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Yuan T, Bi F, Hu K, Zhu Y, Lin Y, Yang J. Clinical Trial Data-Driven Risk Assessment of Drug-Drug Interactions: A Rapid and Accurate Decision-Making Tool. Clin Pharmacokinet 2024:10.1007/s40262-024-01404-0. [PMID: 39102093 DOI: 10.1007/s40262-024-01404-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND In clinical practice, the vast array of potential drug combinations necessitates swift and accurate assessments of pharmacokinetic drug-drug interactions (DDIs), along with recommendations for adjustments. Current methodologies for clinical DDI evaluations primarily rely on basic extrapolations from clinical trial data. However, these methods are limited in accuracy owing to their lack of a comprehensive consideration of various critical factors, including the inhibitory potency, dosage, and type of the inhibitor, as well as the metabolic fraction and intestinal availability of the substrate. OBJECTIVE This study aims to propose an efficient and accurate clinical pharmacokinetic-mediated DDI assessment tool, which comprehensively considers the effects of inhibitory potency and dosage of inhibitors, intestinal availability and fraction metabolized of substrates on DDI outcomes. METHODS This study focuses on DDIs caused by cytochrome P450 3A4 enzyme inhibition, utilizing extensive clinical trial data to establish a methodology to calculate the metabolic fraction and intestinal availability for substrates, as well as the concentration and inhibitory potency for inhibitors ( K i ork inact / K I ). These parameters were then used to predict the outcomes of DDIs involving 33 substrates and 20 inhibitors. We also defined the risk index for substrates and the potency index for inhibitors to establish a clinical DDI risk scale. The training set for parameter calculation consisted of 73 clinical trials. The validation set comprised 89 clinical DDI trials involving 53 drugs. which was used to evaluate the reliability of in vivo values of K i andk inact / K I , the accuracy of DDI predictions, and the false-negative rate of risk scale. RESULTS First, the reliability of the in vivo K i andk inact / K I values calculated in this study was assessed using a basic static model. Compared with values obtained from other methods, this study values showed a lower geometric mean fold error and root mean square error. Additionally, incorporating these values into the physiologically based pharmacokinetic-DDI model facilitated a good fitting of the C-t curves when the substrate's metabolic enzymes are inhibited. Second, area under the curve ratio predictions of studied drugs were within a 1.5 × margin of error in 81% of cases compared with clinical observations in the validation set. Last, the clinical DDI risk scale developed in this study predicted the actual risks in the validation set with only a 5.6% incidence of serious false negatives. CONCLUSIONS This study offers a rapid and accurate approach for assessing the risk of pharmacokinetic-mediated DDIs in clinical practice, providing a foundation for rational combination drug use and dosage adjustments.
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Affiliation(s)
- Tong Yuan
- Key Laboratory of Drug Metabolism and Pharmacokinetics, School of Pharmacy, China Pharmaceutical University, 24 Tongjiaxiang Rd, Nanjing, 210009, People's Republic of China
| | - Fulin Bi
- Key Laboratory of Drug Metabolism and Pharmacokinetics, School of Pharmacy, China Pharmaceutical University, 24 Tongjiaxiang Rd, Nanjing, 210009, People's Republic of China
| | - Kuan Hu
- Key Laboratory of Drug Metabolism and Pharmacokinetics, School of Pharmacy, China Pharmaceutical University, 24 Tongjiaxiang Rd, Nanjing, 210009, People's Republic of China
| | - Yuqi Zhu
- Jiangsu Key Laboratory of Carcinogenesis and Intervention, School of Basic Medical Sciences and Clinical Pharmacy, China Pharmaceutical University, Nanjing, People's Republic of China
| | - Yan Lin
- Department of Clinical Pharmacy, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, 639 Longmiandadao Rd, Nanjing, 211198, People's Republic of China.
| | - Jin Yang
- Key Laboratory of Drug Metabolism and Pharmacokinetics, School of Pharmacy, China Pharmaceutical University, 24 Tongjiaxiang Rd, Nanjing, 210009, People's Republic of China.
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2
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Kirubakaran R, Singh RM, Carland JE, Day RO, Stocker SL. Evaluation of Published Population Pharmacokinetic Models to Inform Tacrolimus Therapy in Adult Lung Transplant Recipients. Ther Drug Monit 2024; 46:434-445. [PMID: 38723160 DOI: 10.1097/ftd.0000000000001210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 02/15/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND The applicability of currently available tacrolimus population pharmacokinetic models in guiding dosing for lung transplant recipients is unclear. In this study, the predictive performance of relevant tacrolimus population pharmacokinetic models was evaluated for adult lung transplant recipients. METHODS Data from 43 lung transplant recipients (1021 tacrolimus concentrations) administered an immediate-release oral formulation of tacrolimus were used to evaluate the predictive performance of 17 published population pharmacokinetic models for tacrolimus. Data were collected from immediately after transplantation up to 90 days after transplantation. Model performance was evaluated using (1) prediction-based assessments (bias and imprecision) of individual predicted tacrolimus concentrations at the fourth dosing based on 1 to 3 previous dosings and (2) simulation-based assessment (prediction-corrected visual predictive check; pcVPC). Both assessments were stratified based on concomitant azole antifungal use. Model performance was clinically acceptable if the bias was within ±20%, imprecision was ≤20%, and the 95% confidence interval of bias crossed zero. RESULTS In the presence of concomitant antifungal therapy, no model showed acceptable performance in predicting tacrolimus concentrations at the fourth dosing (n = 33), and pcVPC plots displayed poor model fit to the data set. However, this fit slightly improved in the absence of azole antifungal use, where 4 models showed acceptable performance in predicting tacrolimus concentrations at the fourth dosing (n = 33). CONCLUSIONS Although none of the evaluated models were appropriate in guiding tacrolimus dosing in lung transplant recipients receiving concomitant azole antifungal therapy, 4 of these models displayed potential applicability in guiding dosing in recipients not receiving concomitant azole antifungal therapy. However, further model refinement is required before the widespread implementation of such models in clinical practice.
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Affiliation(s)
- Ranita Kirubakaran
- School of Clinical Medicine, St. Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
- Department of Pharmacy, Ministry of Health, Putrajaya, Malaysia
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rani M Singh
- School of Clinical Medicine, St. Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Jane E Carland
- School of Clinical Medicine, St. Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Richard O Day
- School of Clinical Medicine, St. Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Sophie L Stocker
- School of Clinical Medicine, St. Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW, Australia ; and
- Sydney Musculoskeletal Health, University of Sydney, Sydney, NSW, Australia
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Meyer E, Dhingra R, Berei T. Assessing the Impact of Posaconazole Cessation on Tacrolimus Serum Concentrations and Incident Cardiac Allograft Rejection: Take Caution. J Pharm Pract 2024:8971900241237057. [PMID: 38395741 DOI: 10.1177/08971900241237057] [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: 02/25/2024]
Abstract
Invasive aspergillosis (IA) is a rare and often fatal complication of immunosuppression following orthotopic heart transplant. Prophylaxis plays a crucial role in preventing the emergence of this opportunistic infection. The azole class of medications are the bellwether agents utilized in this patient population. Unfortunately, given their impact on the Cytochrome P450 enzyme system, significant fluctuations in serum tacrolimus concentrations occur when initiating and stopping azole therapy, increasing the risk for prolonged periods of sub-optimal immunosuppression. While there are recommended dosing adjustments for these transition periods based on small data sets primarily with fluconazole, there is no published literature on recommended dosing adjustments for posaconazole. Given our institution utilizes posaconazole as the primary therapeutic for aspergillosis prophylaxis, we aimed to explore and report our local data to better guide dosing decisions during these transition periods.
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Affiliation(s)
- Ethan Meyer
- Department of Pharmacy, UW Health, Madison, WI, USA
| | - Ravi Dhingra
- Division of Cardiology, Section of Advanced Heart Failure and Transplant Cardiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Hirade K, Kusumoto S, Hashimoto H, Shiraga K, Hagiwara S, Oiwa K, Suzuki T, Kinoshita S, Ri M, Komatsu H, Iida S. Low-dose fluconazole as a useful and safe prophylactic option in patients receiving allogeneic hematopoietic stem cell transplantation. Cancer Med 2024; 13:e6815. [PMID: 38213090 PMCID: PMC10905229 DOI: 10.1002/cam4.6815] [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: 06/22/2023] [Revised: 10/22/2023] [Accepted: 12/03/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Invasive fungal infections (IFIs) represent a potentially fatal complication in patients who undergo allogeneic hematopoietic stem cell transplantation (HSCT) if the initiation of therapy is delayed. Some guidelines recommend antifungal prophylaxis or preemptive therapy for these patients depending on the risk of IFIs following allogeneic HSCT. This retrospective study aimed to identify the group of patients who safely undergo allogeneic HSCT with low-dose fluconazole (FLCZ) prophylaxis (100 mg/day). METHODS We retrospectively reviewed 107 patients who underwent their first allogeneic HSCT at Nagoya City University Hospital from January 1, 2010, to December 31, 2019. We analyzed the efficacy of low-dose FLCZ prophylaxis and investigated the relationship between major risk factors and antifungal prophylaxis failure (APF) within 100 days post-transplant. RESULTS Of the 107 patients, 70 received low-dose FLCZ prophylaxis, showing a cumulative incidence of APF of 37.1% and a proven/probable IFI rate of 4.3%. There were no fungal infection-related deaths, including Aspergillus infections, in the FLCZ prophylaxis group. In a multivariable analysis, cord blood transplantation (CBT) (subdistribution hazard ratio (SHR), 3.55; 95% confidence interval (CI), 1.44-8.77; p = 0.006) and abnormal findings on lung CT before transplantation (SHR, 2.24; 95% CI, 1.02-4.92; p = 0.044) were independent risk factors for APF in the FLCZ prophylaxis group. CONCLUSION Low-dose FLCZ prophylaxis is a useful and safe option for patients receiving allogeneic HSCT, except in those undergoing CBT or having any fungal risk features including history of fungal infections, positive fungal markers, and abnormal findings on lung CT before transplantation.
