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Zhu M, Tao L, Zhu F, Zhang Y. A Comparative Analysis of ADRs under Obeticholic Acid and Ursodeoxycholic Acid in Cholestatic Liver Diseases Using the FAERS Database. Drug Res (Stuttg) 2024. [PMID: 39313201 DOI: 10.1055/a-2401-4700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2024]
Abstract
BACKGROUND The objective of this study was to compare the safety profiles of OCA and UDCA for the treatment of PBC using the FDA Adverse Event Reporting System database. METHODS We extracted reports for OCA from 2016 to 2023 and UDCA from 2004 to 2023. Demographic details, adverse events (AEs), and concomitant medications were analyzed using descriptive statistics and signal detection methods. RESULTS The most common for OCA were pruritus (1345 cases, ROR 20.96) and fatigue (528 cases, ROR 3.46). UDCA was more frequently associated with hepatocellular carcinoma (22 cases, ROR 16.37) and type I hypersensitivity reactions (11 cases, ROR 12.77). OCA was also linked to a higher frequency of constipation (161 cases, ROR 3.92) and increased blood alkaline phosphatase levels (145 cases, ROR 44.27). CONCLUSION This study reveals distinct safety profiles for OCA and UDCA in the treatment of PBC. OCA is associated with a higher frequency of pruritus, fatigue, constipation, and increased blood alkaline phosphatase levels, while UDCA is linked to hepatocellular carcinoma and type I hypersensitivity reactions. These findings support personalized treatment approaches based on individual patient characteristics.
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Affiliation(s)
- Meng Zhu
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Binjiang District, Hangzhou, Zhejiang Province, China
| | - Linghui Tao
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Binjiang District, Hangzhou, Zhejiang Province, China
| | - Feiye Zhu
- Academy of Chinese Medical Sciences, Zhejiang Chinese Medical University, Binjiang District, Hangzhou, Zhejiang Province, China
| | - Yongsheng Zhang
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Binjiang District, Hangzhou, Zhejiang Province, China
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Roy M, Karhana S, Shamsuzzaman M, Khan MA. Recent drug development and treatments for fungal infections. Braz J Microbiol 2023; 54:1695-1716. [PMID: 37219748 PMCID: PMC10484882 DOI: 10.1007/s42770-023-00999-z] [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: 11/25/2022] [Accepted: 04/27/2023] [Indexed: 05/24/2023] Open
Abstract
Fungal infections are now becoming a hazard to individuals which has paved the way for research to expand the therapeutic options available. Recent advances in drug design and compound screening have also increased the pace of the development of antifungal drugs. Although several novel potential molecules are reported, those discoveries have yet to be translated from bench to bedside. Polyenes, azoles, echinocandins, and flucytosine are among the few antifungal agents that are available for the treatment of fungal infections, but such conventional therapies show certain limitations like toxicity, drug interactions, and the development of resistance which limits the utility of existing antifungals, contributing to significant mortality and morbidity. This review article focuses on the existing therapies, the challenges associated with them, and the development of new therapies, including the ongoing and recent clinical trials, for the treatment of fungal infections. Advancements in antifungal treatment: a graphical overview of drug development, adverse effects, and future prospects.
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Affiliation(s)
- Madhura Roy
- Centre for Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
| | - Sonali Karhana
- Centre for Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
| | - Md Shamsuzzaman
- Department of Pharmaceutical Sciences, College of Pharmacy, Shaqra University, Sahqra, Kingdom of Saudi Arabia
| | - Mohd Ashif Khan
- Centre for Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India.
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Etgü F. Retrospective Analysis of Liver Enzyme Abnormalities in Patients Prescribed Terbinafine and Itraconazole for Onychomycosis. Cureus 2023; 15:e44914. [PMID: 37818526 PMCID: PMC10561530 DOI: 10.7759/cureus.44914] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2023] [Indexed: 10/12/2023] Open
Abstract
Introduction Onychomycosis (OM) is defined as a nail fungal infection. Its prevalence increases with advancing age. Human-to-human transmission makes it a serious public health risk. Although OM is not a life-threatening disease, it has a detrimental effect on patients' quality of life. Due to the long therapy duration and potential side effects of systemic antifungal medicines, physicians may be reluctant to treat OM orally. In this study, we aimed to evaluate the effect of terbinafine and itraconazole on liver transaminases, the side effects of these treatments, and patients' adherence to systemic treatment of OM. Methods This is a retrospective study conducted in our dermatology department (Ordu University, Ordu) between June 2020 and October 2021. Hospital records were analyzed, and patients with the diagnosis of tinea unguium (ICD code B35.1) were investigated. Patients who were prescribed terbinafine or itraconazole were included in the study. Following a clinical diagnosis of OM, the researchers first tried to confirm it through direct microscopic examination with potassium hydroxide (KOH). If the direct microscopic examination was negative but the suspicion about OM continued, confirmation was done through a fungal culture. Results This study included 735 patients, of whom 409 (55.6%) were female and 326 (44.4%) were male. The research covered all of the patients who were given one of these two medications. To find patients who could apply to other hospitals, the Turkish National Healthcare System was checked in addition to hospital information. To identify patients who could apply to other healthcare institutions, all hospitals share their data with this national healthcare system. Terbinafine was used by 433 patients (76.4%), 75 patients (13.2%), and 37 patients (6.5%), respectively, for one, two, and three months. A total of 119 patients (70.8%) took itraconazole for a month, 32 patients (19%) took it for two months, and four patients (2.33%) took it for three months. At the end of the first month, the proportion of the patients with elevated aspartate transaminase (AST) levels was 5.2% for terbinafine and 0% for itraconazole. Eighteen (8.4%) patients with terbinafine had elevated alanine aminotransferase (ALT) levels, and four patients (7.5%) who were on itraconazole treatment had high ALT levels. None of the patients reported cutaneous adverse drug reactions, gastrointestinal disturbances, or headaches due to OM treatment. Also, no patients discontinued treatment because of hepatotoxicity. Conclusion In this study, none of the patients discontinued the treatment because of hepatotoxicity. According to the results of this study, oral terbinafine and itraconazole can be used with close follow-up. Baseline and regular laboratory monitoring for AST and ALT should be done to monitor liver toxicity with terbinafine and itraconazole. Besides, we did not observe other side effects like cutaneous or cardiac side effects or drug-drug interactions.
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Loos NH, Beijnen JH, Schinkel AH. The inhibitory and inducing effects of ritonavir on hepatic and intestinal CYP3A and other drug-handling proteins. Biomed Pharmacother 2023; 162:114636. [PMID: 37004323 PMCID: PMC10065864 DOI: 10.1016/j.biopha.2023.114636] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/21/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Ritonavir, originally developed as HIV protease inhibitor, is widely used as a booster in several HIV pharmacotherapy regimens and more recently in Covid-19 treatment (e.g., Paxlovid). Its boosting capacity is due to the highly potent irreversible inhibition of the cytochrome P450 (CYP) 3 A enzyme, thereby enhancing the plasma exposure to coadministered drugs metabolized by CYP3A. Typically used booster doses of ritonavir are 100-200 mg once or twice daily. This review aims to address several aspects of this booster drug, including the possibility to use lower ritonavir doses, 20 mg for instance, resulting in partial CYP3A inactivation in patients. If complete CYP3A inhibition is not needed, lower ritonavir doses could be used, thereby reducing unwanted side effects. In this context, there are contradictory reports on the actual recovery time of CYP3A activity after ritonavir discontinuation, but probably this will take at least one day. In addition to ritonavir's CYP3A inhibitory effect, it can also induce and/or inhibit other CYP enzymes and drug transporters, albeit to a lesser extent. Although ritonavir thus exhibits gene induction capacities, with respect to CYP3A activity the inhibition capacity clearly predominates. Another potent CYP3A inhibitor, the ritonavir analog cobicistat, has been reported to lack the ability to induce enzyme and transporter genes. This might result in a more favorable drug-drug interaction profile compared to ritonavir, although the actual benefit appears to be limited. Indeed, ritonavir is still the clinically most used pharmacokinetic enhancer, indicating that its side effects are well manageable, even in chronic administration regimens.
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Rakhshan A, Rahmati Kamel B, Saffaei A, Tavakoli-Ardakani M. Hepatotoxicity Induced by Azole Antifungal Agents: A Review Study. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2023; 22:e130336. [PMID: 38116543 PMCID: PMC10728840 DOI: 10.5812/ijpr-130336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/31/2023] [Accepted: 02/21/2023] [Indexed: 12/21/2023]
Abstract
Context Fungal infections are very common, and several medications are used to treat them. Azoles are prescribed widely to treat fungal infections. In addition to therapeutic effects, any drug can be accompanied by side effects in patients. One of the most important complications in this regard is liver injury. Therefore, hepatotoxicity induced by azole antifungal drugs were reviewed in this study. Evidence Acquisition English scientific papers were evaluated to review the effects of hepatotoxicity by azole antifungal agents, and the related studies' results were summarized using a table. The systematic search was implemented on electronic databases, including PubMed, Google Scholar, and Science Direct. Original articles and review articles that were published before April 1, 2022, were included in the study. Those articles without available full text or non-English articles were excluded. Also, articles that reported pediatric data were excluded. Results Most studies have reported the effects of hepatotoxicity by azole antifungal agents, and their mechanisms have been described. Conclusions Clinical evaluations regarding the hepatotoxicity of antifungal agents provided in the literature were reviewed. Therefore, it is recommended to prescribe these drugs with caution in high-risk patients suffering from liver diseases, and patients should be monitored for hepatotoxicity. However, more research is needed to evaluate the hepatotoxicity of azole antifungal agents and select appropriate drugs according to cost-effectiveness and the side effects' profiles, relying on lower incidence of this liver complication.
