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Moon JY, Suh W, Jun RM, Han KE. Toxicity of simultaneous intrastromal and intracameral injection of voriconazole on corneal endothelium in a rabbit model. Cutan Ocul Toxicol 2023; 42:144-150. [PMID: 37350680 DOI: 10.1080/15569527.2023.2226714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/11/2023] [Accepted: 06/13/2023] [Indexed: 06/24/2023]
Abstract
PURPOSE To investigate the toxicity of repeated simultaneous intrastromal and intracameral injections of voriconazole in corneal endothelial cells in a rabbit model. METHODS Thirty-six eyes of 18 New Zealand white rabbits (six eyes per group) were divided into 6 groups according to the concentration of voriconazole (Group A, 0%; Group B, 0.05%; Group C, 0.1%; Group D, 0.25%; Group E, 0.5%; Group F, 1%). A combination of intrastromal and intracameral voriconazole injections were administrated to the eyes of each group three times on days 0, 3, and 7. Corneal clouding grades and central corneal thickness (CCT) were examined on days 0, 3, 7, 10, and 14. The endothelial cell counts (ECC) were measured on days 0 and 14. Scanning electron microscopy (SEM) and transmission electron microscopy (TEM) were performed on day 14. RESULTS Group F (1%) showed more severe corneal clouding than the other groups (Groups A-E) from day 7 (p < 0.05, respectively). There were no significant differences in CCT and ECC among the six groups at any time point (p > 0.05, respectively). SEM revealed blurring of the cell border and loss of microvilli at concentrations ≥0.25% (Groups D-F). TEM revealed microstructural changes in endothelial cells at concentrations ≥0.1% (Groups C-F), and multiple vacuoles were observed at a concentration of 1% voriconazole (Group F). CONCLUSIONS Repeated simultaneous intrastromal and intracameral voriconazole injections at a concentration of 0.1% or higher induced microstructural endothelial damage in rabbit corneal endothelial cells.
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Affiliation(s)
- Ji Young Moon
- Department of Ophthalmology, Ewha Womans University College of Medicine, Mokdong Hospital, Seoul, Republic of Korea
| | - Wool Suh
- Department of Ophthalmology, Ewha Womans University College of Medicine, Mokdong Hospital, Seoul, Republic of Korea
| | - Roo Min Jun
- Department of Ophthalmology, Ewha Womans University College of Medicine, Seoul Hospital, Seoul, Republic of Korea
| | - Kyung Eun Han
- Department of Ophthalmology, Ewha Womans University College of Medicine, Mokdong Hospital, Seoul, Republic of Korea
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2
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Shen K, Gu Y, Wang Y, Lu Y, Ni Y, Zhong H, Shi Y, Su X. Therapeutic drug monitoring and safety evaluation of voriconazole in the treatment of pulmonary fungal diseases. Ther Adv Drug Saf 2022; 13:20420986221127503. [PMID: 36225945 PMCID: PMC9549188 DOI: 10.1177/20420986221127503] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 09/04/2022] [Indexed: 11/07/2022] Open
Abstract
Aims: The gene polymorphism of voriconazole metabolism–related liver enzyme is
notable in East Asia population. It casts a significant influence on the
rational use of voriconazole. We conducted this study to investigate the
relationship between steady-state voriconazole trough concentration
(Ctrough) and adverse effects (AEs), especially
hepatotoxicity. Methods: We conducted a real-world study in the Jinling Hospital from January 2015 to
June 2020. A total of 140 patients receiving voriconazole were enrolled in
this study. The determination and scoring of voriconazole-associated
hepatotoxicity were performed according to the Roussel Uclaf Causality
Assessment Method scoring scale and the severity of hepatotoxicity was
graded according to the Common Terminology Criteria for Adverse Events
(CTCAE). Results: Elevated steady-state voriconazole Ctrough with concomitant AEs
are the most common reason for dose adjustments during treatment. Compared
with the group without any AEs, voriconazole Ctrough was
significantly higher in the hepatotoxicity and neurotoxicity groups, and the
incidence of both events showed an overall increasing trend with increasing
voriconazole Ctrough. Hepatotoxicity occurred in 66.7% of
patients within 7 days of the first dose of voriconazole and 94.4% within
15 days of the dose. Steady-state voriconazole Ctrough
>3.61 mg/l was associated with an increased incidence of hepatotoxicity
(area under the curve = 0.645, p = 0.047). Logistic
regression analysis showed that timely voriconazole dose adjustment was a
predictor of attenuated hepatotoxicity after adjustment for confounders, but
hepatotoxicity was not associated with voriconazole Ctrough
measured at a single time point. Conclusion: Hepatotoxicity and neurotoxicity correlate with voriconazole
Ctrough, and dose reduction in patients with elevated
steady-state voriconazole Ctrough may prevent hepatotoxicity. In
patients with early occurrence of hepatotoxicity, initial therapeutic drug
monitoring (TDM) might predict the risk of hepatotoxicity. Follow-up TDM may
be necessary to predict late onset hepatotoxicity. Plain Language Summary Safety of voriconazole for the treatment of pulmonary fungal
diseases Introduction: Several studies have suggested an association
between the concentration of voriconazole in the blood and liver damage, but
the evidence is weak. This study aimed to investigate relationships between
voriconazole drug concentration and side effects and to analyze the factors
affecting liver damage caused by voriconazole. Methods: We conducted a study at the Jinling Hospital from
January 2015 to June 2020, in which a total of 140 patients were finally
enrolled. Results: Voriconazole doses were adjusted in 44 patients due to
abnormal voriconazole drug concentration or side effects, 32 patients
reduced the dose and 8 patients increased the dose. An elevated liver enzyme
level was the most common cause for dose adjustment. After the first dose
adjustment, most patients achieved the target drug concentration. A total of
18 patients were determined as probable or highly probable to have
drug-induced liver injury from voriconazole. Voriconazole drug concentration
was significantly higher in the liver damage and nervous system damage
groups as compared with the group without any side effects, and most liver
damage events occurred within 14 days of the first dose. Voriconazole drug
concentration >3.61 mg/l was associated with an increased incidence of
liver damage. Conclusion: In this study, approximately one-third of patients
with pulmonary fungal disease needed to adjust their dose after the standard
dose of voriconazole treatment. The incidence of liver damage and nervous
system damage showed an overall increasing trend with increasing
voriconazole baseline concentrations. Initial therapeutic drug monitoring
may be predictive of liver damage. Follow-up monitoring of liver enzymes may
be needed.