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Affiliation(s)
- Kentaro Hirade
- Department of Hematology and OncologyNagoya City University Institute of Medical and Pharmaceutical SciencesNagoyaJapan
| | - Shigeru Kusumoto
- Department of Hematology and OncologyNagoya City University Institute of Medical and Pharmaceutical SciencesNagoyaJapan
- Department of Hematology and Cell TherapyAichi Cancer Center HospitalNagoyaJapan
| | - Hiroya Hashimoto
- Clinical Research Management Center of Nagoya City University HospitalNagoyaJapan
| | - Kazuhide Shiraga
- Department of Hematology and OncologyNagoya City University Institute of Medical and Pharmaceutical SciencesNagoyaJapan
| | - Shinya Hagiwara
- Department of Hematology and OncologyNagoya City University Institute of Medical and Pharmaceutical SciencesNagoyaJapan
| | - Kana Oiwa
- Department of Hematology and OncologyNagoya City University Institute of Medical and Pharmaceutical SciencesNagoyaJapan
| | - Tomotaka Suzuki
- Department of Hematology and OncologyNagoya City University Institute of Medical and Pharmaceutical SciencesNagoyaJapan
| | - Shiori Kinoshita
- Department of Hematology and OncologyNagoya City University Institute of Medical and Pharmaceutical SciencesNagoyaJapan
| | - Masaki Ri
- Department of Hematology and OncologyNagoya City University Institute of Medical and Pharmaceutical SciencesNagoyaJapan
| | - Hirokazu Komatsu
- Department of Hematology and OncologyNagoya City University Institute of Medical and Pharmaceutical SciencesNagoyaJapan
| | - Shinsuke Iida
- Department of Hematology and OncologyNagoya City University Institute of Medical and Pharmaceutical SciencesNagoyaJapan
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Hahn E, Chavira R, Wollenberg L, Tan W, Reddy MB. Impact of posaconazole and diltiazem on pharmacokinetics of encorafenib, a BRAF V600 kinase inhibitor for melanoma and colorectal cancer with BRAF mutations. Clin Transl Sci 2023; 16:2675-2686. [PMID: 37837178 PMCID: PMC10719479 DOI: 10.1111/cts.13662] [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: 07/11/2023] [Revised: 09/08/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
Encorafenib is a potent and selective ATP competitive inhibitor of BRAF V600-mutant kinase approved for patients with BRAF-mutant melanoma and colorectal cancer. Encorafenib is mainly metabolized by cytochrome P450 (CYP) 3A4 in vitro and may be susceptible to drug-drug interactions when co-administered with CYP3A inhibitors or inducers. The primary objective was to assess the impact of the strong CYP3A inhibitor posaconazole (part 1) and the moderate CYP3A and P-gp inhibitor diltiazem (part 2) on encorafenib pharmacokinetics in healthy volunteers following a single 50-mg dose. A total of 32 participants were enrolled (16 each in parts 1 and 2). The area under the curve extrapolated to infinity (AUCinf ) and maximum plasma concentration (Cmax ) geometric mean for encorafenib increased by 183% and 68.4%, respectively, when co-administered with posaconazole. Apparent encorafenib clearance decreased from 26.0 to 9.2 L/h when coadministered with posaconazole, and plasma terminal half-life (t½ ) of encorafenib increased from 4.3 to 7.3 h. The AUCinf and Cmax geometric mean for encorafenib increased by 83.0% and 44.7%, respectively, when co-administered with diltiazem. Similarly, the apparent encorafenib clearance decreased from 29.0 to 16.0 L/h when co-administered with diltiazem, and plasma t½ of encorafenib increased from 6.6 to 7.9 h. There were no deaths, serious adverse events (AEs), or patient discontinuations due to AEs in parts 1 or 2. The most frequently reported treatment-related AEs were erythema (n = 14; 88%) and headache (n = 11; 69%) in part 1 and headache (n = 7; 44%) in part 2. The results of this study indicate that co-administration of encorafenib with strong or moderate CYP3A4 inhibitors should be avoided.
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Affiliation(s)
- Erik Hahn
- Global Product DevelopmentPfizer Inc.BoulderColoradoUSA
| | - Renae Chavira
- Global Product DevelopmentPfizer Inc.BoulderColoradoUSA
| | | | - Weiwei Tan
- Global Product DevelopmentPfizer Inc.La JollaCaliforniaUSA
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Lynch JP, Zhanel GG. Part 2: Mucormycosis: Focus on Therapy. Expert Rev Anti Infect Ther 2023. [PMID: 37300820 DOI: 10.1080/14787210.2023.2224564] [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: 03/09/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Mucormycosis (MCR) a rare but life-threatening infection occurs primarily in immunocompromised hosts. Mortality rates with invasive MCR are high (>30-50%), up to 90% with disseminated disease, but lower (10-30%) with localized cutaneous disease. Due to the rarity of MCR, randomized, controlled therapeutic trials are lacking. Lipid formulations of amphotericin B (LFAB) are the mainstay of therapy but oral triazoles (posaconazole and isavuconazole) may be effective as step-down therapy or in MCR cases refractory to or intolerant of LFAB. Early surgical debridement or excision play important adjunctive roles in localized invasive disease. Control of hyperglycemia in diabetic patients, correction of neutropenia and reduction of immunosuppressive therapy is critical for optimal survival. AREAS COVERED The authors discuss various therapeutic options for mucormycosis. A literature search of mucormycosis therapies was performed via PubMed (up to December 2022), using the key words: invasive fungal infections; mold; mucormycosis; Mucorales; amphotericin B; isavuconazole; posaconazole. EXPERT OPINION Randomized, controlled therapeutic trials are lacking. Lipid formulations of amphotericin B (LFAB) are the mainstay of therapy but oral triazoles (posaconazole and isavuconazole) may be effective as step-down therapy, in MCR cases refractory to or intolerant of LFAB. We encourage early surgical debridement or excision as adjunctive measures.
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Affiliation(s)
- Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, the David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - George G Zhanel
- Department of Medical Microbiology/Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Escamilla JE, January SE, Vazquez Guillamet R. Diagnosis and Treatment of Fungal Infections in Lung Transplant Recipients. Pathogens 2023; 12:pathogens12050694. [PMID: 37242364 DOI: 10.3390/pathogens12050694] [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: 03/25/2023] [Revised: 04/27/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023] Open
Abstract
Fungal infections are a significant source of morbidity in the lung transplant population via direct allograft damage and predisposing patients to the development of chronic lung allograft dysfunction. Prompt diagnosis and treatment are imperative to limit allograft damage. This review article discusses incidence, risk factors, and symptoms with a specific focus on diagnostic and treatment strategies in the lung transplant population for fungal infections caused by Aspergillus, Candida, Coccidioides, Histoplasma, Blastomyces, Scedosporium/Lomentospora, Fusarium, and Pneumocystis jirovecii. Evidence for the use of newer triazole and inhaled antifungals to treat isolated pulmonary fungal infections in lung transplant recipients is also discussed.
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Affiliation(s)
- Jesus E Escamilla
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO 63110, USA
| | - Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO 63110, USA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO 63110, USA
- Rodrigo Vazquez Guillamet, 4921 Parkview Place, Saint Louis, MO 63110, USA
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8
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Melenotte C, Aimanianda V, Slavin M, Aguado JM, Armstrong-James D, Chen YC, Husain S, Van Delden C, Saliba F, Lefort A, Botterel F, Lortholary O. Invasive aspergillosis in liver transplant recipients. Transpl Infect Dis 2023:e14049. [PMID: 36929539 DOI: 10.1111/tid.14049] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Liver transplantation is increasing worldwide with underlying pathologies dominated by metabolic and alcoholic diseases in developed countries. METHODS We provide a narrative review of invasive aspergillosis (IA) in liver transplant (LT) recipients. We searched PubMed and Google Scholar for references without language and time restrictions. RESULTS The incidence of IA in LT recipients is low (1.8%), while mortality is high (∼50%). It occurs mainly early (<3 months) after LT. Some risk factors have been identified before (corticosteroid, renal, and liver failure), during (massive transfusion and duration of surgical procedure), and after transplantation (intensive care unit stay, re-transplantation, re-operation). Diagnosis can be difficult and therefore requires full radiological and clinicobiological collaboration. Accurate identification of Aspergillus species is recommended due to the cryptic species, and susceptibility testing is crucial given the increasing resistance of Aspergillus fumigatus to azoles. It is recommended to reduce the dose of tacrolimus (50%) and to closely monitor the trough level when introducing voriconazole, isavuconazole, and posaconazole. Surgery should be discussed on a case-by-case basis. Antifungal prophylaxis is recommended in high-risk patients. Environmental preventative measures should be implemented to prevent outbreaks of nosocomial aspergillosis in LT recipient units. CONCLUSION IA remains a very serious disease in LT patients and should be promptly sought and, if possible, prevented by clinicians when risk factors are identified.
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Affiliation(s)
- Cléa Melenotte
- Service de Maladies Infectieuses et Tropicales, Hôpital Necker Enfants-Malades, AP-HP, Paris, France.,Faculté de Médecine, Université Paris-Cité, Paris, France
| | - Vishukumar Aimanianda
- Institut Pasteur, CNRS, National Reference Center for Invasive Mycoses and Antifungals, Molecular Mycology Unit, UMR2000, Paris, France
| | - Monica Slavin
- Department of Infectious Diseases, National Center for Infections in Cancer, Sir Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Oncology, Sir Peter MacCallum Cancer Center, University of Melbourne, Melbourne, Australia
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain.,Department of Medicine, Universidad Complutense, Madrid, Spain
| | | | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Shahid Husain
- Department of Transplant Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Christian Van Delden
- Transplant Infectious Diseases Unit, University Hospitals Geneva, Geneva, Switzerland
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
| | - Agnès Lefort
- Université de Paris, IAME, UMR 1137, INSERM, Paris, France.,Service de Médecine Interne, Hôpital Beaujon, AP-HP, Clichy, France
| | - Francoise Botterel
- EA Dynamyc 7380 UPEC, ENVA, Faculté de Médecine, Créteil, France.,Unité de Parasitologie-Mycologie, Département de Virologie, Bactériologie-Hygiène, Mycologie-Parasitologie, DHU VIC, CHU Henri Mondor, Créteil, France
| | - Olivier Lortholary
- Service de Maladies Infectieuses et Tropicales, Hôpital Necker Enfants-Malades, AP-HP, Paris, France.,Faculté de Médecine, Université Paris-Cité, Paris, France.,Institut Pasteur, CNRS, National Reference Center for Invasive Mycoses and Antifungals, Molecular Mycology Unit, UMR2000, Paris, France.,Paris University, Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Necker-Enfants Malades Hospital, AP-HP, IHU Imagine, Paris, France
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Kirubakaran R, Uster DW, Hennig S, Carland JE, Day RO, Wicha SG, Stocker SL. Adaptation of a population pharmacokinetic model to inform tacrolimus therapy in heart transplant recipients. Br J Clin Pharmacol 2023; 89:1162-1175. [PMID: 36239542 PMCID: PMC10952588 DOI: 10.1111/bcp.15566] [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: 10/25/2021] [Revised: 09/24/2022] [Accepted: 10/03/2022] [Indexed: 11/28/2022] Open
Abstract
AIM Existing tacrolimus population pharmacokinetic models are unsuitable for guiding tacrolimus dosing in heart transplant recipients. This study aimed to develop and evaluate a population pharmacokinetic model for tacrolimus in heart transplant recipients that considers the tacrolimus-azole antifungal interaction. METHODS Data from heart transplant recipients (n = 87) administered the oral immediate-release formulation of tacrolimus (Prograf®) were collected. Routine drug monitoring data, principally trough concentrations, were used for model building (n = 1099). A published tacrolimus model was used to inform the estimation of Ka , V2 /F, Q/F and V3 /F. The effect of concomitant azole antifungal use on tacrolimus CL/F was quantified. Fat-free mass was implemented as a covariate on CL/F, V2 /F, V3 /F and Q/F on an allometry scale. Subsequently, stepwise covariate modelling was performed. Significant covariates influencing tacrolimus CL/F were included in the final model. Robustness of the final model was confirmed using prediction-corrected visual predictive check (pcVPC). The final model was externally evaluated for prediction of tacrolimus concentrations of the fourth dosing occasion (n = 87) from one to three prior dosing occasions. RESULTS Concomitant azole antifungal therapy reduced tacrolimus CL/F by 80%. Haematocrit (∆OFV = -44, P < .001) was included in the final model. The pcVPC of the final model displayed good model adequacy. One recent drug concentration is sufficient for the model to guide tacrolimus dosing. CONCLUSION A population pharmacokinetic model that adequately describes tacrolimus pharmacokinetics in heart transplant recipients, considering the tacrolimus-azole antifungal interaction was developed. Prospective evaluation is required to assess its clinical utility to improve patient outcomes.
