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Cheng L, You X, Wang X, Yu M, Jia C. The Role of Plasma Trough Concentration of Voriconazole and Voriconazole N-Oxide in Its Hepatotoxicity in Adult Patients. Drug Des Devel Ther 2024; 18:3617-3628. [PMID: 39156484 PMCID: PMC11330242 DOI: 10.2147/dddt.s475706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 08/09/2024] [Indexed: 08/20/2024] Open
Abstract
Objective Hepatotoxicity is an important cause of early withdrawal of voriconazole (VCZ). The role of the plasma trough concentration of VCZ (C0) in hepatotoxicity is confusion. VCZ N-oxide is the primary metabolite of VCZ in plasma. We investigated the role of VCZ C0 and plasma trough concentration of VCZ N-oxide (CN) in hepatotoxicity in adult patients. Materials and Methods This was a prospective study. VCZ C0 and CN were measured using liquid chromatography-tandem mass spectrometry. Results In total, 601 VCZ C0 and CN from 376 adult patients were included. The percentage of grade 1 or higher adverse events for ALP, ALT, AST, γ-GT, and TBIL were 35.4%, 21.0%, 30.1%, 56.2%, and 22.2%, respectively. Compared with younger adult patients, elderly patients (≥65 years) had a higher rate of grade 1 or higher adverse events of ALP. In the multivariate analysis, VCZ C0 was a risk factor for grade 1 or higher adverse events of AST in elderly patients and TBIL in younger adult patients, and VCZ CN was a risk factor for grade 1 or higher adverse events of ALT, AST, and TBIL. Results of the receiver operating characteristic curve analysis indicated that when the VCZ C0 was higher than 4.0 μg/mL, or the VCZ CN was lower than 1.7 μg/mL, the incidence of grade 1 or higher adverse events of AST and TBIL increased. Conclusion VCZ C0 and CN were associated with liver function-related adverse events. Measurement of VCZ CN should be considered for VCZ therapeutic drug monitoring.
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Affiliation(s)
- Lin Cheng
- Department of Pharmacy, the First Affiliated Hospital of Army Medical University, Chongqing, People’s Republic of China
| | - Xi You
- Department of Pharmacy, the First Affiliated Hospital of Army Medical University, Chongqing, People’s Republic of China
| | - Xiaowen Wang
- Department of Pharmacy, the First Affiliated Hospital of Army Medical University, Chongqing, People’s Republic of China
| | - Mingjie Yu
- Department of Pharmacy, the First Affiliated Hospital of Army Medical University, Chongqing, People’s Republic of China
| | - Changsheng Jia
- Department of Pharmacy, the First Affiliated Hospital of Army Medical University, Chongqing, People’s Republic of China
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Umemura T, Kakizaki H, Mutoh Y, Mizuno T, Ito Y, Hioki T, Kato H, Hagihara M, Yamada T, Ikeda Y, Mikamo H, Ichihara T, Hamada Y. Effectiveness and safety of the simulation-based first-dose design of voriconazole. J Infect Chemother 2024:S1341-321X(24)00170-3. [PMID: 38944383 DOI: 10.1016/j.jiac.2024.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 06/17/2024] [Accepted: 06/22/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND We investigated whether the initial voriconazole (VRCZ) dosing design, as determined using simulation software with a population pharmacokinetic model of Japanese patients, impacts the effectiveness and safety when compared with VRCZ initiation according to the package insert. METHODS In this single-center retrospective observational study, we employed records from Tosei General Hospital (a 633-bed hospital), dated April 2017 to September 2023. Eligible patients were divided into the software-based simulation group, comprising patients administered initial VRCZ dosage adjustment by pharmacists using software-based simulation, and the standard therapy group, whose dosage was administered by a physician following the package insert recommendations without simulation. The primary objective of this study was to determine the efficacy of VRCZ first-dose design in reducing the incidence of hepatotoxicity and visual symptoms. RESULTS The median ages of enrolled participants (n = 93) were 75 (68-79) and 72 (65-78) years in the software-based simulation and standard therapy groups, respectively. Regardless of formulation, initial trough concentrations were lower in the VRCZ software-based first dosage adjustment group and higher rate within the appropriate range (1-4 μg/mL). The incidence of all-grade hepatotoxicity or visual symptoms was significantly lower in the software-based simulation group. The log-rank test revealed a significant impact on the occurrence of ≥grade 2 hepatotoxicity in the software-based first dosage adjustment group compared to that in the standard therapy group. CONCLUSIONS The initial VRCZ dosing design using simulation software improved the achievement of appropriate initial trough concentrations and resulted in fewer occurrences of hepatotoxicity (≥grade 2) when compared with the standard therapy.