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Affiliation(s)
- Kunlu Shen
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, The First School of Clinical Medicine, Southern
Medical University, Nanjing, China
| | - Yu Gu
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Yu Wang
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing,
China
| | - Yajie Lu
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing,
China
| | - Yueyan Ni
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Huanhiuan Zhong
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing,
China
| | - Yi Shi
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing,
China
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3
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Parza K, Singh P, Cvinar J, Zimmerman T, Watson B, Faris M. Voriconazole Induced Cutaneous Squamous Cell Carcinoma in an Immunocompetent Patient. Cureus 2022; 14:e25508. [PMID: 35663682 PMCID: PMC9153335 DOI: 10.7759/cureus.25508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2022] [Indexed: 11/25/2022] Open
Abstract
Voriconazole therapy can be associated with hair loss, vision changes, and skin phototoxicity, but rarely is it associated with the development of skin cancer. We present a case of an immunocompetent 42-year-old Caucasian male with a past medical history significant for chronic pulmonary aspergillosis (CPA) and prior cutaneous squamous cell carcinoma (cSCC) of the left hand who arrived at our clinic for evaluation of an enlarging, non-tender left preauricular mass over the past six months. He had diffuse actinic changes and appeared older relative to his age. He had a fair complexion but was compliant with sun protection measures and minimized unnecessary ultraviolet (UV) light exposure. His left-sided facial mass was excised, and the final pathology was consistent with cSCC. His only home medication was oral voriconazole 200 mg once daily for six years for pulmonary aspergillosis. He was negative for human immunodeficiency virus (HIV) and had no history of prior transplant operations. This case highlights the importance of recognizing voriconazole as an independent risk factor in the development of cSCC, especially in patients on chronic therapy for aspergillosis.
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Harding T, Harris C, Smart J, Zacharin M. Debilitating limb pain and weakness as complications of long-term voriconazole therapy. J Paediatr Child Health 2021; 57:2012-2013. [PMID: 33682198 DOI: 10.1111/jpc.15414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 01/16/2021] [Accepted: 02/10/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Tristan Harding
- Department of Endocrinology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Chris Harris
- Department of Orthopaedics, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Joanne Smart
- Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Margaret Zacharin
- Department of Endocrinology, Royal Children's Hospital, Melbourne, Victoria, Australia
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5
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Echeverria-Esnal D, Martín-Ontiyuelo C, Navarrete-Rouco ME, Barcelo-Vidal J, Conde-Estévez D, Carballo N, De-Antonio Cuscó M, Ferrández O, Horcajada JP, Grau S. Pharmacological management of antifungal agents in pulmonary aspergillosis: an updated review. Expert Rev Anti Infect Ther 2021; 20:179-197. [PMID: 34328373 DOI: 10.1080/14787210.2021.1962292] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Aspergillus may cause different types of lung infections: invasive, chronic pulmonary or allergic bronchopulmonary aspergillosis. Pharmacological management with antifungals poses as a challenge. Patients diagnosed with pulmonary aspergillosis are complex, as well as the problems associated with antifungal agents. AREAS COVERED This article reviews the pharmacology of antifungal agents in development and currently used to treat pulmonary aspergillosis, including the mechanisms of action, pharmacokinetics, pharmacodynamics, dosing, therapeutic drug monitoring and safety. Recommendations to manage situations that arise in daily clinical practice are provided. A literature search of PubMed was conducted on November 15th, 2020 and updated on March 30th, 2021. EXPERT OPINION Recent and relevant developments in the treatment of pulmonary aspergillosis have taken place. Novel antifungals with new mechanisms of action that extend antifungal spectrum and improve pharmacokinetic-related aspects, drug-drug interactions and safety are under current study. For those antifungals already marketed, new data related to pharmacokinetics, pharmacodynamics, dose adjustments in special situations, therapeutic drug monitoring and safety are available. To maximize efficacy and reduce the risk of associated toxicities, it is essential to choose the most appropriate antifungal; optimize its dose, interval, route of administration and length of treatment; and prevent side effects.
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Affiliation(s)
- Daniel Echeverria-Esnal
- Pharmacy Department, Hospital Del Mar, Parc De Salut Mar, Barcelona, Spain.,Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital Del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | | | | | | | - David Conde-Estévez
- Pharmacy Department, Hospital Del Mar, Parc De Salut Mar, Barcelona, Spain.,Department Of Pharmacology, Universitat Autònoma De Barcelona, Barcelona, Spain
| | - Nuria Carballo
- Pharmacy Department, Hospital Del Mar, Parc De Salut Mar, Barcelona, Spain
| | | | - Olivia Ferrández
- Pharmacy Department, Hospital Del Mar, Parc De Salut Mar, Barcelona, Spain
| | - Juan Pablo Horcajada
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital Del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain.,Department Of Pharmacology, Universitat Autònoma De Barcelona, Barcelona, Spain.,Infectious Diseases Department, Hospital Del Mar, Parc De Salut Mar, Barcelona, Spain
| | - Santiago Grau
- Pharmacy Department, Hospital Del Mar, Parc De Salut Mar, Barcelona, Spain.,Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital Del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain.,Department Of Pharmacology, Universitat Autònoma De Barcelona, Barcelona, Spain
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6
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D'Arcy ME, Pfeiffer RM, Rivera DR, Hess GP, Cahoon EK, Arron ST, Brownell I, Cowen EW, Israni AK, Triplette MA, Yanik EL, Engels EA. Voriconazole and the Risk of Keratinocyte Carcinomas Among Lung Transplant Recipients in the United States. JAMA Dermatol 2021; 156:772-779. [PMID: 32401271 PMCID: PMC7221851 DOI: 10.1001/jamadermatol.2020.1141] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Question What is the association between voriconazole, an antifungal used to treat aspergillosis infections, and the risk of keratinocyte carcinomas among recipients of lung transplants? Findings In a population-based cohort study of 9599 non-Hispanic white recipients of 9793 lung transplants in the United States (2007-2016) with linkage to pharmacy claims, increasing cumulative voriconazole exposure was associated with an increased risk of cutaneous squamous cell carcinoma. Meaning These findings suggest that physicians caring for lung transplant recipients at high risk for aggressive keratinocyte carcinomas should limit voriconazole exposure when possible and encourage skin protection behaviors and more frequent cancer screenings. Importance The antifungal medication voriconazole is used to prevent and treat aspergillosis, a major cause of mortality among recipients of lung transplants (hereinafter referred to as lung recipients). Small studies suggest that voriconazole increases risk of cutaneous squamous cell carcinoma (SCC). Objective To examine associations of voriconazole and other antifungal medications with risk of keratinocyte carcinomas (SCC and cutaneous basal cell carcinoma [BCC]) in lung recipients. Design, Setting, and Participants This population-based cohort study included non-Hispanic white patients (n = 9599) who underwent lung transplant in the United States from January 1, 2007, to December 31, 2016, identified through the national Scientific Registry of Transplant Recipients with data linkable to pharmacy claims. Data were analyzed from March 1, 2018, to February 13, 2019. Exposures Antifungal medication use, including voriconazole, itraconazole, posaconazole, and other antifungals, was ascertained from pharmacy claims and treated as a time-varying exposure (assessed every 30 days). Cumulative antifungal exposure was calculated as the total number of exposed months. Main Outcomes and Measures Primary outcomes were the first SCC or BCC reported to the transplant registry by transplant centers. Follow-up began at transplant and ended at SCC or BCC diagnosis, transplant failure or retransplant, death, loss to follow-up, or December 31, 2016. Cox proportional hazards regression models were used to estimate adjusted hazard ratios (AHRs) for each antifungal medication. Results Among the 9793 lung transplants in 9599 recipients included in the analysis, median age at transplant was 59 (interquartile range [IQR], 48-65) years, 5824 (59.5%) were male, and 5721 (58.4%) reported ever smoking. During a median follow-up of 3.0 (IQR, 1.4-5.0) years after transplant, 1031 SCCs (incidence, 322 per 10 000 person-years) and 347 BCCs (incidence, 101 per 10 000 person-years) were reported. Compared with lung recipients with no observed voriconazole use, those with 1 to 3 months of voriconazole use experienced increased AHR for SCC of 1.09 (95% CI, 0.90-1.31); 4 to 7 months, 1.42 (95% CI, 1.16-1.73); 8 to 15 months, 2.04 (95% CI, 1.67-2.50); and more than 15 months, 3.05 (95% CI, 2.37-3.91). Ever itraconazole exposure was associated with increased SCC risk (AHR, 1.20; 95% CI, 1.00-1.45). For BCC, risk was not associated with voriconazole use but was increased with itraconazole use (AHR, 1.74; 95% CI, 1.27-2.37) or posaconazole use (AHR, 1.55; 95% CI, 1.00-2.41). Conclusions and Relevance In this study, voriconazole use was associated with increased SCC risk among lung recipients, especially after prolonged exposure. Further research evaluating the risk-benefit ratio of shorter courses or alternative medications in transplant recipients at high risk for SCC should be considered.