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Affiliation(s)
- Amin Rakhshan
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Bardia Rahmati Kamel
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Saffaei
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maria Tavakoli-Ardakani
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Pharmaceutical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Khalil N, Kasten JL, Marsh RA, Danziger-Isakov L. Multifocal Trichosporon asahii Infection in a Patient With Chronic Granulomatous Disease. J Pediatric Infect Dis Soc 2022; 11:467-470. [PMID: 35849130 DOI: 10.1093/jpids/piac064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 06/23/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Nadim Khalil
- Division of Pediatric Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Infectious Diseases, Department of Pediatrics, London Health Science Centre, London, Ontario, Canada
| | - Jennifer L Kasten
- Department of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rebecca A Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lara Danziger-Isakov
- Division of Pediatric Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Zhou ZX, Yin XD, Zhang Y, Shao QH, Mao XY, Hu WJ, Shen YL, Zhao B, Li ZL. Antifungal Drugs and Drug-Induced Liver Injury: A Real-World Study Leveraging the FDA Adverse Event Reporting System Database. Front Pharmacol 2022; 13:891336. [PMID: 35571077 PMCID: PMC9098189 DOI: 10.3389/fphar.2022.891336] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/28/2022] [Indexed: 12/02/2022] Open
Abstract
Aims: We aimed to estimate the risk of drug-induced liver injury (DILI) from various antifungal treatments with azoles and echinocandins causing in real-world practice. Methods: We performed disproportionality and Bayesian analyses based on data from the first quarter in 2004 to the third quarter in 2021 in the Food and Drug Administration Adverse Event Reporting System to characterize the signal differences of antifungal drugs-related DILI. We also compared the onset time and mortality differences of different antifungal agents. Results: A total of 2943 antifungal drugs-related DILI were identified. Affected patients tended to be aged >45 years (51.38%), with more males than females (49.03% vs. 38.09%). Antifungal drug-induced liver injury is most commonly reported with voriconazole (32.45%), fluconazole (19.37%), and itraconazole (14.51%). Almost all antifungal drugs were shown to be associated with DILI under disproportionality and Bayesian analyses. The intraclass analysis of correlation between different antifungal agents and DILI showed the following ranking: caspofungin (ROR = 6.12; 95%CI: 5.36–6.98) > anidulafungin (5.15; 3.69–7.18) > itraconazole (5.06; 4.58–5.60) > voriconazole (4.58; 4.29–4.90) > micafungin (4.53; 3.89–5.27) > posaconazole (3.99; 3.47–4.59) > fluconazole (3.19; 2.93–3.47) > ketoconazole (2.28; 1.96–2.64). The onset time of DILI was significantly different among different antifungal drugs (p < 0.0001), and anidulafungin result in the highest mortality rate (50.00%), while ketoconazole has the lowest mortality rate (9.60%). Conclusion: Based on the Food and Drug Administration Adverse Event Reporting System database, antifungal drugs are significantly associated with DILI, and itraconazole and voriconazole had the greatest risk of liver injury. Due to indication bias, more clinical studies are needed to confirm the safety of echinocandins.
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Affiliation(s)
- Zhi-Xuan Zhou
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xue-Dong Yin
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Zhang
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- Department of Pharmacy, Nanyang Central Hospital, Affiliated Hospital of Zhengzhou University, Nanyang, China
| | - Qi-Hui Shao
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin-Yu Mao
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wen-Juan Hu
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yun-Lin Shen
- Department of Neonatology, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Yun-Lin Shen, ; Bin Zhao, ; Zhi-Ling Li,
| | - Bin Zhao
- Pharmacy Department, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Yun-Lin Shen, ; Bin Zhao, ; Zhi-Ling Li,
| | - Zhi-Ling Li
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Yun-Lin Shen, ; Bin Zhao, ; Zhi-Ling Li,
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O'Flynn R, Zhou YP, Waskin H, Leong R, Straus W. Hepatic safety of the antifungal triazole agent posaconazole: characterization of adverse event reports in a manufacturer's safety database. Expert Opin Drug Saf 2022; 21:1113-1120. [PMID: 35232318 DOI: 10.1080/14740338.2022.2047177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Second-generation triazoles including posaconazole are efficacious for prophylaxis and salvage treatment of life-threatening invasive fungal diseases but have been associated with hepatic adverse events (AEs). This report evaluated hepatic AEs in posaconazole-treated patients. RESEARCH DESIGN AND METHODS Hepatobiliary AEs with posaconazole exposure in the company's global safety database were analyzed to characterize underlying medical conditions and concomitant drug exposure. RESULTS As of October 2019, 516 cases (168 from clinical trials, 348 from postmarketing use) containing 618 hepatobiliary AEs were reported regardless of causality. Frequently reported terms were hyperbilirubinemia, hepatic failure, and hepatic function abnormal (clinical trials reports) and hepatotoxicity, hepatocellular injury, and hepatic function abnormal (postmarketing reports). Cases reporting concurrent medications associated with drug-induced liver injury (DILI) included 8% with verified severe DILI (vMost-DILI) concern, 24% with verified mild to moderate DILI (vLess-DILI) concern, and 37% received both vMost-DILI and vLess-DILI-concern medications in the DILIrank data set. CONCLUSIONS Use of concomitant medications with known risks for hepatic injury appears to be an important contributor for the development of hepatotoxicity in patients treated with posaconazole.
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Voriconazole-Induced Hepatotoxicity Concise up-to-date review. JOURNAL OF BASIC AND CLINICAL HEALTH SCIENCES 2022. [DOI: 10.30621/jbachs.1051669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Burden AM, Hausammann L, Ceschi A, Kupferschmidt H, Weiler S. Observational cross-sectional case study of toxicities of antifungal drugs. J Glob Antimicrob Resist 2021; 29:520-526. [PMID: 34896339 DOI: 10.1016/j.jgar.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 10/19/2021] [Accepted: 11/19/2021] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION In this study we examined the toxicities, including poisoning and overdoses, with polyene, azole, flucytosine and echinocandin antifungals reported to the National Poison Center. METHODS An observational cross-sectional study on antifungals was performed based on reports between 1995 and 2016 to Tox Info Suisse. Patient demographic and clinical characteristics were summarized among all reported calls, stratified by age group. In secondary analyses, we evaluated cases with clinical follow-up information. RESULTS In total, 149 cases were reported to the National Poison Centre within the study period of which 49 (32.9%) were male and 91 (61.1%) were female. 95 (63.8%) were adults and 54 (36.2%) were children (age ≤ 16). The most frequently reported drug class were the azoles (n=136, 91.3%). In 31 cases (21%) reported by the treating physicians, further clinical follow-up information was available. Nearly half of these patients were asymptomatic (n=15, 48%). Among those with symptoms, in 11 (33%) patients, the symptoms of toxicity were categorized with a strong causality to the respective antifungal. Clinical findings caused by the triazoles were effects in the gastrointestinal tract, hallucinations and predilirium state. The clinical findings caused by the polyenes were mostly minor symptoms with infusion-related effects or hypokalemia. In 6 (54.6%) out of 11 cases the severity was categorized as minor and for 5 (45.5%) as moderate, respectively. CONCLUSION Despite high administered doses, no severe or fatal cases occurred within the study period. Although various toxicities can occur with antifungal administration and overdoses, they showed a favorable safety profile.
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Affiliation(s)
- Andrea M Burden
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH, Zurich, Switzerland
| | - Lucy Hausammann
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH, Zurich, Switzerland
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland; Biomedical Faculty, Università della Svizzera Italiana, Lugano, Switzerland
| | - Hugo Kupferschmidt
- Tox Info Suisse, National Poisons Information Centre, Associated Institute of the University of Zurich, Switzerland; Giftnotruf, Charité-Universitätsmedizin, Berlin, Germany
| | - Stefan Weiler
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH, Zurich, Switzerland; Tox Info Suisse, National Poisons Information Centre, Associated Institute of the University of Zurich, Switzerland.
