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Luo S, Wang X, Ren X, Cheng Y, Guo L, Yan P, Lv J, Su X, Shen J, Zhao K, Sun K, Chen J, Wang R. A case of TM infection with challenging differential diagnosis from lymphoma post-renal transplant. BMC Infect Dis 2023; 23:888. [PMID: 38114917 PMCID: PMC10729359 DOI: 10.1186/s12879-023-08912-7] [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: 07/06/2023] [Accepted: 12/14/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Lymphomas involving the gastrointestinal tract may be manifested as anti-inflammatory tract bleeding, abdominal lymph node enlargement, or even perforation of the gastrointestinal tract. After organ transplantation, the likelihood of post-transplant lymphoproliferative disorders increases, and some rare infections may also appear. CASE PRESENTATION Herein, we report a living transplant patient with talaromycosis marneffei (TSM) or Talaromyces marneffei (TM) infection with gastrointestinal hemorrhage and systemic lymph node enlargement, which presented clinically as lymphoma. CONCLUSION This case is TSM in a kidney transplant patient, confirmed by lymph node biopsy and blood culture. The patient discharged from hospital successfully under the treatment of antifungal therapy and immunosuppressive therapy. Physicians should be aware that TSM can mimic lymphoma, and early diagnosis and treatment can benefit the outcomes.
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Affiliation(s)
- Sulin Luo
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang Province, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, China
- Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Xingxia Wang
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Nephrology, 903rd Hospital of PLA, Hangzhou, China
| | - Xue Ren
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Nephrology, Huzhou Central Hospital, Huzhou, Zhejiang Province, China
| | - Yamei Cheng
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang Province, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, China
- Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Luying Guo
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang Province, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, China
- Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Pengpeng Yan
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang Province, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, China
- Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Junhao Lv
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang Province, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, China
- Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Xinhui Su
- Department of Nuclear Medicine, PET Centre, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jia Shen
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang Province, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, China
- Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Kui Zhao
- Department of Nuclear Medicine, PET Centre, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ke Sun
- Department of Pathology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang Province, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, China
- Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Rending Wang
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang Province, China.
- National Key Clinical Department of Kidney Diseases, Hangzhou, China.
- Institute of Nephrology, Zhejiang University, Hangzhou, China.
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China.
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Wang W, Kojima H, Gao M, Yin X, Uchida T, Ni J. Optimization of O/W Emulsion Solvent Evaporation Method for Itraconazole Sustained Release Microspheres. Chem Pharm Bull (Tokyo) 2023; 71:520-527. [PMID: 37394601 DOI: 10.1248/cpb.c22-00747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Itraconazole, a commonly used antifungal drug in the clinic approved by U.S. Food and Drug Administration (FDA), has been gradually found to have anti-tumor, angiogenesis inhibition and other pharmacological activities. However, its poor water solubility and potential toxicity limited its clinical application. In order to improve the water solubility and reduce the side effects caused by the high concentration of itraconazole, a novel preparation method of itraconazole sustained release microspheres was established in this study. Firstly, five kinds of polylactic acid-glycolic acid (PLGA) microspheres loaded with itraconazole were prepared by oil/water (O/W) emulsion solvent evaporation and then characterized by infrared spectroscopy. Then the particle size and morphology of the microspheres were observed by scanning electron microscope (SEM) and transmission electron microscope (TEM). After that, the particle size distribution, drug loading rate, entrapment efficiency, and drug release experiments were evaluated. Our results showed the microspheres prepared in this study had uniform particle size distribution and good integrity. Further study found that the average drug loading of the five kinds of microspheres prepared with PLGA 7505, PLGA 7510, PLGA 7520, PLGA 5020 and PLGA 0020 were 16.88, 17.72, 16.72, 16.57, and 16.64%, respectively, and the encapsulation rate all reached about 100%. More surprisingly, the release experimental results showed that the microspheres prepared with PLGA 7520 did not show sudden release, showing good sustained release performance and high drug release rate. To sum up, this study optimized the preparation method of sustained-release microspheres without sudden release, which provides a new solution for the delivery of itraconazole in the clinic.
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Affiliation(s)
- Wenping Wang
- Department of Pharmacy, China-Japan Friendship Hospital
| | - Honami Kojima
- Faculty of Pharmaceutical Sciences, Mukogawa Women's University
| | - Ming Gao
- Faculty of Pharmaceutical Sciences, Mukogawa Women's University
| | - Xingbin Yin
- School of Chinese Materia Medica, Beijing University of Chinese Medicine
| | - Takahiro Uchida
- Faculty of Pharmaceutical Sciences, Mukogawa Women's University
| | - Jian Ni
- School of Chinese Materia Medica, Beijing University of Chinese Medicine
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3
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Lipner SR. Pharmacotherapy for onychomycosis: new and emerging treatments. Expert Opin Pharmacother 2019; 20:725-735. [DOI: 10.1080/14656566.2019.1571039] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Shari R. Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, NY, USA
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4
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Lipner SR, Scher RK. Onychomycosis: Treatment and prevention of recurrence. J Am Acad Dermatol 2018; 80:853-867. [PMID: 29959962 DOI: 10.1016/j.jaad.2018.05.1260] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/07/2018] [Accepted: 05/10/2018] [Indexed: 11/16/2022]
Abstract
Onychomycosis is a fungal nail infection caused by dermatophytes, nondermatophytes, and yeast, and is the most common nail disorder seen in clinical practice. It is an important problem because it may cause local pain, paresthesias, difficulties performing activities of daily living, and impair social interactions. The epidemiology, risk factors, and clinical presentation and diagnosis of onychomycosis were discussed in the first article in this continuing medical education series. In this article, we review the prognosis and response to onychomycosis treatment, medications for onychomycosis that have been approved by the US Food and Drug Administration, and off-label therapies and devices. Methods to prevent onychomycosis recurrences and emerging therapies are also described.
