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Lehner AF, Johnson SD, Dirikolu L, Johnson M, Buchweitz JP. Mass spectrometric methods for evaluation of voriconazole avian pharmacokinetics and the inhibition of its cytochrome P450-induced metabolism. Toxicol Mech Methods 2024; 34:654-668. [PMID: 38389412 DOI: 10.1080/15376516.2024.2322675] [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: 12/19/2023] [Accepted: 02/19/2024] [Indexed: 02/24/2024]
Abstract
Invasive fungal aspergillosis is a leading cause of morbidity and mortality in many species including avian species such as common ravens (Corvus corax). Methods were developed for mass spectral determination of voriconazole in raven plasma as a means of determining pharmacokinetics of this antifungal agent. Without further development, GC/MS/MS (gas chromatography-tandem quadrupole mass spectrometry) proved to be inferior to LC/MS/MS (liquid chromatography-tandem quadrupole mass spectrometry) for measurement of voriconazole levels in treated raven plasma owing to numerous heat-induced breakdown products despite protection of voriconazole functional groups with trimethylsilyl moieties. LC/MS/MS measurement revealed in multi-dosing experiments that the ravens were capable of rapid or ultrarapid metabolism of voriconazole. This accounted for the animals' inability to raise the drug into the therapeutic range regardless of dosing regimen unless cytochrome P450 (CYP) inhibitors were included. Strategic selection of CYP inhibitors showed that of four selected compounds including cimetidine, enrofloxacin and omeprazole, only ciprofloxacin (Cipro) was able to maintain voriconazole levels in the therapeutic range until the end of the dosing period. The optimal method of administration involved maintenance doses of voriconazole at 6 mg/kg and ciprofloxacin at 20 mg/kg. Higher doses of voriconazole such as 18 mg/kg were also tenable without apparent induction of toxicity. Although most species employ CYP2C19 to metabolize voriconazole, it was necessary to speculate that voriconazole might be subject to metabolism by CYP1A2 in the ravens to explain the utility of ciprofloxacin, a previously unknown enzymatic route. Finally, despite its widespread catalog of CYP inhibitions including CYP1A2 and CYP2C19, cimetidine may be inadequate at enhancing voriconazole levels owing to its known effects on raising gastric pH, a result that may limit voriconazole solubility.
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Affiliation(s)
- Andreas F Lehner
- Section of Toxicology, Michigan State University Veterinary Diagnostic Laboratory, Michigan State University, East Lansing, MI, USA
| | - Sharmie D Johnson
- Department of Veterinary Services, Wildlife World Zoo & Aquarium & Safari Park, Litchfield Park, AZ, USA
| | - Levent Dirikolu
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, USA
| | - Margaret Johnson
- Section of Toxicology, Michigan State University Veterinary Diagnostic Laboratory, Michigan State University, East Lansing, MI, USA
| | - John P Buchweitz
- Section of Toxicology, Michigan State University Veterinary Diagnostic Laboratory, Michigan State University, East Lansing, MI, USA
- Department of Pathobiology & Diagnostic Investigation, College of Veterinary Medicine, Michigan State University, East Lansing, MI, USA
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Kato H, Umemura T, Hagihara M, Shiota A, Asai N, Hamada Y, Mikamo H, Iwamoto T. Development of a therapeutic drug-monitoring algorithm for outpatients receiving voriconazole: A multicentre retrospective study. Br J Clin Pharmacol 2024; 90:1222-1230. [PMID: 38320604 DOI: 10.1111/bcp.16004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 12/27/2023] [Accepted: 01/04/2024] [Indexed: 02/08/2024] Open
Abstract
AIMS Although therapeutic drug monitoring (TDM) of voriconazole is performed in outpatients to prevent treatment failure and toxicity, whether TDM should be performed in all or only selected patients remains controversial. This study evaluated the association between voriconazole trough concentrations and clinical events. METHODS We investigated the aggravation of clinical symptoms, incidence of hepatotoxicity and visual disturbances, change in co-medications and interaction between voriconazole and co-medications in outpatients receiving voriconazole between 2017 and 2021 in three facilities. Abnormal trough concentrations were defined as <1.0 mg/L (low group) and >4.0 mg/L (high group). RESULTS A total of 141 outpatients (578 concentration measurements) met the inclusion criteria (treatment, 37 patients, 131 values; prophylaxis, 104 patients, 447 values). The percentages of patients with abnormal concentrations were 29.0% and 31.5% in the treatment and prophylaxis groups, respectively. Abnormal concentrations showed 50% of the concentrations at the first measurement in both therapies. Aggravation of clinical symptoms was most frequently observed in the low treatment group (18.2%). Adverse events were most common in the high group for both therapies (treatment, hepatotoxicity 6.3%, visual disturbance 18.8%; prophylaxis, hepatotoxicity 27.9%). No differences were found in changes to co-medications and drug interactions. In the prophylaxis group, prescription duration in the presence of clinical events tended to be longer than in their absence (47.4 ± 23.4 days vs 39.7 ± 21.9 days, P = .1132). CONCLUSIONS We developed an algorithm based on clinical events for appropriate implementation of TDM in outpatients. However, future interventions based on this algorithm should be validated.
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Affiliation(s)
- Hideo Kato
- Department of Pharmacy, Mie University Hospital, Tsu, Mie, Japan
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Tsu, Mie, Japan
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takumi Umemura
- Department of Pharmacy, Tosei General Hospital, Seto, Aichi, Japan
| | - Mao Hagihara
- Department of Molecular Epidemiology and Biomedical Sciences, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Arifumi Shiota
- Department of Pharmacy, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Nobuhiro Asai
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan
| | - Yukihiro Hamada
- Department of Pharmacy, Kochi Medical School Hospital, Nankoku, Kochi, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takuya Iwamoto
- Department of Pharmacy, Mie University Hospital, Tsu, Mie, Japan
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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Li G, Li Q, Zhang C, Yu Q, Li Q, Zhou X, Yang R, Yang X, Liu H, Yang Y. The impact of gene polymorphism and hepatic insufficiency on voriconazole dose adjustment in invasive fungal infection individuals. Front Genet 2023; 14:1242711. [PMID: 37693307 PMCID: PMC10484623 DOI: 10.3389/fgene.2023.1242711] [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: 06/19/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Voriconazole (VRZ) is a broad-spectrum antifungal medication widely used to treat invasive fungal infections (IFI). The administration dosage and blood concentration of VRZ are influenced by various factors, posing challenges for standardization and individualization of dose adjustments. On the one hand, VRZ is primarily metabolized by the liver, predominantly mediated by the cytochrome P450 (CYP) 2C19 enzyme. The genetic polymorphism of CYP2C19 significantly impacts the blood concentration of VRZ, particularly the trough concentration (Ctrough), thereby influencing the drug's efficacy and potentially causing adverse drug reactions (ADRs). Recent research has demonstrated that pharmacogenomics-based VRZ dose adjustments offer more accurate and individualized treatment strategies for individuals with hepatic insufficiency, with the possibility to enhance therapeutic outcomes and reduce ADRs. On the other hand, the security, pharmacokinetics, and dosing of VRZ in individuals with hepatic insufficiency remain unclear, making it challenging to attain optimal Ctrough in individuals with both hepatic insufficiency and IFI, resulting in suboptimal drug efficacy and severe ADRs. Therefore, when using VRZ to treat IFI, drug dosage adjustment based on individuals' genotypes and hepatic function is necessary. This review summarizes the research progress on the impact of genetic polymorphisms and hepatic insufficiency on VRZ dosage in IFI individuals, compares current international guidelines, elucidates the current application status of VRZ in individuals with hepatic insufficiency, and discusses the influence of CYP2C19, CYP3A4, CYP2C9, and ABCB1 genetic polymorphisms on VRZ dose adjustments and Ctrough at the pharmacogenomic level. Additionally, a comprehensive summary and analysis of existing studies' recommendations on VRZ dose adjustments based on CYP2C19 genetic polymorphisms and hepatic insufficiency are provided, offering a more comprehensive reference for dose selection and adjustments of VRZ in this patient population.
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Affiliation(s)
- Guolin Li
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Qinhui Li
- Department of Medical, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Changji Zhang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Qin Yu
- College of Pharmacy, Southwest Medical University, Luzhou, China
| | - Qi Li
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoshi Zhou
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Rou Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xuerong Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Hailin Liu
- Department of Pharmacy, The People’s Hospital of Chongqing Liangjiang New Area, Chongqing, China
| | - Yong Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Mushtaq M, Fatima K, Ahmad A, Mohamed Ibrahim O, Faheem M, Shah Y. Pharmacokinetic interaction of voriconazole and clarithromycin in Pakistani healthy male volunteers: a single dose, randomized, crossover, open-label study. Front Pharmacol 2023; 14:1134803. [PMID: 37361220 PMCID: PMC10288581 DOI: 10.3389/fphar.2023.1134803] [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: 12/30/2022] [Accepted: 04/26/2023] [Indexed: 06/28/2023] Open
Abstract
Background: Voriconazole an antifungal drug, has a potential for drug-drug interactions (DDIs) with administered drugs. Clarithromycin is a Cytochromes P450 CYP (3A4 and 2C19) enzyme inhibitor, and voriconazole is a substrate and inhibitor of these two enzymes. Being a substrate of the same enzyme for metabolism and transport, the chemical nature and pKa of both interacting drugs make these drugs better candidates for potential pharmacokinetic drug-drug interactions (PK-DDIs). This study aimed to evaluate the effect of clarithromycin on the pharmacokinetic profile of voriconazole in healthy volunteers. Methods: A single oral dose, open-label, randomized, crossover study was designed for assessing PK-DDI in healthy volunteers, consisting of 2 weeks washout period. Voriconazole, either alone (2 mg × 200 mg, tablet, P/O) or along with clarithromycin (voriconazole 2 mg × 200 mg, tablet + clarithromycin 500 mg, tablet, P/O), was administered to enrolled volunteers in two sequences. The blood samples (approximately 3 cc) were collected from volunteers for up to 24 h. Plasma concentrations of voriconazole were analyzed by an isocratic, reversed-phase high-performance-liquid chromatography ultraviolet-visible detector (RP HPLC UV-Vis) and a non-compartmental method. Results: In the present study, when voriconazole was administered with clarithromycin versus administered alone, a significant increase in peak plasma concentration (Cmax) of voriconazole by 52% (geometric mean ratio GMR: 1.52; 90% CI 1.04, 1.55; p = 0.000) was observed. Similarly, the area under the curve from time zero to infinity (AUC0-∞) and the area under the concentration-time curve from time zero to time-t (AUC0-t) of voriconazole also significantly increased by 21% (GMR: 1.14; 90% CI 9.09, 10.02; p = 0.013), and 16% (GMR: 1.15; 90% CI 8.08, 10.02; p = 0.007), respectively. In addition, the results also showed a reduction in the apparent volume of distribution (Vd) by 23% (GMR: 0.76; 90% CI 5.00, 6.20; p = 0.051), and apparent clearance (CL) by 13% (GMR: 0.87; 90% CI 41.95, 45.73; p = 0.019) of voriconazole. Conclusion: The alterations in PK parameters of voriconazole after concomitant administration of clarithromycin are of clinical significance. Therefore, adjustments in dosage regimens are warranted. In addition, extreme caution and therapeutic drug monitoring are necessary while co-prescribing both drugs. Clinical Trial Registration: clinicalTrials.gov, Identifier NCT05380245.