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Affiliation(s)
- Ranita Kirubakaran
- School of Clinical Medicine, Faculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt. Vincent's HospitalSydneyNew South WalesAustralia
- Department of PharmacyHospital Seberang JayaPenangMalaysia
| | - David W. Uster
- Department of Clinical Pharmacy, Institute of PharmacyUniversity of HamburgHamburgGermany
| | - Stefanie Hennig
- Certara Inc.PrincetonNew JerseyUSA
- School of Clinical Sciences, Faculty of HealthQueensland University of TechnologyBrisbaneQueenslandAustralia
| | - Jane E. Carland
- School of Clinical Medicine, Faculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt. Vincent's HospitalSydneyNew South WalesAustralia
| | - Richard O. Day
- School of Clinical Medicine, Faculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt. Vincent's HospitalSydneyNew South WalesAustralia
| | - Sebastian G. Wicha
- Department of Clinical Pharmacy, Institute of PharmacyUniversity of HamburgHamburgGermany
| | - Sophie L. Stocker
- School of Clinical Medicine, Faculty of Medicine and HealthUniversity of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt. Vincent's HospitalSydneyNew South WalesAustralia
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
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Adverse Events Associated with Universal versus Targeted Antifungal Prophylaxis among Lung Transplant Recipients-A Nationwide Cohort Study 2010-2019. Microorganisms 2022; 10:microorganisms10122478. [PMID: 36557731 PMCID: PMC9787947 DOI: 10.3390/microorganisms10122478] [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: 11/08/2022] [Revised: 11/30/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Background: Invasive fungal infections in lung transplant (LTX) recipients cause substantial morbidity, but the best strategy for prevention has not yet been determined. We evaluated adherence to and rates of adverse events of universal versus targeted prophylaxis. Methods: All LTX recipients in the Danish National LTX Centre (2010−2019) were included. Before July 2016, universal voriconazole prophylaxis was used. After July 2016, only high-risk patients received targeted prophylaxis with posaconazole and inhaled amphotericin B. Proportions of triazole discontinuation, side-effects, off-target calcineurin-inhibitor (CNI) levels, and acute rejection were compared between the two periods. Results: Universal and targeted prophylaxis was initiated in 183/193 and 6/102 patients, respectively. Only 37% completed > 9 of the intended 12 weeks of voriconazole; 72% of discontinuations were due to hepatotoxicity. In the universal vs. targeted prophylaxis period, 89% vs. 72% (p < 0.001) patients had low CNI episodes, and 37% vs. 1% (p < 0.001) of these were associated with discontinuation of triazole; 40% vs. 14% (p < 0.001) had acute rejection; and 23% vs. 3% (p < 0.001) had acute rejection associated with low CNI episodes. Conclusions: Universal voriconazole prophylaxis was associated with high rates of discontinuation, mainly caused by hepatotoxicity. In comparison to the targeted posaconazole period, more patients had low CNI levels and acute rejection in the universal voriconazole period.
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11
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Effect of posaconazole on the concentration of intravenous and oral cyclosporine in patients undergoing hematopoietic stem cell transplantation. Eur J Clin Pharmacol 2022; 78:1677-1685. [PMID: 36045212 DOI: 10.1007/s00228-022-03378-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/25/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE This study aimed to investigate the interactions between posaconazole (POS) and intravenously/orally administered cyclosporine A (CsA) in allogeneic hematopoietic stem cell transplant (HSCT) recipients. METHODS We included 118 allogeneic HSCT patients who received CsA and POS simultaneously between January 2017 and June 2020 in this study. The ratio of CsA blood concentration (ng/mL) to dosage (mg/day) (C/D) before and after POS initiation was compared. RESULTS After the initiation of POS, the level of CsA increased 1 to 2 times in 66% (78/118) of patients compared to those without POS. However, the CsA C/D ratio increased by more than threefold in 6% (7/118) of patients after POS initiation, with an increase of more than fourfold in two patients. The median C/D ratio of CsA increased from 0.89 to 1.23 (P < 0.001) and 0.78 to 1.22 (P < 0.001) after POS initiation when CsA was administered intravenously and orally, respectively. In patients who received POS at the time of transition from intravenous to oral CsA, the value increased from 1.01 to 1.38 (P = 0.001). The route of administration had no significant effect on the change in the CsA C/D ratio (P = 0.615). Additionally, we observed the time required for the C/D ratio to reach a plateau after POS initiation was similar on days 13, 8, and 15 under various scenarios. CONCLUSION POS treatment increased blood CsA levels. A large variability was found in the fold-change in the CsA C/D ratio. Therefore, CsA doses should be adjusted by closely monitoring the blood levels of CsA after POS initiation.
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12
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Fungal Infections in Lung Transplantation. CURRENT TRANSPLANTATION REPORTS 2022. [DOI: 10.1007/s40472-022-00363-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Abstract
Purpose of Review
We aim to understand the most common fungal infections associated with the post-lung transplant period, how to diagnose, treat, and prevent them based on the current guidelines published and our center’s experience.
Recent Findings
Different fungi inhabit specific locations. Diagnosis of invasive fungal infections (IFIs) depends on symptoms, radiologic changes, and a positive microbiological or pathology data. There are several molecular tests that have been used for diagnosis. Exposure to fungal prophylaxis can predispose lung transplant recipients to these emerging molds. Understanding and managing medication interactions and drug monitoring are essential in successfully treating IFIs.
Summary
With the increasing rate of lung transplantations being performed, and the challenges posed by the immunosuppressive regimen, understanding the risk and managing the treatment of fungal infections are imperative to the success of a lung transplant recipient. There are many ongoing clinical trials being conducted in hopes of developing novel antifungals.
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13
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Kim NT, Cho CK, Kang P, Park HJ, Lee YJ, Bae JW, Jang CG, Lee SY. Effects of CYP2C9*3 and *13 alleles on the pharmacokinetics and pharmacodynamics of glipizide in healthy Korean subjects. Arch Pharm Res 2021; 45:114-121. [PMID: 34952963 DOI: 10.1007/s12272-021-01366-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/16/2021] [Indexed: 12/25/2022]
Abstract
Glipizide is a second-generation sulfonylurea antidiabetic drug. It is principally metabolized to inactive metabolites by genetically polymorphic CYP2C9 enzyme. In this study, we investigated the effects of CYP2C9*3 and *13 variant alleles on the pharmacokinetics and pharmacodynamics of glipizide. Twenty-four healthy Korean volunteers (11 subjects with CYP2C9*1/*1, 8 subjects with CYP2C9*1/*3, and 5 subjects with CYP2C9*1/*13) were recruited for this study. They were administered a single oral dose of glipizide 5 mg. The plasma concentration of glipizide was quantified for pharmacokinetic analysis and plasma glucose and insulin concentrations were measured as pharmacodynamic parameters. The results represented that CYP2C9*3 and *13 alleles significantly affected the pharmacokinetics of glipizide. In subjects with CYP2C9*1/*3 and CYP2C9*1/*13 genotypes, the mean AUC0-∞ were increased by 44.8% and 58.2%, respectively (both P < 0.001), compared to those of subjects with CYP2C9*1/*1 genotype, while effects of glipizide on plasma glucose and insulin levels were not significantly different between CYP2C9 genotype groups. In conclusion, individuals carrying the defective CYP2C9*3 and CYP2C9*13 alleles have markedly elevated plasma concentrations of glipizide compared with CYP2C9*1/*1 wild-type.
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Affiliation(s)
- Nam-Tae Kim
- School of Pharmacy, Sungkyunkwan University, Suwon, 16419, Republic of Korea
| | - Chang-Keun Cho
- School of Pharmacy, Sungkyunkwan University, Suwon, 16419, Republic of Korea
| | - Pureum Kang
- School of Pharmacy, Sungkyunkwan University, Suwon, 16419, Republic of Korea
| | - Hye-Jung Park
- School of Pharmacy, Sungkyunkwan University, Suwon, 16419, Republic of Korea
| | - Yun Jeong Lee
- College of Pharmacy, Dankook University, Cheonan, 31116, Republic of Korea
| | - Jung-Woo Bae
- College of Pharmacy, Keimyung University, Daegu, 42601, Republic of Korea.
| | - Choon-Gon Jang
- School of Pharmacy, Sungkyunkwan University, Suwon, 16419, Republic of Korea
| | - Seok-Yong Lee
- School of Pharmacy, Sungkyunkwan University, Suwon, 16419, Republic of Korea.
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14
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Panagopoulou P, Roilides E. Evaluating posaconazole, its pharmacology, efficacy and safety for the prophylaxis and treatment of fungal infections. Expert Opin Pharmacother 2021; 23:175-199. [PMID: 34758695 DOI: 10.1080/14656566.2021.1996562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Invasive fungal diseases (IFDs) are a significant cause of morbidity and mortality among immunocompromised patients. Safe and effective antifungal medications used for prophylaxis and treatment are pivotal in their management. Posaconazole is a promising triazole antifungal agent. AREAS COVERED The authors discuss the pharmacological properties of posaconazole, including pharmacokinetics/pharmacodynamics, safety and tolerability profile, together with efficacy data for prophylaxis and treatment as well as its use in special populations based on current literature. EXPERT OPINION Posaconazole has a favorable safety and tolerability profile; however, caution is advised when co-administered with agents that are CYP3A4 inhibitors, because their concentration may significantly increase, and their levels should be closely monitored. It has an extended spectrum of activity against yeasts and filamentous fungi. It is successfully used as prophylaxis for patients with acute myeloid leukemia (AML)/myelodysplastic syndrome (MDS) and post-hematopoietic cell transplantation (HCT) with graft-versus-host disease (GVHD). It is the first line treatment for oropharyngeal candidiasis and is also used as a salvage treatment for refractory IFDs. Currently available formulations include the oral suspension, delayed-release tablets and solution for intravenous infusion, all with different PK/PD properties and indications. Its use in children and adolescents is currently being examined in Phase-II clinical trials.