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Affiliation(s)
- Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, New York.
| | - Richard K Scher
- Department of Dermatology, Weill Cornell Medicine, New York, New York
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5
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Cyclodextrin-water soluble polymer ternary complexes enhance the solubility and dissolution behaviour of poorly soluble drugs. Case example: Itraconazole. Eur J Pharm Biopharm 2013. [DOI: 10.1016/j.ejpb.2012.11.003] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Uchida K, Shimogawara K, Yamaguchi H. Correlation of in vitro activity and in vivo efficacy of itraconazole intravenous and oral solubilized formulations by testing Candida strains with various itraconazole susceptibilities in a murine invasive infection. J Antimicrob Chemother 2010; 66:626-34. [PMID: 21172782 DOI: 10.1093/jac/dkq475] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To examine whether in vitro antifungal susceptibility test results correlate with in vivo efficacy of two cyclodextrin-solubilized itraconazole formulations (intravenous and oral) against Candida in a murine model of invasive infection. METHODS A selected set of 12 Candida spp. strains with various itraconazole susceptibilities were tested. We studied the efficacy of intravenous and oral itraconazole administered once daily at dosages of 0.63, 2.5, 10 and 40 mg/kg body weight in mice lethally infected with each tested strain. Survival of mice in each treated group was monitored daily until the death of all control mice and compared between groups. RESULTS Survival of mice infected with 9 of 12 Candida strains with itraconazole MICs of ≤0.016-2.0 mg/L was significantly prolonged by treatment with intravenous itraconazole at dosages of 2.5 or 10 mg/kg and above. In contrast, the other three strains resistant to 8 mg/L itraconazole in vitro were refractory to the therapy, even at the highest itraconazole dosage (40 mg/kg). Closely similar in vivo data were obtained with the oral itraconazole therapy. The effective doses of the two itraconazole formulations increased with increasing itraconazole MICs for the infecting strains. CONCLUSIONS The in vivo efficacy of intravenous and oral itraconazole correlated with the in vitro susceptibility data.
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Affiliation(s)
- Katsuhisa Uchida
- Teikyo University Institute of Medical Mycology, Hachioji, Tokyo 192-0395, Japan
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8
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Wang Z, Kim S, Quinney SK, Zhou J, Li L. Non-compartment model to compartment model pharmacokinetics transformation meta-analysis--a multivariate nonlinear mixed model. BMC SYSTEMS BIOLOGY 2010; 4 Suppl 1:S8. [PMID: 20522258 PMCID: PMC2880414 DOI: 10.1186/1752-0509-4-s1-s8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND To fulfill the model based drug development, the very first step is usually a model establishment from published literatures. Pharmacokinetics model is the central piece of model based drug development. This paper proposed an important approach to transform published non-compartment model pharmacokinetics (PK) parameters into compartment model PK parameters. This meta-analysis was performed with a multivariate nonlinear mixed model. A conditional first-order linearization approach was developed for statistical estimation and inference. RESULTS Using MDZ as an example, we showed that this approach successfully transformed 6 non-compartment model PK parameters from 10 publications into 5 compartment model PK parameters. In simulation studies, we showed that this multivariate nonlinear mixed model had little relative bias (<1%) in estimating compartment model PK parameters if all non-compartment PK parameters were reported in every study. If there missing non-compartment PK parameters existed in some published literatures, the relative bias of compartment model PK parameter was still small (<3%). The 95% coverage probabilities of these PK parameter estimates were above 85%. CONCLUSIONS This non-compartment model PK parameter transformation into compartment model meta-analysis approach possesses valid statistical inference. It can be routinely used for model based drug development.
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Affiliation(s)
- Zhiping Wang
- Division of Biostatistics, Department of Medicine, School of Medicine, Indiana University, Indianapolis, IN 46032, USA.
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9
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Shemer A, Nathansohn N, Kaplan B, Trau H. Itraconazole versus ketoconazole in the treatment of tinea versicolor. J DERMATOL TREAT 2009. [DOI: 10.3109/09546639909055906] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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10
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Yu M, Kim S, Wang Z, Hall S, Li L. A Bayesian meta-analysis on published sample mean and variance pharmacokinetic data with application to drug-drug interaction prediction. J Biopharm Stat 2009; 18:1063-83. [PMID: 18991108 DOI: 10.1080/10543400802369004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In drug-drug interaction (DDI) research, a two-drug interaction is usually predicted by individual drug pharmacokinetics (PK). Although subject-specific drug concentration data from clinical PK studies on inhibitor or inducer and substrate PK are not usually published, sample mean plasma drug concentrations and their standard deviations have been routinely reported. Hence there is a great need for meta-analysis and DDI prediction using such summarized PK data. In this study, an innovative DDI prediction method based on a three-level hierarchical Bayesian meta-analysis model is developed. The three levels model sample means and variances, between-study variances, and prior distributions. Through a ketoconazle-midazolam example and simulations, we demonstrate that our meta-analysis model can not only estimate PK parameters with small bias but also recover their between-study and between-subject variances well. More importantly, the posterior distributions of PK parameters and their variance components allow us to predict DDI at both population-average and study-specific levels. We are also able to predict the DDI between-subject/study variance. These statistical predictions have never been investigated in DDI research. Our simulation studies show that our meta-analysis approach has small bias in PK parameter estimates and DDI predictions. Sensitivity analysis was conducted to investigate the influences of interaction PK parameters, such as the inhibition constant Ki, on the DDI prediction.
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Affiliation(s)
- Menggang Yu
- Division of Biostatistics, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana 46023, USA.