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Affiliation(s)
- Mehwish Mushtaq
- Department of Pharmacy, Abdul Wali Khan University Mardan, Mardan, Pakistan
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| | - Kshaf Fatima
- University Medical and Dental College, The University of Faisalabad, Faisalabad, Pakistan
| | - Aneeqa Ahmad
- Punjab Medical College, Faisalabad Medical University, Faisalabad, Pakistan
| | - Osama Mohamed Ibrahim
- College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
- Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Muhammad Faheem
- Department of Pharmacy, University of Swabi, Swabi, Pakistan
| | - Yasar Shah
- Department of Pharmacy, Abdul Wali Khan University Mardan, Mardan, Pakistan
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Veringa A, Brüggemann RJ, Span LFR, Biemond BJ, de Boer MGJ, van den Heuvel ER, Klein SK, Kraemer D, Minnema MC, Prakken NHJ, Rijnders BJA, Swen JJ, Verweij PE, Wondergem MJ, Ypma PF, Blijlevens N, Kosterink JGW, van der Werf TS, Alffenaar JWC. Therapeutic drug monitoring-guided treatment versus standard dosing of voriconazole for invasive aspergillosis in haematological patients: a multicentre, prospective, cluster randomised, crossover clinical trial. Int J Antimicrob Agents 2023; 61:106711. [PMID: 36642232 DOI: 10.1016/j.ijantimicag.2023.106711] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 11/27/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Voriconazole therapeutic drug monitoring (TDM) is recommended based on retrospective data and limited prospective studies. This study aimed to investigate whether TDM-guided voriconazole treatment is superior to standard treatment for invasive aspergillosis. METHODS A multicentre (n = 10), prospective, cluster randomised, crossover clinical trial was performed in haematological patients aged ≥18 years treated with voriconazole. All patients received standard voriconazole dose at the start of treatment. Blood/serum/plasma was periodically collected after treatment initiation of voriconazole and repeated during treatment in both groups. The TDM group had measured voriconazole concentrations reported back, with dose adjustments made as appropriate, while the non-TDM group had voriconazole concentrations measured only after study completion. The composite primary endpoint included response to treatment and voriconazole treatment discontinuation due to an adverse drug reaction related to voriconazole within 28 days after treatment initiation. RESULTS In total, 189 patients were enrolled in the study. For the composite primary endpoint, 74 patients were included in the non-TDM group and 68 patients in the TDM group. Here, no significant difference was found between both groups (P = 0.678). However, more trough concentrations were found within the generally accepted range of 1-6 mg/L for the TDM group (74.0%) compared with the non-TDM group (64.0%) (P < 0.001). CONCLUSIONS In this trial, TDM-guided dosing of voriconazole did not show improved treatment outcome compared with standard dosing. We believe that these findings should open up the discussion for an approach to voriconazole TDM that includes drug exposure, pathogen susceptibility and host defence. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov registration no. NCT00893555.
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Affiliation(s)
- Anette Veringa
- Department of Clinical Pharmacy, OLVG, Amsterdam, the Netherlands; Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands.
| | - Roger J Brüggemann
- Department of Pharmacy, Centre of Expertise in Mycology Radboudumc/CWZ and Radboud Institute of Health Science, University of Nijmegen, Radboudumc Nijmegen, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Lambert F R Span
- Department of Haematology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Bart J Biemond
- Department of Haematology, Amsterdam University Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Edwin R van den Heuvel
- Department of Mathematics and Computer Science, Eindhoven University of Technology, 5612 AZ, Eindhoven, the Netherlands
| | - Saskia K Klein
- Department of Haematology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands; Department of Haematology, Meander Medical Centre Amersfoort, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Doris Kraemer
- Department of Oncology and Haematology, Oldenburg Clinic, Rahel-Straus-Straße 10, 26133, Oldenburg, Germany
| | - Monique C Minnema
- Department of Haematology, University Medical Centre Utrecht, University Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherland
| | - Niek H J Prakken
- Department of Radiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Bart J A Rijnders
- Department of Internal Medicine and Infectious Diseases, Erasmus University Medical Centre, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology, Radboudumc Nijmegen, the Netherlands; Centre of Expertise in Mycology Radboudumc/CWZ, Radboud University, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Mariëlle J Wondergem
- Department of Haematology, VU University Medical Centre, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - Paula F Ypma
- Department of Haematology, Haga Hospital, Els Borst-Eilersplein 275, 2545 AA, The Hague, the Netherlands
| | - Nicole Blijlevens
- Department of Haematology, Radboudumc Nijmegen, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands; Radboud Institute of Health Sciences, Geert Grooteplein Zuid 21, 6525 EZ, Nijmegen, the Netherlands
| | - Jos G W Kosterink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands; Groningen Research Institute of Pharmacy, Pharmacotherapy, Epidemiology & Economics, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Tjip S van der Werf
- Department of Internal Medicine and Department of Pulmonary Diseases and Tuberculosis Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Jan-Willem C Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands; Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Camperdown NSW 2006, Sydney, Australia; Westmead Hospital, Westmead, Sydney, NSW 2145, Australia
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Zhao T, Shen H, Zhang HL, Feng J, Liu SM, Wang TT, Li HJ, Yu LH. Association of CYP2C19, CYP3A4 and ABCC2 polymorphisms and voriconazole plasma concentrations in Uygur pediatric patients. Pharmacogenomics 2023; 24:141-151. [PMID: 36718992 DOI: 10.2217/pgs-2022-0159] [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: 02/01/2023] Open
Abstract
Aim: To evaluate the association between CYP2C19, CYP3A4 and ABCC2 polymorphisms and voriconazole plasma concentrations in Uygur pediatric patients with allogeneic hematopoietic stem cell transplantation. Materials & methods: High performance liquid chromatography-mass spectrometry was employed to monitor voriconazole concentrations. First-generation sequencing was performed to detect gene polymorphisms. Results: Voriconazole concentrations of normal metabolizers were significantly higher than those of intermediate (p < 0.05) and ultrafast (p < 0.001) metabolizers. Patients with ABCC2 GG and GA genotypes exhibited significantly lower voriconazole concentrations compared with patients with the AA genotype (p < 0.05). Conclusion: These results demonstrate a significant association between voriconazole concentrations and the CYP2C19 phenotype in Uygur pediatric patients with allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
- Ting Zhao
- Department of Pharmacy, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Province, 830001, China.,Institute of Clinical Pharmacy of Xinjiang Uygur Autonomous Region, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Province, 830001, China
| | - Hao Shen
- Department of Pharmacy, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Province, 830001, China.,Institute of Clinical Pharmacy of Xinjiang Uygur Autonomous Region, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Province, 830001, China
| | - Hui-Lan Zhang
- Department of Pharmacy, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Province, 830001, China.,Institute of Clinical Pharmacy of Xinjiang Uygur Autonomous Region, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Province, 830001, China
| | - Jie Feng
- Department of Pharmacy, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Province, 830001, China.,Institute of Clinical Pharmacy of Xinjiang Uygur Autonomous Region, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Province, 830001, China
| | - Si-Ming Liu
- Department of Pharmacy, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Province, 830001, China.,Institute of Clinical Pharmacy of Xinjiang Uygur Autonomous Region, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Province, 830001, China
| | - Ting-Ting Wang
- Department of Pharmacy, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Province, 830001, China.,Institute of Clinical Pharmacy of Xinjiang Uygur Autonomous Region, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Province, 830001, China
| | - Hong-Jian Li
- Department of Pharmacy, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Province, 830001, China.,Institute of Clinical Pharmacy of Xinjiang Uygur Autonomous Region, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Province, 830001, China
| | - Lu-Hai Yu
- Department of Pharmacy, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Province, 830001, China.,Institute of Clinical Pharmacy of Xinjiang Uygur Autonomous Region, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Province, 830001, China
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de Almeida Campos L, Fin MT, Santos KS, de Lima Gualque MW, Freire Cabral AKL, Khalil NM, Fusco-Almeida AM, Mainardes RM, Mendes-Giannini MJS. Nanotechnology-Based Approaches for Voriconazole Delivery Applied to Invasive Fungal Infections. Pharmaceutics 2023; 15:pharmaceutics15010266. [PMID: 36678893 PMCID: PMC9863752 DOI: 10.3390/pharmaceutics15010266] [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: 11/18/2022] [Revised: 12/09/2022] [Accepted: 12/20/2022] [Indexed: 01/15/2023] Open
Abstract
Invasive fungal infections increase mortality and morbidity rates worldwide. The treatment of these infections is still limited due to the low bioavailability and toxicity, requiring therapeutic monitoring, especially in the most severe cases. Voriconazole is an azole widely used to treat invasive aspergillosis, other hyaline molds, many dematiaceous molds, Candida spp., including those resistant to fluconazole, and for infections caused by endemic mycoses, in addition to those that occur in the central nervous system. However, despite its broad activity, using voriconazole has limitations related to its non-linear pharmacokinetics, leading to supratherapeutic doses and increased toxicity according to individual polymorphisms during its metabolism. In this sense, nanotechnology-based drug delivery systems have successfully improved the physicochemical and biological aspects of different classes of drugs, including antifungals. In this review, we highlighted recent work that has applied nanotechnology to deliver voriconazole. These systems allowed increased permeation and deposition of voriconazole in target tissues from a controlled and sustained release in different routes of administration such as ocular, pulmonary, oral, topical, and parenteral. Thus, nanotechnology application aiming to delivery voriconazole becomes a more effective and safer therapeutic alternative in the treatment of fungal infections.
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Affiliation(s)
- Laís de Almeida Campos
- Pharmaceutical Nanotechnology Laboratory, Department of Pharmacy, Midwest State University (UNICENTRO), Alameda Élio Antonio Dalla Vecchia St, 838, Guarapuava 85040-167, PR, Brazil
| | - Margani Taise Fin
- Pharmaceutical Nanotechnology Laboratory, Department of Pharmacy, Midwest State University (UNICENTRO), Alameda Élio Antonio Dalla Vecchia St, 838, Guarapuava 85040-167, PR, Brazil
| | - Kelvin Sousa Santos
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Rodovia Araraquara Jaú, Km 01, Araraquara 14801-902, SP, Brazil
| | - Marcos William de Lima Gualque
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Rodovia Araraquara Jaú, Km 01, Araraquara 14801-902, SP, Brazil
| | - Ana Karla Lima Freire Cabral
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Rodovia Araraquara Jaú, Km 01, Araraquara 14801-902, SP, Brazil
| | - Najeh Maissar Khalil
- Pharmaceutical Nanotechnology Laboratory, Department of Pharmacy, Midwest State University (UNICENTRO), Alameda Élio Antonio Dalla Vecchia St, 838, Guarapuava 85040-167, PR, Brazil
| | - Ana Marisa Fusco-Almeida
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Rodovia Araraquara Jaú, Km 01, Araraquara 14801-902, SP, Brazil
| | - Rubiana Mara Mainardes
- Pharmaceutical Nanotechnology Laboratory, Department of Pharmacy, Midwest State University (UNICENTRO), Alameda Élio Antonio Dalla Vecchia St, 838, Guarapuava 85040-167, PR, Brazil
- Correspondence: (R.M.M.); (M.J.S.M.-G.)
| | - Maria José Soares Mendes-Giannini
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Rodovia Araraquara Jaú, Km 01, Araraquara 14801-902, SP, Brazil
- Correspondence: (R.M.M.); (M.J.S.M.-G.)
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Yang L, Wang C, Zhang Y, Wang Q, Qiu Y, Li S, Yang B, Du Q, Chen J, Teng M, Wang T, Dong Y. Central Nervous System Toxicity of Voriconazole: Risk Factors and Threshold - A Retrospective Cohort Study. Infect Drug Resist 2022; 15:7475-7484. [PMID: 36561883 PMCID: PMC9766498 DOI: 10.2147/idr.s391022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose Voriconazole (VRC) is an antifungal agent which is used for treatment and prophylaxis of invasive fungal infections. The common clinical adverse reactions mainly include central nervous system (CNS) toxicity and abnormal liver function. These adverse reactions limit the clinical use of voriconazole to a certain extent. Therefore, the aim of this study was to analyze the risk factors of voriconazole neurotoxic side effects and to determine the plasma trough concentration (C min) threshold of voriconazole-induced CNS toxicity, so as to improve the safety of voriconazole treatment. Patients and Methods This study retrospectively collected the clinical data of 165 patients who received voriconazole and underwent therapeutic drug monitoring (TDM). CNS toxicity was defined using the National Cancer Institute (NCI) criteria, logistic regression was used to analyze the risk factors of CNS toxicity, classification and Regression tree (CART) model was used to determine the C min threshold for CNS toxicity. Results Voriconazole-related CNS toxicity occurred during treatment in 34 of 165 patients (20.6%) and the median time from administration to onset of CNS toxicity was 6 days (range, 2-19 days). The overall incidence of CNS toxicity was 20.6% (34/165), including visual disturbances in 4.8% (8/165) and nervous system disorders in 15.8% (26/165). C min significantly affects the occurrence of CNS toxicity and the threshold of C min for voriconazole CNS toxicity was determined to be 4.85 mg/L, when C min >4.85 mg/L and ≤4.85 mg/L, the incidence of CNS was 32.9% and 11.6%, respectively. Conclusion Voriconazole trough concentration of C min is an independent risk factor for CNS toxicity, and the threshold of C min for CNS toxicity is 4.85mg/L. TDM should be routinely performed in patients with clinical use of voriconazole to reduce the occurrence of CNS toxicity of voriconazole.
