillosis. Clin Microbiol Infect 2006; 11:999-1004. [PMID: 16307554 DOI: 10.1111/j.1469-0691.2005.01262.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This study aimed to investigate whether initial treatment of experimental pulmonary aspergillosis with high loading doses can be used as an alternative to standard therapeutic regimens. Steroid-immunosuppressed rats, infected intratracheally with Aspergillus fumigatus, received either amphotericin B deoxycholate (d-AmB) 1 mg/kg/day, liposomal amphotericin B (L-AmB) 5 mg/kg/day, or underwent a 3-day course of L-AmB 10 mg/kg, or 10 mg/kg for the first 3 or 4 days of treatment, followed by 3 mg/kg until the end of treatment. Therapy started 24 h after fungal challenge and lasted for 7 days. Compared to controls, survival was improved significantly in animals receiving any L-AmB regimen (p <or= 0.003), but not d-AmB. Compared with d-AmB, L-AmB at initial doses of 10 mg/kg followed by 3 mg/kg/day was consistently more effective, but only when measured in terms of survival, lung weight and glucosamine levels, and not log CFU. Despite the absence of significant differences between any of the L-AmB regimens, a trend towards better response rates with the higher loading dose was observed.
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Affiliation(s)
- J Gavaldà
- Servei de Malalties Infeccioses, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Abstract
Many issues need to be addressed by the Intensive Care Unit physician in the decision-making process regarding antifungal therapy for Candida infection, most importantly pharmacokinetic concerns and/or organ failure limitations. In addition, the extensive use of antifungal agents can select for Candida spp. that exhibit decreased susceptibility to these agents. However, the risk appears low, even in the case of prophylactic or pre-emptive antifungal therapy, but this needs to be confirmed in large-scale studies.
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Affiliation(s)
- Philippe Montravers
- Department of Anaesthesia and Surgical Intensive Care Unit, Assistance Publique-Hopitaux de Paris, Hôpital Bichat Claude Bernard-Université Paris 7, France.
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Demartini G, Lequaglie C, Brega Massone PP, Scaglione F, Fraschini F. Penetration of amphotericin B in human lung tissue after single liposomal amphotericin B (AmBisome) infusion. J Chemother 2005; 17:82-5. [PMID: 15828449 DOI: 10.1179/joc.2005.17.1.82] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The distribution of amphotericin B in lung tissue was studied in 18 patients with primary or secondary lung cancer who underwent thoracotomy and pulmonary resection. At different times before surgery the patients were treated with liposomal amphotericin B 1.5 mg/kg by i.v. infusion over 1h. Blood and lung tissue samples were collected during surgery (one subject for each collecting time) and assayed for amphotericin B levels by HPLC. Due to surgical requirements, it was possible to obtain data from the 10th to the 25th h after the end of infusion. Plasma amphotericin B concentrations progressively decreased from 3.4 microg/ml at the 10th h to 1 microg/ml at the 25th h after the end of intravenous infusion. In lung tissue samples the lowest amphotericin B concentration (about 1 microg/g) was observed at the 10th h, then a progressive increase was observed with the highest value (2.5 microg/g) determined at the 25th h.
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Affiliation(s)
- G Demartini
- Dept of Pharmacology, University of Milan, Italy
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Brime B, Molero G, Frutos P, Frutos G. Comparative therapeutic efficacy of a novel lyophilized amphotericin B lecithin-based oil–water microemulsion and deoxycholate-amphotericin B in immunocompetent and neutropenic mice infected with Candida albicans. Eur J Pharm Sci 2004; 22:451-8. [PMID: 15265515 DOI: 10.1016/j.ejps.2004.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2003] [Revised: 04/28/2004] [Accepted: 04/29/2004] [Indexed: 10/26/2022]
Abstract
The in vivo efficacy of a new amphotericin B (AmB) oil-in-water lecithin-based microemulsion delivery system (M-AmB) compared to deoxycholate-AmB (D-AmB) was studied in an immunocompetent and neutropenic murine model of systemic candidiasis. D-AmB was administered at the maximum tolerated dose of 1 mg/kg whereas M-AmB was given at the doses of 1, 2 and 3 mg/kg; doses were well tolerated due to their reduced toxicity. Both formulations were administered 24, 48 and 72 h after infection in immunocompetent mice, and 2, 6 and 24 h after infection in neutropenic mice. Kaplan-Meier survival curves showed that the M-AmB treated group had a better survival time than infected mice without treatment used as a control group (P = 4.66 x 10(-6)), and the Mann-Whitney W statistical test indicated that it reduced the percentage of mortality and fungal load in the most representative organs. This new formulation is a designed competitor which has proved to present better results than D-AmB in an established infection not only in immunocompetent but in neutropenic mice as well.
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Affiliation(s)
- Begoña Brime
- Department of Pharmacy and Pharmaceutical Technology, Complutense University of Madrid, 28040 Madrid, Spain
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Pandey R, Sharma S, Khuller GK. Liposome-based antitubercular drug therapy in a guinea pig model of tuberculosis. Int J Antimicrob Agents 2004; 23:414-5. [PMID: 15081096 DOI: 10.1016/j.ijantimicag.2004.01.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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