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Affiliation(s)
- Monica E D'Arcy
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Ruth M Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Donna R Rivera
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Gregory P Hess
- The Wharton School, University of Pennsylvania, Philadelphia
| | - Elizabeth K Cahoon
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Sarah T Arron
- Department of Dermatology, University of California, San Francisco
| | - Isaac Brownell
- National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | - Edward W Cowen
- National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | - Ajay K Israni
- Kidney Transplant Program, Hennepin Healthcare, University of Minnesota, Minneapolis.,Scientific Registry of Transplant Recipients, Minneapolis, Minnesota
| | - Matthew A Triplette
- Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle
| | | | - Eric A Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
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7
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D’Arcy ME, Castenson D, Lynch CF, Kahn AR, Morton LM, Shiels MS, Pfeiffer RM, Engels EA. Risk of Rare Cancers Among Solid Organ Transplant Recipients. J Natl Cancer Inst 2021; 113:199-207. [PMID: 32462187 PMCID: PMC7850530 DOI: 10.1093/jnci/djaa078] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/04/2020] [Accepted: 05/21/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Immunosuppressed solid organ transplant recipients (SOTRs) have elevated rates of certain rare cancers caused by viruses. Evaluating risk of rare cancers among SOTRs may provide etiological clues for additional cancers linked to poor immunity and viral infections. METHODS We performed a cohort study of 262 455 SOTRs (1987-2014) from the US SOTR registry linked to 17 population-based cancer registries. First cancers in SOTRs were categorized using an established classification scheme based on site and histology. Standardized incidence ratios (SIRs) compared risk in SOTRs with the general population. We used Poisson regression to calculate incidence rate ratios according to immune-related SOTR characteristics, including time since transplant (ie, duration of immunosuppression). All statistical tests were 2-sided. RESULTS We examined 694 distinct cancer subtypes, with 33 manifesting statistically significantly elevated SIRs (Bonferroni P < 7.2 × 10-5). All 33 are rare (incidence <6 per 100 000 person-years) and several have known viral etiology (eg, Merkel cell carcinoma: SIR = 24.7, 95% confidence interval [CI] = 20.8 to 29.1). Additional cancers that were increased include squamous cell carcinomas of the lip (SIR range = 18.3-19.8), eye and adnexa (SIR = 13.8, 95% CI = 7.9 to 22.3), salivary gland (SIR = 9.3, 95% CI = 6.1 to 13.5), and nasal cavity and sinuses (SIR = 4.5, 95% CI = 2.8 to 6.8); sebaceous adenocarcinoma (SIR = 34.3, 95% CI = 26.3 to 44.0); malignant fibrous histiocytoma (15.4); and subtypes of bladder, kidney, lung, and colon cancer (SIR range = 3.2-13.3). Incidence of several cancers increased over time since transplant (Ptrend < .05), including squamous cell carcinomas of the lip, salivary gland, and anogenital sites. CONCLUSIONS SOTRs experience elevated rates of several rare cancers. Because some of these cancers exhibit aggressive behavior with poor outcomes, it is important to further characterize the role of immunity and the potential involvement of oncogenic viruses to improve prevention and treatment.
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MESH Headings
- Adolescent
- Adult
- Aged
- Carcinoma, Merkel Cell/epidemiology
- Carcinoma, Merkel Cell/etiology
- Carcinoma, Merkel Cell/pathology
- Carcinoma, Squamous Cell/epidemiology
- Carcinoma, Squamous Cell/etiology
- Carcinoma, Squamous Cell/immunology
- Carcinoma, Squamous Cell/pathology
- Female
- Humans
- Immune Tolerance/immunology
- Immunocompromised Host/immunology
- Immunosuppression Therapy/adverse effects
- Male
- Middle Aged
- Neoplasms/epidemiology
- Neoplasms/etiology
- Neoplasms/immunology
- Neoplasms/pathology
- Organ Transplantation/adverse effects
- Rare Diseases/epidemiology
- Rare Diseases/etiology
- Rare Diseases/immunology
- Rare Diseases/pathology
- Registries
- Risk Factors
- Sarcoma, Kaposi/epidemiology
- Sarcoma, Kaposi/etiology
- Sarcoma, Kaposi/immunology
- Sarcoma, Kaposi/pathology
- Skin Neoplasms
- Transplant Recipients
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Affiliation(s)
- Monica E D’Arcy
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | | | - Charles F Lynch
- Department of Epidemiology, University of Iowa, Iowa City, IA, USA
| | - Amy R Kahn
- Bureau of Cancer Epidemiology, New York State Department of Health, Albany, NY, USA
| | - Lindsay M Morton
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Meredith S Shiels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Ruth M Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Eric A Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
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Amanati A, Badiee P, Lotfi M, Monabati A, Faghihi MA, Yavarian M, Hatami Mazinani N. Generalized exfoliative skin rash as an early predictor of supratherapeutic voriconazole trough levels in a leukemic child: A case report. Curr Med Mycol 2020; 6:73-78. [PMID: 33834148 PMCID: PMC8018824 DOI: 10.18502/cmm.6.3.4500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background and Purpose: Skin rashes, mostly seen in children and adolescents, are considered among the most common side effects of azole antifungals. Although therapeutic concentrations of voriconazole (VCZ) have been documented for infected skin, there is no evidence specifying whether specific dermatologic side effects could predict high VCZ serum concentration, especially in high-risk leukemic children. Case report: Herein, we report a unique skin side effect of VCZ in a 5-year-old boy with T-cell acute lymphoblastic leukemia (ALL) referred to Amir Medical Oncology Center in Shiraz, Iran. The patient experienced erythroderma and macular rashes shortly after VCZ consumption, leading to generalized exfoliative skin rashes. Concurrent to these skin manifestations, VCZ serum concentration reached the supratherapeutic levels despite the recommended VCZ doses. As a result, VCZ was withheld, and the patient was treated with caspofungin. The lesions were resolved gradually within 2 weeks, and the patient successfully completed his treatment course with caspofungin. Conclusion: The unique case presented in this study emphasizes the need for a high index of suspicion for VCZ toxicity in any patient with atypical dermatologic manifestations, especially generalized exfoliative skin rashes. Based on this report, VCZ supratherapeutic concentration could be predicted early in the course of treatment. Additional therapeutic dose monitoring should be considered to establish a confirmatory diagnosis. It is required to further investigate the toxic effect of high VCZ concentration on the skin epithelium.