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Affiliation(s)
- Luting Yang
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Chuhui Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Yijing Zhang
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Quanfang Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Yulan Qiu
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Sihan Li
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Bo Yang
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Qian Du
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Jiaojiao Chen
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Mengmeng Teng
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Taotao Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China,Correspondence: Yalin Dong; Taotao Wang, Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China, Tel +86-29-85323241; Tel/Fax +86-29-85323243, Fax +86-29-85323240, Email ;
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9
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Schulz J, Michelet R, Zeitlinger M, Mikus G, Kloft C. Microdialysis of Drug and Drug Metabolite: a Comprehensive In Vitro Analysis for Voriconazole and Voriconazole N-oxide. Pharm Res 2022; 39:2991-3003. [PMID: 36171344 PMCID: PMC9633485 DOI: 10.1007/s11095-022-03292-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
Purpose Voriconazole is a therapeutically challenging antifungal drug associated with high interindividual pharmacokinetic variability. As a prerequisite to performing clinical trials using the minimally-invasive sampling technique microdialysis, a comprehensive in vitro microdialysis characterization of voriconazole (VRC) and its potentially toxic N-oxide metabolite (NO) was performed. Methods The feasibility of simultaneous microdialysis of VRC and NO was explored in vitro by investigating the relative recovery (RR) of both compounds in the absence and presence of the other. The dependency of RR on compound combination, concentration, microdialysis catheter and study day was evaluated and quantified by linear mixed-effects modeling. Results Median RR of VRC and NO during individual microdialysis were high (87.6% and 91.1%). During simultaneous microdialysis of VRC and NO, median RR did not change (87.9% and 91.1%). The linear mixed-effects model confirmed the absence of significant differences between RR of VRC and NO during individual and simultaneous microdialysis as well as between the two compounds (p > 0.05). No concentration dependency of RR was found (p = 0.284). The study day was the main source of variability (46.3%) while the microdialysis catheter only had a minor effect (4.33%). VRC retrodialysis proved feasible as catheter calibration for both compounds. Conclusion These in vitro microdialysis results encourage the application of microdialysis in clinical trials to assess target-site concentrations of VRC and NO. This can support the generation of a coherent understanding of VRC pharmacokinetics and its sources of variability. Ultimately, a better understanding of human VRC pharmacokinetics might contribute to the development of personalized dosing strategies.
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Affiliation(s)
- Josefine Schulz
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Gerd Mikus
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
- Department Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
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10
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Towards the Elucidation of the Pharmacokinetics of Voriconazole: A Quantitative Characterization of Its Metabolism. Pharmaceutics 2022; 14:pharmaceutics14030477. [PMID: 35335853 PMCID: PMC8948939 DOI: 10.3390/pharmaceutics14030477] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 12/28/2022] Open
Abstract
The small-molecule drug voriconazole (VRC) shows a complex and not yet fully understood metabolism. Consequently, its in vivo pharmacokinetics are challenging to predict, leading to therapy failures or adverse events. Thus, a quantitative in vitro characterization of the metabolism and inhibition properties of VRC for human CYP enzymes was aimed for. The Michaelis-Menten kinetics of voriconazole N-oxide (NO) formation, the major circulating metabolite, by CYP2C19, CYP2C9 and CYP3A4, was determined in incubations of human recombinant CYP enzymes and liver and intestine microsomes. The contribution of the individual enzymes to NO formation was 63.1% CYP2C19, 13.4% CYP2C9 and 29.5% CYP3A4 as determined by specific CYP inhibition in microsomes and intersystem extrapolation factors. The type of inhibition and inhibitory potential of VRC, NO and hydroxyvoriconazole (OH-VRC), emerging to be formed independently of CYP enzymes, were evaluated by their effects on CYP marker reactions. Time-independent inhibition by VRC, NO and OH-VRC was observed on all three enzymes with NO being the weakest and VRC and OH-VRC being comparably strong inhibitors of CYP2C9 and CYP3A4. CYP2C19 was significantly inhibited by VRC only. Overall, the quantitative in vitro evaluations of the metabolism contributed to the elucidation of the pharmacokinetics of VRC and provided a basis for physiologically-based pharmacokinetic modeling and thus VRC treatment optimization.
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11
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Yu Y, Yang YQ, Zeng NJ, Zhang HW, Sun LN, Wang YQ. Simultaneous Determination of Voriconazole and Its Voriconazole N-Oxide Metabolite in Human Urine by Liquid Chromatography/Tandem Mass Spectrometry. J Chromatogr Sci 2021; 60:800-806. [PMID: 34761250 DOI: 10.1093/chromsci/bmab126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Indexed: 11/13/2022]
Abstract
A convenient and sensitive liquid chromatography-tandem mass spectrometry method was established to simultaneously quantify voriconazole (VRZ) and its metabolite, voriconazole N-oxide (VNO), in human urine. Voriconazole-d3 and voriconazole-d3 N-oxide were used as isotopic internal standards. Samples were processed by protein precipitation and separated using a ZORBAX SB-Aq column (1.8 μm, 2.1 × 50 mm). Mass spectrometry was performed using an API 4000 mass spectrometry by positive electrospray ionization. The flow rate was 0.6 mL/min. Gradient elution was performed with methanol and 0.1% formic acid as the organic and water phase, respectively. The VRZ and VNO calibration curves ranged from 20.0 to 7200 ng/mL in human urine. The specificity, matrix effect, extraction recovery, intra/inter-run precision, accuracy and stability were validated for both VRZ and VNO in human urine. The developed method was used to study urinary excretion after intravenous injection of 4 mg/kg VRZ in healthy Chinese subjects.
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Affiliation(s)
- Yong Yu
- Research Division of Clinical Pharmacology, First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Gulou District, Nanjing 210029, China.,Institute of Bioengineering, School of Pharmacy, Hunan Food and Drug Vocational College, Xueshi Road 345, Yuelu District, Changsha 410208, China
| | - Yu-Qing Yang
- Research Division of Clinical Pharmacology, First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Gulou District, Nanjing 210029, China
| | - Nv-Jin Zeng
- Research Division of Clinical Pharmacology, First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Gulou District, Nanjing 210029, China
| | - Hong-Wen Zhang
- Research Division of Clinical Pharmacology, First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Gulou District, Nanjing 210029, China
| | - Lu-Ning Sun
- Research Division of Clinical Pharmacology, First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Gulou District, Nanjing 210029, China.,Department of Clinical Pharmacy, School of Pharmacy, Nanjing Medical University, Longmian Road 101, Jiangning District, Nanjing 210029, China
| | - Yong-Qing Wang
- Research Division of Clinical Pharmacology, First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Gulou District, Nanjing 210029, China.,Department of Clinical Pharmacy, School of Pharmacy, Nanjing Medical University, Longmian Road 101, Jiangning District, Nanjing 210029, China
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12
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Chuwongwattana S, Jantararoungtong T, Prommas S, Medhasi S, Puangpetch A, Sukasem C. Impact of CYP2C19, CYP3A4, ABCB1, and FMO3 genotypes on plasma voriconazole in Thai patients with invasive fungal infections. Pharmacol Res Perspect 2020; 8:e00665. [PMID: 33124772 PMCID: PMC7596670 DOI: 10.1002/prp2.665] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/06/2020] [Accepted: 09/10/2020] [Indexed: 12/20/2022] Open
Abstract
Voriconazole is the first-line antifungal choice in the treatment of invasive fungal infections (IFIs). Single nucleotide polymorphisms (SNPs) in drug-metabolizing and transporter genes may affect voriconazole pharmacokinetics. This study aimed to determine the frequency of the CYP2C19 rs4244285, rs4986893, rs72552267, and rs12248560, CYP3A4 rs4646437, ABCB1 rs1045642, and FMO3 rs2266782 alleles and determine the association between these genetic variants and voriconazole concentrations in Thai patients with invasive fungal infections. The study comprised 177 Thai patients with IFIs in whom seven SNPs in CYP2C19, CYP3A4, ABCB1, and FMO3 were genotyped using TaqMan real-time polymerase chain reaction (RT-PCR) 5´ nuclease assays, and voriconazole plasma concentrations were measured by high-performance liquid chromatography-tandem mass spectrometry (LC-MS/MS). Of the 177 patients included, 31 were <12 years and 146 were ≥12 years. The CYP2C19 allele frequencies were 0.29 for *2, 0.060 for *3, 0.003 for *6, and 0.008 for *17. The allele frequency of CYP3A4 (rs4646437) was 0.26, ABCB1 (rs1045642) was 0.36, and FMO3 (rs2266782) was 0.16. The median voriconazole dose/weight was significantly lower in patients aged ≥12 years when compared to the patients aged <12 years (P < .001). Patients aged <12 years with CYP2C19*1/*2 exhibited significantly higher median voriconazole plasma concentrations than those with the CYP2C19*1/*1 (P = .038). However, there were no significant differences in median voriconazole plasma concentrations among the CYP2C19 genotypes in the patients aged ≥12 years. There was a lack of association observed among the CYP3A4, ABCB1, and FMO3 genotypes on the plasma voriconazole concentrations in both groups of patients. Our findings indicate that voriconazole plasma concentrations are affected by the CYP2C19*2 allele in patients aged <12 years but not in patients aged ≥12 years.
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Affiliation(s)
- Sumonrat Chuwongwattana
- Division of Pharmacogenomics and Personalized MedicineDepartment of PathologyFaculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
- Laboratory for PharmacogenomicsSomdech Phra Debaratana Medical Center (SDMC)Ramathibodi HospitalBangkokThailand
| | - Thawinee Jantararoungtong
- Division of Pharmacogenomics and Personalized MedicineDepartment of PathologyFaculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
- Laboratory for PharmacogenomicsSomdech Phra Debaratana Medical Center (SDMC)Ramathibodi HospitalBangkokThailand
| | - Santirat Prommas
- Division of Pharmacogenomics and Personalized MedicineDepartment of PathologyFaculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
- Laboratory for PharmacogenomicsSomdech Phra Debaratana Medical Center (SDMC)Ramathibodi HospitalBangkokThailand
| | - Sadeep Medhasi
- Center for Medical GenomicsFaculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Apichaya Puangpetch
- Division of Pharmacogenomics and Personalized MedicineDepartment of PathologyFaculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
- Laboratory for PharmacogenomicsSomdech Phra Debaratana Medical Center (SDMC)Ramathibodi HospitalBangkokThailand
| | - Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized MedicineDepartment of PathologyFaculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
- Laboratory for PharmacogenomicsSomdech Phra Debaratana Medical Center (SDMC)Ramathibodi HospitalBangkokThailand
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13
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Zhao YC, Lin XB, Zhang BK, Xiao YW, Xu P, Wang F, Xiang DX, Xie XB, Peng FH, Yan M. Predictors of Adverse Events and Determinants of the Voriconazole Trough Concentration in Kidney Transplantation Recipients. Clin Transl Sci 2020; 14:702-711. [PMID: 33202102 PMCID: PMC7993276 DOI: 10.1111/cts.12932] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/14/2020] [Indexed: 12/12/2022] Open
Abstract
Voriconazole is the mainstay for the treatment of invasive fungal infections in patients who underwent a kidney transplant. Variant CYP2C19 alleles, hepatic function, and concomitant medications are directly involved in the metabolism of voriconazole. However, the drug is also associated with numerous adverse events. The purpose of this study was to identify predictors of adverse events using binary logistic regression and to measure its trough concentration using multiple linear modeling. We conducted a prospective analysis of 93 kidney recipients cotreated with voriconazole and recorded 213 trough concentrations of it. Predictors of the adverse events were voriconazole trough concentration with the odds ratios (OR) of 2.614 (P = 0.016), cytochrome P450 2C19 (CYP2C19), and hemoglobin (OR 0.181, P = 0.005). The predictive power of these three factors was 91.30%. We also found that CYP2C19 phenotypes, hemoglobin, platelet count, and concomitant use of ilaprazole had quantitative relationships with voriconazole trough concentration. The fit coefficient of this regression equation was R2 = 0.336, demonstrating that the model explained 33.60% of interindividual variability in the disposition of voriconazole. In conclusion, predictors of adverse events are CYP2C19 phenotypes, hemoglobin, and voriconazole trough concentration. Determinants of the voriconazole trough concentration were CYP2C19 phenotypes, platelet count, hemoglobin, concomitant use of ilaprazole. If we consider these factors during voriconazole use, we are likely to maximize the treatment effect and minimize adverse events.