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Rana P, Aleo MD, Wen X, Kogut S. Hepatotoxicity reports in the FDA adverse event reporting system database: A comparison of drugs that cause injury via mitochondrial or other mechanisms. Acta Pharm Sin B 2021; 11:3857-3868. [PMID: 35024312 PMCID: PMC8727782 DOI: 10.1016/j.apsb.2021.05.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 03/02/2021] [Accepted: 05/19/2021] [Indexed: 12/11/2022] Open
Abstract
Drug-induced liver injury (DILI) is a leading reason for preclinical safety attrition and post-market drug withdrawals. Drug-induced mitochondrial toxicity has been shown to play an essential role in various forms of DILI, especially in idiosyncratic liver injury. This study examined liver injury reports submitted to the Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) for drugs associated with hepatotoxicity via mitochondrial mechanisms compared with non-mitochondrial mechanisms of toxicity. The frequency of hepatotoxicity was determined at a group level and individual drug level. A reporting odds ratio (ROR) was calculated as the measure of effect. Between the two DILI groups, reports for DILI involving mitochondrial mechanisms of toxicity had a 1.43 (95% CI 1.42-1.45; P < 0.0001) times higher odds compared to drugs associated with non-mitochondrial mechanisms of toxicity. Antineoplastic, antiviral, analgesic, antibiotic, and antimycobacterial drugs were the top five drug classes with the highest ROR values. Although the top 20 drugs with the highest ROR values included drugs with both mitochondrial and non-mitochondrial injury mechanisms, the top four drugs (ROR values > 18: benzbromarone, troglitazone, isoniazid, rifampin) were associated with mitochondrial mechanisms of toxicity. The major demographic influence for DILI risk was also examined. There was a higher mean patient age among reports for drugs that were associated with mitochondrial mechanisms of toxicity [56.1 ± 18.33 (SD)] compared to non-mitochondrial mechanisms [48 ± 19.53 (SD)] (P < 0.0001), suggesting that age may play a role in susceptibility to DILI via mitochondrial mechanisms of toxicity. Univariate logistic regression analysis showed that reports of liver injury were 2.2 (odds ratio: 2.2, 95% CI 2.12-2.26) times more likely to be associated with older patient age, as compared with reports involving patients less than 65 years of age. Compared to males, female patients were 37% less likely (odds ratio: 0.63, 95% CI 0.61-0.64) to be subjects of liver injury reports for drugs associated with mitochondrial toxicity mechanisms. Given the higher proportion of severe liver injury reports among drugs associated with mitochondrial mechanisms of toxicity, it is essential to understand if a drug causes mitochondrial toxicity during preclinical drug development when drug design alternatives, more clinically relevant animal models, and better clinical biomarkers may provide a better translation of drug-induced mitochondrial toxicity risk assessment from animals to humans. Our findings from this study align with mitochondrial mechanisms of toxicity being an important cause of DILI, and this should be further investigated in real-world studies with robust designs.
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Key Words
- AE, adverse event
- Adverse event reporting
- CI, confidence interval
- CNS, center nervous system
- DILI, drug-induced liver injury
- DNA, deoxyribonucleic acid
- Drug-induced liver injury
- FAERS database
- FAERS, FDA's Adverse Event Reporting System
- FDA, US Food and Drug Administration
- Hepatotoxicity
- MedDRA, Medical Dictionary for Regulatory Activities
- Mitochondrial toxicity
- NCTR-LTKB, National Center for Toxicological Research-Liver Toxicity Knowledge Base
- NSAID, nonsteroidal anti-inflammatory drugs
- ROR, Reporting Odds Ratio
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Affiliation(s)
- Payal Rana
- Drug Safety Research & Development, Pfizer, Groton, CT 06340, USA
- Corresponding author. Tel.: +1 0 715 6154.
| | - Michael D. Aleo
- Drug Safety Research & Development, Pfizer, Groton, CT 06340, USA
| | - Xuerong Wen
- University of Rhode Island, College of Pharmacy, Kingston, RI 02881, USA
| | - Stephen Kogut
- University of Rhode Island, College of Pharmacy, Kingston, RI 02881, USA
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Towards a Standardized Procedure for the Production of Infective Spores to Study the Pathogenesis of Dermatophytosis. J Fungi (Basel) 2021; 7:jof7121029. [PMID: 34947011 PMCID: PMC8709344 DOI: 10.3390/jof7121029] [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: 10/28/2021] [Revised: 11/23/2021] [Accepted: 11/26/2021] [Indexed: 11/16/2022] Open
Abstract
Dermatophytoses are superficial infections of human and animal keratinized tissues caused by filamentous fungi named dermatophytes. Because of a high and increasing incidence, as well as the emergence of antifungal resistance, a better understanding of mechanisms involved in adhesion and invasion by dermatophytes is required for the further development of new therapeutic strategies. In the last years, several in vitro and in vivo models have emerged to study dermatophytosis pathogenesis. However, the procedures used for the growth of fungi are quite different, leading to a highly variable composition of inoculum for these models (microconidia, arthroconidia, hyphae), thus rendering difficult the global interpretation of observations. We hereby optimized growth conditions, including medium, temperature, atmosphere, and duration of culture, to improve the sporulation and viability and to favour the production of arthroconidia of several dermatophyte species, including Trichophyton rubrum and Trichophyton benhamiae. The resulting suspensions were then used as inoculum to infect reconstructed human epidermis in order to validate their ability to adhere to and to invade host tissues. By this way, this paper provides recommendations for dermatophytes culture and paves the way towards a standardized procedure for the production of infective spores usable in in vitro and in vivo experimental models.
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13
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Taher MK, Alami A, Gravel CA, Tsui D, Bjerre LM, Momoli F, Mattison D, Krewski D. Systemic quinolones and risk of retinal detachment I: analysis of data from the US FDA adverse event reporting system. Expert Opin Drug Saf 2021; 21:269-276. [PMID: 34641748 DOI: 10.1080/14740338.2022.1993187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Quinolones comprise a class of antibiotics that are globally preferred for treating a wide range of bacterial infections due to their potency, broad coverage, favorable pharmacologic profile, and mostly mild to moderate adverse reactions. Spontaneous reports on adverse drug events (ADE) and data from some pharmacoepidemiologic studies have raised concerns regarding quinolones and risk of retinal detachment (RD). This study examined ADE reports submitted to FDA adverse event reporting system (FAERS) for evidence on quinolone-associated RD risk. RESEARCH DESIGN AND METHODS We identified all RD reports in FAERS between 2010-2019. We compared ADE signals between quinolones and selected medications that were previously associated with RD, and with reference medications not known to cause RD. For signal detection, we used two techniques: the proportional reporting ratio (PRR) and multi-item gamma Poisson shrinker (MGPS), which are known for their higher sensitivity and specificity for ADE signal detection, respectively. RESULTS Moxifloxacin showed a positive and significant PRR signal for RD [PRR: 2.54 (1.60, 4.04)], and a marginally significant EBGM signal [EBGM: 2.21 (1.41, 3.02)]. CONCLUSION Moxifloxacin is the only quinolone showing a positive disproportionality signal for RD. Further epidemiologic research is needed to clarify the association between moxifloxacin and RD risk.
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Affiliation(s)
- Mohamed Kadry Taher
- McLaughlin Centre for Population Health Risk Assessment, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Risk Sciences International, Ottawa, ON, Canada
| | | | - Christopher A Gravel
- McLaughlin Centre for Population Health Risk Assessment, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Derek Tsui
- Risk Sciences International, Ottawa, ON, Canada
| | - Lise M Bjerre
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.,Institut Du Savoir Montfort, Ottawa, ON, Canada
| | - Franco Momoli
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Risk Sciences International, Ottawa, ON, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Donald Mattison
- McLaughlin Centre for Population Health Risk Assessment, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Risk Sciences International, Ottawa, ON, Canada
| | - Daniel Krewski
- McLaughlin Centre for Population Health Risk Assessment, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Risk Sciences International, Ottawa, ON, Canada
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14
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Taher MK, Alami A, Gravel CA, Tsui D, Bjerre LM, Momoli F, Mattison DR, Krewski D. Systemic quinolones and risk of acute liver failure I: Analysis of data from the US FDA adverse event reporting system. JGH OPEN 2021; 5:778-784. [PMID: 34263072 PMCID: PMC8264239 DOI: 10.1002/jgh3.12585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/18/2021] [Accepted: 05/18/2021] [Indexed: 11/25/2022]
Abstract
Background and Aim Quinolones are a potent and globally popular group of antibiotics that are used to treat a wide range of infections. Some case reports have raised concern about their possible association with acute hepatic failure (AHF). Data from the US FDA Adverse Event Reporting System were evaluated for signals of AHF in association with systemically administered quinolone antibiotics. Methods AHF reports between 1969 and 2019q2, with a focus on 2010–2019q2, were analyzed. Specifically, AHF reports linked to non‐quinolone antibiotics of known hepatotoxicity were compared to reports with non‐quinolone, non‐hepatotoxic (reference) antibiotics; and AHF reports with quinolones were also compared to reports with the same group of reference antibiotics. Two disproportionality signal detection techniques (proportional reporting ratio, PRR, and empirical Bayes geometric mean, EBGM) were used to assess the AHF signal for both analyses. Results Only ciprofloxacin showed a marginal and significant AHF signal (PRR: 1.85 [1.21, 2.81]; EBGM: 1.54 [1.06, 1.81]); moxifloxacin, levofloxacin, and ofloxacin showed weak and nonsignificant signals. Conclusion Further pharmacovigilance studies are required to confirm the association between ciprofloxacin and AHF seen in the present analysis.
