Posaconazole: An Update of Its Clinical Use

Clinical safety and efficacy of a single-dose gentamicin, posaconazole and mometasone furoate otic suspension for treatment of canine otitis externa

BACKGROUND

A single-dose, in-clinic, veterinary professional-administered treatment for canine otitis externa was developed to improve compliance and canine welfare.

METHODS

This multicentre, controlled, examiner-masked, randomised field trial was conducted in 316 dogs over 42 days. Dogs were treated once, on day 0, with the investigational product containing gentamicin, posaconazole and mometasone furoate (Mometamax Ultra [MU]) or twice (days 0 and 7) with a control product containing florfenicol, terbinafine and betamethasone acetate (CP). The primary endpoint was a composite otitis index score of 4 or less (of 12) on day 14 and 3 or less (of 12) on day 28.

RESULTS

On day 28, treatment success was recorded in 128 of 143 MU-treated dogs (89.5%), significantly non-inferior to 116 of 133 (87.2%) CP-treated dogs (Farrington-Manning test, Z = 4.1351, p < 0.0001). For mixed cultures of Staphylococcus pseudintermedius and Malassezia pachydermatis, there was 100% treatment success in MU-treated dogs (n = 33), significantly non-inferior to 90.2% (37 of 41) in CP-treated dogs (Farrington-Manning test, Z = 3.1954, p = 0.0007).

LIMITATIONS

Efficacy in chronic otitis externa cases was not investigated. Cytology was not used to aid in diagnosis or for identification of secondary pathogens.

CONCLUSION

This unique combination, single-dose product is safe and effective in dogs with otitis externa. It offers enhanced compliance, canine welfare and quality of life by eliminating the owner burden of treating this painful condition.

Recent Advances in Diagnosis and Treatment Approaches in Fungal Keratitis: A Narrative Review

Fungal keratitis represents a potentially sight-threatening infection associated with poor prognosis, as well as financial burden. Novel diagnostic methods include polymerase-chain-reaction (PCR)-based approaches, metagenomic deep sequences, in vivo confocal microscopy, and antifungal susceptibility testing. The ideal therapeutic approaches and outcomes have been widely discussed in recent times, with early therapy being of the utmost importance for the preservation of visual acuity, minimizing corneal damage and reducing the scar size. However, combination therapy can be more efficacious compared to monotherapy. Understanding the pathogenesis, early diagnosis, and prevention strategies can be of great importance. In this narrative, we discuss the recent progress that may aid our understanding of the diagnosis, treatment, and prevention of mycotic keratitis.

Network pharmacology, molecular docking-driven, Qbd-Engineered antifungal in-situ gel loaded with voriconazole nanostructured lipid carriers

Fungal infections (FIs) affect majority of the population, but the current treatments face challenges in terms of their effectiveness. This study focused on specific fungal targets, including dihydrofolate reductase (DHFR), acetohydroxy-acid synthase (AHAS), farnesyltransferase and endoglucanase. The docking studies were conducted with the drug voriconazole (VCZ), comparing it with Fluconazole (FCZ) and Amphotericin B (ATB) against 11 protein data bank (PDB) IDs (IDYR, 3NZB, 6DEQ, 1KS5, 7T0C, 1FY4, 5AJH, 7R79, 6TZ6 and 6IDY). Molecular dynamics (MD) analysis, including RMSD, RMSF, PCA and FEL, confirmed the stability of VCZ. The solubility of VCZ was a problem, so nanostructured lipid carriers (NLCs) were developed to improve ocular penetration. VCF5 was the optimized formulation by using 32 full factorial design. VCZF5-NLCs were the best in terms of nanoparticle size (126.6 nm), Zeta potential (33.5 mV), drug content (DC; 97.38 ± 0.210), encapsulation efficiency (EE; 88.01 ± 0.272) and extended drug release. The results of the ex-vivo corneal diffusion study indicate that VCZ-NLC-loaded in-situ gel (VCZ-NLC-IG3) exhibited DC of 88.25% and drug entrapment (DE) of 74.2%. The results of the zone of inhibition indicated that VCZ-NLC-IG3 had superior efficacy compared to ATB. Network pharmacology showed VCZ interacts with the genes which are responsible for fungus ergosterol biosynthesis, including lanosterol 14-alpha demethylase inhibitors (ERG11), ergosterol biosynthesis protein 5 (ERG5), dimethylallyltransferase 2 (DIT2), ketosynthase (KCN), methylsterol monooxygenase (MSMO1), lamin B receptor (LBR), squalene epoxidase (SQLE), 3-hydroxy-3-methylglutaryl-coenzyme A Reductase (MGCR), 3-hydroxy-3-methylglutaryl-coenzyme A Synthase (HMGCS) and 3-keto-steroid reductase (HSD17B7). In conclusion, the optimized VCZ-loaded NLCs present a promising approach to treat ocular FIs.Communicated by Ramaswamy H. Sarma.