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Affiliation(s)
- Takumi Umemura
- Department of Pharmacy, Tosei General Hospital, Seto, Aichi, Japan; Department of Clinical Infectious Diseases, Tosei General Hospital, Seto, Aichi, Japan; Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan; College of Pharmacy, Kinjo Gakuin University, Nagoya, Aichi, Japan.
| | - Hiromi Kakizaki
- Department of Pharmacy, Tosei General Hospital, Seto, Aichi, Japan
| | - Yoshikazu Mutoh
- Department of Clinical Infectious Diseases, Tosei General Hospital, Seto, Aichi, Japan
| | - Takahito Mizuno
- Department of Pharmacy, Tosei General Hospital, Seto, Aichi, Japan
| | - Yuki Ito
- Department of Pharmacy, Tosei General Hospital, Seto, Aichi, Japan
| | - Tatsuya Hioki
- Department of Clinical Infectious Diseases, Tosei General Hospital, Seto, Aichi, Japan
| | - Hideo Kato
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan; Department of Pharmacy, Mie University Hospital, Tsu, Mie, Japan
| | - Mao Hagihara
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan
| | - Tetsuya Yamada
- Department of Pharmacy, Tosei General Hospital, Seto, Aichi, Japan
| | - Yoshiaki Ikeda
- College of Pharmacy, Kinjo Gakuin University, Nagoya, Aichi, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan
| | | | - Yukihiro Hamada
- Department of Pharmacy, Kochi Medical School Hospital, Nankoku, Kochi, Japan
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Wang X, Hu X, Ye C, Zhao J, Tan SC, Zhou L, Zhao C, Wu KH, Yang X, Wei J, Yang M. Astragalus Polysaccharide Enhances Voriconazole Metabolism under Inflammatory Conditions through the Gut Microbiota. J Clin Transl Hepatol 2024; 12:481-495. [PMID: 38779521 PMCID: PMC11106349 DOI: 10.14218/jcth.2024.00024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/03/2024] [Accepted: 04/08/2024] [Indexed: 05/25/2024] Open
Abstract
Background and Aims Voriconazole (VRC), a widely used antifungal drug, often causes hepatotoxicity, which presents a significant clinical challenge. Previous studies demonstrated that Astragalus polysaccharide (APS) can regulate VRC metabolism, thereby potentially mitigating its hepatotoxic effects. In this study, we aimed to explore the mechanism by which APS regulates VRC metabolism. Methods First, we assessed the association of abnormal VRC metabolism with hepatotoxicity using the Roussel Uclaf Causality Assessment Method scale. Second, we conducted a series of basic experiments to verify the promotive effect of APS on VRC metabolism. Various in vitro and in vivo assays, including cytokine profiling, immunohistochemistry, quantitative polymerase chain reaction, metabolite analysis, and drug concentration measurements, were performed using a lipopolysaccharide-induced rat inflammation model. Finally, experiments such as intestinal biodiversity analysis, intestinal clearance assessments, and Bifidobacterium bifidum replenishment were performed to examine the ability of B. bifidum to regulate the expression of the VRC-metabolizing enzyme CYP2C19 through the gut-liver axis. Results The results indicated that APS does not have a direct effect on hepatocytes. However, the assessment of gut microbiota function revealed that APS significantly increases the abundance of B. bifidum, which could lead to an anti-inflammatory response in the liver and indirectly enhance VRC metabolism. The dual-luciferase reporter gene assay revealed that APS can hinder the secretion of pro-inflammatory mediators and reduce the inhibitory effect on CYP2C19 transcription through the nuclear factor-κB signaling pathway. Conclusions The study offers valuable insights into the mechanism by which APS alleviates VRC-induced liver damage, highlighting its immunomodulatory influence on hepatic tissues and its indirect regulatory control of VRC-metabolizing enzymes within hepatocytes.