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Affiliation(s)
- Paraskevi Panagopoulou
- 4th Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Papageorgiou General Hospital, Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Hippokration General Hospital, Thessaloniki, Greece.,Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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15
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Kirubakaran R, Hennig S, Maslen B, Day RO, Carland JE, Stocker SL. Evaluation of published population pharmacokinetic models to inform tacrolimus dosing in adult heart transplant recipients. Br J Clin Pharmacol 2021; 88:1751-1772. [PMID: 34558092 DOI: 10.1111/bcp.15091] [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: 04/13/2021] [Revised: 08/26/2021] [Accepted: 09/13/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND AIM Identification of the most appropriate population pharmacokinetic model-based Bayesian estimation is required prior to its implementation in routine clinical practice to inform tacrolimus dosing decisions. This study aimed to determine the predictive performances of relevant population pharmacokinetic models of tacrolimus developed from various solid organ transplant recipient populations in adult heart transplant recipients, stratified based on concomitant azole antifungal use. Concomitant azole antifungal therapy alters tacrolimus pharmacokinetics substantially, necessitating dose adjustments. METHODS Population pharmacokinetic models of tacrolimus were selected (n = 17) for evaluation from a recent systematic review. The models were transcribed and implemented in NONMEM version 7.4.3. Data from 85 heart transplant recipients (2387 tacrolimus concentrations) administered the oral immediate-release formulation of tacrolimus (Prograf) were obtained up to 391 days post-transplant. The performance of each model was evaluated using: (i) prediction-based assessment (bias and imprecision) of the individual predicted tacrolimus concentration of the fourth dosing occasion (MAXEVAL = 0, FOCE-I) from 1-3 prior dosing occasions; and (ii) simulation-based assessment (prediction-corrected visual predictive check). Both assessments were stratified based on concomitant azole antifungal use. RESULTS Regardless of the number of prior dosing occasions (1-3) and concomitant azole antifungal use, all models demonstrated unacceptable individual predicted tacrolimus concentration of the fourth dosing occasion (n = 152). The prediction-corrected visual predictive check graphics indicated that these models inadequately predicted observed tacrolimus concentrations. CONCLUSION All models evaluated were unable to adequately describe tacrolimus pharmacokinetics in adult heart transplant recipients included in this study. Further work is required to describe tacrolimus pharmacokinetics for our heart transplant recipient cohort.
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Affiliation(s)
- Ranita Kirubakaran
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.,Ministry of Health, Putrajaya, Malaysia
| | - Stefanie Hennig
- Certara Inc., Princeton, NJ, USA.,School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Ben Maslen
- Mark Wainwright Analytical Centre, University of New South Wales, Sydney, NSW, Australia
| | - Richard O Day
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.,Garvan Institute of Medical Research, Sydney, NSW, Australia
| | - Jane E Carland
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.,School of Medical Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Sophie L Stocker
- St. Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia.,Garvan Institute of Medical Research, Sydney, NSW, Australia.,School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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16
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Whitmore TJ, Yaw M, Lavender M, Musk M, Boan P, Wrobel J. A novel highly bio-available itraconazole formulation (SUBA®-Itraconazole) for anti-fungal prophylaxis in lung transplant recipients. Transpl Infect Dis 2021; 23:e13587. [PMID: 33590676 DOI: 10.1111/tid.13587] [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: 11/11/2020] [Revised: 01/28/2021] [Accepted: 02/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antifungal prophylaxis remains a mainstay of lung transplantation, given invasive fungal infection is a common and serious complication after lung transplantation. Choice of systemic agent to prevent invasive fungal infection varies between centers and funding of agents remains challenging. Our center has recently changed from posaconazole to a highly bioavailable formulation of itraconazole (SUBA®-itraconazole) at substantially reduced cost, but safety and toxicity require further assessment. A retrospective study of lung transplant patients receiving systemic antifungal prophylaxis from December 2016 through December 2019 following change from posaconazole to itraconazole as standard practice. 150 patients with lung transplants were managed in this time period, with 88 (59%) receiving at least 1 mold-active triazole during the study period. 48 (58%) of these patients received SUBA®-itraconazole; 68 (82%) received posaconazole and 10 (12%) received voriconazole. The average cost per patient during the study period was significantly lower on SUBA®-itraconazole (mean $1548/patient/6 month course) than posaconazole (mean $16 921.35/patient/6 month course). Target trough concentrations for prophylaxis of itraconazole > 0.5 mg/L and posaconazole > 0.7 mg/L were achieved on empiric dosing in 49% and 68% respectively. Overall trough itraconazole (0.50 vs 1.12 mg/L, P < .001) and posaconazole (1.37 vs 2.10 mg/L P < .001) concentrations were significantly lower in patients with cystic fibrosis. Calcineurin inhibitor dose changes on introduction or cessation were similar for SUBA®-itraconazole and posaconazole. Breakthrough invasive fungal infection and toxicity were rare. SUBA®-itraconazole is well-tolerated, associated with rare breakthrough invasive fungal infection, and lower cost. Prospective studies following general introduction are required to determine long-term safety, tolerability, and efficacy.
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Affiliation(s)
- Timothy James Whitmore
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, WA, Australia.,Department of Microbiology, PathWest Laboratory Medicine WA, Perth, WA, Australia.,Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Meow Yaw
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Melanie Lavender
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Michael Musk
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Peter Boan
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, WA, Australia.,Department of Microbiology, PathWest Laboratory Medicine WA, Perth, WA, Australia
| | - Jeremy Wrobel
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia.,School of Medicine, University of Notre Dame Australia, Fremantle, WA, Australia
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17
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Bhagat V, Pandit RA, Ambapurkar S, Sengar M, Kulkarni AP. Drug Interactions between Antimicrobial and Immunosuppressive Agents in Solid Organ Transplant Recipients. Indian J Crit Care Med 2021; 25:67-76. [PMID: 33603305 PMCID: PMC7874296 DOI: 10.5005/jp-journals-10071-23439] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The number of allogeneic solid organ and bone marrow transplants is increasing all over the world. To prevent transplant rejection and treat acute rejection of transplant, immunosuppressant drugs are used. The outcomes of solid organ transplants have dramatically improved over last 30 years, due to availability of multiple immunosuppressive agents, with varied mechanisms of action. The use of intense immunosuppression makes the individual having undergone solid organ transplant at the risk of several serious infections, which may prove fatal. To prevent and treat these infections (when they occur), patients are often given antimicrobial prophylaxis and therapy. The use of antimicrobials can interfere with the metabolism of the immunosuppressants, and may put the patient at risk of developing severe adverse effects due to unwanted increase or decrease in the serum levels of immunosuppressive agents. Knowledge of these interactions is essential for successful management of solid organ transplant patients. We therefore decided to review the literature and present the interactions that commonly occur between these two life-saving groups of drugs. How to cite this article: Bhagat V, Pandit RA, Ambapurkar S, Sengar M, Kulkarni AP. Drug Interactions between Antimicrobial and Immunosuppressive Agents in Solid Organ Transplant Recipients. Indian J Crit Care Med 2021;25(1):67–76.
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Affiliation(s)
- Vikas Bhagat
- Department of Critical Care Medicine, Aster Hospital, Dubai, UAE
| | | | | | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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18
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Soskind R, Xiang E, Lewis T, Al-Homsi AS, Papadopoulos J, Cirrone F. Initial tacrolimus weight-based dosing strategy in allogeneic hematopoietic stem-cell transplantation. J Oncol Pharm Pract 2020; 27:1447-1453. [PMID: 32957861 DOI: 10.1177/1078155220959416] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Tacrolimus is a mainstay medication for graft-versus-host disease (GVHD) prophylaxis in combination with other immunosuppressive agents. Achieving therapeutic tacrolimus levels is vital in preventing acute GVHD (aGVHD), while supratherapeutic levels may increase risk of toxicity and relapse. We performed a single center retrospective chart review including all adult patients post-allogeneic hematopoietic stem-cell transplantation who received initial tacrolimus continuous intravenous infusion for GVHD prophylaxis between June 1, 2017 and December 31, 2019. The primary outcome was the percent of patients with an initial therapeutic tacrolimus level, defined as 5-12 ng/mL, after empiric weight-based dosing at 0.02 mg/kg/day. Secondary outcomes included evidence of tacrolimus toxicity within seven days of initiation, incidence of aGVHD by day 100, and relapse after six months. An initial therapeutic level was achieved in 47% of patients with a median initial level of 12.4 ng/mL. Fifty-two percent of patients had supratherapeutic levels. No significant nephrotoxicity, hepatotoxicity, or neurotoxicity occurred within a week of starting tacrolimus or at neutrophil engraftment. Grade II-IV aGVHD by day 100 was observed in 22% of patients, and relapse after six months was found in 16% of patients. These results have led to consideration of an empiric 20% dose reduction to 0.016 mg/kg/day or an expanded initial tacrolimus target of 5-15 ng/mL as there was low aGVHD incidence and no increased risk of toxicity.
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19
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Zhang H, Wang K, Chen H, Sun L, Wang Z, Fei S, Tan R, Gu M. The Double-Edged Sword of Immunosuppressive Therapy in Kidney Transplantation: A Rare Case Report of Pulmonary Mucormycosis Post-Transplant and Literature Review. Front Med (Lausanne) 2020; 7:500. [PMID: 33072770 PMCID: PMC7538690 DOI: 10.3389/fmed.2020.00500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022] Open
Abstract
Immunosuppressive therapy is improving the graft survival of kidney transplant recipients and increasing the potential risk of infection. Pulmonary mucormycosis is a rare post-operative infection complication characterized with rapid deterioration and high mortality. In this case, a 33-year-old patient underwent a kidney transplantation with regular immunosuppressive therapy. Soon, 38 days post-transplant, pulmonary patchy shadows can be seen in the radiological examination and rounded into a large cavity formation with splenic rupture 25 days later. The diagnosis of mucormycosis was confirmed by lung biopsy and spleen histopathology. This case is a reminder that early diagnosis is imperative, meanwhile, rational antifungal therapy, timely elimination of immunosuppressants, and alternatively, abandoning the graft should be prudently assessed in the treatment of mucormycosis.