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11
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Zhou J, Qin Z, Quinney SK, Kim S, Wang Z, Yu M, Chien JY, Lucksiri A, Hall SD, Li L. A new probabilistic rule for drug-dug interaction prediction. J Pharmacokinet Pharmacodyn 2009; 36:1-18. [PMID: 19156505 DOI: 10.1007/s10928-008-9107-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2007] [Accepted: 12/03/2008] [Indexed: 11/29/2022]
Abstract
An innovative probabilistic rule is proposed to predict the clinical significance or clinical insignificance of DDI. This rule is coupled with a hierarchical Bayesian model approach to summarize substrate/inhibitor's PK models from multiple published resources. This approach incorporates between-subject and between-study variances into DDI prediction. Hence, it can predict both population-average and subject-specific AUCR. The clinically significant DDI, weak DDI, and clinically insignificant inhibitions are decided by the probabilities of predicted AUCR falling into three intervals, (-infinity, 1.25), (1.25, 2), and (2, infinity). The main advantage of this probabilistic rule to predict clinical significance of DDI over the deterministic rule is that the probabilistic rule considers the sample variability, and the decision is independent of sampling variation; while deterministic rule based decision will vary from sample to sample. The probabilistic rule proposed in this paper is best suited for the situation when in vivo PK studies and models are available for both the inhibitor and substrate. An early decision on clinically significant or clinically insignificant inhibition can avoid additional DDI studies. Ketoconazole and midazolam are used as an interaction pair to illustrate our idea. AUCR predictions incorporating between-subject variability always have greater variances than population-average AUCR predictions. A clinically insignificant AUCR at population-average level is not necessarily true when considering between-subject variability. Additional simulation studies suggest that predicted AUCRs highly depend on the interaction constant K(i) and dose combinations.
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Affiliation(s)
- Jihao Zhou
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
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12
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Buchanan CM, Buchanan NL, Edgar KJ, Klein S, Little JL, Ramsey MG, Ruble KM, Wacher VJ, Wempe MF. Pharmacokinetics of itraconazole after intravenous and oral dosing of itraconazole‐cyclodextrin formulations. J Pharm Sci 2007; 96:3100-16. [PMID: 17712849 DOI: 10.1002/jps.20878] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The current research evaluated and compared the efficacy of hydroxybutenyl-beta-cyclodextrin (HBenBCD) and hydroxypropyl-beta-cyclodextrin (HPBCD) as enhancers of itraconazole solubility and oral bioavailability. At 10 wt% cyclodextrin, 17-fold and 3.8-fold increases in itraconazole aqueous solubility were observed in the presence of HBenBCD and HPBCD, respectively. Significant differences in the dissolution of itraconazole in the presence of these two cyclodextrins were also observed. Itraconazole pharmacokinetics is known to exhibit a significant food effect. However, testing in biorelevant media indicated that no food effects should be observed after oral administration of itraconazole:HBenBCD complexes. Formulations of itraconazole with HBenBCD were prepared and these complexes, along with the commercial forms of itraconazole with and without HPBCD (Sporanox) were administered to male Sprague-Dawley rats by oral and intravenous routes. Intravenous administration of itraconazole formulated with HBenBCD resulted in a higher AUC relative to Sporanox. When administered as oral solutions, the itraconazole:HBenBCD formulation provided higher oral bioavailability than the Sporanox oral solution. When administered as solid formulations, the itraconazole:HBenBCD solid formulation provided a 2x increase in oral bioavailability relative to the Sporanox solid formulation. No food effects were observed with the itraconazole:HBenBCD solid dosage forms. Drug/metabolite ratios were dependent upon the dosage form.
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Affiliation(s)
- Charles M Buchanan
- Eastman Chemical Company, Research Laboratories, PO Box 1972, Kingsport, Tennessee 37662, USA.
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13
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Li L, Yu M, Chin R, Lucksiri A, Flockhart DA, Hall SD. Drug-drug interaction prediction: a Bayesian meta-analysis approach. Stat Med 2007; 26:3700-21. [PMID: 17357990 DOI: 10.1002/sim.2837] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In drug-drug interaction (DDI) research, a two drug interaction is usually predicted by individual drug pharmacokinetics (PK). Although subject-specific drug concentration data from clinical PK studies on inhibitor/inducer or substrate's PK are not usually published, sample mean plasma drug concentrations and their standard deviations have been routinely reported. In this paper, an innovative DDI prediction method based on a three-level hierarchical Bayesian meta-analysis model is developed. The first level model is a study-specific sample mean model; the second level model is a random effect model connecting different PK studies; and all priors of PK parameters are specified in the third level model. A Monte Carlo Markov chain (MCMC) PK parameter estimation procedure is developed, and DDI prediction for a future study is conducted based on the PK models of two drugs and posterior distributions of the PK parameters. The performance of Bayesian meta-analysis in DDI prediction is demonstrated through a ketoconazole-midazolam example. The biases of DDI prediction are evaluated through statistical simulation studies. The DDI marker, ratio of area under the concentration curves, is predicted with little bias (less than 5 per cent), and its 90 per cent credible interval coverage rate is close to the nominal level. Sensitivity analysis is conducted to justify prior distribution selections.
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Affiliation(s)
- Lang Li
- Division of Biostatistics, Department of Medicine, Indiana University, IN, USA.
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Frosco M, Barrett JF. Importance of antifungal drug-resistance: clinical significance and need for novel therapy. Expert Opin Investig Drugs 2005; 7:175-98. [PMID: 15991951 DOI: 10.1517/13543784.7.2.175] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The incidence of fungal infections has increased dramatically over the past few decades due to the increase in the members of the population susceptible to such infections. This population includes individuals undergoing chemotherapy for cancer, those enduring long-term treatment with antibacterial agents, those receiving immunosuppressive drugs following transplantations, or those immunosuppressed due to diseases, such as AIDS, or malignancies. Newer antifungal agents, namely the triazoles, have aided in both the treatment of fungal infections and in the prevention of disease in susceptible individuals. However, resistance to the azoles, as well as to the polyenes, has resulted in clinical failures. Only a few potential antifungal targets have been exploited to date and there is a critical need for the discovery and development of novel antifungal agents that will result in improved therapy in this ever-expanding patient population. An increased intensity in the study of fungal pathogens at the molecular level holds the key to such advances.