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Affiliation(s)
- Mohamed Kadry Taher
- McLaughlin Centre for Population Health Risk Assessment, Faculty of Medicine University of Ottawa Ottawa ON Canada.,School of Epidemiology and Public Health University of Ottawa Ottawa ON Canada.,Risk Sciences International Ottawa ON Canada
| | | | - Christopher A Gravel
- McLaughlin Centre for Population Health Risk Assessment, Faculty of Medicine University of Ottawa Ottawa ON Canada.,School of Epidemiology and Public Health University of Ottawa Ottawa ON Canada.,Department of Epidemiology, Biostatistics and Occupational Health McGill University Montreal QC Canada
| | - Derek Tsui
- Risk Sciences International Ottawa ON Canada
| | - Lise M Bjerre
- School of Epidemiology and Public Health University of Ottawa Ottawa ON Canada.,Department of Family Medicine University of Ottawa Ottawa ON Canada.,C.T. Lamont Primary Health Care Research Centre Bruyère Research Institute Ottawa ON Canada
| | - Franco Momoli
- School of Epidemiology and Public Health University of Ottawa Ottawa ON Canada.,Risk Sciences International Ottawa ON Canada.,Children's Hospital of Eastern Ontario Research Institute Ottawa ON Canada
| | - Donald R Mattison
- McLaughlin Centre for Population Health Risk Assessment, Faculty of Medicine University of Ottawa Ottawa ON Canada.,Risk Sciences International Ottawa ON Canada
| | - Daniel Krewski
- McLaughlin Centre for Population Health Risk Assessment, Faculty of Medicine University of Ottawa Ottawa ON Canada.,School of Epidemiology and Public Health University of Ottawa Ottawa ON Canada.,Risk Sciences International Ottawa ON Canada
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15
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Lavertu A, Vora B, Giacomini KM, Altman R, Rensi S. A New Era in Pharmacovigilance: Toward Real-World Data and Digital Monitoring. Clin Pharmacol Ther 2021; 109:1197-1202. [PMID: 33492663 PMCID: PMC8058244 DOI: 10.1002/cpt.2172] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/08/2021] [Indexed: 12/20/2022]
Abstract
Adverse drug reactions (ADRs) are a major concern for patients, clinicians, and regulatory agencies. The discovery of serious ADRs leading to substantial morbidity and mortality has resulted in mandatory phase IV clinical trials, black box warnings, and withdrawal of drugs from the market. Real‐world data, data collected during routine clinical care, is being adopted by innovators, regulators, payors, and providers to inform decision making throughout the product life cycle. We outline several different approaches to modern pharmacovigilance, including spontaneous reporting databases, electronic health record monitoring and research frameworks, social media surveillance, and the use of digital devices. Some of these platforms are well‐established while others are still emerging or experimental. We highlight both the potential opportunity, as well as the existing challenges within these pharmacovigilance systems that have already begun to impact the drug development process, as well as the landscape of postmarket drug safety monitoring. Further research and investment into different and complementary pharmacovigilance systems is needed to ensure the continued safety of pharmacotherapy.
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Affiliation(s)
- Adam Lavertu
- Biomedical Informatics Training Program, Stanford University, Stanford, California, USA
| | - Bianca Vora
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Kathleen M Giacomini
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Russ Altman
- Department of Bioengineering, Stanford University, Stanford, California, USA.,Departments of Biomedical Data Science, Genetics, and Medicine, Stanford University, Stanford, California, USA
| | - Stefano Rensi
- Department of Bioengineering, Stanford University, Stanford, California, USA
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16
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Moreno-Sabater A, Ouali N, Chasset F, Frances C, Senet P, Faucon C, Hennequin C, Bachmeyer C. Severe onychomycosis management with oral terbinafine in a kidney transplantation setting: Clinical follow-up by image analysis. Mycoses 2020; 64:309-315. [PMID: 33245794 DOI: 10.1111/myc.13220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/25/2020] [Accepted: 10/06/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Severe onychomycosis treatment in kidney transplant recipients (KTR) is challenging because of drug interactions and adverse events. Tacrolimus remains the antirejection treatment (ART) of choice in kidney transplantation but tolerance with systemic terbinafine for the management of severe onychomycosis has not been studied. OBJECTIVE This study illustrates severe onychomycosis management in a kidney transplantation setting and investigates systemic terbinafine tolerance profile in KTR. PATIENTS/METHODS We retrospective analysed clinical data of KTR with a confirmed diagnosis of severe onychomycosis. RESULTS We retrieved a total of 29 KTR with severe onychomycosis needing an oral treatment to manage onychomycosis. In 55.1% (16/29) KTR, altered renal biological parameters or lack of guidelines to manage severe onychomycosis were the main reasons to deterring clinicians from prescribing oral treatments. 13 patients received an oral terbinafine treatment (9, 3 and 1 with a tacrolimus, cyclosporine and everolimus-based ART, respectively). Clinical and biological follow-up did not reveal severe drug interactions. ART blood levels showed significant variations in 2 patients without clinical consequences in renal graft. Two patients reported mild adverse events but after only one dose of terbinafine. Using an open-source image analysis program, clinical evolution of onychomycosis could be retrospectively quantified and followed up. CONCLUSIONS The results presented here suggest that oral terbinafine can be proposed to treat severe onychomycosis with an acceptable tolerance profile in KTR with different ART such as tacrolimus and highlight the need of multicentric studies to establish guidelines for onychomycosis treatment in KTR.
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Affiliation(s)
- Alicia Moreno-Sabater
- Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Inserm U1135, Paris, France.,Service de Parasitologie-Mycologie, AP-HP, Hôpital Saint-Antoine, Paris, France
| | - Nacéra Ouali
- Service d'Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Paris, France
| | - François Chasset
- Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Inserm U1135, Paris, France.,Service de Dermatologie-Allergologie, AP-HP, Hôpital Tenon, Paris, France
| | - Camille Frances
- Service de Dermatologie-Allergologie, AP-HP, Hôpital Tenon, Paris, France
| | - Patricia Senet
- Service de Dermatologie-Allergologie, AP-HP, Hôpital Tenon, Paris, France
| | - Caroline Faucon
- Service de Dermatologie-Allergologie, AP-HP, Hôpital Tenon, Paris, France
| | - Christophe Hennequin
- Service de Parasitologie-Mycologie, AP-HP, Hôpital Saint-Antoine, Paris, France.,Centre de Recherche Saint-Antoine, CRSA, AP-HP, Sorbonne Université, Inserm, Paris, France
| | - Claude Bachmeyer
- Service de Dermatologie-Allergologie, AP-HP, Hôpital Tenon, Paris, France
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17
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Navarro BS, Auler ME, Dos Santos RLO, da Silva Ruiz L, Nascimento DC, Felippe PAN, Domaneschi C, Moreira D, Baroni FA, Pires MFC, Paula CR. Antifungal sensitivity and species of yeasts in oral mucosa of street mixed-breed dogs. J Mycol Med 2020; 30:101010. [PMID: 32690370 DOI: 10.1016/j.mycmed.2020.101010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 10/05/2019] [Accepted: 06/24/2020] [Indexed: 02/08/2023]
Abstract
The aim of this research is to verify the yeast species isolated from oral mucosa in street mixed-breed dogs and to determine the antifungal profiles. After capturing and sedating the animals, oral mucosa samples were collected from fifty dogs and the materials were inoculated on Sabouraud dextrose agar with chloramphenicol. Forty-three yeast strains were isolated and identified trough the API-20C AUX method. Thirty-seven (86.1%) of the yeasts belonged to genus Candida, five (11.6%) to genus Trichosporon and only one strain (2.3%) to genus Malassezia. The sensitivity profiles to anifungals (amphotericin B, itraconanole, ketoconazole, fluconazole and variconazole) were determined through Etest® method. This study found resistance of some yeasts to amphotericin B and a good susceptibility to voriconazole and ketoconazole. Some of these antifungals are used in veterinary medical practice. This research is the first investigation on street mixed-breed dogs regarding yeast identifications and antifungals profiles.
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Affiliation(s)
- B S Navarro
- Department of Stomatology, School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - M E Auler
- School of Pharmacy, University of Paraná-Unicentro, Paraná, Brazil
| | - R L O Dos Santos
- Department of Stomatology, School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - L da Silva Ruiz
- Adolfo Lutz Institute, Section of Biomedical Sciences, Mycology Laboratory, Bauru, São Paulo, Brazil
| | | | | | - C Domaneschi
- Department of Stomatology, School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - D Moreira
- University Brasil, São Paulo, Brazil
| | - F A Baroni
- Rural Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - M F C Pires
- Adolfo Lutz Institute, Section of Biomedical Sciences, São Paulo, São Paulo, Brazil
| | - C R Paula
- Department of Stomatology, School of Dentistry, University of São Paulo, São Paulo, Brazil.