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Affiliation(s)
- Hengcheng Zhang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Transplantation Research Center, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Ke Wang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hao Chen
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Li Sun
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zijie Wang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shuang Fei
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ruoyun Tan
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Min Gu
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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20
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Interpretation and Understanding of Clinical Drug Interactions Between Azoles and Immunosuppressants in Solid Organ Transplant Recipients. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00404-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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21
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Ling J, Dong LL, Yang XP, Qian Q, Jiang Y, Zou SL, Hu N. Effects of CYP3A5, ABCB1 and POR*28 polymorphisms on pharmacokinetics of tacrolimus in the early period after renal transplantation. Xenobiotica 2020; 50:1501-1509. [PMID: 32453653 DOI: 10.1080/00498254.2020.1774682] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Jing Ling
- Department of Pharmacy, the First People’s Hospital of Changzhou, the Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Lu-Lu Dong
- Department of Pharmacy, the First People’s Hospital of Changzhou, the Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xu-Ping Yang
- Department of Pharmacy, the First People’s Hospital of Changzhou, the Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Qing Qian
- Department of Pharmacy, the First People’s Hospital of Changzhou, the Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Yan Jiang
- Department of Pharmacy, the First People’s Hospital of Changzhou, the Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Su-Lan Zou
- Department of Pharmacy, the First People’s Hospital of Changzhou, the Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Nan Hu
- Department of Pharmacy, the First People’s Hospital of Changzhou, the Third Affiliated Hospital of Soochow University, Changzhou, China
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22
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Robinson DH, Hughes CFM, Grigg A. Optimal oral cyclosporin dosing with concomitant posaconazole post allogeneic stem cell transplantation. Leuk Lymphoma 2020; 61:2448-2452. [PMID: 32476517 DOI: 10.1080/10428194.2020.1768381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Cyclosporin is an immunosuppressive agent in allogeneic hematopoietic stem cell transplantation and its metabolism is strongly affected by concomitant drugs, including posaconazole which is now extensively used as anti-fungal prophylaxis post-allograft. We undertook a retrospective audit of 29 patients undergoing their first allograft who were receiving posaconazole at the time of transition from intravenous to oral cyclosporin. This group had a median initial oral cyclosporin dose of 2.58 mg/kg bd (range 1.75-3.95) and high incidence of cyclosporin-related toxicity was noted, requiring significant dose reductions such that by day 60 the media dose was 1.60 mg/kg bd (range 0.86-3.33). We subsequently amended our dosing protocol and analyzed a further 20 patients specifying an initial oral cyclosporin dose of 2.25 mg/kg bd and found this had little impact on toxicity or requirement for dose reductions. Starting doses of no greater than 2 mg/kg bd appear optimal to prevent toxicity in allograft recipients receiving concomitant posaconazole.
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Affiliation(s)
- Danielle H Robinson
- Department of Clinical Haematology, Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Melbourne, Victoria, Australia
| | - Charlotte F M Hughes
- Department of Clinical Haematology, Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Melbourne, Victoria, Australia
| | - Andrew Grigg
- Department of Clinical Haematology, Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Melbourne, Victoria, Australia
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23
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Van Daele R, Spriet I, Maertens J. Posaconazole in prophylaxis and treatment of invasive fungal infections: a pharmacokinetic, pharmacodynamic and clinical evaluation. Expert Opin Drug Metab Toxicol 2020; 16:539-550. [DOI: 10.1080/17425255.2020.1764939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Ruth Van Daele
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
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24
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Abstract
Objectives The objectives of this study were to investigate the population pharmacokinetics of posaconazole in immunocompromised children, evaluate the influence of patient characteristics on posaconazole exposure and perform simulations to recommend optimal starting doses. Methods Posaconazole plasma concentrations from paediatric patients undergoing therapeutic drug monitoring were extracted from a tertiary paediatric hospital database. These were merged with covariates collected from electronic sources and case-note reviews. An allometrically scaled population-pharmacokinetic model was developed to investigate the effect of tablet and suspension relative bioavailability, nonlinear bioavailability of suspension, followed by a step-wise covariate model building exercise to identify other important sources of variability. Results A total of 338 posaconazole plasma concentrations samples were taken from 117 children aged 5 months to 18 years. A one-compartment model was used, with tablet apparent clearance standardised to a 70-kg individual of 15 L/h. Suspension was found to have decreasing bioavailability with increasing dose; the estimated suspension dose to yield half the tablet bioavailability was 99 mg/m2. Diarrhoea and proton pump inhibitors were also associated with reduced suspension bioavailability. Conclusions In the largest population-pharmacokinetic study to date in children, we have found similar covariate effects to those seen in adults, but low bioavailability of suspension in patients with diarrhoea or those taking concurrent proton pump inhibitors, which may in particular limit the use of posaconazole in these patients. Electronic supplementary material The online version of this article (10.1007/s40262-018-0658-1) contains supplementary material, which is available to authorized users.
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25
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Peçanha-Pietrobom PM, Falqueto A, Rodrigues Gandarella AD, Moyzés JV, Rangel KA, Miranda LB, Hemerly MC, Careta RS, Peçanha PM. Case Report: Paracoccidioidomycosis in Solid Organ Transplantation: Disseminated Disease in a Liver Recipient and Literature Review. Am J Trop Med Hyg 2019; 101:1100-1106. [PMID: 31516118 PMCID: PMC6838593 DOI: 10.4269/ajtmh.18-1008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 07/17/2019] [Indexed: 01/15/2023] Open
Abstract
Paracoccidioidomycosis (PCM) is an endemic systemic mycosis that is of great importance in Latin America. Its occurrence in solid organ transplantation (SOT) is rare, but with high mortality rate. In this report, we describe a case of PCM in a liver transplant recipient 19 months after transplantation. The patient presented with multiple skin abscesses, arthritis, osteolytic lesions, and pulmonary and adrenal involvement. Despite the presence of disseminated disease and the patient's immunosuppressed condition, the patient responded well to prolonged antifungal treatment with no sequelae, thus suggesting that early diagnosis and correct treatment may lead to favorable outcomes in SOT recipients with PCM.
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Affiliation(s)
- Paula M. Peçanha-Pietrobom
- Division of Infectious Diseases, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Aloisio Falqueto
- Infectious Diseases Unit, Hospital Universitário Cassiano Antônio Moraes, Universidade Federal do Espírito Santo, Vitoria, Brazil
| | | | - Júlia Vieira Moyzés
- Infectious Diseases Unit, Hospital Universitário Cassiano Antônio Moraes, Universidade Federal do Espírito Santo, Vitoria, Brazil
| | - Karoline Almeida Rangel
- Infectious Diseases Unit, Hospital Universitário Cassiano Antônio Moraes, Universidade Federal do Espírito Santo, Vitoria, Brazil
| | - Letícia Balarini Miranda
- Infectious Diseases Unit, Hospital Universitário Cassiano Antônio Moraes, Universidade Federal do Espírito Santo, Vitoria, Brazil
| | - Matheus Compart Hemerly
- Infectious Diseases Unit, Hospital Universitário Cassiano Antônio Moraes, Universidade Federal do Espírito Santo, Vitoria, Brazil
| | - Renata Scarpa Careta
- Department of Pathology, Hospital Universitário Cassiano Antônio Moraes, Universidade Federal do Espírito Santo, Vitoria, Brazil
| | - Paulo Mendes Peçanha
- Infectious Diseases Unit, Hospital Universitário Cassiano Antônio Moraes, Universidade Federal do Espírito Santo, Vitoria, Brazil
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Jović Z, Janković SM, Ružić Zečević D, Milovanović D, Stefanović S, Folić M, Milovanović J, Kostić M. Clinical Pharmacokinetics of Second-Generation Triazoles for the Treatment of Invasive Aspergillosis and Candidiasis. Eur J Drug Metab Pharmacokinet 2019; 44:139-157. [PMID: 30284178 DOI: 10.1007/s13318-018-0513-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Second-generation triazoles were developed in response to the quest for more efficacious and safer therapeutic options for the treatment of severe systemic aspergillosis and candidiasis. These agents include voriconazole, posaconazole, isavuconazole, and ravuconazole. The aim of this review was to present and compare the pharmacokinetic characteristics of second-generation triazoles for the treatment of invasive aspergillosis and candidiasis, emphasizing their clinical implications. The MEDLINE, Scopus, EBSCO, Google Scholar, and SCIndeks databases were searched using advanced search options, including the names of second-generation triazoles and pharmacokinetic terms as keywords. The intravenous administration of voriconazole, posaconazole, and isavuconazole results in stable pharmacokinetics of these drugs, with mostly predictable variations influenced by common and usually known factors in routine clinical settings. The high oral bioavailability of isavuconazole and, to some extent, voriconazole makes them suitable for intravenous-to-oral switch strategies. Except for intravenous voriconazole (due to the accumulation of the toxic vehicle hydroxypropyl betadex), dose reduction of second-generation triazoles is not needed in patients with renal failure; patients with hepatic insufficiency require dose reduction only in advanced disease stages. The introduction of therapeutic drug monitoring could aid attempts to optimize the blood concentrations of triazoles and other drugs that are known to or that possibly interact, thus increasing treatment efficacy and safety. There is a need for new studies that are designed to provide useful data on second-generation triazole pharmacokinetics, particularly in special circumstances such as central nervous system and ocular infections, infections in newborns and infants, and in subjects with genetic polymorphisms of metabolizing enzymes.
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Affiliation(s)
- Zorica Jović
- Faculty of Medicine, University of Niš, Niš, Serbia
| | - Slobodan M Janković
- Faculty of Medical Sciences, University of Kragujevac, Zmaj Jovina Street, 30, Kragujevac, 34000, Serbia.
| | - Dejana Ružić Zečević
- Faculty of Medical Sciences, University of Kragujevac, Zmaj Jovina Street, 30, Kragujevac, 34000, Serbia
| | - Dragan Milovanović
- Faculty of Medical Sciences, University of Kragujevac, Zmaj Jovina Street, 30, Kragujevac, 34000, Serbia
| | - Srđan Stefanović
- Faculty of Medical Sciences, University of Kragujevac, Zmaj Jovina Street, 30, Kragujevac, 34000, Serbia
| | - Marko Folić
- Faculty of Medical Sciences, University of Kragujevac, Zmaj Jovina Street, 30, Kragujevac, 34000, Serbia
| | - Jasmina Milovanović
- Faculty of Medical Sciences, University of Kragujevac, Zmaj Jovina Street, 30, Kragujevac, 34000, Serbia
| | - Marina Kostić
- Faculty of Medical Sciences, University of Kragujevac, Zmaj Jovina Street, 30, Kragujevac, 34000, Serbia
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Sparkes T, Lemonovich TL. Interactions between anti-infective agents and immunosuppressants-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13510. [PMID: 30817021 DOI: 10.1111/ctr.13510] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/12/2019] [Indexed: 01/14/2023]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation provide an update on potential drug-drug interactions between anti-infectives and immunosuppressants, which are most notable with calcineurin and mTOR inhibitors. Drug-drug interactions may occur through pharmacokinetic mechanisms leading to altered drug concentrations of either the anti-infective or immunosuppressive drug, or by pharmacodynamic interactions increasing or decreasing the efficacy or toxicity of the medications. Many of the significant pharmacokinetic interactions occur through inhibition or induction of the cytochrome 3A4 system by anti-infective agents leading to increased or decreased immunosuppressive agent levels, respectively. The membrane transporter P-glycoprotein is also often involved in drug interactions. Since the last iteration of these guidelines, multiple new hepatitis C virus direct-acting antivirals have become available for use in SOT recipients. Of these agents, some are substrates of cytochrome and drug transporter systems, while others inhibit these systems and may affect immunosuppressive agents. Due to the high risk for drug-drug interactions in the solid organ transplant population, practitioners must be aware of potential interactions and be vigilant in monitoring and adjusting drug dosing when appropriate.