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Affiliation(s)
- M Frosco
- Bristol-Myers Squibb Pharmaceutical Research Institute, Wallingford, CT 06492, USA
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15
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Abstract
BACKGROUND Treatment of white piedra remains an area of therapeutic frustration. Several topical and systemic antifungal agents have failed to eradicate the fungus and prevent disease recurrence. Itraconazole is a safe and effective systemic antifungal agent for various superficial and deep mycotic infections of the skin and hair. In vitro studies have shown significant antifungal activity against Trichosporon beigelii. OBJECTIVE Our study was intended to assess the efficacy of itraconazole in the treatment of uncomplicated white piedra affecting the scalp hair. METHODS The study was designed as an open trial involving 12 female patients with white piedra of the scalp hair. They were administered oral itraconazole 100 mg once daily until culture negativity was achieved; they were then followed up for 3 months. RESULTS Eleven patients (91.67%) showed disease remission after 8 weeks of treatment. One patient (8.33%) showed no improvement, and the disease recurred in 2 patients (16.67%) after completion of therapy. No significant side effects were noted.
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Affiliation(s)
- Sujay Khandpur
- Department of Dermatology and S.T.D., Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi, India.
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Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Centre, Sehgal Nursing Home, Panchwati, Azadpur, Delhi, India.
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Pinchbeck LR, Hillier A, Kowalski JJ, Kwochka KW. Comparison of pulse administration versus once daily administration of itraconazole for the treatment of Malassezia pachydermatis dermatitis and otitis in dogs. J Am Vet Med Assoc 2002; 220:1807-12. [PMID: 12092953 DOI: 10.2460/javma.2002.220.1807] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED OBJECTIVE To compare clinical efficacy of pulse administration with itraconazole versus once daily administration for the treatment of cutaneous and otic M pachydermatis infection in dogs. DESIGN Randomized controlled trial. ANIMALS 20 dogs. PROCEDURE Dogs were treated with itraconazole orally (n = 10/group), using a pulse administration regimen (5 mg/kg [2.3 mg/lb], PO, q 24 h for 2 consecutive days per week for 3 weeks) or once daily administration (5 mg/kg, PO, q 24 h for 21 days). No other treatment was permitted. On days 0 and 21, clinical severity of cutaneous and otic disease was assessed, and samples were collected for cytologic examination and yeast culture. Cytology (sum of the mean number of yeast organisms per oil immersion field for affected sites) and culture (mean of the score for extent of yeast growth for samples from affected sites) scores were calculated. RESULTS For dogs in both treatment groups, clinical severity of cutaneous and otic disease was significantly decreased by day 21, but decrease in severity was not significantly different between groups. Similarly, skin cytology, skin culture, and ear culture scores were significantly decreased on day 21, compared with day 0, for both groups, but decreases were not significantly different between groups except that dogs in the pulse administration group had a significantly greater decrease in ear culture scores than did dogs in the daily administration group. However, when cytology scores only for ear samples were analyzed, day 21 score was not significantly decreased, compared with day 0 score, for either group. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that both pulse administration and once daily administration of itraconazole were efficacious in the treatment of M pachydermatis cutaneous infection in dogs. However, adjunctive treatment may be needed in dogs with M pachydermatis otitis.
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Affiliation(s)
- Lauren R Pinchbeck
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus 43210, USA
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18
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Abstract
OBJECTIVE To review the pharmacology, mycology, chemistry, pharmacokinetics, efficacy, safety, tolerability, dosage, administration, and economic issues of intravenous itraconazole. DATA SOURCES A MEDLINE search from 1978 to June 2000 of the English-language literature and an extensive review of meeting abstracts was conducted. Due to the paucity of published information concerning the pharmacokinetics, efficacy, and safety of the intravenous formulation of intravenous itraconazole, additional information was obtained from the manufacturer. DATA EXTRACTION Data from in vitro and preclinical studies, as well as Phase II and III clinical trials, were included. DATA SYNTHESIS The triazole antifungal agent itraconazole is available in a cyclodextrin-based intravenous formulation. Intravenous itraconazole is indicated for the treatment of pulmonary and extrapulmonary blastomycosis; histoplasmosis, including chronic cavitary pulmonary disease and disseminated, nonmeningeal histoplasmosis; and pulmonary and extrapulmonary aspergillosis in patients who are intolerant of or who are refractory to amphotericin B. This formulation provides quicker and more consistent therapeutic concentrations than the oral formulations. Clinical data comparing the efficacy of intravenous itraconazole with that of amphotericin B are lacking. CONCLUSIONS Intravenous itraconazole offers a less toxic alternative for patients with pulmonary and extrapulmonary blastomycosis, histoplasmosis, and aspergillosis who cannot receive oral medications or who are intolerant of or refractory to amphotericin B.
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Affiliation(s)
- D Slain
- Department of Clinical Pharmacy, School of Pharmacy, West Virginia University, Morgantown, WV, USA
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19
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Abstract
Systemic antifungal therapy for superficial mycoses has advanced greatly since the introduction of griseofulvin in 1958. The discovery of the azole antifungal compounds, ketoconazole, itraconazole, and fluconazole, allowed for a broader spectrum of treatment and a shorter treatment duration. Terbinafine, through a unique mechanism of action, has a fungicidal power not seen previously in the other antifungals. It is important to use our knowledge of the pharmacology in combination with clinical experience and cost of therapy in order to select the proper drug. The search to identify new oral antifungal agents should continue, since none of the five currently used drugs fulfill the criteria of the "ideal" antifungal.
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Affiliation(s)
- M Moossavi
- Department of Dermatology, Columbia University College of Physicians and Surgeons, New York City, New York, USA
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Auclair B, Berning SE, Huitt GA, Peloquin CA. Potential interaction between itraconazole and clarithromycin. Pharmacotherapy 1999; 19:1439-44. [PMID: 10600094 DOI: 10.1592/phco.19.18.1439.30907] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Three patients negative for human immunodeficiency virus infection were admitted for pulmonary Mycobacterium avium complex (MAC) and aspergillosis infections. They were treated with different drug combinations, but all regimens included clarithromycin for MAC and itraconazole for aspergillosis. All patients experienced an increase in clarithromycin concentrations and clarithromycin: 14-OH-clarithromycin ratio compared with expected range values. They had no clinical side effects. The time course suggested a possible interaction between clarithromycin and itraconazole, presumably through itraconazole's effects on cytochrome P450 3A4 activity. A bidirectional interaction cannot be ruled out. The data suggest that, when necessary, these two drugs can be administered together safely. Further investigation is necessary to determine the extent and clinical consequences of coadministration in humans.