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Affiliation(s)
- Ali Amanati
- Professor Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parisa Badiee
- Professor Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrzad Lotfi
- Medical Imaging Research Center, Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ahmad Monabati
- Department of Hematopathology, Molecular Pathology and Cytogenetics, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Ali Faghihi
- Center for Therapeutic Innovation, Department of Psychiatry and Behavioral Sciences, University of Miami, Miami, USA.,Persian Bayan Gene Research and Training Center, Shiraz, Iran
| | - Majid Yavarian
- Persian Bayan Gene Research and Training Center, Shiraz, Iran.,Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nazafarin Hatami Mazinani
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
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9
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Olum R, Baluku JB, Kazibwe A, Russell L, Bongomin F. Tolerability of oral itraconazole and voriconazole for the treatment of chronic pulmonary aspergillosis: A systematic review and meta-analysis. PLoS One 2020; 15:e0240374. [PMID: 33052954 PMCID: PMC7556473 DOI: 10.1371/journal.pone.0240374] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 09/24/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Chronic pulmonary aspergillosis (CPA) requires prolonged treatment with itraconazole or voriconazole. However, adverse events (AEs) are common with the use of these agents, with the need to discontinue the offending drug in a significant proportion of the patients. The aim of this study was to evaluate the frequency of adverse events of itraconazole and voriconazole for the treatment of CPA. METHODS We searched Embase and Medline to select clinical studies providing information on AEs to itraconazole or voriconazole for the treatment of CPA from inception to May 2020. Reviews, single case reports, and case series reporting less than 10 patients were excluded. Random effect meta-analysis was performed using STATA 16.0. RESULTS We included 9 eligible studies with an overall total of 534 CPA patients enrolled. Of these, 69% (n = 366) were treated with voriconazole and 31% (n = 168) with itraconazole. The median daily dose of both itraconazole and voriconazole used was 400mg. In a pooled analysis, AEs were observed in 36% (95% CI: 20-52%, N = 366) of patients on voriconazole and 25% (95% CI: 18 to 31%, N = 168) in those treated with itraconazole. Discontinuation rate due to AEs was the same for both drugs; 35% (47/366) and 35% (15/168) for voriconazole and itraconazole, respectively. There were 70 AEs reported with itraconazole use, the commonest being cardiotoxicity (29%). Skin AEs (28%) were the most frequent among the 204 AEs reported with voriconazole use. None of the studies compared the tolerability of itraconazole head-to-head with voriconazole. CONCLUSIONS AEs due itraconazole and voriconazole are common and may lead to discontinuation of treatment in a significant proportion of patients. This information can be used to educate patients prior to commencement of these antifungal therapies. PROSPERO REGISTRATION NUMBER CRD42020191627.
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Affiliation(s)
- Ronald Olum
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joseph Baruch Baluku
- Department of Programs, MildMay Uganda, Wakiso, Uganda
- Division of Pulmonology, Mulago National Referral Hospital, Kampala, Uganda
| | - Andrew Kazibwe
- The AIDS Support Organisation, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Laura Russell
- Medical Library, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Felix Bongomin
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
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Voriconazole-Induced Squamous Cell Carcinoma after Hematopoietic Stem Cell Transplantation Showing Early-Stage Vascular Invasion. Dermatopathology (Basel) 2020; 7:48-52. [PMID: 33050167 PMCID: PMC7719265 DOI: 10.3390/dermatopathology7030008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 10/01/2020] [Accepted: 10/02/2020] [Indexed: 11/25/2022] Open
Abstract
Voriconazole is a triazole antifungal agent used for the prevention and treatment of fungal infections in immunocompromised patients. Prolonged voriconazole therapy may induce phototoxicity and lead to the development of malignant neoplasms of the epidermis, such as squamous cell carcinoma (SCC), especially in immunocompromised patients. We report a case of voriconazole-induced phototoxicity and SCC occurring after hematopoietic stem cell transplantation (HSCT) in a 56-year-old man with primary myelofibrosis. The patient developed chronic graft-versus-host disease (GVHD) post-transplantation and had been receiving long-term immunosuppressive treatment. A year after the initiation of voriconazole therapy for prophylaxis, he developed keratotic erythema, followed by SCC with vascular invasion after three years. A review of SCC in HSCT recipients suggests that the prolonged use of voriconazole is regarded as a risk for SCC after HSCT in patients with chronic GVHD on immunosuppressive therapy. Moreover, a histological examination of the completely resected tumor revealed vascular invasion in this case, although neither the clinical features nor the histological findings of the preoperative biopsy suggested invasive carcinoma. This case may partially explain why voriconazole-associated SCCs show a more aggressive clinical course than non-voriconazole SCCs do.
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11
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Blakely KM, Drucker AM, Rosen CF. Drug-Induced Photosensitivity-An Update: Culprit Drugs, Prevention and Management. Drug Saf 2020; 42:827-847. [PMID: 30888626 DOI: 10.1007/s40264-019-00806-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Photosensitive drug eruptions are cutaneous adverse events due to exposure to a medication and either ultraviolet or visible radiation. In this review, the diagnosis, prevention and management of drug-induced photosensitivity is discussed. Diagnosis is based largely on the history of drug intake and the appearance of the eruption primarily affecting sun-exposed areas of the skin. This diagnosis can also be aided by tools such as phototesting, photopatch testing and rechallenge testing. The mainstay of management is prevention, including informing patients of the possibility of increased photosensitivity as well as the use of appropriate sun protective measures. Once a photosensitivity reaction has occurred, it may be necessary to discontinue the culprit medication and treat the reaction with corticosteroids. For certain medications, long-term surveillance may be indicated because of a higher risk of developing melanoma or squamous cell carcinoma at sites of earlier photosensitivity reactions. A large number of medications have been implicated as causes of photosensitivity, many with convincing clinical and scientific supporting evidence. We review the medical literature regarding the evidence for the culpability of each drug, including the results of phototesting, photopatch testing and rechallenge testing. Amiodarone, chlorpromazine, doxycycline, hydrochlorothiazide, nalidixic acid, naproxen, piroxicam, tetracycline, thioridazine, vemurafenib and voriconazole are among the most consistently implicated and warrant the most precaution by both the physician and patient.
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Affiliation(s)
- Kim M Blakely
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Aaron M Drucker
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Department of Medicine, Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Cheryl F Rosen
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada. .,Division of Dermatology, Toronto Western Hospital, Toronto, ON, Canada.