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Affiliation(s)
- Tracy Sparkes
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland
| | - Tracy L Lemonovich
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
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Collins J, Shea K, Parsad S, Plach K, Lee P. The impact of initiating posaconazole on tacrolimus pharmacokinetics in allogeneic stem cell transplantation. J Oncol Pharm Pract 2019; 26:5-12. [DOI: 10.1177/1078155219833440] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Posaconazole reduces the risk of invasive Aspergillus in transplant patients, but significantly inhibits tacrolimus metabolism. One study demonstrated that a three-fold dose reduction of tacrolimus was required to obtain therapeutic concentrations when used with posaconazole. However, with empiric dose reduction, there is a risk of subtherapeutic tacrolimus levels and subsequent graft failure or graft-versus-host disease. Overall, the existing data on the impact of posaconazole on tacrolimus pharmacokinetics is limited. Objective The purpose of this study is to determine whether tacrolimus doses should be decreased upon initiation of posaconazole in patients receiving an allogeneic stem cell transplant. Methods This is a retrospective chart review at an academic medical center. All allogeneic stem cell transplant adults who received concomitant posaconazole and tacrolimus from February 2016 through December 2017 were included. Results Seventy-nine patients identified using an internal electronic database were analyzed. The median time to therapeutic tacrolimus concentration was significantly longer in patients who did not receive an empiric dose reduction (0% DR, 10d; 1–30% DR, 4d; 31–65% DR, 5d; >65% DR, 4d; p = 0.0395). The rate of supratherapeutic levels was highest amongst patients who did not receive an empiric DR, and was noted to be significant compared to the group that had 31–65% DR ( p < 0.001). Conclusion This study validates our current practice of instituting an empiric 50% dose reduction of oral tacrolimus to 0.03 mg/kg/day when used concomitantly with posaconazole to achieve therapeutic levels in allogeneic stem cell transplant patients.
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Affiliation(s)
| | | | | | - Kelly Plach
- Barnes-Jewish Hospital, Saint Louis, MO, USA
| | - Pauline Lee
- University of Chicago Medicine, Chicago, IL, USA
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Moran C, Delafield NL, Kenny G, Asbury KL, Larsen BT, Lambert KL, Patron RL. A case ofVerruconis gallopavainfection in a heart transplant recipient successfully treated with posaconazole. Transpl Infect Dis 2019; 21:e13044. [DOI: 10.1111/tid.13044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/06/2018] [Accepted: 12/16/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Conor Moran
- Department of Medicine Mater Misericordiae University Hospital Dublin Ireland
| | | | - Grace Kenny
- Department of Medicine Mater Misericordiae University Hospital Dublin Ireland
| | - Kara L. Asbury
- Division of Infectious Diseases Mayo Clinic Hospital Phoenix Arizona
| | - Brandon T. Larsen
- Department of Laboratory Medicine and Pathology Mayo Clinic Scottsdale Arizona
| | - Karen L. Lambert
- Department of Laboratory Medicine and Pathology Mayo Clinic Hospital Phoenix Arizona
| | - Roberto L. Patron
- Division of Infectious Diseases Mayo Clinic Hospital Phoenix Arizona
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Zhang J, Li L, Lv Q, Yan L, Wang Y, Jiang Y. The Fungal CYP51s: Their Functions, Structures, Related Drug Resistance, and Inhibitors. Front Microbiol 2019; 10:691. [PMID: 31068906 PMCID: PMC6491756 DOI: 10.3389/fmicb.2019.00691] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 03/19/2019] [Indexed: 12/18/2022] Open
Abstract
CYP51 (Erg11) belongs to the cytochrome P450 monooxygenase (CYP) superfamily and mediates a crucial step of the synthesis of ergosterol, which is a fungal-specific sterol. It is also the target of azole drugs in clinical practice. In recent years, researches on fungal CYP51 have stepped into a new stage attributing to the discovery of crystal structures of the homologs in Candida albicans, Cryptococcus neoformans and Aspergillus fumigatus. This review summarizes the functions, structures of fungal CYP51 proteins, and the inhibitors targeting these homologs. In particular, several drug-resistant mechanisms associated with the fungal CYP51s are introduced. The sequences and crystal structures of CYP51 proteins in different fungal species are also compared. These will provide new insights for the advancement of research on antifungal agents.
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Affiliation(s)
- Jingxiang Zhang
- Center for New Drug Research, School of Pharmacy, Second Military Medical University, Shanghai, China
| | - Liping Li
- Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Department of Pharmacology, Tongji University School of Medicine, Shanghai, China
| | - Quanzhen Lv
- Center for New Drug Research, School of Pharmacy, Second Military Medical University, Shanghai, China
| | - Lan Yan
- Center for New Drug Research, School of Pharmacy, Second Military Medical University, Shanghai, China
- *Correspondence: Lan Yan, Yan Wang, Yuanying Jiang,
| | - Yan Wang
- Center for New Drug Research, School of Pharmacy, Second Military Medical University, Shanghai, China
- *Correspondence: Lan Yan, Yan Wang, Yuanying Jiang,
| | - Yuanying Jiang
- Center for New Drug Research, School of Pharmacy, Second Military Medical University, Shanghai, China
- Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Department of Pharmacology, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Lan Yan, Yan Wang, Yuanying Jiang,
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31
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Nel JS, Bartelt LA, van Duin D, Lachiewicz AM. Endemic Mycoses in Solid Organ Transplant Recipients. Infect Dis Clin North Am 2018; 32:667-685. [PMID: 30146029 DOI: 10.1016/j.idc.2018.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The endemic mycoses are a group of thermally dimorphic fungal pathogens occupying a specific geographic range. In North America, the chief endemic mycoses are histoplasmosis, coccidioidomycosis, and blastomycosis. Endemic fungi can cause serious infections in solid organ transplant recipients from primary infection, reactivation of latent disease, or donor-derived infection.
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Affiliation(s)
- Jeremy S Nel
- Division of Infectious Diseases, University of North Carolina, CB 7030, 130 Mason Farm Road, Chapel Hill, NC 27599, USA
| | - Luther A Bartelt
- Division of Infectious Diseases, University of North Carolina, CB 7030, 130 Mason Farm Road, Chapel Hill, NC 27599, USA
| | - David van Duin
- Division of Infectious Diseases, University of North Carolina, CB 7030, 130 Mason Farm Road, Chapel Hill, NC 27599, USA
| | - Anne M Lachiewicz
- Division of Infectious Diseases, University of North Carolina, CB 7030, 130 Mason Farm Road, Chapel Hill, NC 27599, USA.
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Analysis of Clinical Drug-Drug Interaction Data To Predict Magnitudes of Uncharacterized Interactions between Antiretroviral Drugs and Comedications. Antimicrob Agents Chemother 2018; 62:AAC.00717-18. [PMID: 29686151 PMCID: PMC6021627 DOI: 10.1128/aac.00717-18] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Indexed: 12/12/2022] Open
Abstract
Despite their high potential for drug-drug interactions (DDI), clinical DDI studies of antiretroviral drugs (ARVs) are often lacking, because the full range of potential interactions cannot feasibly or pragmatically be studied, with some high-risk DDI studies also being ethically difficult to undertake. Thus, a robust method to screen and to predict the likelihood of DDIs is required. We developed a method to predict DDIs based on two parameters: the degree of metabolism by specific enzymes, such as CYP3A, and the strength of an inhibitor or inducer. These parameters were derived from existing studies utilizing paradigm substrates, inducers, and inhibitors of CYP3A to assess the predictive performance of this method by verifying predicted magnitudes of changes in drug exposure against clinical DDI studies involving ARVs. The derived parameters were consistent with the FDA classification of sensitive CYP3A substrates and the strength of CYP3A inhibitors and inducers. Characterized DDI magnitudes (n = 68) between ARVs and comedications were successfully quantified, meaning 53%, 85%, and 98% of the predictions were within 1.25-fold (0.80 to 1.25), 1.5-fold (0.66 to 1.48), and 2-fold (0.66 to 1.94) of the observed clinical data. In addition, the method identifies CYP3A substrates likely to be highly or, conversely, minimally impacted by CYP3A inhibitors or inducers, thus categorizing the magnitude of DDIs. The developed effective and robust method has the potential to support a more rational identification of dose adjustment to overcome DDIs, being particularly relevant in an HIV setting, given the treatment's complexity, high DDI risk, and limited guidance on the management of DDIs.
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Gupta AK, Versteeg SG, Shear NH. Common drug-drug interactions in antifungal treatments for superficial fungal infections. Expert Opin Drug Metab Toxicol 2018; 14:387-398. [DOI: 10.1080/17425255.2018.1461834] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Aditya K. Gupta
- Department of Medicine, University of Toronto School of Medicine, Toronto, Canada
- Mediprobe Research Inc., London, Canada
| | | | - Neil H. Shear
- Department of Medicine (Dermatology, Clinical Pharmacology and Toxicology) and Department of Pharmacology, Sunnybrook and Women’s College Health Science Centre and the University of Toronto, Toronto, Canada
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Launay M, Roux A, Beaumont L, Douvry B, Lecuyer L, Douez E, Picard C, Grenet D, Jullien V, Boussaud V, Guillemain R, Billaud EM. Posaconazole Tablets in Real-Life Lung Transplantation: Impact on Exposure, Drug-Drug Interactions, and Drug Management in Lung Transplant Patients, Including Those with Cystic Fibrosis. Antimicrob Agents Chemother 2018; 62:e02061-17. [PMID: 29311077 PMCID: PMC5826104 DOI: 10.1128/aac.02061-17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 12/14/2017] [Indexed: 01/02/2023] Open
Abstract
Appropriate exposure to posaconazole (PSZ) has been limited until the recent approval of the delayed-release oral tablet formulation. Our goal was to determine the exposure obtained by using the standard dose of 300 mg once a day in lung transplant (LT) patients, including patients with cystic fibrosis (CF). PSZ trough concentrations (C0) were determined using a liquid chromatography-tandem mass spectrometry assay. Indicative thresholds of interest were <0.7 mg/liter for prophylaxis and 1 to 3 mg/liter for cure. The tacrolimus (TRL) and everolimus (ERL) C0 measured during PSZ exposure were also collected. The interaction with proton-pump inhibitors (PPI) was evaluated. We recorded the results for 21 CF patients with LT (CFLT patients), 11 non-CF patients with LT (NCFLT patients), and 27 nontransplant (NT) patients in pneumology departments. The weights of the NCFLT, CFLT, and NT patients were 59.2 ± 8.4, 48.8 ± 8.4, and 63.7 ± 16.6 kg, respectively (P = 0.001* [asterisk means that statistical test is significant]), and the PSZ C0 exposures for these patients were 1.9 ± 1.5, 1.1 ± 0.8, and 2.4 ± 1.8 mg/liter, respectively (P < 0.00001*). More than 60% of the concentrations were in the therapeutic range. In CFLT patients, the administration of one 300-mg PSZ tablet quickly achieved an exposure similar to that achieved with the PSZ oral suspension formulation (OSF) administered 3 or 4 times a day for several months. The TRL C0/dose ratio (C0/D) was 7.4 ± 4.4 mg/liter with PSZ tablets, whereas it was 4.6 ± 0.8 mg/liter with the PSZ oral solution (P = 0.034*). The ERL C0/D was similar with both formulations. PPI had no impact on the PSZ concentration (1.49 ± 1.07 mg/liter without PPI versus 1.33 ± 1.17 mg/liter with PPI; P = 0.4134*). Despite the high levels of exposure, PSZ remained well tolerated (one case of diarrhea and one case of fatigue were reported). PSZ tablet administration allows satisfactory exposure, even in CFLT patients, with a dosage lower than that of the PSZ OSF. This once-a-day formulation was not impacted by PPI, which are extensively used in CF patients.