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Affiliation(s)
- B Auclair
- Department of Medicine, National Jewish Center for Immunology and Respiratory Medicine, University of Colorado, Denver 80206, USA
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21
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Del Rosso JQ, Gupta AK. The use of intermittent itraconazole therapy for superficial mycotic infections: a review and update on the 'one week' approach. Int J Dermatol 1999; 38 Suppl 2:28-39. [PMID: 10515527 DOI: 10.1046/j.1365-4362.1999.00011.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- J Q Del Rosso
- Department of Dermatology, University of Nevada School of Medicine, Las Vegas, USA
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22
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Ramos-e-Silva M, Marques SA, Gontijo B, Zaitz C, Campbell I, Veloso ST. Efficacy and safety of itraconazole pulse therapy: Brazilian multicentric study on toenail onychomycosis caused by dermatophytes. J Eur Acad Dermatol Venereol 1998. [DOI: 10.1111/j.1468-3083.1998.tb00762.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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23
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Zhou H, Goldman M, Wu J, Woestenborghs R, Hassell AE, Lee P, Baruch A, Pesco-Koplowitz L, Borum J, Wheat LJ. A pharmacokinetic study of intravenous itraconazole followed by oral administration of itraconazole capsules in patients with advanced human immunodeficiency virus infection. J Clin Pharmacol 1998; 38:593-602. [PMID: 9702843 DOI: 10.1002/j.1552-4604.1998.tb04465.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
A randomized, open-label, comparative study was conducted in 30 male patients with moderately advanced human immunodeficiency virus (HIV) infection to examine the pharmacokinetics of an investigational intravenous preparation of itraconazole compared with pharmacokinetics after administration of itraconazole capsules. The study also assessed whether adequate plasma concentrations of itraconazole could be rapidly achieved with the intravenous formulation and then maintained after cessation of intravenous therapy with itraconazole capsules. All patients received 200 mg intravenous itraconazole as a 1-hour infusion in 40% hydroxypropyl-beta-cyclodextrin (HP-beta-CD) vehicle twice daily for 2 days, and then 200 mg intravenously once daily for 5 days. Patients then received itraconazole capsules, either 200 mg twice daily or 200 mg once daily for 28 days. Steady-state plasma concentrations of itraconazole were reached by day 3 with intravenous infusion, a much shorter time than observed with administration of itraconazole capsules. Steady-state concentrations of itraconazole and hydroxyitraconazole were effectively maintained during the rest of the intravenous infusions of itraconazole. Oral follow-up with administration of 200-mg capsules once daily could not maintain the plasma concentrations of itraconazole and hydroxyitraconazole obtained at the end of the intravenous treatment, whereas twice-daily oral administration maintained or increased these concentrations. Mean plasma concentrations of itraconazole and hydroxyitraconazole on day 7 were similar to those on day 36 in the twice-daily group. Mean renal clearance was comparable to mean total body clearance, and approximately 93% to 101% of the HP-beta-CD was excreted unchanged in urine within 12 hours of administration. The HP-beta-CD was essentially eliminated through the kidney, and little accumulation in the body was observed in this patient population. Adverse events during the intravenous phase were most commonly associated with intravenous administration. Intravenous infusion of itraconazole for 7 days followed by administration of itraconazole capsules twice daily for 28 days is an effective dose regimen in patients with advanced HIV infection.
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Affiliation(s)
- H Zhou
- Novartis Pharmaceuticals, East Hanover, New Jersey, USA
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24
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Barone JA, Moskovitz BL, Guarnieri J, Hassell AE, Colaizzi JL, Bierman RH, Jessen L. Enhanced bioavailability of itraconazole in hydroxypropyl-beta-cyclodextrin solution versus capsules in healthy volunteers. Antimicrob Agents Chemother 1998; 42:1862-5. [PMID: 9661037 PMCID: PMC105699 DOI: 10.1128/aac.42.7.1862] [Citation(s) in RCA: 131] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/1997] [Accepted: 04/06/1998] [Indexed: 02/08/2023] Open
Abstract
The bioavailabilities and bioequivalences of single 200-mg doses of itraconazole solution and two capsule formulations were evaluated in a crossover study of 30 male volunteers. The two capsule formulations were bioequivalent. The bioavailabilities of the solutions itraconazole and hydroxyitraconazole were 30 to 33% and 35 to 37% greater, respectively, than those of either capsule. However, the maximum concentrations of the drug in plasma (Cmax), the times to Cmax, and the terminal half-lives were comparable for all three formulations. These data indicate that the bioavailabilities of itraconazole and hydroxyitraconazole are enhanced when administered as an oral solution instead of capsules.
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Affiliation(s)
- J A Barone
- College of Pharmacy, Rutgers-State University of New Jersey, Piscataway 08855-0789, USA.
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Graybill JR, Vazquez J, Darouiche RO, Morhart R, Greenspan D, Tuazon C, Wheat LJ, Carey J, Leviton I, Hewitt RG, MacGregor RR, Valenti W, Restrepo M, Moskovitz BL. Randomized trial of itraconazole oral solution for oropharyngeal candidiasis in HIV/AIDS patients. Am J Med 1998; 104:33-9. [PMID: 9528717 DOI: 10.1016/s0002-9343(97)00307-0] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Oropharyngeal candidasis (thrush) is the most common opportunistic infection in individuals who are positive for the human immunodeficiency virus (HIV) and those who have progressed to AIDS. Itraconazole has a broad in vitro spectrum of activity, including a wide variety of Candida species. Our study determined the relative efficacy of a new oral solution formulation of itraconazole and fluconazole tablets in the treatment of oropharyngeal candidiasis. PATIENTS AND METHODS This was a prospective randomized, third-party-blind, multicenter trial conducted at 12 centers in the United States. One hundred seventy-nine HIV-positive patients with mycologically documented oropharyngeal candidiasis were treated with itraconazole oral solution 200 mg/ day for 7 or 14 days, or fluconazole tablets 100 mg/day for 14 days. Severity of disease was scored clinically before treatment and at clinical evaluations on days 3, 7, 14, 21, 35, and 42. Semi-quantitative cultures of mouth washings were also obtained on these days. RESULTS Both 14-day and 7-day regimens of itraconazole oral solution were equivalent to fluconazole for most efficacy parameters. The clinical response rate was 97% after 14 days of itraconazole and 87% after 14 days of fluconazole. Itraconazole oral solution given for 7 days was also equivalent to fluconazole treatment for 14 days. Approximately one half of patients in all three groups relapsed by 1 month after completion of treatment. There were few adverse reactions to either drug. CONCLUSION Itraconazole oral solution is well tolerated and offers an alternative at least as effective as fluconazole in the treatment of oropharyngeal candidiasis.