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18
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Comparative Study of Traditional Ablative CO 2 Laser-Assisted Topical Antifungal with only Topical Antifungal for Treating Onychomycosis: A Multicenter Study. Clin Drug Investig 2020; 40:575-582. [PMID: 32314298 DOI: 10.1007/s40261-020-00914-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The predominance of onychomycosis has been increasing recently. New medications and treatment modalities are being researched for better saturation of the antifungal agents through the nail plate topically because of the low resilience of some patients for the oral antifungal agents. Treatment of onychomycosis, mainly moderate to severe, can be very challenging, expensive, and time consuming. OBJECTIVE The objective of this clinical trial is to compare the efficacy and safety of a manually operated ablative CO2 laser combined with a topical antifungal agent in patients with onychomycosis. STUDY DESIGN We conducted an open-label controlled prospective study of 160 eligible patients randomized into control and treatment groups with a 1:1 allocation in the department of dermatology in five different hospitals in Shanghai. It was a 6-month study where both groups were treated with a topical antifungal agent, with the treatment group also receiving ablation by the traditional CO2 laser once a month for the first 3 months. RESULTS The clinical efficacy and mycological cure rate were significantly higher (p < 0.001) for the treatment group. Three (3.75%) patients from the control group and 18 (25%) patients from the treatment group achieved complete nail clearance along with negative potassium hydroxide and negative culture (primary endpoint) results at 24 weeks. Mycological clearance with at least moderate nail clearance (secondary endpoint) for the treatment group was also significantly higher (p < 0.001) for the laser treatment group. The laser treatment was mildly painful but tolerable by the patients. No drug interactions for both groups were encountered. CONCLUSIONS The ablative CO2 laser is a primitive yet effective modality to be considered for the delivery of topical antifungal agents for the management of mild-to-severe onychomycosis. The laser has good tolerance in patients and is a common equipment found in most dermatology units even those without the latest medical technology.
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19
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Gupta MA, Vujcic B, Sheridan AD, Gupta AK. Reduced risk of suicidal behaviours associated with the treatment of hidradenitis suppurativa with tumour necrosis factor alpha antagonists: results from the US FDA Adverse Events Reporting System pharmacovigilance database. J Eur Acad Dermatol Venereol 2020; 34:1564-1568. [PMID: 31981260 DOI: 10.1111/jdv.16224] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 01/08/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hidradenitis suppurativa (HS) is a chronic, recurrent condition that presents as painful, suppurating lesions in the apocrine gland-bearing skin regions. HS has been associated with increased suicidal behaviours (SB), independent of any treatment. TNF-alpha antagonists are used to treat moderate-to-severe HS and have also been associated with SB, a factor that could confound the decision to use the TNF-α antagonists in the moderately to severely affected HS patients, who may already be experiencing increased SB risk. OBJECTIVES To determine presence or absence of a safety signal for SB when HS is treated with TNF-α antagonists. METHODS We calculated the reporting odds ratios (ROR) with 95% CI of SB associated with treatment for HS with TNF-α antagonists vs. the reference group of all other treatments for HS in the US Food and Drug Administration pharmacovigilance database from 1 January 2004 to 31 March 2019. A second analysis excluded isotretinoin (which has been used to treat HS and has also been associated with SB) from the reference group. RESULTS There was a signal for decreased risk of SB with TNF-α antagonists (ROR = 0.1959, 95% CI 0.1247-0.3079; z = 7.071, P < 0.0001] vs. all other HS treatments; the ROR did not change significantly after isotretinoin was excluded from the reference group. CONCLUSIONS Treatment of HS with TNF-α antagonists is associated with a decreased risk of SB.
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Affiliation(s)
- M A Gupta
- Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.,Department of Medicine, University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - B Vujcic
- Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.,Department of Medicine, University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - A D Sheridan
- Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.,Department of Medicine, University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - A K Gupta
- Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.,Department of Medicine, University of Toronto Faculty of Medicine, Toronto, ON, Canada
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20
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Bühler T, Medinger M, Bouitbir J, Krähenbühl S, Leuppi-Taegtmeyer A. Hepatotoxicity Due to Azole Antimycotic Agents in a HLA B*35:02-Positive Patient. Front Pharmacol 2019; 10:645. [PMID: 31244659 PMCID: PMC6580185 DOI: 10.3389/fphar.2019.00645] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/17/2019] [Indexed: 01/25/2023] Open
Abstract
We will present a 42-year-old woman with acute myeloid leukemia and pulmonary aspergillosis. She was treated with several antifungal agents, including three triazoles. Voriconazole, posaconazole, and isavuconazole all led to hepatocellular liver injury. Voriconazole administration led to a peak alanine aminotransferase (ALT) value of 1,793 U/L (normal range, 9–59 U/L). After posaconazole and isavuconazole treatment, ALT rose over 500 U/L. The typical course of events, exclusion of differential diagnoses, and normalization of the liver function tests (LFTs) after stopping the triazoles were highly suspicious for a drug-induced liver injury (DILI). Interestingly, our patient carries a rare HLA B allele (HLA B*35:02), which occurs in less than 1% of the population and is known to be associated with minocycline-induced liver injury. Over the course of 4 months, the patient received two induction chemotherapies and afterward underwent a successful allogenic hematopoietic stem cell transplantation. Her liver function recovered rapidly and favorable clinical findings concerning the aspergillosis led to a de-escalation of the antifungal treatment to prophylactic dose fluconazole. Delayed hepatotoxicity suggested a dose dependency and a cumulative effect. The question of a common pathophysiology and a cross-toxicity was raised. At the present time, only a few case reports describe cross-toxicity or its absence after rechallenge with different azoles. The pathophysiology is not well understood. Ketoconazole was found to impair rat mitochondrial function in vitro. Further investigations showed cell membrane toxicity and ATP depletion in isolated human liver cancer cells. Our case report suggests a cross-toxicity, dose-dependency, and a possible genetic predisposition of triazole-induced liver injury.
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Affiliation(s)
- Tim Bühler
- Department of Clinical Pharmacology and Toxicology, University Hospital Basel, Basel, Switzerland
| | - Michael Medinger
- Divisions of Hematology and Internal Medicine, Department of Medicine, University Hospital Basel, Basel, Switzerland
| | - Jamal Bouitbir
- Department of Clinical Pharmacology and Toxicology, University Hospital Basel, Basel, Switzerland
| | - Stephan Krähenbühl
- Department of Clinical Pharmacology and Toxicology, University Hospital Basel, Basel, Switzerland
| | - Anne Leuppi-Taegtmeyer
- Department of Clinical Pharmacology and Toxicology, University Hospital Basel, Basel, Switzerland
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22
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Groll AH, Rijnders BJA, Walsh TJ, Adler-Moore J, Lewis RE, Brüggemann RJM. Clinical Pharmacokinetics, Pharmacodynamics, Safety and Efficacy of Liposomal Amphotericin B. Clin Infect Dis 2019; 68:S260-S274. [PMID: 31222253 PMCID: PMC6495018 DOI: 10.1093/cid/ciz076] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Since its introduction in the 1990s, liposomal amphotericin B (LAmB) continues to be an important agent for the treatment of invasive fungal diseases caused by a wide variety of yeasts and molds. This liposomal formulation was developed to improve the tolerability of intravenous amphotericin B, while optimizing its clinical efficacy. Since then, numerous clinical studies have been conducted, collecting a comprehensive body of evidence on its efficacy, safety, and tolerability in the preclinical and clinical setting. Nevertheless, insights into the pharmacokinetics and pharmacodynamics of LAmB continue to evolve and can be utilized to develop strategies that optimize efficacy while maintaining the compound's safety. In this article, we review the clinical pharmacokinetics, pharmacodynamics, safety, and efficacy of LAmB in a wide variety of patient populations and in different indications, and provide an assessment of areas with a need for further clinical research.
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Affiliation(s)
- Andreas H Groll
- Infectious Disease Research Program, Department of Pediatric Hematology and Oncology and Center for Bone Marrow Transplantation, University Children’s Hospital Muenster, Germany
| | - Bart J A Rijnders
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Thomas J Walsh
- Departments of Medicine, Pediatrics, and Microbiology & Immunology, Weill Cornell Medicine of Cornell University, New York, New York
| | - Jill Adler-Moore
- Department of Biological Sciences, California State Polytechnic University, Pomona
| | - Russell E Lewis
- Unit of Infectious Diseases, Policlinico Sant’Orsola-Malpighi, Department of Medical Sciences and Surgery, University of Bologna, Italy
| | - Roger J M Brüggemann
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
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24
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Greenblatt DJ, Mikus G. Ketoconazole and Liver Injury: A Five-Year Update. Clin Pharmacol Drug Dev 2019; 8:6-8. [DOI: 10.1002/cpdd.652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology; University of Heidelberg; Heidelberg Germany
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25
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Pre-Existing Liver Disease and Toxicity of Antifungals. J Fungi (Basel) 2018; 4:jof4040133. [PMID: 30544724 PMCID: PMC6309049 DOI: 10.3390/jof4040133] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/05/2018] [Accepted: 12/07/2018] [Indexed: 12/17/2022] Open
Abstract
Pre-existing liver disease in patients with invasive fungal infections further complicates their management. Altered pharmacokinetics and tolerance issues of antifungal drugs are important concerns. Adjustment of the dosage of antifungal agents in these cases can be challenging given that current evidence to guide decision-making is limited. This comprehensive review aims to evaluate the existing evidence related to antifungal treatment in individuals with liver dysfunction. This article also provides suggestions for dosage adjustment of antifungal drugs in patients with varying degrees of hepatic impairment, after accounting for established or emerging pharmacokinetic–pharmacodynamic relationships with regard to antifungal drug efficacy in vivo.