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Affiliation(s)
- Yi-Chang Zhao
- Department of Clinical Pharmacy, The Second Xiangya Hospital of Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Xiao-Bin Lin
- Department of Pharmacy, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Bi-Kui Zhang
- Department of Clinical Pharmacy, The Second Xiangya Hospital of Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Yi-Wen Xiao
- Department of Clinical Pharmacy, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Ping Xu
- Department of Clinical Pharmacy, The Second Xiangya Hospital of Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Feng Wang
- Department of Clinical Pharmacy, The Second Xiangya Hospital of Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Da-Xiong Xiang
- Department of Clinical Pharmacy, The Second Xiangya Hospital of Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Xu-Biao Xie
- Department of Urological Organ Transplantation, the Second Xiangya Hospital of Central South University, Changsha, China
| | - Feng-Hua Peng
- Department of Urological Organ Transplantation, the Second Xiangya Hospital of Central South University, Changsha, China
| | - Miao Yan
- Department of Clinical Pharmacy, The Second Xiangya Hospital of Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
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14
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Shang S, Cheng L, Li X, Xiang R, Yu M, Xiong L, Chen Y. Effect of CYP2C19 polymorphism on the plasma voriconazole concentration and voriconazole-to-voriconazole-N-oxide concentration ratio in elderly patients. Mycoses 2020; 63:1181-1190. [PMID: 32416606 DOI: 10.1111/myc.13105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/05/2020] [Accepted: 05/08/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Effects of CYP2C19 polymorphism on voriconazole concentration (C0 ), dose-adjusted trough concentrations (C0 /dose) and voriconazole-to-voriconazole-N-oxide concentration ratio (C0 /CN ) have not been fully investigated. OBJECTIVES To investigate correlations of CYP2C19 polymorphisms with plasma concentrations of voriconazole and the major metabolite voriconazole-N-oxide in elderly patients. METHODS A prospective, multi-centre, non-intervention, open clinical study was conducted within Southwestern Chinese patients clinically diagnosed with invasive fungal infections, to investigate the associations of CYP2C19∗2 (681G > A), CYP2C19∗3 (636G > A) and CYP2C19∗17 (-806C > T) genetic polymorphisms with voriconazole C0 , C0 /dose and C0 /CN . RESULTS The study included 131 adult patients, of which 72 were elderly (≥60 years) and 59 were adults (<60 years). The allele frequencies of CYP2C19∗2, ∗3 and ∗17 in the elderly cohort were 61.1%, 29.9% and 7.6%, respectively, which were similar to those in the adult cohort (66.9%, 29.7% and 2.5%, respectively; P > .05). The median voriconazole C0 (C0 ), C0 /dose and C0 /CN ratio in patients with the CYP2C19∗1/∗2 and CYP2C19∗2/∗2 genotypes were significantly higher than those in patients with the CYP2C19∗1/∗1 genotype in the adult cohort (P < .05). The C0 and C0 /dose in patients with the CYP2C19∗1/∗3 and CYP2C19∗2/∗2 genotypes, and the C0 /CN ratio for patients with the CYP2C19∗1/∗2 genotype were numerically higher than those in patients with the CYP2C19∗1/∗1 genotype in the elderly cohort, but this difference was not statistically significant (P > 0.05). The C0 , C0 /dose and C0 /CN in patients with poor metaboliser phenotypes were higher than in those with normal metaboliser phenotypes and C0 in patients with intermediate metaboliser phenotypes were significantly higher than in those with normal metaboliser phenotypes in the adult cohort (P < .05). However, there were no significant differences in the C0 , C0 /dose and C0 /CN among different CYP2C19-predicted metabolic phenotypes in the elderly cohort. CONCLUSIONS Voriconazole C0 , C0 /dose and C0 /CN ratio are not significantly affected by the CYP2C19∗2/∗3 polymorphisms in the elderly patients.
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Affiliation(s)
- Shenglan Shang
- Department of Pharmacy, The First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, China
| | - Lin Cheng
- Department of Pharmacy, The First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, China
| | - Xiaoyu Li
- Department of Pharmacy, The First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, China
- Department of Pharmacy, Handan Branch of No. 980 Hospital of PLA, Handan, China
| | - Rongfeng Xiang
- Department of Pharmacy, The First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, China
| | - Mingjie Yu
- Department of Pharmacy, The First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, China
| | - Lirong Xiong
- Department of Pharmacy, The First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, China
| | - Yongchuan Chen
- Department of Pharmacy, The First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, China
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15
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Luo X, Xue X, Li T, Zhang Y, Huang L, Cheng G. Differential Impacts of Azole Antifungal Drugs on the Pharmacokinetic Profiles of Dasatinib in Rats by LC-MS-MS. Curr Drug Metab 2020; 21:1022-1030. [PMID: 33092505 DOI: 10.2174/1389200221666201022140656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/01/2020] [Accepted: 09/15/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Dasatinib, as an oral multi-targeted inhibitor of BCR-ABL and SRC family kinases, has been widely used for the treatment of Philadelphia Chromosome Positive Leukemias in imatinib-acquired resistance and intolerance. The study aimed to develop and validate a simple and robust assay with a small volume of plasma based on liquid chromatography coupled with tandem mass spectrometry to determine the concentration of dasatinib and to investigate the impact of the cytochrome 3A4 inhibitors, including ketoconazole, voriconazole, itraconazole and posaconazole, on the pharmacokinetics of dasatinib in rats. METHODS Thirty rats were divided randomly into five groups, control group (0.5% carboxymethylcellulose sodium), ketoconazole (30 mg/kg) group, voriconazole group (30 mg/kg), itraconazole group (30 mg/kg) and posaconazole group (30 mg/kg). After 150 μL blood samples were collected at 0, 0.5, 1, 2, 4, 6, 8, 10, 12, 24, and 48 h and precipitated with acetonitrile, the plasma concentration of dasatinib was determined through Fluoro- Phenyl column (150 mm×2.1 mm, 3 μm) in a positive ionization mode. RESULTS The results suggested that ketoconazole, voriconazole, and posaconazole could increase the AUC0-t of dasatinib to varying degrees while significantly reducing its clearance. However, there was no significant impact on the pharmacokinetics of dasatinib, co-administered with itraconazole except for the CL and MRT0-t of dasatinib. Additionally, voriconazole could significantly increase Cmax of dasatinib by approximately 4.12 fold. CONCLUSION These data indicated that ketoconazole, posaconazole and voriconazole should be cautiously co-administered with dasatinib or close therapeutic drug monitoring of dasatinib concentration, which might cause the drug-drug interaction.
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Affiliation(s)
- Xingxian Luo
- School of Life Science and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Xuecai Xue
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Taifeng Li
- School of Life Science and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Ying Zhang
- School of Life Science and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Lin Huang
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Gang Cheng
- School of Life Science and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
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16
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Blanco-Dorado S, Maroñas O, Latorre-Pellicer A, Rodríguez Jato MT, López-Vizcaíno A, Gómez Márquez A, Bardán García B, Belles Medall D, Barbeito Castiñeiras G, Pérez Del Molino Bernal ML, Campos-Toimil M, Otero Espinar F, Blanco Hortas A, Durán Piñeiro G, Zarra Ferro I, Carracedo Á, Lamas MJ, Fernández-Ferreiro A. Impact of CYP2C19 Genotype and Drug Interactions on Voriconazole Plasma Concentrations: A Spain Pharmacogenetic-Pharmacokinetic Prospective Multicenter Study. Pharmacotherapy 2020; 40:17-25. [PMID: 31782536 DOI: 10.1002/phar.2351] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Voriconazole, a first-line agent for the treatment of invasive fungal infections, is mainly metabolized by cytochrome P450 (CYP) 2C19. A significant portion of patients fail to achieve therapeutic voriconazole trough concentrations, with a consequently increased risk of therapeutic failure. OBJECTIVE To show the association between subtherapeutic voriconazole concentrations and factors affecting voriconazole pharmacokinetics: CYP2C19 genotype and drug-drug interactions. METHODS Adults receiving voriconazole for antifungal treatment or prophylaxis were included in a multicenter prospective study conducted in Spain. The prevalence of subtherapeutic voriconazole troughs was analyzed in the rapid metabolizer and ultra-rapid metabolizer patients (RMs and UMs, respectively), and compared with the rest of the patients. The relationship between voriconazole concentration, CYP2C19 phenotype, adverse events (AEs), and drug-drug interactions was also assessed. RESULTS In this study 78 patients were included with a wide variability in voriconazole plasma levels with only 44.8% of patients attaining trough concentrations within the therapeutic range of 1 and 5.5 µg/ml. The allele frequency of *17 variant was found to be 29.5%. Compared with patients with other phenotypes, RMs and UMs had a lower voriconazole plasma concentration (RM/UM: 1.85 ± 0.24 µg/ml vs other phenotypes: 2.36 ± 0.26 µg/ml). Adverse events were more common in patients with higher voriconazole concentrations (p<0.05). No association between voriconazole trough concentration and other factors (age, weight, route of administration, and concomitant administration of enzyme inducer, enzyme inhibitor, glucocorticoids, or proton pump inhibitors) was found. CONCLUSION These results suggest the potential clinical utility of using CYP2C19 genotype-guided voriconazole dosing to achieve concentrations in the therapeutic range in the early course of therapy. Larger studies are needed to confirm the impact of pharmacogenetics on voriconazole pharmacokinetics.