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Affiliation(s)
- Manon Launay
- Laboratory of Pharmacology and Toxicology, European Hospital Georges Pompidou-APHP, Paris, France
| | - Antoine Roux
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
- Université Versailles Saint-Quentin, Versailles, France
| | - Laurence Beaumont
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Benoit Douvry
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Lucien Lecuyer
- Thoracic Transplantation, European Hospital Georges Pompidou-APHP, Paris, France
| | - Emmanuel Douez
- Laboratory of Pharmacology and Toxicology, European Hospital Georges Pompidou-APHP, Paris, France
| | - Clément Picard
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Dominique Grenet
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Vincent Jullien
- Laboratory of Pharmacology and Toxicology, European Hospital Georges Pompidou-APHP, Paris, France
| | - Véronique Boussaud
- Thoracic Transplantation, European Hospital Georges Pompidou-APHP, Paris, France
| | - Romain Guillemain
- Thoracic Transplantation, European Hospital Georges Pompidou-APHP, Paris, France
| | - Eliane M Billaud
- Laboratory of Pharmacology and Toxicology, European Hospital Georges Pompidou-APHP, Paris, France
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Chen M, Zhuang JL, Duan MH, Zhang W, Li J, Zhu TN, Cai HC, Cao XX, Feng J, Yang C, Zhang Y, Zhang L, Zhou DB, Han B. [Posaconazole as primary prevention of fungal infection in intensive immunosuppressive therapy for severe aplastic anemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 39:128-131. [PMID: 29562447 PMCID: PMC7342574 DOI: 10.3760/cma.j.issn.0253-2727.2018.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Indexed: 11/30/2022]
Abstract
Objective: To Evaluate the efficacy and safety of posaconazole as primary prevention of invasive fungal disease (IFD) in patients with severe aplastic anemia (SAA) treated with anti-thymus/lymphocyte immunoglobulin (ATG/ALG) combined with cyclosporine intensive immunosuppressive therapy (IST). Methods: A retrospective analysis of clinical data of 58 SAA patients who received IST of anti-thymocyte immunoglobulin combining cyclosporine and antifungal prophylaxis during April 2013 to May 2017 in Peking Union Medical College Hospital was performed. The patients were divided into posaconazole prophylaxis group and the control group (itraconazole or fluconazole). The disease characteristics, IFD prevention effect and adverse drug reaction, curative effect and prognosis of the two groups were compared. Results: Posaconazole was used to prevent fungal infection in 20 patients. The other 38 patients were used as the control group. Retrospective analysis showed comparable characteristics (gender, age, disease severity, etiology, interval between the onset of disease to treatment, ATG/ALG type) of both groups. The incidence of IFD were 0 and 15.8% in posaconazole prophylaxis group and the control group, respectively (P=0.084). In the control group, there were 6 cases diagnosed as IFD. Of them, 2 were confirmed, 2 suspected and 2 not identified. Five of the 6 cases were pulmonary infection, 1 bloodstream infections. Of the 6 IFD cases, 5 were very severe aplastic anemia (VSAA). There was no obvious adverse reaction in posaconazole prophylaxis group. Conclusion: Posaconazole is safe and effective for primary prevention of fungal infection of SAA patients receiving IST, especially for the VSAA.
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Affiliation(s)
- M Chen
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100730, China
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Groll AH, Townsend R, Desai A, Azie N, Jones M, Engelhardt M, Schmitt-Hoffman AH, Brüggemann RJM. Drug-drug interactions between triazole antifungal agents used to treat invasive aspergillosis and immunosuppressants metabolized by cytochrome P450 3A4. Transpl Infect Dis 2017; 19. [PMID: 28722255 DOI: 10.1111/tid.12751] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 05/15/2017] [Accepted: 05/15/2017] [Indexed: 01/03/2023]
Abstract
Patients undergoing treatment with immunosuppressant drugs following solid organ or hematopoietic stem cell transplantation are at particular risk for development of serious infections such as invasive aspergillosis. Four triazole antifungal drugs, voriconazole, posaconazole, itraconazole, and isavuconazole, are approved to treat invasive aspergillosis either as first- or second-line therapy. All of these agents are inhibitors of cytochrome P450 3A4, which plays a key role in metabolizing immunosuppressant drugs such as cyclosporine, tacrolimus, and sirolimus. Thus, co-administration of a triazole antifungal drug with these immunosuppressant drugs can potentially increase plasma concentrations of the immunosuppressant drugs, thereby resulting in toxicity, or upon discontinuation, inadvertently decrease the respective concentrations with increased risk of rejection or graft-versus-host disease. In this article, we review the evidence for the extent of inhibition of cytochrome P450 3A4 by each of these triazole antifungal drugs and assess their effects on cyclosporine, tacrolimus, and sirolimus. We also consider other factors affecting interactions of these two classes of drugs. Finally, we examine recommendations and strategies to evaluate and address those potential drug-drug interactions in these patients.
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Affiliation(s)
- Andreas H Groll
- Department of Pediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany
| | - Robert Townsend
- Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Amit Desai
- Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Nkechi Azie
- Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Mark Jones
- Basilea Pharmaceutica International Ltd, Basel, Switzerland
| | | | | | - Roger J M Brüggemann
- Department of Pharmacy, Radboud University Nijmegen Medical Centre, and Centre of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
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37
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Fishman JA. Infection in Organ Transplantation. Am J Transplant 2017; 17:856-879. [PMID: 28117944 DOI: 10.1111/ajt.14208] [Citation(s) in RCA: 433] [Impact Index Per Article: 61.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/09/2017] [Indexed: 01/25/2023]
Abstract
The prevention, diagnosis, and management of infectious disease in transplantation are major contributors to improved outcomes in organ transplantation. The risk of serious infections in organ recipients is determined by interactions between the patient's epidemiological exposures and net state of immune suppression. In organ recipients, there is a significant incidence of drug toxicity and a propensity for drug interactions with immunosuppressive agents used to maintain graft function. Thus, every effort must be made to establish specific microbiologic diagnoses to optimize therapy. A timeline can be created to develop a differential diagnosis of infection in transplantation based on common patterns of infectious exposures, immunosuppressive management, and antimicrobial prophylaxis. Application of quantitative molecular microbial assays and advanced antimicrobial therapies have advanced care. Pathogen-specific immunity, genetic polymorphisms in immune responses, and dynamic interactions between the microbiome and the risk of infection are beginning to be explored. The role of infection in the stimulation of alloimmune responses awaits further definition. Major hurdles include the shifting worldwide epidemiology of infections, increasing antimicrobial resistance, suboptimal assays for the microbiologic screening of organ donors, and virus-associated malignancies. Transplant infectious disease remains a key to the clinical and scientific investigation of organ transplantation.
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Affiliation(s)
- J A Fishman
- Transplant Infectious Disease and Immunocompromised Host Program and MGH Transplant Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Agarwal SK, DiNardo CD, Potluri J, Dunbar M, Kantarjian HM, Humerickhouse RA, Wong SL, Menon RM, Konopleva MY, Salem AH. Management of Venetoclax-Posaconazole Interaction in Acute Myeloid Leukemia Patients: Evaluation of Dose Adjustments. Clin Ther 2017; 39:359-367. [DOI: 10.1016/j.clinthera.2017.01.003] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 12/08/2016] [Accepted: 01/03/2017] [Indexed: 11/29/2022]
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Lefeuvre S, Jelassi ML, Benlmouden A, Berge M, Le Guellec C, Billaud EM. [Not Available]. Therapie 2016; 66:115-22. [PMID: 27393646 DOI: 10.2515/therapie/2011010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Accepted: 09/30/2010] [Indexed: 11/20/2022]
Abstract
Posaconazole, systemic antifungal marketed in France since 2006, is indicated as second line in curative treatment of invasive fungal infections (IFI) (aspergillosis. . . ) and prophylaxis of IFI in patients receiving chemotherapy or hematopoietic stem cell transplantation. The analysis of the literature indicates a concentration-efficacy relationship, but to date, no study has been able to show a concentration-toxicity correlation due to its favourable safety profile and the difficulty to obtain high concentrations. In curative, maintenance of trough plasma concentrations between 0.5 and 1.5 mg/L seems to be associate with an efficacy. In prophylaxis, a threshold of 0.5 mg/L corresponds to a minimal exposure. However this target is not yet well defined. Saturation of absorption above the 800 mg oral dose limits the adjustment of concentrations. As such, the Therapeutic Drug Monitoring of posaconazole can be recommended.
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Affiliation(s)
- Sandrine Lefeuvre
- Laboratoire de Pharmacologie-Toxicologie, Assistance Publique-Hôpitaux de Paris, Hôpital EuropéenGeorgesPompidou, Paris, France; Université Paris Descartes, Paris, France
| | - Mohammed-Larbi Jelassi
- Laboratoire de Pharmacologie-Toxicologie, Assistance Publique-Hôpitaux de Paris, Hôpital EuropéenGeorgesPompidou, Paris, France
| | - Amine Benlmouden
- Laboratoire de Pharmacologie-Toxicologie, Assistance Publique-Hôpitaux de Paris, Hôpital EuropéenGeorgesPompidou, Paris, France
| | - Maud Berge
- Laboratoire de Pharmacologie-Toxicologie, Assistance Publique-Hôpitaux de Paris, Hôpital EuropéenGeorgesPompidou, Paris, France; Université Paris Descartes, Paris, France
| | | | - Eliane M Billaud
- Laboratoire de Pharmacologie-Toxicologie, Assistance Publique-Hôpitaux de Paris, Hôpital EuropéenGeorgesPompidou, Paris, France; Université Paris Descartes, Paris, France.