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26
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Fontana RJ, Cirulli ET, Gu J, Kleiner D, Ostrov D, Phillips E, Schutte R, Barnhart H, Chalasani N, Watkins PB, Hoofnagle JH. The role of HLA-A*33:01 in patients with cholestatic hepatitis attributed to terbinafine. J Hepatol 2018; 69:1317-1325. [PMID: 30138689 PMCID: PMC6472700 DOI: 10.1016/j.jhep.2018.08.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/27/2018] [Accepted: 08/02/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Terbinafine is an antifungal agent that has been associated with rare instances of hepatotoxicity. In this study we aimed to describe the presenting features and outcomes of patients with terbinafine hepatotoxicity and to investigate the role of human leukocyte antigen (HLA)-A*33:01. METHODS Consecutive high causality cases of terbinafine hepatotoxicity enrolled into the Drug Induced Liver Injury Network were reviewed. DNA samples underwent high-resolution confirmatory HLA sequencing using the Ilumina MiSeq platform. RESULTS All 15 patients with terbinafine hepatotoxicity were more than 40 years old (median = 57 years), 53% were female and the median latency to onset was 38 days (range 24 to 114 days). At the onset of drug-induced liver injury, 80% were jaundiced, median serum alanine aminotransferase was 448 U/L and alkaline phosphatase was 333 U/L. One individual required liver transplantation for acute liver failure during follow-up, and 7 of the 13 (54%) remaining individuals had ongoing liver injury at 6 months, with 4 demonstrating persistently abnormal liver biochemistries at month 24. High-resolution HLA genotyping confirmed that 10 of the 11 (91%) European ancestry participants were carriers of the HLA-A*33:01, B*14:02, C*08:02 haplotype, which has a carrier frequency of 1.6% in European Ancestry population controls. One African American patient was also an HLA-A*33:01 carrier while 2 East Asian patients were carriers of a similar HLA type: A*33:03. Molecular docking studies indicated that terbinafine may interact with HLA-A*33:01 and A*33:03. CONCLUSIONS Patients with terbinafine hepatotoxicity most commonly present with a mixed or cholestatic liver injury profile and frequently have residual evidence of chronic cholestatic injury. A strong genetic association of HLA-A*33:01 with terbinafine drug-induced liver injury was confirmed amongst Caucasians. LAY SUMMARY A locus in the human leukocyte antigen gene (HLA-A*33:01, B*14:02, C*08:02) was significantly overrepresented in Caucasian and African American patients with liver injury attributed to the antifungal medication, terbinafine. These data along with the molecular docking studies demonstrate that this genetic polymorphism is a plausible risk factor for developing terbinafine hepatotoxicity and could be used in the future to help doctors make a diagnosis more rapidly and confidently.
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Affiliation(s)
| | | | | | | | - David Ostrov
- University of Florida College of Medicine, Gainesville, FL
| | | | - Ryan Schutte
- University of Florida College of Medicine, Gainesville, FL
| | | | | | | | - Jay H. Hoofnagle
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
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27
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Gupta AK, Mays RR, Versteeg SG, Shear NH, Piguet V. Update on current approaches to diagnosis and treatment of onychomycosis. Expert Rev Anti Infect Ther 2018; 16:929-938. [DOI: 10.1080/14787210.2018.1544891] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Aditya K. Gupta
- Mediprobe Research Inc., London, Canada
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, Canada
| | | | | | - Neil H. Shear
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, Canada
- Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, Canada
- Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK
- Division of Dermatology, Women’s College Hospital, Toronto, Canada
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28
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Antonazzo IC, Poluzzi E, Forcesi E, Riise T, Bjornevik K, Baldin E, Muratori L, De Ponti F, Raschi E. Liver injury with drugs used for multiple sclerosis: A contemporary analysis of the FDA Adverse Event Reporting System. Mult Scler 2018; 25:1633-1640. [DOI: 10.1177/1352458518799598] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Drug-induced liver injury (DILI) has been observed in patients with multiple sclerosis (MS), raising concerns on the liver safety of MS drugs. Objective: To describe DILI events with MS drugs by analyzing the FDA Adverse Event Reporting System. Methods: DILI reports were extracted and classified in overall liver injury (OLI), including asymptomatic elevation of liver enzymes, and severe liver injury (SLI). We performed disproportionality analysis by calculating adjusted reporting odds ratios (RORs) with 95% confidence interval (CI) and case-by-case evaluation for concomitant drugs with hepatotoxic potential. Results: Fampridine showed statistically significant ROR for both OLI and SLI, whereas teriflunomide and fingolimod generated solid disproportionality (ROR > 2) only for OLI (ROR, 2.31; 95% CI, 2.12–2.52; and 2.53; 2.40–2.66, respectively). Among monoclonal antibodies, only alemtuzumab generated higher-than-expected ROR for OLI (1.34; 1.09–1.65). We also detected the expected hepatotoxic potential of beta interferon and mitoxantrone. Concomitant reporting of hepatotoxic drugs ranged from 26% (dimethyl fumarate) to 90% (mitoxantrone). Conclusion: These real-world pharmacovigilance findings suggest that DILI might be a common feature of MS drugs and call for (1) formal population-based study to verify the risk of fampridine and (2) awareness by clinicians, who should assess the possible responsibility of MS drugs when they diagnose DILI.
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Affiliation(s)
- Ippazio Cosimo Antonazzo
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Elisabetta Poluzzi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Emanuele Forcesi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Trond Riise
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway/The Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Kjetil Bjornevik
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway/The Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway/Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Elisa Baldin
- Epidemiology and Biostatistics Service, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Luigi Muratori
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy/ Center for the Study and Treatment of the Autoimmune Diseases of the Liver and Biliary System, Policlinico di Sant’Orsola, Bologna, Italy
| | - Fabrizio De Ponti
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Bongomin F, Rodriguez-Goncer I, Lorden C, Otu A, Bazaz R. Late-onset isavuconazole-induced liver injury. Med Mycol Case Rep 2018; 22:11-13. [PMID: 30094131 PMCID: PMC6076222 DOI: 10.1016/j.mmcr.2018.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 07/11/2018] [Indexed: 11/19/2022] Open
Abstract
Antifungal agents account for approximately 3% of Drug-Induced Liver Injury (DILI) cases. Isavuconazole is a novel triazole, and experience with long-term use of it is lacking. We report a case of late-onset DILI occurring after 11 months of isavuconazole therapy in a 55-year old man of Angolan descent on long-term antifungal therapy for the management of chronic pulmonary aspergillosis complicating previously treated pulmonary tuberculosis. The DILI could be described as idiosyncratic as it was not associated with high isavuconazole serum levels and his liver function tests returned to normal following treatment discontinuation.
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Affiliation(s)
- Felix Bongomin
- The National Aspergillosis Centre, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9PL, UK
| | - Isabel Rodriguez-Goncer
- The National Aspergillosis Centre, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK
| | - Carol Lorden
- The National Aspergillosis Centre, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK
| | - Akaninyene Otu
- The National Aspergillosis Centre, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK
| | - Rohit Bazaz
- The National Aspergillosis Centre, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK
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Haegler P, Joerin L, Krähenbühl S, Bouitbir J. Hepatocellular Toxicity of Imidazole and Triazole Antimycotic Agents. Toxicol Sci 2018; 157:183-195. [PMID: 28329820 DOI: 10.1093/toxsci/kfx029] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Hepatotoxicity has been described for all antimycotic azoles currently marketed. A possible mechanism involving mitochondrial dysfunction has been postulated for ketoconazole, but not for the other azoles. The aim of the current investigations was to study the toxicity of different azoles in human cell models and to find out mechanisms of their toxicity. In HepG2 cells, posaconazole and ketoconazole were cytotoxic starting at 20 and 50 µM and decreased the cellular ATP content starting at 5 and 10 µM, respectively. In HepaRG cells, cytotoxicity started at 20 and 100 µM for posaconazole and ketoconazole, respectively, and was slightly accentuated by cytochrome P450 3A4 induction with rifampicin and 1A2 with 3-methylcholantrene. Voriconazole and fluconazole were not cytotoxic. In isolated mouse liver mitochondria, ketoconazole impaired membrane potential and complex I activity, whereas the other azoles were not toxic. In HepG2 cells exposed for 24 h, both posaconazole and ketoconazole (but not fluconazole or voriconazole) decreased the mitochondrial membrane potential, impaired the function of enzyme complexes of the electron transport chain, were associated with mitochondrial superoxide accumulation, decreased mitochondrial DNA and induced apoptosis. In HepG2 cells with mitochondrial dysfunction induced by the vitamin B12 antagonist hydroxy-cobalamin[c-lactam], cytotoxicity and/or ATP depletion was more accentuated than in untreated cells. We conclude that ketoconazole and posaconazole are mitochondrial toxicants starting at concentrations, which can be reached in vivo. Cytotoxicity and ATP depletion are more accentuated in cells with mitochondrial damage, suggesting that preexisting mitochondrial dysfunction is a susceptibility factor for hepatotoxicity associated with these drugs.