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Kryczyk-Poprawa A, Kwiecień A, Opoka W. Photostability of Topical Agents Applied to the Skin: A Review. Pharmaceutics 2019; 12:pharmaceutics12010010. [PMID: 31861803 PMCID: PMC7023431 DOI: 10.3390/pharmaceutics12010010] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/11/2019] [Accepted: 12/11/2019] [Indexed: 12/15/2022] Open
Abstract
Topical treatment modalities have multiple advantages starting with the convenient application and non-invasive treatment and ending with the reduction of the risk of the systemic side effects. Active pharmaceutical substances must reach the desired concentration at the target site in order to produce a particular therapeutic effect. In contrast to other dosage forms topical agents applied to the skin may also be susceptible to photodegradation after application. That is why the knowledge of the susceptibility of these topical drugs to UV irradiation, which may contribute to their degradation or changes in chemical structure, is very important. Active pharmaceutical substances used in dermatology may differ both in chemical structure and photostability. Furthermore, various factors-such as light intensity and wavelength, pH, temperature, concentration-can influence the photodegradation process, which is reflected in particular in kinetics of photodegradation of active pharmaceutical substances as well as both the quantitative and qualitative composition of by-products. The aim of this study was to conduct a systematic review of the photostability of dermatological drugs, as well as of other substances commonly applied topically. The photostability of glucocorticosteroids, retinoids, and antifungal drugs as well as non-steroidal anti-inflammatory drugs applied topically and selected UV-filters have been discussed. Furthermore, the impact of photoinstability on the effectiveness of pharmacotherapy and some photostabilization strategies have been also included.
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14
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Cutaneous Complications in Recipients of Lung Transplants: A Pictorial Review. Chest 2018; 155:178-193. [PMID: 30201407 DOI: 10.1016/j.chest.2018.08.1060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 08/16/2018] [Indexed: 12/26/2022] Open
Abstract
Lung transplant is now an established modality for a broad spectrum of end-stage pulmonary diseases. According to the International Society for Heart and Lung Transplantation Registry, more than 50,000 lung transplants have been performed worldwide, with nearly 11,000 recipients of lung transplants alive in the United States. With the increasing use of lung transplant, pulmonologists must be cognizant of the common as well as the unique posttransplant dermatologic complications. Immunosuppression, infections, and a variety of medications and environmental exposures can contribute to these complications. This review aims to provide representative pictures and describe the pathogenesis, epidemiologic characteristics, and clinical manifestations of dermatologic complications encountered among recipients of lung transplants.
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15
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Dahmani R, Ben Yaghlane S, Boughdiri S, Mogren Al-Mogren M, Prakash M, Hochlaf M. Insights on the interaction of Zn 2+ cation with triazoles: Structures, bonding, electronic excitation and applications. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2018; 193:375-384. [PMID: 29272808 DOI: 10.1016/j.saa.2017.12.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 11/24/2017] [Accepted: 12/04/2017] [Indexed: 06/07/2023]
Abstract
At present, we investigate the structures, the stability, the bonding and the spectroscopy of the Zn2+-triazole complexes (Zn2+-Tz), which are subunits of triazolate based porous materials and Zn-enzymes. This theoretical work is performed using ab initio methods and density functional theory (DFT) where dispersion correction is included. Through these benchmarks, we establish the ability and reliability of M05-2X+D3 and PBE0+D3 functionals for the correct description of Zn2+-Tz bond since these DFTs lead to close agreement with post Hartree-Fock methods. Therefore, M05-2X+D3 and PBE0+D3 functionals are recommended for the characterization of larger organometallic complexes formed by Zn and N-rich linkers. For Zn2+-Tz, we found two stable σ-type complexes: (i) a planar structure where Zn2+ links to unprotonated nitrogen and (ii) an out-of-plane cluster where carbon interacts with Zn2+. The most stable isomers consist on a coordinated covalent bond between the lone pair of unprotonated nitrogen and the vacant 4s orbital of Zn2+. The roles of covalent interactions within these complexes are discussed after vibrational, NBO, NPA charges and orbital analyses. The bonding is dominated by charge transfer from Zn2+ to Tz and intramolecular charge transfer, which plays a vital role for the catalytic activity of these complexes. These findings are important to understand, at the microscopic level, the structure and the bonding within triazolate based macromolecular porous materials and Zn-enzymes.
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Affiliation(s)
- R Dahmani
- Université Paris-Est, Laboratoire Modélisation et Simulation Multi Echelle, MSME UMR 8208 CNRS, 5 bd Descartes, 77454 Marne-la-Vallée, France; Laboratoire de Spectroscopie Atomique, Moléculaire et Applications - LSAMA, Université de Tunis El Manar, Tunis, Tunisia; Unité de Recherche Physico-Chimie des Matériaux à l'Etat Condensé, Département de Chimie, Faculté des Sciences de Tunis, Université Tunis El Manar, Tunis 2092, Tunisia
| | - S Ben Yaghlane
- Laboratoire de Spectroscopie Atomique, Moléculaire et Applications - LSAMA, Université de Tunis El Manar, Tunis, Tunisia
| | - S Boughdiri
- Unité de Recherche Physico-Chimie des Matériaux à l'Etat Condensé, Département de Chimie, Faculté des Sciences de Tunis, Université Tunis El Manar, Tunis 2092, Tunisia
| | - M Mogren Al-Mogren
- Chemistry Department, Faculty of Science, King Saud University, P.O. Box 2455, Riyadh 11451, Saudi Arabia
| | - M Prakash
- SRM Research Institute and Department of Chemistry, SRM University, Kattankulathur 603203, Tamilnadu, India
| | - M Hochlaf
- Université Paris-Est, Laboratoire Modélisation et Simulation Multi Echelle, MSME UMR 8208 CNRS, 5 bd Descartes, 77454 Marne-la-Vallée, France.
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Giuliano S, Guastalegname M, Russo A, Falcone M, Ravasio V, Rizzi M, Bassetti M, Viale P, Pasticci MB, Durante-Mangoni E, Venditti M. Candida endocarditis: systematic literature review from 1997 to 2014 and analysis of 29 cases from the Italian Study of Endocarditis. Expert Rev Anti Infect Ther 2017; 15:807-818. [PMID: 28903607 DOI: 10.1080/14787210.2017.1372749] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Candida Endocarditis (CE) is a deadly disease. It is of paramount importance to assess risk factors for acquisition of both Candida native (NVE) and prosthetic (PVE) valve endocarditis and relate clinical features and treatment strategies with the outcome of the disease. Areas covered: We searched the literature using the Pubmed database. Cases of CE from the Italian Study on Endocarditis (SEI) were also included. Overall, 140 cases of CE were analyzed. Patients with a history of abdominal surgery and antibiotic exposure had higher probability of developing NVE than PVE. In the PVE group, time to onset of CE was significantly lower for biological prosthesis compared to mechanical prosthesis. In the whole population, greater age and longer time to diagnosis were associated with increased likelihood of death. Patients with effective anti-biofilm treatment, patients who underwent cardiac surgery and patients who were administered chronic suppressive antifungal treatment showed increased survival. For PVE, moderate active anti-biofilm and highly active anti-biofilm treatment were associated with lower mortality. Expert commentary: Both NVE and PVE could be considered biofilm-related diseases, pathogenetically characterized by Candida intestinal translocation and initial transient candidemia. Cardiac surgery, EAB treatment and chronic suppressive therapy might be crucial in increasing patient survival.