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Affiliation(s)
- Xiaokang Wang
- The Marine Biomedical Research Institute of Guangdong Zhanjiang, Zhanjiang, Guangdong, China
- Guangdong Provincial Key Laboratory of Research and Development of Natural Drugs, Guangdong Medical University, Dongguan, Guangdong, China
- Department of Pharmacy, Shenzhen Longhua District Central Hospital, Shenzhen, Guangdong, China
| | - Xianjing Hu
- Guangdong Provincial Key Laboratory of Research and Development of Natural Drugs, Guangdong Medical University, Dongguan, Guangdong, China
- Dongguan Key Laboratory of Chronic Inflammatory Diseases, The First Dongguan Affiliated Hospital, Guangdong Medical University, Dongguan, Guangdong, China
| | - Chunxiao Ye
- Department of Pharmacy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jingqian Zhao
- Department of Pharmacy, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong, China
| | - Shing Cheng Tan
- UKM Medical Molecular Biology Institute, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Liangbin Zhou
- Department of Biomedical Engineering, Faculty of Engineering, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Chenyu Zhao
- Department of Pharmacy, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong, China
| | - Kit Hang Wu
- Department of Pharmacy, Nossa Senhora do Carmo-Lago Health Centre, Health Bureau, Macau, China
| | - Xixiao Yang
- Department of Pharmacy, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong, China
| | - Jinbin Wei
- Pharmaceutical College, Guangxi Medical University, Nanning, Guangxi, China
| | - Maoxun Yang
- The Marine Biomedical Research Institute of Guangdong Zhanjiang, Zhanjiang, Guangdong, China
- Guangdong Provincial Key Laboratory of Research and Development of Natural Drugs, Guangdong Medical University, Dongguan, Guangdong, China
- Dongguan Key Laboratory of Chronic Inflammatory Diseases, The First Dongguan Affiliated Hospital, Guangdong Medical University, Dongguan, Guangdong, China
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Bharti V, Jung B, Lam S, Fabros A, Selvaratnam R. Stability and Analytical Characterization of Voriconazole as Measured by Immunoassay. J Appl Lab Med 2024; 9:565-572. [PMID: 38366039 DOI: 10.1093/jalm/jfad139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/18/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Voriconazole is a broad-spectrum triazole antifungal agent recommended for invasive fungal diseases, including invasive aspergillosis. Therapeutic drug monitoring via voriconazole target trough concentration is important to ensure efficacy while preventing toxicity. Our aim was to determine the stability of voriconazole as adapted and measured by an immunoassay. METHODS Plasma from patient samples (n = 45) evaluated by a liquid chromatography with tandem mass spectrometry (LC-MS/MS) method was compared against an ARK immunoassay method, adapted and optimized on the Abbott Alinity c analyzer. Stability of voriconazole and analytical performance of ARK immunoassay was assessed, including functional sensitivity, limit of blank (LoB), limit of detection (LoD), and limit of quantification (LoQ), linearity, and precision. RESULTS ARK voriconazole immunoassay was highly correlated (Pearson R = 0.988) to the LC-MS/MS method, with an average bias of 0.09 mg/L (2%). CV at LoQ of 0.5 mg/L was 3.7% while the functional sensitivity was established at 0.05 mg/L. Overall imprecision with liquid quality control material obtained from ARK was 5.0%, 6.3%, and 5.9% at 1 mg/L, 5 mg/L, and 10 mg/L, respectively. Limit of blank and LoD were 0.02 mg/L and 0.05 mg/L, respectively. Voriconazole in lithium heparin plasma separator tube declines over time, with a decrease that is more evident near or above toxic concentrations. CONCLUSION Voriconazole collected in gel separation tubes declines over time, possibly due to absorptive properties. Voriconazole measurements by immunoassay and LC-MS/MS demonstrated acceptable comparability with sufficient level of sensitivity and precision.