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Affiliation(s)
- J R Graybill
- Audie Murphy VA Hospital, San Antonio, Texas 78284, USA
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26
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Murray PA, Koletar SL, Mallegol I, Wu J, Moskovitz BL. Itraconazole oral solution versus clotrimazole troches for the treatment of oropharyngeal candidiasis in immunocompromised patients. Clin Ther 1997; 19:471-80. [PMID: 9220211 DOI: 10.1016/s0149-2918(97)80131-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This multicenter, open-label, third-party-masked trial compared the efficacy and safety of itraconazole oral solution (200 mg once daily) and clotrimazole troches (10 mg five times daily) in a population of immunocompromised subjects composed primarily of patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). Patients were treated for 14 days; patients who exhibited a clinical response were followed up for an additional month to document the occurrence of relapse. Efficacy was judged by changes from baseline in symptoms of oropharyngeal candidiasis (erythema, soreness/burning), extent of oral lesions, and the presence/absence of Candida species on fungal culture. A total of 162 patients were randomized, and 149 were evaluated for efficacy. The percentage of patients with negative cultures at the end of treatment was significantly greater in the itraconazole group than in the clotrimazole group (60% vs 32%, respectively). Negative culture plus clinical response was achieved in significantly more itraconazole-treated patients (53%) than clotrimazole-treated patients (30%); results were similar in the subgroup of patients with HIV/AIDS. Both drugs were well tolerated, with the most frequently reported adverse events for both agents involving the gastrointestinal system. In conclusion, systemic therapy with intraconazole oral solution is efficacious and well tolerated in immunocompromised patients, including those with HIV/AIDS, when administered once daily for 14 days for the treatment of oral candidiasis.
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Affiliation(s)
- P A Murray
- Ohio State University Medical Center, Columbus, USA
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Lange D, Pavao JH, Jacqmin P, Woestenborghs R, Ding C, Klausner M. The effect of coadministration of a cola beverage on the bioavailability of itraconazole in patients with acquired immunodeficiency syndrome. Curr Ther Res Clin Exp 1997. [DOI: 10.1016/s0011-393x(97)80016-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Kauffman CA, Carver PL. Use of azoles for systemic antifungal therapy. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 1997; 39:143-89. [PMID: 9160115 DOI: 10.1016/s1054-3589(08)60071-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- C A Kauffman
- Department of Internal Medicine, Department of Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
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Affiliation(s)
- N C Klein
- State University of New York School of Medicine, Stony Brook 11501, USA
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30
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Glasmacher A, Molitor E, Mezger J, Marklein G. Antifungal prophylaxis with itraconazole in neutropenic patients: pharmacological, microbiological and clinical aspects. Mycoses 1996; 39:249-58. [PMID: 9009641 DOI: 10.1111/j.1439-0507.1996.tb00134.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- A Glasmacher
- Medizinische Klinik und Poliklinik, Allgemeine Innere Medizin, Rheinische Friedrich-Wilhelms-Universität Bonn, Germany
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31
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Abstract
Treatment of eumycetoma, both medical and surgical, is difficult and often unsuccessful. We describe a case of maduromycosis, 18 years in duration, with significant improvement after 6 months of itraconazole therapy.
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Affiliation(s)
- B I Resnik
- Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Florida, USA
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32
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Schäfer-Korting M, Korting HC, Rittler W, Obermüller W. Influence of serum protein binding on the in vitro activity of anti-fungal agents. Infection 1995; 23:292-7. [PMID: 8557388 DOI: 10.1007/bf01716289] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Historically it has been assumed that the pharmacological effect is related to the free drug concentration. In exposing Candida albicans to itraconazole and ketoconazole serum concentration-time profiles, however, antifungal activity was not diminished despite intense albumin binding. The relevance of serum protein binding was further investigated, by in vitro susceptibility testing of C. albicans (40 clinical isolates) and Trichophyton rubrum (ten strains) against antifungal agents using microdilution tests allowing the determination of IC30- and MIC-values. The range of serum protein binding ranges from 11% with fluconazole to > 99% with itraconazole and terbinafine. The ratios of IC30- and MIC-values with and without serum protein (albumin, alpha- and gamma-globulin, human plasma) were related to the loss of susceptibility expected according to the free-drug hypothesis. A difference in the albumin effect with the test strains was not observed. With most antifungals including terbinafine, the activity declined as expected. IC30- and MIC-ratios for miconazole were 7 and 13 (observed) vs. 12-20 (expected), for fluconazole 1.5 and 3.5 vs. 1.1, for amphotericin B 10 vs. 11-20, for griseofulvin 3.6 vs. 4, and for terbinafine 61 vs. 100. Itraconazole activity, however, was not diminished by albumin (expected ratio 286), and ketoconazole effects decreased less than expected (ratio 5-15, expected about 100). alpha-globulin, but not gamma-globulin induced a major loss in anti-Candida activity of itraconazole and ketoconazole, which is paralleled by a decline in ketoconazole (but not itraconazole) activity due to plasma. With the other antifungals (except for ciclopiroxolamine) IC30-values for C. albicans increased, too. Due to the complete inhibition of T. rubrum growth by gamma-globulin, this species proved unsuitable for studying the gamma-globulin effects. The present study demonstrates that the effects of intense protein binding on drug activity are only partly predictable from binding studies in vitro.