Mucoadhesive Alginate/Pectin Films Crosslinked by Calcium Carbonate as Carriers of a Model Antifungal Drug-Posaconazole

The mucosal membrane of the oral cavity, due to its unique structure and availability, constitutes an appropriate site for the delivery of drugs, both with local and systemic effects. Mucoadhesive buccal films are drug dosage forms that due to their convenience of application, flexibility and size, are characterized by patients' compliance. Sodium alginate and pectin are natural polymers from the polysaccharides group, with mucoadhesive properties, that are widely applied to obtain buccal films. However, their hydrophilic nature and poor water resistance limit their application in sustained drug release formulations. Hence, the aim of this investigation was to design alginate/pectin buccal films by a one-step crosslinking technique-with the application of calcium carbonate. This technique was applied to prepare crosslinked alginate and alginate/pectin mucoadhesive films with a model antifungal drug-posaconazole. The obtained formulations were evaluated for the impact of crosslinking and pectin's presence on their pharmaceutical, mucoadhesive, mechanical and physicochemical properties. Additionally, the antifungal activity of the prepared films against Candida spp. was evaluated. It was shown that pectin's presence in the formulations improved flexibility, mucoadhesion and antifungal activity. The crosslinking process reduced mucoadhesiveness and antifungal activity but significantly enhanced the mechanical properties and stability and enabled prolonged drug release.

Evaluation of antifungal susceptibility and clinical characteristics in fungal keratitis in a tertiary care center in North India

Purpose

To study the antifungal susceptibility of common corneal pathogenic fungi to antifungal agents in the North Indian population.

Methods

Prospective study of the antifungal sensitivity testing (natamycin, amphotericin B, voriconazole, itraconazole, fluconazole, posaconazole, caspofungin, micafungin) of fungal isolates from 50 cases of culture positive fungal keratitis by using E test method. Details noted included demographic data, visual acuity, clinical details, grade of keratitis, healing time, and success in medical management.

Results

Of 50 patients with fungal keratitis (mean age: 40.28 ± 16.77 years), 12 eyes healed within 3 weeks, 14 had a delayed healing response, and 24 had chronic keratitis. Among the 15 cases of Fusarium isolates, 93.3% were sensitive to natamycin, while 40% to amphotericin B; 66.6% to voriconazole, 13.4% to itraconazole and fluconazole each. 80% of Fusarium cases (n = 12) showed susceptibility to posaconazole. Among Aspergillus flavus isolates, 53.4% (n = 8) were sensitive to natamycin, with only 40% (n = 7) showing sensitivity to amphotericin B and good susceptibility to azoles. MIC against susceptible Fusarium spp. for natamycin was 3-16 μg/mL, amphotericin B: 1-8 μg/mL, voriconazole: 0.5-1.5 μg/mL, itraconazole: 0.5-12 μg/mL, posaconazole: 0.094-1.5 μg/mL. MIC against Aspergillus flavus was natamycin: 8-32 μg/mL, amphotericin B: 0.5-16 μg/mL, voriconazole: 0.025-4 μg/mL, itraconazole: 0.125-8 μg/mL, posaconazole: 0.047-0.25 μg/mL; against Aspergillus niger isolates, to natamycin was 6 μg/mL (n=1), amphotericin B 8-12 μg/mL (n = 3), voriconazole: 0.125-0.19 μg/mL (n = 3), itraconazole: 0.38-0.75 μg/mL, posaconazole: 0.064-0.19 μg/mL and against Aspergillus fumigatus (n = 1), was natamycin4 μg/mL, amphotericin B - 8 μg/mL, voriconazole 0.25 μg/mL, itraconazole 1 μg/mL, and posaconazole 0.19 μg/mL. MIC against susceptible Acremonium spp. for natamycin was 1.5-16 μg/mL, amphotericin B: 0.5-8 μg/mL, voriconazole: 0.19-3 μg/mL, itraconazole: 0.125 μg/mL, posaconazole: 0.125-0.5 μg/mL and against susceptible Curvularia was natamycin 0.75-4 μg/mL, amphotericin B 0.5-1 μg/mL, voriconazole 0.125-0.19 μg/mL, itraconazole 0.047-0.094 μg/mL, posaconazole 0.047-0.094 μg/mL. MIC against Mucor spp.+ Rhizopus spp. (n = 1) was natamycin: 8 μg/mL, amphotericin B: 0.75 μg/mL, posaconazole: 1.5 μg/mL. MIC against of Alternaria (n = 1) was voriconazole: 0.19 μg/mL, posaconazole: 0.094 μg/mL. MIC against Penicillium (n=1) was natamycin: 8 μg/mL, voriconazole: 0.25 μg/mL, itraconazole: 0.5 μg/mL, and Posaconazole: 0.125 μg/mL.