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Affiliation(s)
- Sara Blanco-Dorado
- Pharmacy Department, University Clinical Hospital Santiago de Compostela (CHUS), Santiago de Compostela, Spain.,Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), University Clinical Hospital, Santiago de Compostela, Spain.,Department of Pharmacology, Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - Olalla Maroñas
- Genomic Medicine Group, Centro Nacional de Genotipado (CEGEN-PRB3), CIBERER, CIMUS, University of Santiago de Compostela (USC), Santiago de Compostela, Spain.,Galician Foundation of Genomic Medicine, Health Research Institute of Santiago de Compostela (IDIS), SERGAS, Santiago de Compostela, Spain
| | - Ana Latorre-Pellicer
- Genomic Medicine Group, Centro Nacional de Genotipado (CEGEN-PRB3), CIBERER, CIMUS, University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - María Teresa Rodríguez Jato
- Pharmacy Department, University Clinical Hospital Santiago de Compostela (CHUS), Santiago de Compostela, Spain
| | - Ana López-Vizcaíno
- Pharmacy Department, University Hospital Lucus Augusti (HULA), Lugo, Spain
| | | | | | | | - Gema Barbeito Castiñeiras
- Microbiology Department, University Clinical Hospital Santiago de Compostela (CHUS), Santiago de Compostela, Spain
| | | | - Manuel Campos-Toimil
- Department of Pharmacology, Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - Francisco Otero Espinar
- Department of Pharmacology, Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - Andrés Blanco Hortas
- Epidemiology Unit, Fundación Instituto de Investigación Sanitaria de Santiago de Compostela (FIDIS), University Hospital Lucus Augusti (HULA), Lugo, Spain
| | - Goretti Durán Piñeiro
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), University Clinical Hospital, Santiago de Compostela, Spain
| | - Irene Zarra Ferro
- Pharmacy Department, University Clinical Hospital Santiago de Compostela (CHUS), Santiago de Compostela, Spain.,Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), University Clinical Hospital, Santiago de Compostela, Spain
| | - Ángel Carracedo
- Genomic Medicine Group, Centro Nacional de Genotipado (CEGEN-PRB3), CIBERER, CIMUS, University of Santiago de Compostela (USC), Santiago de Compostela, Spain.,Galician Foundation of Genomic Medicine, Health Research Institute of Santiago de Compostela (IDIS), SERGAS, Santiago de Compostela, Spain
| | - María Jesús Lamas
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), University Clinical Hospital, Santiago de Compostela, Spain
| | - Anxo Fernández-Ferreiro
- Pharmacy Department, University Clinical Hospital Santiago de Compostela (CHUS), Santiago de Compostela, Spain.,Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), University Clinical Hospital, Santiago de Compostela, Spain.,Department of Pharmacology, Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Santiago de Compostela (USC), Santiago de Compostela, Spain
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Patel JN, Hamadeh IS, Robinson M, Shahid Z, Symanowski J, Steuerwald N, Hamilton A, Reese ES, Plesca DC, Arnall J, Taylor M, Trivedi J, Grunwald MR, Gerber J, Ghosh N, Avalos B, Copelan E. Evaluation of CYP2C19 Genotype-Guided Voriconazole Prophylaxis After Allogeneic Hematopoietic Cell Transplant. Clin Pharmacol Ther 2019; 107:571-579. [PMID: 31549386 DOI: 10.1002/cpt.1642] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 07/22/2019] [Indexed: 01/09/2023]
Abstract
There is a high risk of voriconazole failure in those with subtherapeutic drug concentrations, which is more common in CYP2C19 (cytochrome P450 2C19) rapid/ultrarapid metabolizers (RMs/UMs). We evaluated CYP2C19 genotype-guided voriconazole dosing on drug concentrations and clinical outcomes in adult allogeneic hematopoietic cell transplant recipients. Poor (PMs), intermediate (IMs), and normal metabolizers (NMs) received voriconazole 200 mg twice daily; RMs/UMs received 300 mg twice daily. Steady-state trough concentrations were obtained after 5 days, targeting 1.0-5.5 mg/L. Of 89 evaluable patients, 29% had subtherapeutic concentrations compared with 50% in historical controls (P < 0.001). Zero, 26%, 50%, and 16% of PMs, IMs, NMs, and RMs/UMs were subtherapeutic. Voriconazole success rate was 78% compared with 54% in historical controls (P < 0.001). No patients experienced an invasive fungal infection (IFI). Genotype-guided dosing resulted in $4,700 estimated per patient savings as compared with simulated controls. CYP2C19 genotype-guided voriconazole dosing reduced subtherapeutic drug concentrations and effectively prevented IFIs.
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Affiliation(s)
- Jai N Patel
- Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Issam S Hamadeh
- Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Myra Robinson
- Department of Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Zainab Shahid
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - James Symanowski
- Department of Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Nury Steuerwald
- Molecular Biology Core Laboratory, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Alicia Hamilton
- Molecular Biology Core Laboratory, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Emily S Reese
- Translational Research, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Dragos C Plesca
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Justin Arnall
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Margaret Taylor
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Jigar Trivedi
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Jonathan Gerber
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Health Care, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Nilanjan Ghosh
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Belinda Avalos
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Edward Copelan
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
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18
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Zeng G, Shi L, Li H, Wang L, Zhu M, Luo J, Zhang Z. Effect of cyclosporine a and polymorphisms in CYP2C19 and ABCC2 on the concentration of voriconazole in patients undergoing allogeneic hematopoietic stem cell transplantation. Xenobiotica 2019; 50:614-619. [PMID: 31573401 DOI: 10.1080/00498254.2019.1672907] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Guangting Zeng
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Lihong Shi
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Huilan Li
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Linlin Wang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Miaomiao Zhu
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan Mental Health Centre, Wuhan Hospital for Psychotherapy, Wuhan, China
| | - Jia Luo
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Zanling Zhang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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19
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Prediction models for voriconazole pharmacokinetics based on pharmacogenetics: AN exploratory study in a Spanish population. Int J Antimicrob Agents 2019; 54:463-470. [PMID: 31279853 DOI: 10.1016/j.ijantimicag.2019.06.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/24/2019] [Accepted: 06/28/2019] [Indexed: 02/02/2023]
Abstract
Individualisation of the therapeutic strategy for the oral antifungal agent voriconazole (VCZ) is extremely important for treatment optimisation. To date, regulatory agencies include CYP2C19 as the only major pharmacogenetic (PGx) biomarker in their dosing guidelines; however, the effect of other genes might be important for VCZ dosing prediction. We developed an exploratory PGx study to identify new biomarkers related to VCZ pharmacokinetics. We first designed a 'clinical practice VCZ-AUC prediction model' based on CYP2C19 to be used as a reference model in this study. We then designed a multifactorial polygenic prediction model and found that genetic variability in FMO3, NR1I2, POR, CYP2C9 and CYP3A4 partially contributes to VCZ total area under the concentration-time curve (AUC0-∞) interindividual variability, and its inclusion in VCZ AUC0-∞ prediction algorithms improves model precision. To our knowledge, there are no PGx studies specifically relating POR, FMO3 and NR1I2 polymorphisms to VCZ pharmacokinetic variability. Further research is needed in order to test the model proposed here.
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20
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Chen M, Zhang X, Chen Y, Sun W, Wang Z, Huang C, Hu G, Chen R. Comparison of the inhibitory effect of ketoconazole, voriconazole, fluconazole, and itraconazole on the pharmacokinetics of bosentan and its corresponding active metabolite hydroxy bosentan in rats. Xenobiotica 2019; 50:280-287. [PMID: 31199171 DOI: 10.1080/00498254.2019.1628321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Mengchun Chen
- Department of Pharmacy, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xufei Zhang
- Laboratory of Animal Centre, Wenzhou Medical University, Wenzhou, China
| | - Yijie Chen
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wei Sun
- Department of Pharmacy, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhe Wang
- Department of Pharmacy, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chengke Huang
- Department of Pharmacy, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Guoxin Hu
- School of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Ruijie Chen
- Department of Pharmacy, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
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21
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Zhang Z, Gao B, He Z, Li L, Shi H, Wang M. Enantioselective metabolism of four chiral triazole fungicides in rat liver microsomes. CHEMOSPHERE 2019; 224:77-84. [PMID: 30818197 DOI: 10.1016/j.chemosphere.2019.02.119] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/18/2019] [Accepted: 02/18/2019] [Indexed: 06/09/2023]
Abstract
Triazole fungicides with one or two chiral centers are widely used worldwide. The liver microsomes plays a major role in the metabolism and systemic elimination of chiral pesticides after exposure. In this present work, enantioselective metabolism of four representative chiral triazole fungicides (prothioconazole, flutriafol, triticonazole, and epoxiconazole) in rat liver microsomes (RLM) was investigated using LC-MS/MS. Baseline separation of the four chiral fungicides and prothioconazole-desthio was achieved on Lux-cellulose-1. The results demonstrated that the R-enantiomers of flutriafol and triticonazole were preferentially metabolized with half-life ranged from 17.33 min to 99.00 min. The R,S-epoxiconazole accumulated with a half-life of 173.25 min. There was no stereoselectivity for prothioconazole. However, remarkable stereoselective metabolism was observed for prothioconazole-desthio. The results of enzyme kinetic revealed different affinities between the enantiomers and metabolic enzymes. In addition, homologous modeling and molecular docking results indicated that enantioselectivity were partially to enantiospecific binding affinities with CYP enzymes. This study highlights a new quantitative approach for stereoselective metabolism of chiral agrochemicals and provides more accurate data on risk assessment of triazole fungicides.
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Affiliation(s)
- Zhaoxian Zhang
- Department of Pesticide Science, College of Plant Protection, Nanjing Agricultural University, State & Local Joint Engineering Research Center of Green Pesticide Invention and Application, Ministry of Education, Nanjing, 210095, PR China
| | - Beibei Gao
- Department of Pesticide Science, College of Plant Protection, Nanjing Agricultural University, State & Local Joint Engineering Research Center of Green Pesticide Invention and Application, Ministry of Education, Nanjing, 210095, PR China
| | - Zongzhe He
- Department of Pesticide Science, College of Plant Protection, Nanjing Agricultural University, State & Local Joint Engineering Research Center of Green Pesticide Invention and Application, Ministry of Education, Nanjing, 210095, PR China
| | - Lianshan Li
- Department of Pesticide Science, College of Plant Protection, Nanjing Agricultural University, State & Local Joint Engineering Research Center of Green Pesticide Invention and Application, Ministry of Education, Nanjing, 210095, PR China
| | - Haiyan Shi
- Department of Pesticide Science, College of Plant Protection, Nanjing Agricultural University, State & Local Joint Engineering Research Center of Green Pesticide Invention and Application, Ministry of Education, Nanjing, 210095, PR China
| | - Minghua Wang
- Department of Pesticide Science, College of Plant Protection, Nanjing Agricultural University, State & Local Joint Engineering Research Center of Green Pesticide Invention and Application, Ministry of Education, Nanjing, 210095, PR China.
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22
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High-Resolution Melting Assay for Genotyping Variants of the CYP2C19 Enzyme and Predicting Voriconazole Effectiveness. Antimicrob Agents Chemother 2019; 63:AAC.02399-18. [PMID: 30910893 DOI: 10.1128/aac.02399-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/03/2019] [Indexed: 01/05/2023] Open
Abstract
Voriconazole is a triazole antifungal agent recommended as primary treatment for invasive aspergillosis, as well as some other mold infections. However, it presents some pharmacokinetic singularities that lead to a great variability intra- and interindividually, nonlinear pharmacokinetics, and a narrow therapeutic range. Most experts have recommended tracing the levels of voriconazole in patients when receiving treatment. This azole is metabolized through the hepatic enzyme complex cytochrome P450 (CYPP450), with the isoenzyme CYP2C19 being principally involved. Allelic variations (polymorphisms) of the gene that encodes this enzyme are known to contribute to variability in voriconazole exposure. Three different allelic variants, CYP2C19*17, CYP2C19*2, and CYP2C19*3, could explain most of the phenotypes related to the voriconazole metabolism and some of its pharmacokinetic singularities. We designed a rapid molecular method based on high-resolution melting to characterize these polymorphisms in a total of 142 samples, avoiding sequencing. Three PCRs were designed with similar cycling conditions to run simultaneously. The results showed that our method represents a fast, accurate, and inexpensive means to study these variants related to voriconazole metabolism. In clinical practice, this could offer a useful tool to individually optimize therapy and reduce expenses in patients with fungal infections.
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23
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Zhong X, Tong X, Ju Y, Du X, Li Y. Interpersonal Factors in the Pharmacokinetics and Pharmacodynamics of Voriconazole: Are CYP2C19 Genotypes Enough for Us to Make a Clinical Decision? Curr Drug Metab 2019; 19:1152-1158. [PMID: 29361899 PMCID: PMC6635675 DOI: 10.2174/1389200219666171227200547] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 09/04/2017] [Accepted: 11/26/2017] [Indexed: 02/08/2023]
Abstract
Background: Invasive mycoses are serious infections with high mortality and increasing inci-dence. Voriconazole, an important drug to treat invasive mycosis, is metabolized mainly by the cytochrome P450 family 2 subfamily C member 19 enzyme (CYP2C19) and is affected by the genotypes of CYP2C19. Objective: We reviewed studies on how genotypes affect the pharmacokinetics and pharmacodynamics of voriconazole, and attempted to determine a method to decide on dosage adjustments based on genotypes, after which, the main characteristic of voriconazole was clarified in details. The pharmacokinetics of voriconazole are influenced by various inter and intrapersonal factors, and for certain populations, such as geriatric patients and pediatric patients, these influences must be considered. CYP2C19 genotype represents the main part of the interpersonal variability related to voriconazole blood concentrations. Thus monitoring the concentration of voriconazole is needed in clinical scenarios to minimize the negative influences of inter and intrapersonal factors. Several studies provided evidence on the stable trough concentration range from 1-2 to 4-6 mg/L, which was combined to consider the efficacy and toxicity. However, the therapeutic drug concentration needs to be narrowed down and evaluated by large-scale clinical trials. Conclusion: Though there is insufficient evidence on the relationship between CYP2C19 genotypes and clinical outcomes, there is a great potential for the initial voriconazole dose selection to be guided by the CYP2C19 genotype. Finally, voriconazole therapeutic drug monitoring is essential to provide patient-specific dosing recommendations, leading to more effective anti-fungal regimens to increase clinical effica-cy and reduce adverse drug reactions.