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33
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Egger T, Gratwohl A, Tichelli A, Uhr M, Stebler Gysi C, Passweg J, Pless M, Wernli M, Buser U, Wuhrmann J. Comparison of fluconazole with oral polyenes in the prevention of fungal infections in neutropenic patients. A prospective, randomized, single-center study. Support Care Cancer 1995; 3:139-46. [PMID: 7773582 DOI: 10.1007/bf00365855] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The goal of this prospective randomized single-center study was the comparison of safety and efficacy of high-dose oral/intravenous fluconazole (400 mg daily) (group A) with oral nystatin plus miconazole inhalations (group B) in the prevention of fungal infections on a hemato-oncological isolation Ward. Of 157 patients admitted to the isolation ward during the study period only 90 (57%) were eligible for randomization; 22 (14%) had a fungal infection at admission. Of the 90 randomized patients, 89 were evaluable, 43 in group A and 46 in group B. The age, sex, diagnosis, planned therapy and risk factors for fungal infections at admission as well as the duration of neutropenia were in the same proportions in both groups. Oral thrush and mucocutaneous candidiasis were prevented in all patients of both groups, and 29 patients (32%: 17 in group A, 12 in group B) were discharged after successful prophylaxis (NS). Empiric amphotericin B was given according to predetermined criteria to 45 patients (51%: 23 group A, 22 group B; NS). Fluconazole significantly delayed the time before the start of intravenous amphotericin B. It was begun after a median of 10 days (0-45 days, range) of neutropenia below 0.5 x 10(9) granulocytes/l in group A and 7.5 days (0-26, range) in group B (P < 0.05). The duration of successful prophylaxis was significantly longer in group A (26 days median) than in group B (21 days, median) (P < 0.05). Systematic fungal infection was documented in 3 patients (1 group A, 2 group B; NS).
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Affiliation(s)
- T Egger
- Department of Internal Medicine, University Hospital, Basel, Switzerland
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34
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Abstract
The recent introduction of a new generation of antifungal drugs promises to alter significantly therapy for both systemic and superficial mycoses, in particular, onychomycosis. This article presents an in-depth review of the azoles (the triazoles itraconazole and fluconazole), the allylamines (naftifine and terbinafine), and the morpholine derivative amorolfine.
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Affiliation(s)
- A K Gupta
- Department of Medicine, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
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35
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Zuckerman JM, Tunkel AR. Itraconazole: A New Triazole Antifungal Agent. Infect Control Hosp Epidemiol 1994. [DOI: 10.2307/30145593] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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36
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Kintzel PE, Trausch DE, Copfer AL. Otic administration of amphotericin B 0.25% in sterile water. Ann Pharmacother 1994; 28:333-5. [PMID: 8193421 DOI: 10.1177/106002809402800308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To report otic administration of parenteral amphotericin B 0.25% in sterile water. CASE SUMMARY A 44-year-old HIV+ man was diagnosed with otitis externa. The patient's past medical history was remarkable for positive Coccidioides immitis serology for more than five months, essential hypertension, and Barrett's esophagitis. Culture results from an ear swab revealed 4+ Aspergillus fumigatus and 3+ Staphylococcus, coagulase negative. Antiinfective therapy for the otitis externa included oral and topical antibacterial and antifungal medications. Amphotericin B 0.25% in sterile water was prepared by the pharmacy for topical otic administration. The otic amphotericin B was dispensed with instructions to refrigerate and assigned a one-week expiration date. The prescription called for instillation of 1-2 drops in each ear three times a day. The patient's signs and symptoms of otitis externa resolved during several weeks of antiinfective therapy. Topical administration of amphotericin B 0.25% in sterile water was not associated with any local adverse effects in this patient. DISCUSSION The rationale for use of the parenteral amphotericin B formulation to prepare an otic dosage form, and the rationale for the specific concentration and expiration date chosen are discussed. CONCLUSIONS This patient tolerated topical otic administration of amphotericin B 0.25% in sterile water when administered three times daily.
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Affiliation(s)
- P E Kintzel
- Inpatient Pharmacy, University Medical Center, University of Arizona Health Sciences Center, Tucson 85724
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37
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Honig PK, Wortham DC, Hull R, Zamani K, Smith JE, Cantilena LR. Itraconazole affects single-dose terfenadine pharmacokinetics and cardiac repolarization pharmacodynamics. J Clin Pharmacol 1993; 33:1201-6. [PMID: 8126255 DOI: 10.1002/j.1552-4604.1993.tb03920.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The object of this study was to examine prospectively the effects of itraconazole on the pharmacokinetics and electrocardiographic repolarization pharmacodynamics (QTc intervals) of single-dose terfenadine in six healthy volunteers. It was designed as a prospective cohort study with each subject serving as his own control, set in an outpatient cardiology clinic. The participants were six healthy volunteers (two men, four women; ages 24-35) not taking any prescription or over-the-counter medications. Single-dose terfenadine administration (120 mg) was accompanied by pharmacokinetic profiles and serial determination of the QTc interval for 12 hours. The subjects then began daily oral itraconazole (200 mg each morning) for 7 days. Repeat pharmacokinetic and pharmacodynamic determinations were made after administration of a second dose (120 mg) of terfenadine while receiving itraconazole. The main outcome measures were terfenadine and acid metabolite serum concentrations; corrected QT intervals as determined by 12-lead electrocardiogram (ECG); and presence or absence of late potentials as determined by signal-averaged ECGs over 150 cardiac cycles. There were significant changes in the pharmacokinetic parameters of acid metabolite after treatment with itraconazole. All subjects had detectable levels of unmetabolized terfenadine after addition of itraconazole, which was associated with QT prolongation. There was no evidence of late depolarization as manifested by an increase in QRS duration found using signal-averaged electrocardiography. Itraconazole influences the metabolism of terfenadine in normal volunteers and results in the accumulation of unmetabolized parent drug associated with altered cardiac repolarization. This drug combination should be avoided.