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Affiliation(s)
- Simone Giuliano
- a Department of Public Health and Infectious Diseases , Policlinico Umberto I 'Sapienza' University of Rome , Rome , Italy
| | - Maurizio Guastalegname
- a Department of Public Health and Infectious Diseases , Policlinico Umberto I 'Sapienza' University of Rome , Rome , Italy
| | - Alessandro Russo
- a Department of Public Health and Infectious Diseases , Policlinico Umberto I 'Sapienza' University of Rome , Rome , Italy
| | - Marco Falcone
- a Department of Public Health and Infectious Diseases , Policlinico Umberto I 'Sapienza' University of Rome , Rome , Italy
| | - Veronica Ravasio
- b Infectious Diseases Unit , ASST Papa Giovanni XXIII , Bergamo , Italy
| | - Marco Rizzi
- b Infectious Diseases Unit , ASST Papa Giovanni XXIII , Bergamo , Italy
| | - Matteo Bassetti
- c Infectious Diseases Division , Santa Maria Misericordia University Hospital , Udine , Italy
| | - Pierluigi Viale
- d Infectious Diseases Unit, Department of Medical and Surgical Sciences , Alma Mater Studiorum University of Bologna , Bologna , Italy
| | | | - Emanuele Durante-Mangoni
- f Department of Clinical and Experimental Medicine , Università della Campania 'Luigi Vanvitelli', AORN dei Colli-Ospedale Monaldi , Naples , Italy
| | - Mario Venditti
- a Department of Public Health and Infectious Diseases , Policlinico Umberto I 'Sapienza' University of Rome , Rome , Italy
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Hayes GE, Novak-Frazer L. Chronic Pulmonary Aspergillosis-Where Are We? and Where Are We Going? J Fungi (Basel) 2016; 2:jof2020018. [PMID: 29376935 PMCID: PMC5753080 DOI: 10.3390/jof2020018] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 05/19/2016] [Accepted: 06/01/2016] [Indexed: 02/06/2023] Open
Abstract
Chronic pulmonary aspergillosis (CPA) is estimated to affect 3 million people worldwide making it an under recognised, but significant health problem across the globe, conferring significant morbidity and mortality. With variable disease forms, high levels of associated respiratory co-morbidity, limited therapeutic options and prolonged treatment strategies, CPA is a challenging disease for both patients and healthcare professionals. CPA can mimic smear-negative tuberculosis (TB), pulmonary histoplasmosis or coccidioidomycosis. Cultures for Aspergillus are usually negative, however, the detection of Aspergillus IgG is a simple and sensitive test widely used in diagnosis. When a fungal ball/aspergilloma is visible radiologically, the diagnosis has been made late. Sometimes weight loss and fatigue are predominant symptoms; pyrexia is rare. Despite the efforts of the mycology community, and significant strides being taken in optimising the care of these patients, much remains to be learnt about this patient population, the disease itself and the best use of available therapies, with the development of new therapies being a key priority. Here, current knowledge and practices are reviewed, and areas of research priority highlighted.
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Affiliation(s)
- Gemma E Hayes
- The University of Manchester, Oxford Road, Manchester M13 9PL, UK.
- Manchester Academic Health Science Centre, 46 Grafton Street, Manchester M13 9NT, UK.
- National Aspergillosis Centre, 2nd Floor Education and Research Centre, University Hospital of South Manchester, Southmoor Road, Manchester M23 9LT, UK.
| | - Lilyann Novak-Frazer
- The University of Manchester, Oxford Road, Manchester M13 9PL, UK.
- Manchester Academic Health Science Centre, 46 Grafton Street, Manchester M13 9NT, UK.
- The University of Manchester, Manchester Academic Health Science Centre, 2nd Floor Education and Research Centre, University Hospital of South Manchester, Southmoor Road, Manchester M23 9LT, UK.
- Mycology Reference Centre, Manchester, 2nd Floor Education and Research Centre, University Hospital of South Manchester, Southmoor Road, Manchester M23 9LT, UK.
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18
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Neofytos D, Ostrander D, Shoham S, Laverdiere M, Hiemenz J, Nguyen H, Clarke W, Brass L, Lu N, Marr KA. Voriconazole therapeutic drug monitoring: results of a prematurely discontinued randomized multicenter trial. Transpl Infect Dis 2015; 17:831-7. [PMID: 26346408 DOI: 10.1111/tid.12454] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 04/24/2015] [Accepted: 08/15/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Voriconazole (VOR) levels are highly variable, with potential implications to both efficacy and safety. We hypothesized that VOR therapeutic drug monitoring (TDM) will decrease the incidence of treatment failures and adverse events (AEs). METHODS We initiated a prospective, randomized, non-blinded multicenter study to compare clinical outcomes in adult patients randomized to standard dosing (clinician-driven) vs. TDM (doses adjusted based on levels). VOR trough levels were obtained on day 5, 14, 28, and 42 (or at completion of drug; ± 3 days). Real-time dose adjustments were made to maintain a range between 1-5 μg/mL on the TDM-arm, while levels were assessed retrospectively in the standard-arm. Patient questionnaires were administered to assess subjective AEs. RESULTS The study was discontinued prematurely, after 29 patients were enrolled. Seventeen (58.6%) patients experienced 38 AEs: visual changes (22/38, 57.9%), neurological symptoms (13/38, 34.2%), and liver abnormalities (3/38, 7.9%). VOR was discontinued in 7 (25%) patients because of an AE (4 standard-arm, 3 TDM-arm). VOR levels were frequently out of range in the standard-arm (8 tests >5 μg/mL; 9 tests <1 μg/mL). Three dose changes occurred in the TDM-arm for VOR levels <1 μg/mL. Levels decreased over time in the standard-arm, with mean VOR levels lower at end of therapy compared to TDM (1.3 vs. 4.6 μg/mL, P = 0.008). CONCLUSIONS VOR TDM has become widespread clinical practice, based on known variability in drug levels, which impaired accrual in this study. Although comparative conclusions are limited, observations of variability and waning levels over time support TDM.
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Affiliation(s)
- D Neofytos
- School of Medicine, The Johns Hopkins University, Baltimore, Maryland, USA
| | - D Ostrander
- School of Medicine, The Johns Hopkins University, Baltimore, Maryland, USA
| | - S Shoham
- School of Medicine, The Johns Hopkins University, Baltimore, Maryland, USA
| | - M Laverdiere
- Hopital Maisonneuve-Rosemont, University of Montreal, Montreal, Quebec, Canada
| | - J Hiemenz
- University of Florida, Gaineville, Florida, USA
| | - H Nguyen
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - W Clarke
- School of Medicine, The Johns Hopkins University, Baltimore, Maryland, USA
| | - L Brass
- School of Medicine, The Johns Hopkins University, Baltimore, Maryland, USA
| | - N Lu
- School of Medicine, The Johns Hopkins University, Baltimore, Maryland, USA
| | - K A Marr
- School of Medicine, The Johns Hopkins University, Baltimore, Maryland, USA
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19
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Abstract
Voriconazole's antifungal spectrum, oral bioavailability, and proven efficacy in treatment of invasive mycoses have led to its widespread off-label use for antifungal prophylaxis. There is an increasing recognition that long-term voriconazole use is associated with accelerated sun-induced skin changes that include acute phototoxicity reactions, photoaging, actinic keratosis and esp. among immunocompromised patients, skin cancers. The mechanisms underlying these dermatologic adverse events are not clearly understood. Population-risks of long-term voriconazole use need to be prospectively investigated. This review aims to provide an in-depth assessment of published literature and highlight salient findings from retrospective studies and case series. A broad practical guideline for assessment and management of these patients is provided.