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Affiliation(s)
- Veni Bharti
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Benjamin Jung
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Division of Clinical Biochemistry, Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sarah Lam
- Division of Clinical Biochemistry, Laboratory Medicine Program, University Health Network, Toronto, ON, Canada
| | - Ansel Fabros
- Division of Clinical Biochemistry, Laboratory Medicine Program, University Health Network, Toronto, ON, Canada
| | - Rajeevan Selvaratnam
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Division of Clinical Biochemistry, Laboratory Medicine Program, University Health Network, Toronto, ON, Canada
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Kato H, Umemura T, Hagihara M, Shiota A, Asai N, Hamada Y, Mikamo H, Iwamoto T. Development of a therapeutic drug-monitoring algorithm for outpatients receiving voriconazole: A multicentre retrospective study. Br J Clin Pharmacol 2024; 90:1222-1230. [PMID: 38320604 DOI: 10.1111/bcp.16004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 12/27/2023] [Accepted: 01/04/2024] [Indexed: 02/08/2024] Open
Abstract
AIMS Although therapeutic drug monitoring (TDM) of voriconazole is performed in outpatients to prevent treatment failure and toxicity, whether TDM should be performed in all or only selected patients remains controversial. This study evaluated the association between voriconazole trough concentrations and clinical events. METHODS We investigated the aggravation of clinical symptoms, incidence of hepatotoxicity and visual disturbances, change in co-medications and interaction between voriconazole and co-medications in outpatients receiving voriconazole between 2017 and 2021 in three facilities. Abnormal trough concentrations were defined as <1.0 mg/L (low group) and >4.0 mg/L (high group). RESULTS A total of 141 outpatients (578 concentration measurements) met the inclusion criteria (treatment, 37 patients, 131 values; prophylaxis, 104 patients, 447 values). The percentages of patients with abnormal concentrations were 29.0% and 31.5% in the treatment and prophylaxis groups, respectively. Abnormal concentrations showed 50% of the concentrations at the first measurement in both therapies. Aggravation of clinical symptoms was most frequently observed in the low treatment group (18.2%). Adverse events were most common in the high group for both therapies (treatment, hepatotoxicity 6.3%, visual disturbance 18.8%; prophylaxis, hepatotoxicity 27.9%). No differences were found in changes to co-medications and drug interactions. In the prophylaxis group, prescription duration in the presence of clinical events tended to be longer than in their absence (47.4 ± 23.4 days vs 39.7 ± 21.9 days, P = .1132). CONCLUSIONS We developed an algorithm based on clinical events for appropriate implementation of TDM in outpatients. However, future interventions based on this algorithm should be validated.