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Affiliation(s)
- P K Honig
- Division of Clinical Pharmacology, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814-4799
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38
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Abstract
This study evaluated the efficacy of itraconazole, a broad-spectrum triazole antifungal drug, which has previously been demonstrated to exhibit activity against Candida albicans C. krusei, C. glabrata, Aspergillus, Histoplasma and Blastomyces as a potential treatment for cryptococcosis. The susceptibility of 62 strains of Cryptococcus neoformans was tested in vitro. All strains were inhibited by itraconazole 0.1 microgram ml-1. Itraconazole was fungicidal after replenishment at a concentration that can easily be achieved in vivo. When mice were infected intracerebrally with Cr. neoformans all control animals died, whereas only 11% and 26% of itraconazole-treated animals died. In a group treated with ketoconazole, 67% died. After intravenous infection, 30% of control guinea pigs died, while other animals treated with itraconazole (5 or 10 mg kg-1) or amphotericin B (1.25 or 2.5 mg kg-1) all survived. Itraconazole 10 mg kg-1 produced the best results, with brain and meningeal cultures becoming negative in 55-64% of animals. In addition, intravenously infected guinea pigs received oral or intraperitoneal treatment with itraconazole or fluconazole (each 5 or 10 mg kg-1) as monotherapy or in combination. Although both treatments were active, itraconazole 10 mg kg-1 was the most effective. In two out of six immunosuppressed guinea pigs infected with Cr. neoformans oral itraconazole was effective, resulting in negative brain and meningeal cultures. A combination of itraconazole (5 mg kg-1) with flucytosine or amphotericin B was more efficacious than monotherapy. Therefore, itraconazole is a potentially effective therapy for the treatment of Cryptococcus infection when administered either alone or in combination with other antifungal drugs. It may also be effective in immunocompromised patients.
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Affiliation(s)
- J Van Cutsem
- Department of Bacteriology and Mycology, Janssen Research Foundation, Beerse, Belgium
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39
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Abstract
OBJECTIVE To review the role of itraconazole as oral therapy for the major infections caused by Aspergillus spp.: allergic bronchopulmonary aspergillosis, aspergilloma, and invasive aspergillosis. DATA SOURCES A MEDLINE search of articles published in the English language between 1986 and 1993 was used to identify relevant citations, including review articles. In addition, a search of the published abstracts of the past two Interscience Conferences on Antimicrobial Agents and Chemotherapy (ICAAC) was performed. STUDY SELECTION Clinical trials that evaluated itraconazole therapy in either allergic bronchopulmonary aspergillosis, aspergilloma, or invasive aspergillosis were critically reviewed. Trials were evaluated based upon entry criteria for the diagnosis of each type of aspergillosis, risk factors for the development of aspergillosis (neutropenia, transplant recipient, hematologic malignancy), prior antifungal chemotherapy, and dose and duration of itraconazole therapy. DATA SYNTHESIS Overall, the clinical trials of itraconazole therapy for aspergillosis are limited and of variable quality. In the treatment of allergic bronchopulmonary aspergillosis, itraconazole has been reported to prompt a reduction in corticosteroid dosage in selected patients. There have been no controlled trials of itraconazole as treatment for aspergilloma, but data from several open-label trials suggest that this agent may be of clinical benefit in aspergilloma, primarily as an alternative to surgery. The use of itraconazole for invasive aspergillosis has been evaluated in several trials, most often in patients who were intolerant to amphotericin B treatment. Response to oral itraconazole has generally been promising. CONCLUSIONS Although itraconazole offers promise for oral therapy against infections caused by Aspergillus spp., it should not presently be regarded as primary therapy for any of these diseases. Amphotericin B, in doses ranging from 1 to 1.5 mg/kg to a total dose of 1.5-4.0 g, should remain the treatment of choice in both aspergilloma and invasive aspergillosis. Itraconazole use should be restricted to patients who experience severe toxicity with amphotericin B therapy. Corticosteroids continue to be first-line therapy for allergic bronchopulmonary aspergillosis, with the use of itraconazole reserved for those patients who would benefit from a reduction in corticosteroid dose.
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Affiliation(s)
- T S Jennings
- Pharmacy Service, Audie L. Murphy Memorial Veterans Hospital, San Antonio, TX 78284
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40
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Barone JA, Koh JG, Bierman RH, Colaizzi JL, Swanson KA, Gaffar MC, Moskovitz BL, Mechlinski W, Van de Velde V. Food interaction and steady-state pharmacokinetics of itraconazole capsules in healthy male volunteers. Antimicrob Agents Chemother 1993; 37:778-84. [PMID: 8388198 PMCID: PMC187759 DOI: 10.1128/aac.37.4.778] [Citation(s) in RCA: 173] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The influence of food on itraconazole pharmacokinetics was evaluated for 27 healthy male volunteers in a single-dose (200 mg) crossover study with capsules containing itraconazole-coated sugar spheres. This study was followed by a study of the steady-state pharmacokinetics for the same subjects with 15 days of administration of itraconazole at 200 mg every 12 h. Concentrations of itraconazole and hydroxyitraconazole, the active main metabolite, were measured in plasma by high-performance liquid chromatography. The results of the food interaction segment showed that a meal significantly enhances the amount of itraconazole absorbed. The mean maximum concentration in plasma of unmetabolized itraconazole after fasting (140 ng/ml) was about 59% that after the standard meal (239 ng/ml). The rate of elimination was not affected (terminal half-life, approximately 21 h). The mean maximum concentration in plasma of hydroxyitraconazole after fasting was about 72% the postmeal concentration (287 and 397 ng/ml, respectively). The terminal half-life of hydroxyitraconazole was approximately 12 h. Steady-state concentrations of itraconazole and hydroxyitraconazole were reached after 14 or 15 days of daily dosing. The average steady-state concentrations were approximately 1,900 ng/ml for itraconazole and 3,200 ng/ml for hydroxyitraconazole. The shape of the elimination curve for itraconazole after the last dose was indicative of saturable elimination. This conclusion was confirmed by the sevenfold increase in the area under the curve from 0 to 12 h at steady state compared with the area under the curve from 0 h to infinity after a single dose. It was furthermore confirmed by the larger-than-expected number of half-lives required to achieve steady-state plasma drug levels.
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Affiliation(s)
- J A Barone
- College of Pharmacy, Rutgers-State University of New Jersey, Piscataway 08855-0789
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