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Affiliation(s)
- Rakesh K Goyal
- a Division of Blood and Marrow Transplantation and Cellular Therapies, Department of Pediatrics , Children's Hospital of Pittsburgh of UPMC , Pittsburgh , PA , USA.,b University of Pittsburgh , Pittsburgh , PA , USA
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20
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Hussein N, Qamar S, Abid Q. Systemic aspergilloma post aortic root surgery following coronary artery stenting: diagnostic and management dilemma. BMJ Case Rep 2015; 2015:bcr-2014-207702. [PMID: 26025972 DOI: 10.1136/bcr-2014-207702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Aspergillus infections such as Aspergillus endocarditis were once relatively rare occurrences, however, due to the increased use of intracardiac devices, the incidence has grown. With mortality rates close to 100%, in medically treated cases, it is paramount that early diagnosis and treatment are performed. An immunocompetent aviculturist presented 8 months post aortic root replacement for severe aortic regurgitation with a composite graft, with central crushing chest pain. Investigations confirmed ST elevation inferior myocardial infarction due to stenosis of the origin of the right coronary artery, which was stented. Echocardiogram demonstrated a mobile mass posterior to the left ventricular outflow tract. Following referral to our cardiothoracic surgeons, a polypoidal mass covering the right ostial button was noted along with systemic complications of the disease. Emergency redo aortic valve replacement with a homograft and coronary artery bypass was performed. Histological analysis confirmed A. fumigatus and the patient was started on intravenous voriconazole.
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Affiliation(s)
| | - Sombul Qamar
- Medical School, Keele University, Stoke on Trent, UK
| | - Qamar Abid
- Department of Cardiothoracic Surgery, Royal Stoke University Hospital, Stoke on Trent, UK
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21
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Abdel-Haq N, Surapaneni V, Seth D, Pansare M, Asmar BI. Voriconazole-Induced Photosensitivity in Children: A Case Report and Literature Review. Glob Pediatr Health 2014; 1:2333794X14562230. [PMID: 27335925 PMCID: PMC4804675 DOI: 10.1177/2333794x14562230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Nahed Abdel-Haq
- Children's Hospital of Michigan, Detroit, MI, USA; Wayne State University, Detroit, MI, USA
| | | | - Divya Seth
- Children's Hospital of Michigan, Detroit, MI, USA; Wayne State University, Detroit, MI, USA
| | - Milind Pansare
- Children's Hospital of Michigan, Detroit, MI, USA; Wayne State University, Detroit, MI, USA
| | - Basim I Asmar
- Children's Hospital of Michigan, Detroit, MI, USA; Wayne State University, Detroit, MI, USA
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22
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Photostability of triazole antifungal drugs in the solid state. CURRENT ISSUES IN PHARMACY AND MEDICAL SCIENCES 2013. [DOI: 10.12923/j.2084-980x/26.3/a.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
The publication is devoted to photostability assessment of four triazole antifungal drugs: fluconazole, itraconazole, posaconazole and voriconazole. The compounds were exposed in the solid state using the whole spectrum of UV-Vis radiation. The analyses were performed using high performance thin layer chromatography (HPTLC) technique with densitometric detection. The results indicates considerable degradation of structurally similar itraconazole and posaconazole which could be clinically significant. After 72 hours of itraconazole irradiation there remain less than 25%, and 60% in case of posaconazole. To a lesser extent photodegradation concern two other compounds with a separate chemical structure: fluconazole and voriconazole. After 72 hours of irradiation there left 75% and 82% of these substances, respectively. The strict dependence between compound photostability and its chemical structure was observed.
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23
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Markantonis SL, Katelari A, Pappa E, Doudounakis S. Voriconazole pharmacokinetics and photosensitivity in children with cystic fibrosis. J Cyst Fibros 2012; 11:246-52. [DOI: 10.1016/j.jcf.2011.12.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 12/21/2011] [Accepted: 12/29/2011] [Indexed: 10/14/2022]
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Singer JP, Boker A, Metchnikoff C, Binstock M, Boettger R, Golden JA, Glidden DV, Arron ST. High cumulative dose exposure to voriconazole is associated with cutaneous squamous cell carcinoma in lung transplant recipients. J Heart Lung Transplant 2012; 31:694-9. [PMID: 22484291 DOI: 10.1016/j.healun.2012.02.033] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2011] [Revised: 02/21/2012] [Accepted: 02/27/2012] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Lung transplant recipients (LTR) have an increased risk of cutaneous squamous cell carcinoma (SCC) due to immunosuppressive therapy. Voriconazole, which is associated with phototoxic side effects in some patients, may be an additional risk factor for SCC in this population. METHODS To test whether voriconazole is a risk factor for developing SCC in LTR, we evaluated cumulative exposure to voriconazole in 327 adults who underwent lung transplantation at one center between 1991 and 2010. Voriconazole exposure was assessed as a time-varying covariate. We used survival analysis methods to assess the risk of developing SCC over time. RESULTS Exposure to voriconazole was associated with a 2.6-fold increased risk for SCC. This phenomenon was dose-dependent: the risk for SCC increased by 5.6% with each 60-day exposure at a standard dose of 200 mg twice daily. At 5 years after transplant, voriconazole conferred an absolute risk increase for SCC of 28%. CONCLUSIONS These results suggest that caution should be taken when using voriconazole in LTR because this drug increases the already high risk for SCC in this population.
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Affiliation(s)
- Jonathan P Singer
- Division of Pulmonary and Critical Care Medicine, University of California at San Francisco, San Francisco, California 94115, USA.
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25
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Epaulard O, Leccia MT, Blanche S, Chosidow O, Mamzer-Bruneel MF, Ravaud P, Thiebaut A, Villier C, Lortholary O. Phototoxicity and photocarcinogenesis associated with voriconazole. Med Mal Infect 2011; 41:639-45. [PMID: 22055586 DOI: 10.1016/j.medmal.2011.09.016] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 08/03/2011] [Accepted: 09/23/2011] [Indexed: 11/15/2022]
Abstract
The antifungal voriconazole was given its marketing authorization in 2002. Several kinds of adverse effects have been reported, including acute and chronic cutaneous adverse effects, mainly due to a phototoxicity mechanism. More recently, some authors have reported that voriconazole was involved in the occurrence of multiple and often-aggressive cutaneous squamous cell carcinomas if the treatment was maintained for a long time. According to safety data in studies assessing voriconazole effectiveness, 8% of outpatients may experience phototoxic events. An overview of the different types of phototoxicity and of the concerned population was given by the 61 published case reports of photo-induced voriconazole-related skin adverse events (including 18 cases of squamous cell carcinomas). The most likely mechanisms may be phototoxicity directly related to either voriconazole or to its N-oxide main metabolite, and an interaction with retinoid metabolism; moreover, immunodeficiency may enhance the risk of skin cancer. Several issues remain to be investigated, and studies are needed concerning the phototoxicity and photocarcinogenesis of voriconazole and the prognosis of chronic non-malignant skin lesions. Voriconazole prescription must be associated with strict photoprotection; in case of a phototoxic adverse event, another azole may be recommended.