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Affiliation(s)
- Patrizia Haegler
- Clinical Pharmacology & Toxicology, University Hospital, Basel, Switzerland.,Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Lorenz Joerin
- Clinical Pharmacology & Toxicology, University Hospital, Basel, Switzerland.,Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Stephan Krähenbühl
- Clinical Pharmacology & Toxicology, University Hospital, Basel, Switzerland.,Department of Biomedicine, University of Basel, Basel, Switzerland.,Swiss Centre of Applied Human Toxicology (SCAHT), University of Basel, Basel, Switzerland
| | - Jamal Bouitbir
- Clinical Pharmacology & Toxicology, University Hospital, Basel, Switzerland.,Department of Biomedicine, University of Basel, Basel, Switzerland.,Swiss Centre of Applied Human Toxicology (SCAHT), University of Basel, Basel, Switzerland
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31
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Gupta A, Carviel J, Gupta M, Shear N. Assessing dutasteride-associated sexual dysfunction using the U.S. Food and Drug Administration Adverse Event Reporting System. J Eur Acad Dermatol Venereol 2017; 32:1373-1376. [DOI: 10.1111/jdv.14728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/21/2017] [Indexed: 10/18/2022]
Affiliation(s)
- A.K. Gupta
- Department of Medicine; University of Toronto School of Medicine; Toronto ON Canada
- Mediprobe Research Inc.; London ON Canada
| | - J. Carviel
- Mediprobe Research Inc.; London ON Canada
| | - M.A. Gupta
- Department of Psychiatry; Schulich School of Medicine and Dentistry; University of Western Ontario; London ON Canada
| | - N.H. Shear
- Division of Dermatology; Department of Medicine; Sunnybrook Health Sciences Centre; University of Toronto; Toronto ON Canada
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Gupta AK, Versteeg SG, Shear NH. Confirmatory Testing Prior to Initiating Onychomycosis Therapy Is Cost-Effective. J Cutan Med Surg 2017; 22:129-141. [DOI: 10.1177/1203475417733461] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: Onychomycosis can be investigated by sampling. Information gleaned includes nail bed involvement, nail plate penetration, fungal viability, and species identification. Testing samples can confirm a diagnosis. While diagnostic testing is considered useful in directing therapy, a substantial number of clinicians do not confirm diagnosis prior to treatment. Objectives: The aim of this study is to quantify the benefit of confirmatory testing prior to treating toenail onychomycosis. Methods: The cost of mycological cure (negative potassium hydroxide and negative culture) and the cost-effectiveness of confirmatory testing were determined using the average cost of potassium hydroxide (KOH), culture, periodic acid–Schiff (PAS), efinaconazole, ciclopirox, terbinafine, and itraconazole. Costs were obtained through literature searches, public domain websites, and telephone surveys to local pharmacies and laboratories. To represent the potential risks of prescribing onychomycosis treatment, the costs associated with liver monitoring, potential life-threatening adverse events, and drug-drug interactions were obtained through public domain websites, published studies, and product inserts. Results: PAS was determined to be the most sensitive confirmatory test and KOH the least expensive. The overall cost of an incorrect diagnosis (no confirmatory test used) ranged between $350 and $1175 CAD per patient for treatment of 3 infected toenails. Comparatively, performing confirmatory testing prior to treatment decreases the overall cost to $320 to $930, depending on the therapy, physician, and test. Conclusions: It is preferred to diagnose onychomycosis prior to treatment. Furthermore, there are cost savings when confirmatory testing is performed before initiating treatment with both topical and oral antifungals in Canada.
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Affiliation(s)
- Aditya K. Gupta
- Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada
- Mediprobe Research, London, ON, Canada
| | | | - Neil H. Shear
- Department of Medicine (Dermatology, Clinical Pharmacology and Toxicology) and Department of Pharmacology, Sunnybrook and Women’s College Health Science Centre and the University of Toronto, Toronto, ON, Canada
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34
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Shi Q, Yang X, Greenhaw JJ, Salminen AT, Russotti GM, Salminen WF. Drug-Induced Liver Injury in Children: Clinical Observations, Animal Models, and Regulatory Status. Int J Toxicol 2017; 36:365-379. [PMID: 28820004 DOI: 10.1177/1091581817721675] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Drug-induced liver injury in children (cDILI) accounts for about 1% of all reported adverse drug reactions throughout all age groups, less than 10% of all clinical DILI cases, and around 20% of all acute liver failure cases in children. The overall DILI susceptibility in children has been assumed to be lower than in adults. Nevertheless, controversial evidence is emerging about children's sensitivity to DILI, with children's relative susceptibility to DILI appearing to be highly drug-specific. The culprit drugs in cDILI are similar but not identical to DILI in adults (aDILI). This is demonstrated by recent findings that a drug frequently associated with aDILI (amoxicillin/clavulanate) was rarely associated with cDILI and that the drug basiliximab caused only cDILI but not aDILI. The fatality in reported cDILI studies ranged from 4% to 31%. According to the US Food and Drug Administration-approved drugs labels, valproic acid, dactinomycin, and ampicillin appear more likely to cause cDILI. In contrast, deferasirox, isoniazid, dantrolene, and levofloxacin appear more likely to cause aDILI. Animal models have been explored to mimic children's increased susceptibility to valproic acid hepatotoxicity or decreased susceptibility to acetaminophen or halothane hepatotoxicity. However, for most drugs, animal models are not readily available, and the underlying mechanisms for the differential reactions to DILI between children and adults remain highly hypothetical. Diagnosis tools for cDILI are not yet available. A critical need exists to fill the knowledge gaps in cDILI. This review article provides an overview of cDILI and specific drugs associated with cDILI.
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Affiliation(s)
- Qiang Shi
- 1 Division of Systems Biology, National Center for Toxicological Research, Food and Drug Administration, Jefferson, AR, USA
| | - Xi Yang
- 1 Division of Systems Biology, National Center for Toxicological Research, Food and Drug Administration, Jefferson, AR, USA
| | - James J Greenhaw
- 1 Division of Systems Biology, National Center for Toxicological Research, Food and Drug Administration, Jefferson, AR, USA
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35
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Gallant R, Bonney P, Peek L, Yu Z, Crawford D. Voriconazole-induced hepatotoxicity following the administration of PEG-asparaginase: Case report. Pediatr Blood Cancer 2017; 64. [PMID: 27748018 DOI: 10.1002/pbc.26293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 09/11/2016] [Accepted: 09/12/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Rachel Gallant
- Department of Pediatrics, University of Oklahoma Health Sciences Center
| | - Phillip Bonney
- Department of Pediatrics, University of Oklahoma Health Sciences Center
| | - Leigh Peek
- Department of Pharmacy, OU Medical System
| | - Zhongxin Yu
- Department of Pediatric Pathology, University of Oklahoma Health Sciences Center
| | - David Crawford
- Department of Pediatric Hematology-Oncology, University of Oklahoma Health Sciences Center
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36
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Hepatotoxicity of Antimycotics Used for Invasive Fungal Infections: In Vitro Results. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9658018. [PMID: 28473992 PMCID: PMC5394398 DOI: 10.1155/2017/9658018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 02/17/2017] [Accepted: 03/21/2017] [Indexed: 12/11/2022]
Abstract
Purpose. Drug-induced liver injury (DILI) is the most common cause of liver injury and a serious clinical problem; antimycotics are involved in approximately 3% of all DILI cases. The hepatotoxicity of many drugs, including the antimycotics, is poorly screened in human models. Methods. In a standardized assay the cytotoxicity on hepatocytes of different concentrations (Cmax, 5x Cmax, and 10x Cmax) of the antimycotics used for systemic infections was tested. Anidulafungin (ANI), liposomal amphotericerin B (L-AmB), caspofungin (CASPO), fluconazole (FLUCO), and voriconazole (VORI) were incubated with HepG2/C3A cells. After incubation, the viability of cells (XTT test, LDH release, trypan blue staining), the synthesis of albumin, the cytochrome 1A2 activity, and the cell death (DNA fragmentation) were determined. Kruskal-Wallis and Mann-Whitney tests were used for statistical analyses. Results. L-AmB, ANI, and CASPO showed a mild hepatotoxicity in the Cmax concentrations. Higher concentrations of anidulafungin led to a severe impairment of hepatocyte viability and function. The azoles FLUCO and VORI had a higher hepatotoxic potential in all concentrations. Conclusion. Antimycotics, especially azoles, used for systemic infections should be given with caution in patient with liver insufficiency or liver failure or high risk for this; therefore, therapeutic drug monitoring should be used. Further studies with this approach are encouraged.
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Gupta AK, Carviel J, MacLeod MA, Shear N. Assessing finasteride-associated sexual dysfunction using the FAERS database. J Eur Acad Dermatol Venereol 2017; 31:1069-1075. [PMID: 28300347 DOI: 10.1111/jdv.14223] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 02/23/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Postmarketing reports suggest that finasteride causes sexual dysfunction despite a low incidence reported in clinical trials. Therefore, the extent of risk remains unknown. OBJECTIVE To determine whether the risk of sexual dysfunction is higher among individuals treated with finasteride compared to a baseline risk for all other drugs using the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) database. METHODS A case by non-case disproportionality approach was used whereby a reporting odds ratio (ROR) with 95% confidence interval (CI) was calculated. The National Ambulatory Medical Care Survey (NAMCS) was used to confirm results. RESULTS A significant disproportionality in reporting of sexual dysfunction with the use of finasteride was observed whether finasteride was indicated for hair loss (ROR = 138.17, 95% CI: 133.13, 143.4), prostatic hyperplasia (ROR = 93.88, 95% CI: 84.62, 104.16) or any indication (ROR = 173.18, 95% CI: 171.08, 175.31). When these results were stratified by age, disproportionality was strongest at 31-45 years. CONCLUSION Use of finasteride has led to an increase in reports of sexual dysfunction where it is believed to be the primary suspect.