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Affiliation(s)
- Hideo Kato
- Department of Pharmacy, Mie University Hospital, Tsu, Mie, Japan
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Tsu, Mie, Japan
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takumi Umemura
- Department of Pharmacy, Tosei General Hospital, Seto, Aichi, Japan
| | - Mao Hagihara
- Department of Molecular Epidemiology and Biomedical Sciences, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Arifumi Shiota
- Department of Pharmacy, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Nobuhiro Asai
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan
| | - Yukihiro Hamada
- Department of Pharmacy, Kochi Medical School Hospital, Nankoku, Kochi, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takuya Iwamoto
- Department of Pharmacy, Mie University Hospital, Tsu, Mie, Japan
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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Chen J, Xu S, Yu W, Sun C, Zhang W. Evaluating cardiac disorders associated with triazole antifungal agents based on the US Food and Drug Administration Adverse Event reporting system database. Front Pharmacol 2024; 15:1255918. [PMID: 38584605 PMCID: PMC10997335 DOI: 10.3389/fphar.2024.1255918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 03/07/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction Triazole antifungal agents are widely used to treat and prevent systemic mycoses. With wide clinical use, the number of reported adverse events has gradually increased. The aim of this study was to analyze the cardiac disorders associated with TAAs (fluconazole, voriconazole, itraconazole, posaconazole and isavuconazole) based on data from the US Food and Drug Administration Adverse Event Reporting System FDA Adverse Event Reporting System. Methods Data were extracted from the FAERS database between the first quarter of 2004 and third quarter of 2022. The clinical characteristics in TAA-associated cardiac AE reports were analyzed. Disproportionality analysis was performed to evaluate the potential association between AEs and TAAs using the reporting odds ratio (ROR) and proportional reporting ratio (PRR). Results Among 10,178,522 AE reports, 1719 reports were TAA-associated cardiac AEs as primary suspect drug. Most reports were related to fluconazole (38.34%), voriconazole (28.56%) and itraconazole (26.76%). Itraconazole (N = 195, 42.39%) and isavuconazole (N = 2, 14.29%) had fewer serious outcome events than three other drugs including fluconazole, voriconazole, and posaconazole. 13, 11, 26, 5 and 1 signals were detected for fluconazole, voriconazole, itraconazole, posaconazole and isavuconazole, respectively. The number of new signals unrecorded in the drug label was 9, 2, 13, 2 and 0 for fluconazole, voriconazole, itraconazole, posaconazole and isavuconazole, respectively. Conclusion Isavuconazole might be the safest of the five TAAs for cardiac AEs. TAA-associated cardiac disorders may result in serious adverse outcomes. Therefore, in addition to AEs on the drug label, we should pay attention to new AEs unrecorded on the drug label during the clinical use of TAAs.
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Affiliation(s)
- Jinhua Chen
- Department of Pharmacy, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Henan Engineering Research Center for Tumor Precision Medicine and Comprehensive Evaluation, Henan Provincial Key Laboratory of Anticancer Drug Research, Zhengzhou, China
| | - Shijun Xu
- Department of Interventional Radiology, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Weijiang Yu
- Department of Pharmacy, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Henan Engineering Research Center for Tumor Precision Medicine and Comprehensive Evaluation, Henan Provincial Key Laboratory of Anticancer Drug Research, Zhengzhou, China
| | - Cuicui Sun
- Department of Pharmacy, Qilu Hospital of Shandong University, Ji’nan, China
| | - Wenzhou Zhang
- Department of Pharmacy, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Henan Engineering Research Center for Tumor Precision Medicine and Comprehensive Evaluation, Henan Provincial Key Laboratory of Anticancer Drug Research, Zhengzhou, China
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Taher KW, Almofada R, Alomair S, Albassam AA, Alsultan A. Therapeutic Drug Monitoring of Voriconazole in Critically Ill Pediatric Patients: A Single-Center Retrospective Study. Paediatr Drugs 2024; 26:197-203. [PMID: 38228969 DOI: 10.1007/s40272-023-00616-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND AND OBJECTIVE Voriconazole pharmacokinetics are highly variable in pediatric patients, and the optimal dosage has yet to be determined. The purpose of this study was to describe voriconazole pharmacokinetic and pharmacodynamic targets achieved and evaluate the efficacy and safety of voriconazole for critically ill pediatrics. METHODS This is a single-center retrospective study conducted at a pediatric intensive care unit at a tertiary/quaternary hospital. Pediatrics admitted to the pediatric intensive care unit and who received voriconazole for a proven or suspected fungal infection with at least one measured trough concentration were included. The primary outcomes included the percentage of pediatric patients who achieved the pharmacokinetic and pharmacodynamic targets. Secondary outcomes included assessing the correlation between voriconazole trough concentrations and clinical/microbiological outcomes. All statistical analyses were performed using the R statistical software and Microsoft Excel. Multiple logistic regression was used to assess the predictors of both clinical and microbiologic cures. Multiple linear regression was used to determine significant factors associated with trough concentrations. RESULTS A total of 129 voriconazole trough concentrations were measured from 71 participants at steady state after at least three doses of voriconazole. The mean (± standard deviation) of the first and second trough concentrations were 2.9 (4.2) and 2.3 (3.3) mg/L, respectively. Among the first trough concentrations, only 33.8% were within the therapeutic range (1-5 mg/L), 46.5% were below the therapeutic range, and 19.7% were above the therapeutic range. A clinical cure occurred in 78% of patients, while a microbiologic cure occurred in 80% of patients. CONCLUSIONS Voriconazole trough concentrations vary widely in critically ill pediatric patients and only a third of the patients achieved therapeutic concentrations with initial doses.