Conclusion

Our observations highlight the variations in susceptibility to antifungal agents. Posaconazole seems to be effective with low MIC against common corneal pathogenic fungal isolates.

Electromembrane Extraction of Posaconazole for Matrix-Assisted Laser Desorption/Ionization Mass Spectrometric Detection

A new mode of electromembrane extraction (EME) has been developed for detection via matrix-assisted laser desorption/ionization mass spectrometry (MALDI/MS). Posaconazole, extracted from 8 mL of a 10 mM trifluoroacetic acid solution onto a thin polyvinylidene difluoride (PVDF) membrane, was used as a model analyte. The transport was forced by an electrical potential difference between two electrodes inside the lumen of a hollow fiber and glass tube. Under an application of 80 V, cationic posaconazole in the sample solution moved toward the negative electrode inside the glass tube and was trapped by the PVDF membrane on the side. After 15 min of extraction, 3 μL of α-cyano-4-hydroxycinnamic acid (CHCA) solution was applied on top of the membrane, which was then analyzed by MALDI/MS. Under optimal extraction conditions, the calibration curve of posaconazole was linear over a concentration range of 0.10-100.00 nM. The limit of detection (LOD) at a signal-to-noise ratio of 3 was 0.03 nM with an enhancement factor of 138 for posaconazole. The application of this method to the determination of posaconazole in human serum samples was also successfully demonstrated.

Emerging Antifungal Targets and Strategies

Despite abundant research in the field of antifungal drug discovery, fungal infections remain a significant healthcare burden. There is an emerging need for the development of novel antifungals since those currently available are limited and do not completely provide safe and secure protection. Since the current knowledge regarding the physiology of fungal cells and the infection mechanisms is greater than ever, we have the opportunity to use this for the development of novel generations of antifungals. In this review, we selected and summarized recent studies describing agents employing different antifungal mechanisms. These mechanisms include interference with fungal resistance, including impact on the efflux pumps and heat shock protein 90. Additionally, interference with virulence factors, such as biofilms and hyphae; the impact on fungal enzymes, metabolism, mitochondria, and cell wall; and antifungal vaccines are explored. The agents investigated belong to different classes of natural or synthetic molecules with significant attention given also to plant extracts. The efficacy of these antifungals has been studied mainly in vitro with some in vivo, and clinical studies are needed. Nevertheless, there is a large quantity of products employing novel antifungal mechanisms that can be further explored for the development of new generation of antifungals.

Design and microwave-assisted synthesis of a novel Mannich base and conazole derivatives and their biological assessment

4-Amino-5-methyl-2,4-dihydro-3H-1,2,4-triazol-3-one (1) was converted to the corresponding Schiff base (2) by treatment with salicylaldehyde. 1,2,4-Triazoles were then converted to the corresponding Mannich bases containing fluroquinolone core using a one-pot three-component procedure. Moreover, the synthesis of six compounds, which can be considered as conazole analogues, was performed starting from 1,2,4-triazole-3-one compounds via three steps by either conventional or microwave-mediated conditions. All the newly synthesized compounds were screened for their antimicrobial activities. Most exhibited good to moderate antibacterial and/or antifungal activity. The structural assignments of the new compounds were based on elemental analysis and spectral (IR, 1H NMR, 13C NMR, and LC-MS) data.

Characterisation of the antifungal effects of a plant-based compound, CIN-102, on the main septal filamentous fungi involved in human pathology

OBJECTIVES

Today, the increase of invasive fungal infections and the emergence of resistant strains are observed in medical practice. New antifungals are expected, and the plant world offers a panel of potentially active molecules. CIN-102 is a mixture of seven different compounds of plant origin developed from the formulation of cinnamon essential oil.

METHODS

The in vitro activity of CIN-102 was characterised against Aspergillus spp., Fusarium spp. and Scedosporium spp. by studying the minimum inhibitory concentration (MIC), inoculum effect, germination inhibition, fungal growth, post-antifungal effect (PAFE) and synergy.

RESULTS

MICs determined for the three genera followed a unimodal distribution and their mean values ranged from 62-250 μg/mL. CIN-102 demonstrated an inoculum effect similar to voriconazole and amphotericin B, 100% inhibition of spore germination and a PAFE.