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Affiliation(s)
- O Epaulard
- Service des maladies infectieuses et de médecine tropicale, CHU de Grenoble, France.
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Abstract
The treatment of Candida infective endocarditis generally involves infected valve removal accompanied by antifungal therapy with amphotericin B or a lipid-based derivative, with or without flucytosine. While often used as chronic suppressive therapy in these patients, the precise role for fluconazole has not been established. We conducted a meta-analysis of 64 literature cases of Candida endocarditis whose management did not include valve replacement but who received fluconazole, alone or concurrently or in sequence with 1 or more other antifungal drugs.Forty-nine (77%) patients were cured (n = 44) or improved (n = 5), 4 relapsed (6%), and 11 failed (10 of whom died) (17%). Among 19 patients for whom fluconazole was administered as the sole antifungal therapy, 11 (58%) were cured or improved. In contrast, among 45 patients who received 1 or more other antifungal agents in addition to fluconazole, 38 (84%) were cured or improved (p = 0.02). Eighteen of 21 (86%) patients with native valve infection were cured or improved compared with 13 of 19 (68%) patients with prosthetic valve endocarditis (p = 0.13). The mean duration of successful fluconazole regimens was 134 days. Twenty of 21 (95%) patients who received fluconazole as chronic suppressive therapy for ≥6 months were cured. Prognosis was independent of Candida species or patient age. Among 23 historical controls managed with fluconazole-containing antifungal therapy plus valvular surgery, survival was 91%.In conclusion, fluconazole-containing, combination antifungal therapy, with or without concomitant valve replacement, and followed by prolonged, perhaps indefinite fluconazole suppression, is effective in patients with Candida endocarditis.
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Affiliation(s)
- Raymond A Smego
- From Department of Medicine, The Commonwealth Medical College, Scranton, Pennsylvania
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Kumar J, Fish D, Burger H, Weiser B, Ross JS, Jones D, Robstad K, Li X, Chaturvedi V. Successful Surgical Intervention for the Management of Endocarditis due to Multidrug Resistant Candida parapsilosis: Case Report and Literature Review. Mycopathologia 2011; 172:287-92. [DOI: 10.1007/s11046-011-9430-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 04/12/2011] [Indexed: 10/18/2022]
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Multifocal aggressive squamous cell carcinomas induced by prolonged voriconazole therapy: a case report. Case Rep Med 2010; 2010:351084. [PMID: 21209800 PMCID: PMC3014742 DOI: 10.1155/2010/351084] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Accepted: 11/15/2010] [Indexed: 11/18/2022] Open
Abstract
Voriconazole is a treatment for severe fungal infections. Prolonged voriconazole therapy may induce skin reactions, with 1% of severe photosensitivity accidents. Recently the imputability of voriconazole in skin carcinogenesis has been suggested. This report concerns a 55-year-old man suffering from pulmonary aspergillosis who presented a phototoxic reaction a few months after introduction of voriconazole, followed by multiple squamous cell carcinomas of sun-exposed skin areas. After voriconazole discontinuation, no new carcinoma was observed. The detection of EBV and HPV in skin lesions was negative. Exploration of gene mutations involved in skin carcinogenesis showed two variants of the MICR gene. The occurrence of multiple, recurrent, aggressive squamous cell carcinomas is rare with voriconazole, but its imputability is strongly suggested. A plausible hypothesis is that several factors including voriconazole uptake, immunosuppression, and genetic background could explain the phenotype of fast-developing skin carcinomas. Voriconazole therapy should be accompanied by stringent photoprotection and skin monitoring.
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Vöhringer S, Schrum J, Ott H, Höger PH. Severe phototoxicity associated with long-term voriconazole treatment. J Dtsch Dermatol Ges 2010; 9:274-6. [PMID: 21050383 DOI: 10.1111/j.1610-0387.2010.07563.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Voriconazole is a second-generation triazole antifungal approved for the treatment of invasive fungal infections, particularly with Aspergillus, Candida, Fusarium, and Scedosporium spp. Frequently reported adverse effects of voriconazole include visual disturbance (21 %), elevated liver enzymes (15.6 %) and rashes (7 %), which are largely attributable to drug-induced photosensitivity. We report a case of serious phototoxicity in a 8 year old boy who underwent chemotherapy for AML. He received voriconazole for the treatment and subsequent re-infection prophylaxis after pulmonary aspergillosis. One year after the start of therapy he developed blistering eruptions on his face after minimal sunlight exposure. Recent reports about the development of squamous cell carcinoma and melanoma, respectively, in children during and after oral therapy with voriconazole seem to warrant systematic follow-up investigations of all voriconazole-treated patients.
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Affiliation(s)
- Sabine Vöhringer
- Department of Pediatric Dermatology, Catholic Children's Hospital Wilhelmstift, Hamburg, Germany
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Voriconazole plasma levels in children are highly variable. Eur J Clin Microbiol Infect Dis 2010; 30:283-7. [DOI: 10.1007/s10096-010-1079-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 09/22/2010] [Indexed: 10/18/2022]
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31
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Epaulard O, Saint-Raymond C, Villier C, Charles J, Roch N, Beani JC, Leccia MT. Multiple aggressive squamous cell carcinomas associated with prolonged voriconazole therapy in four immunocompromised patients. Clin Microbiol Infect 2010; 16:1362-4. [DOI: 10.1111/j.1469-0691.2009.03124.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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32
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Photosensitivity in immunocompromised patients receiving long-term therapy with oral voriconazole. Pediatr Infect Dis J 2010; 29:480-1. [PMID: 20431387 DOI: 10.1097/inf.0b013e3181d60a82] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Neofytos D, Avdic E, Magiorakos AP. Clinical safety and tolerability issues in use of triazole derivatives in management of fungal infections. DRUG HEALTHCARE AND PATIENT SAFETY 2010; 2:27-38. [PMID: 21701616 PMCID: PMC3108707 DOI: 10.2147/dhps.s6321] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/17/2010] [Indexed: 12/15/2022]
Abstract
There has been an increase in the number of patients susceptible to invasive fungal infections (IFIs) leading to a greater need for effective, well tolerated, and easily administered antifungal agents. The advent of triazoles has revolutionized the care of patients requiring treatment or prophylaxis for IFIs. However, triazoles have been associated with a number of adverse events and significant drug–drug interactions. While commonly used, physicians and patients should be aware of the distinct properties of these agents in order to ensure that patients are optimally treated with the least amount of toxicity possible. Clinicians should have a full understanding of the basic pharmacokinetics, absorption, and bioavailability of triazoles. Moreover, knowledge of the drug–drug interactions and potential toxicities of each agent is critical prior to administering a triazole. Careful history taking, thorough review of the patient’s medication list, and detailed discussion with the patients and their families about the efficacy, safety, and tolerability of these agents should be performed. Clinicians treating patients with triazoles should closely follow them, monitor pertinent laboratory tests, and consider measuring drug levels as needed. This article will review the basic pharmacokinetic properties and most frequently encountered adverse events and pitfalls associated with triazoles in clinical practice.
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Affiliation(s)
- Dionissios Neofytos
- Transplant and Oncology Infectious Disease Program, The Johns Hopkins University School of Medicine, Division of Infectious Diseases
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