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Affiliation(s)
- Khalid W Taher
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, MBC 11, P.O. Box 3354, 11211, Riyadh, Saudi Arabia.
| | - Razan Almofada
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, MBC 11, P.O. Box 3354, 11211, Riyadh, Saudi Arabia
| | - Sufyan Alomair
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Department of Pharmacy Practice, College of Clinical Pharmacy, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Ahmed A Albassam
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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Xie M, Jiang M, Qiu H, Rong L, Kong L. Optimization of Voriconazole Dosing Regimens Against Aspergillus Species and Candida Species in Pediatric Patients After Hematopoietic Cell Transplantation: A Theoretical Study Based on Pharmacokinetic/Pharmacodynamic Analysis. J Clin Pharmacol 2023; 63:993-1001. [PMID: 37083934 DOI: 10.1002/jcph.2254] [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: 01/03/2023] [Accepted: 04/17/2023] [Indexed: 04/22/2023]
Abstract
This study aimed to optimize the dosing regimens of voriconazole (VRC) for pediatric patients after hematopoietic cell transplantation with different cytochrome P450 (CYP) 2C19 phenotypes and body weights, based on pharmacokinetic (PK)/pharmacodynamic (PD) analysis. The PK parameters of VRC were derived from previous literature. Combined with key factors affecting VRC, patients were categorized into 9 subgroups based on different CYP2C19 phenotypes (poor metabolizer/intermediate metabolizer, normal metabolizer, and rapid metabolizer/ultrarapid metabolizer) and typical body weights (15, 40, and 65 kg). Monte Carlo simulation was used to investigate dosing regimens for different groups. The area under the 24-hour free drug concentration-time curve to the minimum inhibitory concentration (MIC) > 25 was used as the target value for effective treatment. The probability of target achievement and the cumulative fraction of response were determined on the basis of the assumed MICs and MICs distribution frequency of Aspergillus species and Candida species. When the MIC was ≤1 mg/L, 4 mg/kg every 12 hours was sufficient for optimal effects in groups 1-3 and groups 5 and 6; however, 6 mg/kg every 12 hours was required for group 4, and 8 mg/kg every 12 hours was required for groups 7-9. In empirical treatment, lower (2-6 mg/kg every 12 hours) and higher (6-12 mg/kg every 12 hours) dosing regimens were recommended for Candida spp. and Aspergillus spp., respectively. Our findings will assist in selecting appropriate dosing regimens of VRC for pediatric patients after hematopoietic cell transplantation with different CYP2C19 phenotypes and body weights. Clinically, it is better to continuously adjust the dosing on the basis of the therapeutic drug monitoring.