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Affiliation(s)
- Xuefeng Zhong
- Department of Respiratory and Critical Care Medicine, National Center of Gerontology, Beijing Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Xunliang Tong
- Department of Geriatrics, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Yang Ju
- Department of Respiratory and Critical Care Medicine, National Center of Gerontology, Beijing Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Xiaoman Du
- Department of Respiratory and Critical Care Medicine, National Center of Gerontology, Beijing Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Yanming Li
- Department of Respiratory and Critical Care Medicine, National Center of Gerontology, Beijing Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
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24
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Chen L, Zhu L, Li M, Li N, Qi F, Wang N. Predicting the Effects of Different Triazole Antifungal Agents on the Pharmacokinetics of Tamoxifen. AAPS PharmSciTech 2019; 20:24. [PMID: 30604153 DOI: 10.1208/s12249-018-1219-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/11/2018] [Indexed: 01/12/2023] Open
Abstract
Tamoxifen is an antiestrogen drug that is widely used in the adjuvant chemotherapy of estrogen receptor-α (ERα)-positive breast cancer. Chemotherapy could suppress immune function in breast cancer patients, which may cause invasive fungal infections (IFIs). Triazoles (voriconazole, fluconazole, and itraconazole) were commonly used for IFI. The physiologically based pharmacokinetic (PBPK) models were developed to investigate the influence of different triazoles on tamoxifen pharmacokinetics in this paper. To investigate the influence of different triazoles (voriconazole, fluconazole, itraconazole) on tamoxifen pharmacokinetics. Adjusted physicochemical data and pharmacokinetic parameters of voriconazole, fluconazole, itraconazole, and tamoxifen were obtained from published literatures. PBPK models were built and verified in healthy subjects using GastroPlus™. Voriconazole, itraconazole, and tamoxifen were administered orally. Fluconazole was administered intravenously. Simulated plasma concentration-time curves of the voriconazole, fluconazole, itraconazole, and tamoxifen showed good agreement with the observed profiles, respectively. The DDI simulations showed that the pharmacokinetic parameters of tamoxifen were increased by various degrees when coadministered with different triazoles. In healthy subjects, the area under the plasma concentration-time curve from 0 to t h (AUC0-t) of tamoxifen was increased by 41%, 5%, and1% when coadministrated with voriconazole, fluconazole, and itraconazole, respectively. The PBPK models adequately characterized the pharmacokinetics of tamoxifen and triazoles. Among the three triazoles, voriconazole exhibited the greatest effect on tamoxifen pharmacokinetics. In clinical practice, an effective dosage adjustment of tamoxifen may need to be considered and TDM for tamoxifen is advisable to guide dosing and optimize therapy when coadministered with voriconazole.
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25
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Miao Q, Tang JT, van Gelder T, Li YM, Bai YJ, Zou YG, Wang LL, Shi YY. Correlation of CYP2C19 genotype with plasma voriconazole exposure in South-western Chinese Han patients with invasive fungal infections. Medicine (Baltimore) 2019; 98:e14137. [PMID: 30653146 PMCID: PMC6370172 DOI: 10.1097/md.0000000000014137] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The aim of this study was to investigate the correlation between CYP2C19 genotype and dose-adjusted voriconazole (VCZ) trough concentrations (C0/dose).We analyzed the correlation between CYP2C192(681G>A), CYP2C193(636G>A), and CYP2C1917(-806C>T) genetic polymorphisms and the dose-corrected pre-dose concentration (C0/dose) in 106 South-western Chinese Han patients.The frequencies of variant alleles of CYP2C192, 3, and 17 were 29.7%, 4.25%, and 0.92%. For 49.3% of the VCZ samples, the therapeutic window between 1.5 and 5.5 μg/ml was reached. Following the first dose VCZ measurement, in subsequent samples the proportion of VCZ C0 within the therapeutic window increased, suggesting effective therapeutic drug monitoring (TDM) (P = .001). The VCZ C0 was significantly different (P = .010) between patients with normal metabolism (NMs), intermediate metabolism (IMs), and poor metabolism (PMs). The VZC C0/dose was 12.2 (interquartile range (IQR), 8.33-18.2 μg·ml/kg·day), and 7.68 (IQR, 4.07-16.3 μg·ml/kg·day) in PMs and IMs patients, respectively, which was significantly higher than in NMs phenotype patients (4.68; IQR, 2.51-8.87 μg·ml/kg·day, P = .008 and P = .014).This study demonstrated that the VCZ C0/dose was significantly influenced by the CYP2C19 genotype in South-western Chinese Han patients. In this patient population, more over-exposure was observed in patients with a CYP2C19 genotype associated with poor or intermediate metabolism. CYP2C19 genotype-based dosing combined with TDM will support individualization of VCZ dosing, and potentially will minimize toxicity and maximize therapeutic efficacy.
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Affiliation(s)
- Qiang Miao
- Department of Laboratory Medicine, Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jiang-Tao Tang
- Department of Laboratory Medicine, Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Ya-Mei Li
- Department of Laboratory Medicine, Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yang-Juan Bai
- Department of Laboratory Medicine, Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yuan-Gao Zou
- Department of Laboratory Medicine, Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lan-Lan Wang
- Department of Laboratory Medicine, Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yun-Ying Shi
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
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26
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Mangal N, Hamadeh I, Arwood MJ, Cavallari LH, Samant TS, Klinker KP, Bulitta J, Schmidt S. Optimization of Voriconazole Therapy for the Treatment of Invasive Fungal Infections in Adults. Clin Pharmacol Ther 2018; 104:957-965. [PMID: 29315506 PMCID: PMC6037619 DOI: 10.1002/cpt.1012] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 11/10/2022]
Abstract
Therapeutic concentrations of voriconazole in invasive fungal infections (IFIs) are ensured using a drug monitoring approach, which relies on attainment of steady-state pharmacokinetics. For voriconazole, time to reach steady state can vary from 5-7 days, not optimal for critically ill patients. We developed a population pharmacokinetic/pharmacodynamic model-based approach to predict doses that can maximize the net benefit (probability of efficacy-probability of adverse events) and ensure therapeutic concentrations, early on during treatment. The label-recommended 200 mg voriconazole dose resulted in attainment of targeted concentrations in ≥80% patients in the case of Candida spp. infections, as compared to only 40-50% patients, with net benefit ranging from 5.8-61.8%, in the case of Aspergillus spp. infections. Voriconazole doses of 300-600 mg were found to maximize the net benefit up to 51-66.7%, depending on the clinical phenotype (due to CYP2C19 status and pantoprazole use) of the patient and type of Aspergillus infection.
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Affiliation(s)
- Naveen Mangal
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL
| | - Issam Hamadeh
- Levine Cancer Institute, Department of Cancer Pharmacology, Charlotte, NC
| | - Meghan J. Arwood
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL
| | | | - Kenneth P. Klinker
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL
| | - Jurgen Bulitta
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL
| | - Stephan Schmidt
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL
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Patel JN, Wiebe LA, Dunnenberger HM, McLeod HL. Value of Supportive Care Pharmacogenomics in Oncology Practice. Oncologist 2018; 23:956-964. [PMID: 29622698 PMCID: PMC6156181 DOI: 10.1634/theoncologist.2017-0599] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 02/21/2018] [Indexed: 12/14/2022] Open
Abstract
Genomic medicine provides opportunities to personalize cancer therapy for an individual patient. Although novel targeted therapies prolong survival, most patients with cancer continue to suffer from burdensome symptoms including pain, depression, neuropathy, nausea and vomiting, and infections, which significantly impair quality of life. Suboptimal management of these symptoms can negatively affect response to cancer treatment and overall prognosis. The effect of genetic variation on drug response-otherwise known as pharmacogenomics-is well documented and directly influences an individual patient's response to antiemetics, opioids, neuromodulators, antidepressants, antifungals, and more. The growing body of pharmacogenomic data can now guide clinicians to select the safest and most effective supportive medications for an individual patient with cancer from the very first prescription. This review outlines a theoretical patient case and the implications of using pharmacogenetic test results to personalize supportive care throughout the cancer care continuum. IMPLICATIONS FOR PRACTICE Integration of palliative medicine into the cancer care continuum has resulted in increased quality of life and survival for patients with many cancer types. However, suboptimal management of symptoms such as pain, neuropathy, depression, and nausea and vomiting continues to place a heavy burden on patients with cancer. As demonstrated in this theoretical case, pharmacogenomics can have a major effect on clinical response to medications used to treat these conditions. Recognizing the value of supportive care pharmacogenomics in oncology and application into routine practice offers an objective choice for the safest and most effective treatment compared with the traditional trial and error method.
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Affiliation(s)
- Jai N Patel
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina, USA
| | - Lauren A Wiebe
- NorthShore University Health System, Evanston, Illinois, USA
| | | | - Howard L McLeod
- The DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, Florida, USA
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28
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Hösl J, Gessner A, El-Najjar N. Liquid chromatography-tandem mass spectrometry for the quantification of moxifloxacin, ciprofloxacin, daptomycin, caspofungin, and isavuconazole in human plasma. J Pharm Biomed Anal 2018; 157:92-99. [PMID: 29777985 DOI: 10.1016/j.jpba.2018.05.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 05/04/2018] [Accepted: 05/11/2018] [Indexed: 01/20/2023]
Abstract
A simple and precise ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method was developed for the simultaneous analysis of five anti-infective agents used to treat severe infections [three antibiotics (daptomycin, moxifloxacin, ciprofloxacin) and two antifungals (isavuconazole, caspofungin)] in human plasma. Sample preparation was based on protein precipitation with ice cold methanol. All five agents were analyzed with the corresponding isotopically labeled internal standards. All analytes were detected in multiple reactions monitoring (MRM) using API 4000 triple-quadrupole mass spectrometer with electrospray (ESI) source operating in positive mode. The calibration curves were linear over the selected ranges (r > 0.99). The method is precise and accurate with a total run time of 5.5 min. Accuracy of all target analytes ranged between 95.9-116.6%, measured with an imprecision of less than 10.8%. The lower limit of quantification was 1.25 mg/L for caspofungin, 0.3125 mg/L for isavuconazole, 3.125 mg/L for daptomycin, 0.075 mg/L for ciprofloxacin, and 0.1875 mg/L for moxifloxacin. The successful application of the method in patient samples proved its suitability for the medical surveillance of antimicrobial therapy in intensive care units as well as to other pharmacokinetic studies.
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Affiliation(s)
- Julian Hösl
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - André Gessner
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany.
| | - Nahed El-Najjar
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany; Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany.
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29
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Impact of CYP2C19 Genotype and Liver Function on Voriconazole Pharmacokinetics in Renal Transplant Recipients. Ther Drug Monit 2018; 39:422-428. [PMID: 28604474 PMCID: PMC5538305 DOI: 10.1097/ftd.0000000000000425] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Invasive fungal infection (IFI) is one of the leading causes of early death after renal transplantation. Voriconazole (VRC) is the first-line drug of IFI. Because of the large inter- and intraindividual variability in VRC plasma concentrations and the narrow therapeutic window for treating patients with IFIs, it is crucial to study the factors which could influence pharmacokinetic variability. We performed a population pharmacokinetics (PPK) study of VRC for personalized medicine. METHODS A total of 125 trough concentrations (Cmin) from 56 patients were evaluated, retrospectively. Nonlinear mixed effect model was used to describe a PPK model that was internally validated by bootstrap method. Potential covariates included demographic characteristics, physiological and pathological data, concomitant medications, and CYP2C19 genotype. RESULTS A 1-compartment model with first-order absorption and elimination was fit to characterize the VRC pharmacokinetics in renal transplant recipients (RTRs). Aspartate aminotransferase (AST) had a significant influence on clearance (CL) while CYP2C19 genotype had a major impact on the volume of distribution (V). The parameters of CL and V were 4.76 L/h and 22.47 L, respectively. The final model was V (L) = 22.47 × [1 + 2.21 × (EM = 1)] × [1 + 4.67 × (IM = 1)] × [1 + 3.30 × (PM = 1)] × exp (0.96); CL (L/h) = 4.76 × (AST/33)^(-0.23) × exp (0.14). VRC Cmin in intermediate metabolizers was significantly higher than in extensive metabolizers. CONCLUSIONS Liver function and CYP2C19 polymorphism are major determinants of VRC pharmacokinetic variability in RTRs. Genotypes and clinical biomarkers can determine the initial scheme. Subsequently, therapeutic drug monitoring can optimize clinical efficacy and minimize toxicity. Hence, this is a feasible way to facilitate personalized medicine in RTRs. In addition, it is the first report about PPK of VRC in RTRs.