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40
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Greco R, Barbanti MC, Lupo Stranghellini MT, Giglio F, Morelli M, Messina C, Forcina A, Oltolini C, Piemontese S, Scarpellini P, Marktel S, Assanelli A, Carrabba M, Vago L, Corti C, Bernardi M, Peccatori J, Ciceri F. Coadministration of posaconazole and sirolimus in allogeneic hematopoietic stem cell transplant recipients. Bone Marrow Transplant 2016; 51:1022-4. [PMID: 27111047 DOI: 10.1038/bmt.2016.112] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- R Greco
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - M C Barbanti
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - M T Lupo Stranghellini
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - F Giglio
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - M Morelli
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - C Messina
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - A Forcina
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - C Oltolini
- Infectious Disease Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - S Piemontese
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - P Scarpellini
- Infectious Disease Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - S Marktel
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - A Assanelli
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - M Carrabba
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - L Vago
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Unit of Immunogenetics, Leukemia Genomics and Immunobiology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - C Corti
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - M Bernardi
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - J Peccatori
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - F Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy.,University Vita-Salute, Milano, Italy
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Vanhove T, Annaert P, Kuypers DRJ. Clinical determinants of calcineurin inhibitor disposition: a mechanistic review. Drug Metab Rev 2016; 48:88-112. [DOI: 10.3109/03602532.2016.1151037] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Robinson C, Chau C, Yerkovich S, Azzopardi M, Hopkins P, Chambers D. Posaconazole in lung transplant recipients: use, tolerability, and efficacy. Transpl Infect Dis 2016; 18:302-8. [DOI: 10.1111/tid.12497] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 09/04/2015] [Accepted: 11/01/2015] [Indexed: 11/29/2022]
Affiliation(s)
- C.L. Robinson
- Toowoomba Base Hospital; Toowoomba Queensland Australia
| | - C. Chau
- School of Pharmacy; The University of Queensland; Brisbane Queensland Australia
| | - S.T. Yerkovich
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
- Queensland Lung Transplant Service; The Prince Charles Hospital; Brisbane Queensland Australia
| | - M. Azzopardi
- Queensland Lung Transplant Service; The Prince Charles Hospital; Brisbane Queensland Australia
| | - P. Hopkins
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
- Queensland Lung Transplant Service; The Prince Charles Hospital; Brisbane Queensland Australia
| | - D. Chambers
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
- Queensland Lung Transplant Service; The Prince Charles Hospital; Brisbane Queensland Australia
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43
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Abstract
Posaconazole, a broad-spectrum triazole antifungal agent, is approved for the prevention of invasive aspergillosis and candidiasis in addition to the treatment of oropharyngeal candidiasis. There is evidence of efficacy in the treatment and prevention of rarer, more difficult-to-treat fungal infections. Posaconazole oral suspension solution has shown limitations with respect to fasting state absorption, elevated gastrointestinal pH and increased motility. The newly approved delayed-release oral tablet and intravenous solution formulations provide an attractive treatment option by reducing interpatient variability and providing flexibility in critically ill patients. On the basis of clinical experience and further clinical studies, posaconazole was found to be a valuable pharmaceutical agent for the treatment of life-threatening fungal infections. This review will examine the development history of posaconazole and highlight the most recent advances.
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Affiliation(s)
- Jason N Moore
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, 132 South Tenth Street, Main Building, Room 1170, Philadelphia, PA 19107, USA
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44
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Leung S, Poulakos MN, Machin J. Posaconazole: An Update of Its Clinical Use. PHARMACY 2015; 3:210-268. [PMID: 28975914 PMCID: PMC5597105 DOI: 10.3390/pharmacy3040210] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 08/11/2015] [Accepted: 08/26/2015] [Indexed: 12/03/2022] Open
Abstract
Posaconazole (PCZ) is a relatively new addition to the azole antifungals. It has fungicidal activities against Aspergillus fumigatus, Blastomyces dermatitidis, selected Candida species, Crytopcoccus neoformans, and Trichosporon. PCZ also has fungistatic activities against Candida, Coccidioides, selected Fusarium spp., Histoplasma, Scedosporium and Zygomycetes. In addition, combining the drug with caspofungin or amphotericin B results in a synergistic interaction against A. fumigatus, C. glabrata and C. neoformans. The absorption of PCZ suspension is enhanced when given with food, nutritional supplements, and carbonated beverages. Oral administration of PCZ in divided doses also increases its bioavailability. PCZ has a large volume of distribution and is highly protein bound (>95%). The main elimination route of PCZ is fecal. PCZ is an inhibitor of the CYP3A4 enzyme; therefore, monitoring for drug-drug interactions is warranted with other CYP3A4 substrates/inhibitors/inducers. The most common adverse effects include headache, fatigue, nausea, vomiting and elevated hepatic enzymes. PCZ, with its unique antifungal activities, expands the azole class of antifungal agents. Because of its limit in formulation, PCZ oral suspension is recommended in immunocompromised patients with functional gastrointestinaltracts who fail conventional antifungal therapies or who are suspected to have a breakthrough fungal infection. However, a delayed-release tablet formulation and intravenous (IV) injection became available in 2014, expanding the use of PCZ in other patient populations, including individuals who are unable to take oral formulations.
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Affiliation(s)
- Simon Leung
- Memorial Regional Hospital, Hollywood, FL 33021, USA.
| | - Mara N Poulakos
- Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL 33416.
| | - Jade Machin
- Boca Raton Regional Hospital, Boca Raton, FL 33486, USA.
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Role of New Antifungal Agents in the Treatment of Invasive Fungal Infections in Transplant Recipients: Isavuconazole and New Posaconazole Formulations. J Fungi (Basel) 2015; 1:345-366. [PMID: 29376915 PMCID: PMC5753129 DOI: 10.3390/jof1030345] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 10/06/2015] [Accepted: 10/06/2015] [Indexed: 11/30/2022] Open
Abstract
Invasive fungal infections are a major cause of morbidity and mortality among solid organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) recipients. Transplant patients are at risk for such invasive fungal infections. The most common invasive fungal infections are invasive candidiasis in the SOT and invasive aspergillosis in the HSCT. In this article, we will discuss the epidemiology of invasive fungal infections in the transplant recipients and susceptibility patterns of the fungi associated with these infections. Additionally, the pharmacology and clinical efficacy of the new antifungal, isavuconazole, and the new posaconazole formulations will be reviewed. Isavuconazole is a new extended-spectrum triazole that was recently approved for the treatment of invasive aspergillosis and mucormycosis. Advantages of this triazole include the availability of a water-soluble intravenous formulation, excellent bioavailability of the oral formulation, and predictable pharmacokinetics in adults. Posaconazole, a broad-spectrum triazole antifungal agent, is approved for the prevention of invasive aspergillosis and candidiasis in addition to the treatment of oropharyngeal candidiasis. Posaconazole oral suspension solution has shown some limitations in the setting of fasting state absorption, elevated gastrointestinal pH, and increased motility. The newly approved delayed-release oral tablet and intravenous solution formulations provide additional treatment options by reducing interpatient variability and providing flexibility in these set of critically ill patients. This review will detail these most recent studies.
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46
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Chau MM, Kong DCM, van Hal SJ, Urbancic K, Trubiano JA, Cassumbhoy M, Wilkes J, Cooper CM, Roberts JA, Marriott DJE, Worth LJ. Consensus guidelines for optimising antifungal drug delivery and monitoring to avoid toxicity and improve outcomes in patients with haematological malignancy, 2014. Intern Med J 2015; 44:1364-88. [PMID: 25482746 DOI: 10.1111/imj.12600] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Antifungal agents may be associated with significant toxicity or drug interactions leading to sub-therapeutic antifungal drug concentrations and poorer clinical outcomes for patients with haematological malignancy. These risks may be minimised by clinical assessment, laboratory monitoring, avoidance of particular drug combinations and dose modification. Specific measures, such as the optimal timing of oral drug administration in relation to meals, use of pre-hydration and electrolyte supplementation may also be required. Therapeutic drug monitoring (TDM) of antifungal agents is warranted, especially where non-compliance, non-linear pharmacokinetics, inadequate absorption, a narrow therapeutic window, suspected drug interaction or unexpected toxicity are encountered. Recommended indications for voriconazole and posaconazole TDM in the clinical management of haematology patients are provided. With emerging knowledge regarding the impact of pharmacogenomics upon metabolism of azole agents (particularly voriconazole), potential applications of pharmacogenomic evaluation to clinical practice are proposed.
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Affiliation(s)
- M M Chau
- Pharmacy Department, The Royal Melbourne Hospital, Melbourne Health, Parkville, Victoria
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47
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Oda K, Yamano K, Otsuka Y. In vitro-in vivoextrapolations to evaluate the effect of concomitant drugs on tacrolimus (FK506) exposure. Biopharm Drug Dispos 2015; 36:265-74. [DOI: 10.1002/bdd.1938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 01/07/2015] [Accepted: 01/09/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Kazuo Oda
- Analysis and Pharmacokinetics Research Laboratories; Astellas Pharma Inc.; Yodogawa-ku Osaka 532-8514 Japan
| | - Katsuhiro Yamano
- Analysis and Pharmacokinetics Research Laboratories; Astellas Pharma Inc.; Yodogawa-ku Osaka 532-8514 Japan
| | - Yukio Otsuka
- Analysis and Pharmacokinetics Research Laboratories; Astellas Pharma Inc.; Yodogawa-ku Osaka 532-8514 Japan
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48
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Therapeutic drug monitoring for triazoles: A needs assessment review and recommendations from a Canadian perspective. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2015; 25:327-43. [PMID: 25587296 PMCID: PMC4277162 DOI: 10.1155/2014/340586] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Invasive fungal infections cause significant morbidity and mortality in patients with concomitant underlying immunosuppressive diseases. The recent addition of new triazoles to the antifungal armamentarium has allowed for extended-spectrum activity and flexibility of administration. Over the years, clinical use has raised concerns about the degree of drug exposure following standard approved drug dosing, questioning the need for therapeutic drug monitoring (TDM). Accordingly, the present guidelines focus on TDM of triazole antifungal agents. A review of the rationale for triazole TDM, the targeted patient populations and available laboratory methods, as well as practical recommendations based on current evidence from an extended literature review are provided in the present document.
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49
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Gavaldà J, Meije Y, Fortún J, Roilides E, Saliba F, Lortholary O, Muñoz P, Grossi P, Cuenca-Estrella M. Invasive fungal infections in solid organ transplant recipients. Clin Microbiol Infect 2014; 20 Suppl 7:27-48. [DOI: 10.1111/1469-0691.12660] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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50
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Umeyama Y, Fujioka Y, Okuda T. Clarification of P-glycoprotein inhibition-related drug–drug interaction risks based on a literature search of the clinical information. Xenobiotica 2014; 44:1135-44. [DOI: 10.3109/00498254.2014.928958] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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