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Affiliation(s)
- Mengyuan Xie
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
- School of Pharmacy, Bengbu Medical College, Bengbu, China
| | - Manxue Jiang
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
- School of Pharmacy, Bengbu Medical College, Bengbu, China
| | - Hongyu Qiu
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
- School of Pharmacy, Bengbu Medical College, Bengbu, China
| | - Li Rong
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
- School of Pharmacy, Bengbu Medical College, Bengbu, China
| | - Lingti Kong
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
- School of Pharmacy, Bengbu Medical College, Bengbu, China
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Gu L, Ai T, Pang L, Xu D, Wang H. Voriconazole-Induced Hepatotoxicity in a Patient with Pulmonary Aspergillosis: A Case Report. Infect Drug Resist 2023; 16:5405-5411. [PMID: 37614681 PMCID: PMC10443690 DOI: 10.2147/idr.s419382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 08/01/2023] [Indexed: 08/25/2023] Open
Abstract
Voriconazole is the therapy of choice for aspergillosis. However, hepatotoxicity is the most common reason for the discontinuation of voriconazole. In contrast, posaconazole is well tolerated, with a low incidence of hepatotoxicity. In most cases, hepatotoxicity is associated with high voriconazole trough concentration influenced mainly by cytochrome P450 (CYP) 2C19 gene polymorphism. Compared with normal metabolizers, intermediate and poor metabolizers generally have higher voriconazole trough concentrations with an increased risk of hepatotoxicity. Here, we describe changes in hepatotoxicity throughout azole therapy in a patient with pulmonary aspergillosis (PA). Nevertheless, the patient with the normal metabolism genotype of CYP2C19 developed severe hepatotoxicity caused by voriconazole but tolerated posaconazole well, with a lack of direct cross-hepatotoxicity between the both. Interestingly, the patient had a high risk of hepatotoxicity at a low voriconazole trough concentration. Fortunately, elevated liver enzymes declined to the baselines with posaconazole treatment.
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Affiliation(s)
- Li Gu
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College and State Key Laboratory for Diagnosis and Treatment of Severe Zoonostic Infectious Disease, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Tao Ai
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Ling Pang
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College and State Key Laboratory for Diagnosis and Treatment of Severe Zoonostic Infectious Disease, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Dong Xu
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College and State Key Laboratory for Diagnosis and Treatment of Severe Zoonostic Infectious Disease, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Han Wang
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
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Ma J, Wang Y, Ma S, Li J. The Investigation and Prediction of Voriconazole-Associated Hepatotoxicity under Therapeutic Drug Monitoring . ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-4. [PMID: 38082975 DOI: 10.1109/embc40787.2023.10340343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Voriconazole is commonly used as the first-line agent to treat invasive fungal infections (IFIs), but the induction of hepatotoxicity limits its use. To improve the treatment outcomes and minimize toxicity, doctors often administer Therapeutic Drug Monitoring (TDM) to patients receiving voriconazole treatment. Here, we conducted a real-world clinical investigation of voriconazole-treated patients and found significant differences between the TDM (n=318) and non-TDM cohort (n=6,379), and such incidence of hepatotoxicity showed 10.6% in the non-TDM cohort, compared with 21.5% in the TDM cohort. Based on our previous investigation, we presented and compared several machine learning models (including AdaBoost, decision tree, GBDT, logistic regression, neural networks, and random forest) for the early warning of voriconazole-associated hepatoxicity. Through the five-fold cross validation, the logistic model outperformed other models with a mean AUC of 0.7933±0.0934. Our findings offer important insights into the safe and effective application of voriconazole.
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Morris SA, Nguyen DG, Patel JN. Pharmacogenomics in allogeneic hematopoietic stem cell transplantation: Implications on supportive therapies and conditioning regimens. Best Pract Res Clin Haematol 2023; 36:101470. [PMID: 37353294 DOI: 10.1016/j.beha.2023.101470] [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: 02/28/2023] [Revised: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 06/25/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation mortality has declined over the years, though prevention and management of treatment-related toxicities and post-transplant complications remains challenging. Applications of pharmacogenomic testing can potentially mitigate adverse drug outcomes due to interindividual variability in drug metabolism and response. This review summarizes clinical pharmacogenomic applications relevant to hematopoietic stem cell transplantation, including antifungals, immunosuppressants, and supportive care management, as well as emerging pharmacogenomic evidence with conditioning regimens.
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Affiliation(s)
- Sarah A Morris
- Department of Cancer Pharmacology & Pharmacogenomics Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, Charlotte, NC, 28204, USA.
| | - D Grace Nguyen
- Department of Cancer Pharmacology & Pharmacogenomics Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, Charlotte, NC, 28204, USA.
| | - Jai N Patel
- Department of Cancer Pharmacology & Pharmacogenomics Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, Charlotte, NC, 28204, USA.
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