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30
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Lei M, Yao H, Dong Y, Wang M, Wang Z, Cheng X. Development and validation of an LC-MS/MS method for simultaneous quantification of voriconazole and its main metabolite voriconazole N-oxide in human plasma and its clinical application. J LIQ CHROMATOGR R T 2017. [DOI: 10.1080/10826076.2017.1402187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Meng Lei
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Hongping Yao
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Maoyi Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Xiaoliang Cheng
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
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31
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Pergam SA. Fungal Pneumonia in Patients with Hematologic Malignancies and Hematopoietic Cell Transplantation. Clin Chest Med 2017; 38:279-294. [PMID: 28477639 DOI: 10.1016/j.ccm.2016.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Invasive fungal infections, which occur primarily as a consequence of prolonged neutropenia and immunosuppression, are a life-threatening complication seen among patients with hematologic malignancies. The routine use of triazole antifungal prophylaxis, enhanced diagnostics, and newer antifungal agents have led to improvements in the care of fungal pneumonias, but invasive fungal infections remain a major cause of morbidity and mortality. This article covers risk factors for major fungal infections, diagnostic approaches, and treatment options for specific fungal pathogens, including Aspergillus and Mucorales species, and discusses current approved strategies for prevention of common and uncommon fungal pneumonias.
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Affiliation(s)
- Steven A Pergam
- Vaccine & Infectious Disease Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, E4-100, Seattle, WA 98109, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, E4-100, Seattle, WA 98109, USA; Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA; Infection Prevention, Seattle Cancer Care Alliance, 825 Eastlake Avenue East, Seattle, WA 98109, USA.
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32
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Kim SB, Cho SY, Lee DG, Choi JK, Lee HJ, Kim SH, Park SH, Choi SM, Choi JH, Yoo JH, Lee JW. Breakthrough invasive fungal diseases during voriconazole treatment for aspergillosis: A 5-year retrospective cohort study. Med Mycol 2017; 55:237-245. [PMID: 27562861 PMCID: PMC5654366 DOI: 10.1093/mmy/myw067] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 07/08/2016] [Indexed: 01/19/2023] Open
Abstract
Breakthrough invasive fungal diseases (bIFDs) during voriconazole treatment are concerning, as they are associated with high rates of mortality and pathogen distribution. To evaluate the prevalence, incidence, patient characteristics, including IFD events, and overall mortality of bIFDs during voriconazole treatment for invasive aspergillosis (IA). We retrospectively analyzed the medical records of consecutive patients who had undergone voriconazole treatment for IA and who had bIFD events between January 2011 and December 2015. Eleven bIFD events occurred in 9 patients. The prevalence and incidence of bIFDs were 2.25% (9/368) and 0.22 cases per year, respectively. Overall mortality was 44.4% (4/9). The severity of the illness and persistence of immunodeficiency, mixed infection, and low concentration of the treatment drug at the site of infection were identified as possible causes of bIFDs. Seven of 11 events (63.6%) required continued voriconazole treatment with drug level monitoring. In 4 (36.3%) cases, the treatment was changed to liposomal amphotericin B. Two cases resulted in surgical resection (18.2%). Clinicians should be aware that bIFDs during voriconazole treatment for IA can occur, and active therapeutic approaches are required in these cases.
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Affiliation(s)
- Sun Bean Kim
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Yeon Cho
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,The Catholic Blood and Marrow Transplantation Centre, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae-Ki Choi
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyo-Jin Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Si-Hyun Kim
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun Hee Park
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Su-Mi Choi
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung-Hyun Choi
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin-Hong Yoo
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong-Wook Lee
- The Catholic Blood and Marrow Transplantation Centre, College of Medicine, The Catholic University of Korea, Seoul, Korea
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33
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Amsden JR, Gubbins PO. Pharmacogenomics of triazole antifungal agents: implications for safety, tolerability and efficacy. Expert Opin Drug Metab Toxicol 2017; 13:1135-1146. [DOI: 10.1080/17425255.2017.1391213] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Jarrett R. Amsden
- Department of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis, IN, USA
| | - Paul O. Gubbins
- Division of Pharmacy Practice and Administration, UMKC School of Pharmacy at MSU, Springfield, MO, USA
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34
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Walsh TJ, Moriyama B, Penzak SR, Klein TE, Caudle KE. Response to "Pharmacogenetics of Voriconazole: CYP2C19 but Also CYP3A4 Need to Be Genotyped" - The Role of CYP3A4 and CYP3A5 Polymorphisms in Clinical Pharmacokinetics of Voriconazole. Clin Pharmacol Ther 2017; 102:190. [PMID: 28455946 DOI: 10.1002/cpt.681] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 03/09/2017] [Indexed: 11/09/2022]
Affiliation(s)
- T J Walsh
- Transplantation-Oncology Infectious Diseases Program, Departments of Medicine, Pediatrics, and Microbiology and Infectious Diseases, Weill Cornell Medical Center of Cornell University, New York, New York, USA
| | - B Moriyama
- NIH Clinical Center Pharmacy Department, Bethesda, Maryland, USA
| | - S R Penzak
- Department of Pharmacotherapy, University of North Texas, System College of Pharmacy, Fort Worth, Texas, USA
| | - T E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - K E Caudle
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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35
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Patel JN, Villadolid J. Cancer Drug Delivery. PHARMACEUTICAL SCIENCES 2017. [DOI: 10.4018/978-1-5225-1762-7.ch008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Advancements in cancer drug delivery have led to the development of personalized oncology care through molecularly-driven targeted therapies. Understanding molecular and cellular mechanisms which drive tumor progression and resistance is critical in managing new treatment strategies which have shifted from empiric to biomarker-directed therapy selection. Biomarker-directed therapies have improved clinical outcomes in multiple malignancies as monotherapy and in combination with other treatment modalities, however the changing scope of treatment options presents new opportunities and challenges for research. Furthermore, pharmacogenetics may provide a rationale method of personalizing anticancer drug dosing and supportive care management for oncology patients. This chapter reviews biomarker classifications and pharmacogenetics in anticancer therapy and supportive care. Examples of biomarker-directed therapies and clinical assays, in addition to future directions of molecular profiling in oncology therapy management are discussed.
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36
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Ahmed S, Zhou Z, Zhou J, Chen SQ. Pharmacogenomics of Drug Metabolizing Enzymes and Transporters: Relevance to Precision Medicine. GENOMICS PROTEOMICS & BIOINFORMATICS 2016; 14:298-313. [PMID: 27729266 PMCID: PMC5093856 DOI: 10.1016/j.gpb.2016.03.008] [Citation(s) in RCA: 155] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 02/17/2016] [Accepted: 03/08/2016] [Indexed: 01/11/2023]
Abstract
The interindividual genetic variations in drug metabolizing enzymes and transporters influence the efficacy and toxicity of numerous drugs. As a fundamental element in precision medicine, pharmacogenomics, the study of responses of individuals to medication based on their genomic information, enables the evaluation of some specific genetic variants responsible for an individual’s particular drug response. In this article, we review the contributions of genetic polymorphisms to major individual variations in drug pharmacotherapy, focusing specifically on the pharmacogenomics of phase-I drug metabolizing enzymes and transporters. Substantial frequency differences in key variants of drug metabolizing enzymes and transporters, as well as their possible functional consequences, have also been discussed across geographic regions. The current effort illustrates the common presence of variability in drug responses among individuals and across all geographic regions. This information will aid health-care professionals in prescribing the most appropriate treatment aimed at achieving the best possible beneficial outcomes while avoiding unwanted effects for a particular patient.
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Affiliation(s)
- Shabbir Ahmed
- Department of Precision Medicine and Biopharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Zhan Zhou
- Department of Precision Medicine and Biopharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Jie Zhou
- Department of Precision Medicine and Biopharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Shu-Qing Chen
- Department of Precision Medicine and Biopharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China; International Center for Precision Medicine, Zhejiang California International NanoSystems Institute, Hangzhou 310058, China.
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37
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Patterson TF, Thompson GR, Denning DW, Fishman JA, Hadley S, Herbrecht R, Kontoyiannis DP, Marr KA, Morrison VA, Nguyen MH, Segal BH, Steinbach WJ, Stevens DA, Walsh TJ, Wingard JR, Young JAH, Bennett JE. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 63:e1-e60. [PMID: 27365388 DOI: 10.1093/cid/ciw326] [Citation(s) in RCA: 1588] [Impact Index Per Article: 198.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 05/11/2016] [Indexed: 12/12/2022] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
- Thomas F Patterson
- University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System
| | | | - David W Denning
- National Aspergillosis Centre, University Hospital of South Manchester, University of Manchester, United Kingdom
| | - Jay A Fishman
- Massachusetts General Hospital and Harvard Medical School
| | | | | | | | - Kieren A Marr
- Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Vicki A Morrison
- Hennepin County Medical Center and University of Minnesota, Minneapolis
| | | | - Brahm H Segal
- University at Buffalo Jacobs School of Medicine and Biomedical Sciences, and Roswell Park Cancer Institute, New York
| | | | | | - Thomas J Walsh
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | | | | | - John E Bennett
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
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38
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Lamoureux F, Duflot T, Woillard JB, Metsu D, Pereira T, Compagnon P, Morisse-Pradier H, El Kholy M, Thiberville L, Stojanova J, Thuillez C. Impact of CYP2C19 genetic polymorphisms on voriconazole dosing and exposure in adult patients with invasive fungal infections. Int J Antimicrob Agents 2016; 47:124-31. [DOI: 10.1016/j.ijantimicag.2015.12.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 11/10/2015] [Accepted: 12/01/2015] [Indexed: 12/01/2022]
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Chuwongwattana S, Jantararoungtong T, Chitasombat MN, Puangpetch A, Prommas S, Dilokpattanamongkol P, Watcharananan SP, Sukasem C. A prospective observational study of CYP2C19 polymorphisms and voriconazole plasma level in adult Thai patients with invasive aspergillosis. Drug Metab Pharmacokinet 2016; 31:117-22. [PMID: 26861072 DOI: 10.1016/j.dmpk.2015.12.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 12/10/2015] [Accepted: 12/27/2015] [Indexed: 01/22/2023]
Abstract
The aim of this study was to investigate the association of genetic variants of CYP2C19 (CYP2C19*2, CYP2C19*3 and CYP2C19*17 alleles) and voriconazole trough plasma concentrations in Thai patients with invasive fungal infection. A total of 285 samples from patients with invasive fungal infection and treated with voriconazole were prospectively enrolled. At steady state, trough voriconazole concentrations were measured using tandem mass spectrophotometry and high performance liquid chromatography. The genetic variants in the CYP2C19 gene were genotyped for CYP2C19*2 (G681A), CYP2C19*3 (G636A) and CYP2C19*17 (C-806T) on plasma voriconazole level. Voriconazole Ctrough levels were positively associated with CYP2C19*3. The median Ctrough level for patients with the 636GA genotype (2.109, IQR 1.054-4.166 μg/ml) was statistically significantly higher than those with the 636GG genotype (1.596, IQR 0.755-2.980 μg/ml), P = 0.046. The patients with a poor metabolizer (PM; CYP2C19*2/*2, *2/*3) had voriconazole Ctrough level of 1.900 (IQR, 1.130-3.673 μg/ml). This was statistically significantly higher than that seen with the extensive metabolizer phenotype (1.470; IQR, 0.632-2.720 μg/ml), P = 0.039. An association between CYP2C19 variant alleles and high voriconazole plasma level was identified. Therefore, determining the CYP2C19 genotype before initiation of voriconazole treatment may be useful in optimizing the dosing regimen in Thai patients with invasive fungal infections.