CONCLUSION

CIN-102 has significant activity against filamentous fungi involved in human pathologies and should be further explored as a potential new treatment. Other studies regarding its mechanisms of action as well as animal investigations are awaited.

Sample Preparation of Posaconazole Oral Suspensions for Identification of the Crystal Form of the Active Pharmaceutical Ingredient

Determination of the polymorphic form of an active pharmaceutical ingredient (API) in a suspension could be really challenging because of the water phase and the low concentration of the API in this formulation. Posaconazole is an antifungal drug available also as an oral suspension. The aim of this study was to develop a sample-preparation method for polymorphic identification of the dispersed API by increasing the concentration of the API but with no compromise of polymorph stability. For this purpose, filtration, drying and centrifugation were tested for separating the API from the suspending medium. Centrifugation was selected because it succeeded in separating Posaconazole API with no polymorph transformation during the process. During this study, it was found that Posaconazole in oral suspensions is Form-S. However, when slower scanning rates were used for acquiring an XRPD pattern with better signal/noise ratio, Posaconazole was converted to Form I due to water loss. In order to protect the sample from conversion, different approaches were tested to secure an airtight sample including a commercially available XRPD sample holder with a dome-like transparent cap, standard polymethylmethacrylate (PMMA) sample holders covered with Mylar film, transparent pressure-sensitive tape and a transparent food membrane. Only usage of the transparent food membrane was found to protect the API from conversion for a period of at least two weeks and resulted in a Posaconazole Form-S XRPD pattern with no artificial peaks.

Efficacy of Posaconazole Prophylaxis for Fungal Disease in Hematology Patients Treated With Chemotherapy and Transplantation: An Open-Label, Prospective, Observational Study

Background

Posaconazole (PCZ) is used prophylactically to prevent invasive fungal infections (IFIs) in patients with hematological malignancies.

Objective

To evaluate the cut-off serum concentration of PCZ for successful IFI prophylaxis in Chinese subjects.

Patients and Methods

A total of 74 patients treated with induction chemotherapy (n = 10) and allogeneic hematopoietic stem cell transplantation (HSCT) (n = 64), who received PCZ prophylactically as an oral suspension for >7 days, were included in the study. Clinical, radiological, microbiological culture results, and treatment responses were analyzed and drug concentration assays performed.

Results

The overall incidence of possible, probable, and proven IFIs was 13.5% (10/74), with five patients in the chemotherapy group and five in the HSCT group. The PCZ serum concentration in most patients (54/63) was in the range of 0.25–1.0 μg/ml, and this concentration range was significantly associated with the success rate of PCZ prophylaxis. A cut-off value of 0.47 μg/ml can be considered as an evaluation index for PCZ prophylaxis. Taking a proton pump inhibitor (PPI) would reduce the PCZ blood concentration, but not affect the IFD breakthrough point. PCZ treatment for hematopoietic malignancy or HSCT patients with a serum concentration of PCZ < 0.47 μg/ml were risk factors for PCZ prophylaxis of IFIs, determined by univariable and multivariable regression analyses.

Conclusion

The serum concentration of PCZ was related to the incidence of IFIs and a serum concentration of >0.47 μg/ml is highly recommended to avoid IFIs after chemotherapy or HSCT.

Clinical Trial Registration

Chinese Clinical Trial Registry: ChiCTR1900026294.

Simultaneous Quantification of Benznidazole and Posaconazole by HPLC-DAD Using QbD Approach

Objective

To develop an analytical method to simultaneous quantification of benznidazole (BNZ) and posaconazole (POS) by high-performance liquid chromatography with diode-array detection (HPLC-DAD) using design of experiments.

Methods

Percentages of organic phase, buffer pH and flow rates of mobile phase were selected as independent variables by full factorial design (33), totaling 27 experiments. Significant factors were evaluated using factorial analysis of variance with 95% confidence level. Method optimization was performed using desirability profiles, considering BNZ/POS chromatographic resolution and peak areas. Further, the method was evaluated regarding its suitability and properly validated according to the international compendiums using the parameters: specificity, linearity, accuracy, precision, limit of detection and limit of quantification.

Results

The optimized method was achieved using Discovery® C8 column (250 mm × 4.6 mm; 5 μm particle size), methanol/acetate buffer (pH 3.5)(71:29) and detection at 260 nm. Retention times were 3.6 and 7.6 min for BNZ and POS, respectively, with good suitability of system and it was specific and linear (r2 >0.99) for both drugs, proving the efficiency of the method even in the presence of degradation products of POS.

Conclusion

This new method is a great alternative to perform reliable, faster and cheaper analysis since the simultaneous quantification of the association BZN/POS is not reported yet in the literature.