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Affiliation(s)
- Sumonrat Chuwongwattana
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok, Thailand
| | - Thawinee Jantararoungtong
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok, Thailand
| | - Maria N Chitasombat
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Apichaya Puangpetch
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok, Thailand
| | - Santirat Prommas
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok, Thailand
| | | | - Siriorn P Watcharananan
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok, Thailand.
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40
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Implications of Pharmacogenetics for Antimicrobial Prescribing. Mol Microbiol 2016. [DOI: 10.1128/9781555819071.ch43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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41
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Chen X, Gu E, Wang S, Zheng X, Chen M, Wang L, Hu G, Cai JP, Zhou H. Evaluation of the Effects of Ketoconazole and Voriconazole on the Pharmacokinetics of Oxcarbazepine and Its Main Metabolite MHD in Rats by UPLC-MS-MS. J Chromatogr Sci 2015; 54:334-42. [PMID: 26499119 DOI: 10.1093/chromsci/bmv146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Indexed: 11/13/2022]
Abstract
Oxcarbazepine (OXC), a second-generation antiepileptic drug, undergoes rapid reduction with formation of the active metabolite 10,11-dihydro-10-hydroxy-carbazepine (MHD) in vivo. In this study, a method for simultaneous determination of OXC and MHD in rat plasma using ultra-performance liquid chromatography with tandem mass spectrometry (UPLC-MS-MS) was developed and validated. Under given chromatographic conditions, OXC, MHD and internal standard diazepam were separated well and quantified by electrospray positive ionization mass spectrometry in the multiple reaction monitoring transitions mode. The method validation demonstrated good linearity over the range of 10-2,000 ng/mL for OXC and 5-1,000 ng/mL for MHD. The lower limit of quantification was 5 ng/mL for OXC and 2.5 ng/mL for MHD, respectively. The method was successfully applied to the evaluation of the pharmacokinetics of OXC and MHD in rats, with or without pretreatment by ketoconazole (KET) and voriconazole (VOR). Statistics indicated that KET and VOR significantly affected the disposition of OXC and MHD in vivo, whereas VOR predominantly interfered with the disposition of MHD. This method is suitable for pharmacokinetic study in small animals.
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Affiliation(s)
- Xinxin Chen
- Pharmacology Department, School of Pharmacy, Wenzhou Medical University, Wenzhou 325035, China
| | - Ermin Gu
- Pharmacology Department, School of Pharmacy, Wenzhou Medical University, Wenzhou 325035, China
| | - Shuanghu Wang
- The Laboratory of Clinical Pharmacy, The People's Hospital of Lishui, Lishui 323000, China
| | - Xiang Zheng
- Pharmacology Department, School of Pharmacy, Wenzhou Medical University, Wenzhou 325035, China
| | - Mengchun Chen
- Pharmacology Department, School of Pharmacy, Wenzhou Medical University, Wenzhou 325035, China
| | - Li Wang
- Pharmacology Department, School of Pharmacy, Wenzhou Medical University, Wenzhou 325035, China
| | - Guoxin Hu
- Pharmacology Department, School of Pharmacy, Wenzhou Medical University, Wenzhou 325035, China
| | - Jian-ping Cai
- The Key Laboratory of Geriatrics, Beijing Hospital & Beijing Institute of Geriatrics, Ministry of Health, Beijing 100730, China
| | - Hongyu Zhou
- Pharmacology Department, School of Pharmacy, Wenzhou Medical University, Wenzhou 325035, China
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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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Aung AK, Haas DW, Hulgan T, Phillips EJ. Pharmacogenomics of antimicrobial agents. Pharmacogenomics 2015; 15:1903-30. [PMID: 25495412 DOI: 10.2217/pgs.14.147] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Antimicrobial efficacy and toxicity varies between individuals owing to multiple factors. Genetic variants that affect drug-metabolizing enzymes may influence antimicrobial pharmacokinetics and pharmacodynamics, thereby determining efficacy and/or toxicity. In addition, many severe immune-mediated reactions have been associated with HLA class I and class II genes. In the last two decades, understanding of pharmacogenomic factors that influence antimicrobial efficacy and toxicity has rapidly evolved, leading to translational success such as the routine use of HLA-B*57:01 screening to prevent abacavir hypersensitivity reactions. This article examines recent advances in the field of antimicrobial pharmacogenomics that potentially affect treatment efficacy and toxicity, and challenges that exist between pharmacogenomic discovery and translation into clinical use.
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Affiliation(s)
- Ar Kar Aung
- Department of General Medicine & Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
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Abidi MZ, D'Souza A, Kuppalli K, Ledeboer N, Hari P. CYP2C19*17 genetic polymorphism--an uncommon cause of voriconazole treatment failure. Diagn Microbiol Infect Dis 2015; 83:46-8. [PMID: 25986028 DOI: 10.1016/j.diagmicrobio.2015.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 04/25/2015] [Accepted: 05/01/2015] [Indexed: 11/28/2022]
Abstract
We describe an immunosuppressed, 48-year-old male, allogeneic hematopoietic stem cell transplant recipient with severe graft-versus-host disease who developed invasive pulmonary Aspergillus fumigatus infection 6 months after transplant. His lack of response to voriconazole and undetectable serum trough levels of the drug led us to establish that he had the uncommon cytochrome P450, CYP2C19*17 allele, which leads to a rapid metabolism of voriconazole but not of the other azole antifungals. We discuss the particular challenges encountered in this case.
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Affiliation(s)
- Maheen Z Abidi
- Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Anita D'Souza
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Krutika Kuppalli
- Division of Infectious Diseases, Department of Medicine, Loyola University Medical Center, Maywood, IL, USA; Division of Infectious Diseases, Department of Medicine, Edward Hines, Jr. Veterans Administration Hospital, Hines, IL, USA
| | - Nathan Ledeboer
- Divison of Microbiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Parmeswaran Hari
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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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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46
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Trubiano JA, Crowe A, Worth LJ, Thursky KA, Slavin MA. Putting CYP2C19 genotyping to the test: utility of pharmacogenomic evaluation in a voriconazole-treated haematology cohort. J Antimicrob Chemother 2015; 70:1161-5. [PMID: 25558073 DOI: 10.1093/jac/dku529] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES The clinical utility of pharmacogenomic testing in haematology patients with invasive fungal disease (IFD) receiving azole therapy has not been defined. We report our experience with CYP2C19 testing in haematological patients requiring voriconazole therapy for IFD. METHODS As a single-centre pilot study, 19 consecutive patients with a haematological malignancy undergoing active chemotherapy with a possible, probable or proven IFD requiring voriconazole therapy underwent CYP2C19 testing from 2013 to 2014. Baseline patient demographics, concurrent medications, voriconazole levels and IFD history were captured. RESULTS The median voriconazole levels for intermediate metabolizer (IM) (CYP2C19*2 or 3/*1 or 17), extensive metabolizer (EM) (CYP2C19*1/*1) and heterozygote ultrarapid metabolizer (HUM)/ultrarapid metabolizer (UM) (UM, CYP2C19*17/*17; HUM, CYP2C19*1/*17) patients were 5.23, 3.3 and 1.25 mg/L, respectively. Time to therapeutic voriconazole levels was longest in the IM group, whilst voriconazole levels <1 mg/L were only seen in UM, HUM and EM phenotypes. The highest rates of clinical toxicity were seen in the IM group (3/5, 60%). CONCLUSIONS Voriconazole exposure and toxicity was highest for IM and lowest for HUM/UM phenotypes. Time to therapeutic voriconazole level was longest in IM, whilst refractory subtherapeutic levels requiring CYP2C19 inhibition were only seen in the EM, HUM and UM phenotypes. CYP2C19 genotyping may predict those likely to have supratherapeutic or subtherapeutic levels and/or toxicity. Prospective evaluation of clinical pathways incorporating genotyping and voriconazole dose-titrating algorithms is required.
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Affiliation(s)
- J A Trubiano
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia
| | - A Crowe
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia
| | - L J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia
| | - K A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - M A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, VIC, Australia
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Effects of CYP3A4 polymorphisms on the plasma concentration of voriconazole. Eur J Clin Microbiol Infect Dis 2014; 34:811-9. [PMID: 25515945 DOI: 10.1007/s10096-014-2294-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 11/26/2014] [Indexed: 10/24/2022]
Abstract
Voriconazole is frequently utilized for the prevention and treatment of invasive fungal infections (IFIs), and is extensively metabolized by the cytochrome P450 (CYP) system. The impact of activity of the genes encoding CYP3A4, CYP3A5, and CYP2C9 on the pharmacokinetics of voriconazole cannot be ignored because, second to CYP2C19, they are the most important enzymes involved in voriconazole metabolism. The influence of genetic polymorphisms in CYP3A4, CYP3A5, and CYP2C9 on the plasma concentrations of voriconazole was evaluated in the present study. The study cohort comprised 158 patients with IFIs in whom 22 single-nucleotide polymorphisms (SNPs) in CYP3A4, CYP3A5, and CYP2C9 were genotyped using the Sequenom MassARRAY RS1000 system, and voriconazole plasma concentrations were measured by high-performance liquid chromatography (HPLC). 40, 91, and 27 patients presented with low (<1 mg/L), normal (1-4 mg/L), and high (>4 mg/L) plasma voriconazole concentrations, respectively. Correlation analysis between polymorphisms and the plasma voriconazole concentration revealed an association between the presence of the rs4646437 T allele and a higher plasma voriconazole concentration [p = 0.033, odds ratio (OR) = 2.832, 95% confidence interval (CI) = 1.086-7.384]. This study has identified a new SNP related to the metabolism of voriconazole, potentially providing novel insight into the influence of CYP3A4 on the pharmacokinetics of this antifungal agent.
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Wang L, Wang S, Chen M, Chen X, Lin Y, Hu X, Huang X, Li X, Hu G. Inhibitory effect of ketoconazole and voriconazole on the pharmacokinetics of carvedilol in rats. Drug Dev Ind Pharm 2014; 41:1661-6. [DOI: 10.3109/03639045.2014.983930] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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49
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Wang T, Zhu H, Sun J, Cheng X, Xie J, Dong H, Chen L, Wang X, Xing J, Dong Y. Efficacy and safety of voriconazole and CYP2C19 polymorphism for optimised dosage regimens in patients with invasive fungal infections. Int J Antimicrob Agents 2014; 44:436-42. [DOI: 10.1016/j.ijantimicag.2014.07.013] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 06/22/2014] [Accepted: 07/03/2014] [Indexed: 11/28/2022]
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50
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Bouatou Y, Samer C, Ing Lorenzini K, Daali Y, Daou S, Fathi M, Rebsamen M, Desmeules J, Calmy A, Escher M. Therapeutic drug monitoring of voriconazole: a case report of multiple drug interactions in a patient with an increased CYP2C19 activity. AIDS Res Ther 2014; 11:25. [PMID: 25120580 PMCID: PMC4130425 DOI: 10.1186/1742-6405-11-25] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 07/15/2014] [Indexed: 11/10/2022] Open
Abstract
Background Voriconazole is metabolized by cytochrome P450 (CYP) 2C19 and CYP 3A4. Drug-drug interactions and genetic polymorphisms modulate their activities. Case presentation A 35-year old African female patient with resistant HIV and a cerebral mass of unknown origin was treated with voriconazole for a suspicion of disseminated Aspergillosis infection. Voriconazole trough concentrations (C0) were within target range while the patient was under esomeprazole, a CYP2C19 inhibitor. Phenotyping showed decreased CYP2C19 activity, whereas genotyping showed a variant allele associated with increased enzyme activity. The patient was switched to ranitidine because of the introduction of atazanavir. CYP3A4 inhibition by atazanavir combined with uninhibited CYP2C19 activity resulted in subtherapeutic voriconazole C0. The reintroduction of esomeprazole allowed restoring voriconazole C0 back to target range. Conclusion The integration of drug-drug interactions and pharmacogenetics data is crucial to interpret drug concentrations correctly, thus preventing suboptimal exposure to voriconazole.
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