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Affiliation(s)
- A K Gupta
- Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada.,Mediprobe Research Inc., London, ON, Canada
| | - J Carviel
- Mediprobe Research Inc., London, ON, Canada
| | | | - N Shear
- Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Kyriakidis I, Tragiannidis A, Munchen S, Groll AH. Clinical hepatotoxicity associated with antifungal agents. Expert Opin Drug Saf 2016; 16:149-165. [PMID: 27927037 DOI: 10.1080/14740338.2017.1270264] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Invasive fungal diseases (IFDs) are a leading cause of morbidity and mortality among immunocompromised patients with bone marrow failure syndromes, hematological malignancies, hematopoietic stem cell transplantation (HSCT), those admitted in intensive care units (ICUs) and those with prolonged febrile neutropenia. IFDs occur in a setting of multiple morbidities and are associated with case fatality rates between 30 and 70%. Along with the development of classes and compounds, the last two decades have seen substantial improvements in the prevention and management of these infections and an overall increased use of antifungal agents. Areas covered: All antifungal agents, including amphotericin B formulations, echinocandins and the triazoles, may cause hepatic toxicity that ranges from mild and asymptomatic abnormalities in liver function tests to substantial liver injury and fulminant hepatic failure. Expert opinion: The present article reviews incidence and severity of hepatotoxicity associated with different classes and agents to provide a better understanding of this specific end organ toxicity and safer use of antifungal agents A thorough understanding of the distribution, metabolism, elimination and drug-drug interactions of antifungal agents used for management of IFDs in combination with safety data from clinical trials, pharmacokinetic and pharmacodynamic studies may guide the use of antifungal treatment in patients at high risk for the development of hepatic dysfunction and in those with underlying liver damage due to cytotoxic therapy.
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Affiliation(s)
- Ioannis Kyriakidis
- a Hematology Oncology Unit, 2nd Pediatric Department , Aristotle University of Thessaloniki, University General Hospital AHEPA , Thessaloniki , Greece
| | - Athanasios Tragiannidis
- a Hematology Oncology Unit, 2nd Pediatric Department , Aristotle University of Thessaloniki, University General Hospital AHEPA , Thessaloniki , Greece
| | - Silke Munchen
- b Institute for Pharmaceutical and Medicinal Chemistry , University of Münster , Münster , Germany
| | - Andreas H Groll
- c Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology , University Children's Hospital of Münster , Münster , Germany
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Levine MT, Chandrasekar PH. Adverse effects of voriconazole: Over a decade of use. Clin Transplant 2016; 30:1377-1386. [PMID: 27581783 DOI: 10.1111/ctr.12834] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2016] [Indexed: 12/22/2022]
Abstract
Voriconazole use has increased since the drug's introduction in 2002, and new and unique adverse effects are emerging as patients undergo prolonged therapy. Most concerning is the increased risk of cutaneous malignancies, primarily squamous cell carcinoma (SCC); this risk is duration dependent and the associated malignancies tend to be more aggressive and multifocal. Voriconazole is also associated with phototoxicity (which may be a precursor to malignancy), periostitis, hallucinations and encephalopathy, peripheral neuropathy, alopecia, nail changes, hyponatremia, and other adverse effects. Some toxicities (neuropsychiatric and gastrointestinal including hepatic) are seen in clear association with supratherapeutic serum voriconazole levels; thus, careful monitoring of voriconazole levels is a critical component of safe drug use. Guidelines for screening for adverse effects after long-term voriconazole use may be beneficial and need to be established.
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Affiliation(s)
- Miriam T Levine
- Division of Infectious Diseases, Department of Medicine, Wayne State University, Detroit, MI, USA.
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40
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Gupta AK, Foley KA, Versteeg SG. New Antifungal Agents and New Formulations Against Dermatophytes. Mycopathologia 2016; 182:127-141. [PMID: 27502503 DOI: 10.1007/s11046-016-0045-0] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 07/26/2016] [Indexed: 11/24/2022]
Abstract
A variety of oral and topical antifungal agents are available for the treatment of superficial fungal infections caused by dermatophytes. This review builds on the antifungal therapy update published in this journal for the first special issue on Dermatophytosis (Gupta and Cooper 2008;166:353-67). Since 2008, there have not been additions to the oral antifungal armamentarium, with terbinafine, itraconazole, and fluconazole still in widespread use, albeit for generally more severe or recalcitrant infections. Griseofulvin is used in the treatment of tinea capitis. Oral ketoconazole has fallen out of favor in many jurisdictions due to risks of hepatotoxicity. Topical antifungals, applied once or twice daily, are the primary treatment for tinea pedis, tinea corporis/tinea cruris, and mild cases of tinea unguium. Newer topical antifungal agents introduced include the azoles, efinaconazole, luliconazole, and sertaconazole, and the oxaborole, tavaborole. Research is focused on developing formulations of existing topical antifungals that utilize novel delivery systems in order to enhance treatment efficacy and compliance.
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Affiliation(s)
- Aditya K Gupta
- Department of Medicine, University of Toronto, Toronto, Canada. .,Mediprobe Research Inc., 645 Windermere Road, London, ON, Canada.
| | - Kelly A Foley
- Mediprobe Research Inc., 645 Windermere Road, London, ON, Canada
| | - Sarah G Versteeg
- Mediprobe Research Inc., 645 Windermere Road, London, ON, Canada
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Outeiro N, Hohmann N, Mikus G. No Increased Risk of Ketoconazole Toxicity in Drug-Drug Interaction Studies. J Clin Pharmacol 2016; 56:1203-11. [PMID: 27406945 DOI: 10.1002/jcph.795] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 07/08/2016] [Accepted: 07/08/2016] [Indexed: 11/08/2022]
Abstract
In July 2013 the U.S. Food and Drug Administration (FDA) released a safety announcement regarding the use of ketoconazole and its adverse drug reactions. The FDA report advised against the use ketoconazole tablets as a first-line treatment for any fungal infections because of the risk of potentially serious drug-drug interactions and liver and adrenal gland complications. The European Medicines Agency (EMA) also proposed to limit the use of oral ketoconazole in fungal infections because of the same risk of harmful effects and interactions. In addition, the FDA also advised against the use of oral ketoconazole in drug interaction studies, in which it has been extensively used as an index inhibitor of drug metabolism. The aim of this investigation was to evaluate the risks of ketoconazole-induced hepatotoxicity described by the FDA and EMA in published drug interaction studies with ketoconazole and compare these data with the toxicity reported for ketoconazole when used as antifungal treatment. In the drug interaction studies (2355 participants; healthy volunteers and patients; median treatment duration, 6 days), only 40 participants were reported to have increased liver transaminase activity (1.7%), and no deaths were reported or associated with ketoconazole. In studies investigating ketoconazole treatment, patients were treated for 276 days (median), and 5.6% of patients had elevated liver enzyme activity. Because of the short treatment period in drug interaction studies the risk of drug-induced hepatic injury is considered very low. As such, we recommend that ketoconazole remain a safe CYP3A index inhibitor for use in drug interaction studies with healthy volunteers.
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Affiliation(s)
- Noémi Outeiro
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Nicolas Hohmann
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany.
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Tverdek FP, Kofteridis D, Kontoyiannis DP. Antifungal agents and liver toxicity: a complex interaction. Expert Rev Anti Infect Ther 2016; 14:765-76. [PMID: 27275514 DOI: 10.1080/14787210.2016.1199272] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The number of antifungal agents has sharply increased in recent decades. Antifungals differ in their spectrum of activity, pharmacokinetic/pharmacodynamic properties, dosing, safety-profiles and costs. Risk of developing antifungal associated hepatotoxicity is multifactorial and is influenced by pre-existing liver disease, chemical properties of the drug, patient demographics, comorbidities, drug-drug interactions, environmental and genetic factors. Antifungal related liver injury typically manifests as elevations in serum aminotransferase levels, although the clinical significance of these biochemical alterations is not always clear. Incidence rates of hepatotoxicity induced by antifungal therapy range widely, occurring most frequently in patients treated with azole antifungals for documented fungal infections. AREAS COVERED This review provides an update regarding the hepatotoxicity profiles of the modern systemic antifungals used in treatment of invasive fungal infections. Expert commentary: Understanding the likelihood and pattern of hepatotoxicity for all suspected drugs can aid the clinician in early detection of liver injury allowing for intervention and potential mitigation of liver damage. Therapeutic drug monitoring is emerging as a potential tool to assess risk for hepatotoxicity.
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Affiliation(s)
- Frank P Tverdek
- a Department of Pharmacy Clinical Programs , The University of Texas M.D. Anderson Cancer Center , Houston , TX , USA
| | - Diamantis Kofteridis
- b Infectious Disease Unit, Department of Internal Medicine , University Hospital of Heraklion , Crete , Greece
| | - Dimitrios P Kontoyiannis
- c Departments of Infectious Diseases , Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center , Houston , TX , USA
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de Souza MCP, Santos AGD, Reis AMM. Adverse Drug Reactions in Patients Receiving Systemic Antifungal Therapy at a High-Complexity Hospital. J Clin Pharmacol 2016; 56:1507-1515. [PMID: 27198583 DOI: 10.1002/jcph.772] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/07/2016] [Accepted: 05/14/2016] [Indexed: 11/06/2022]
Abstract
The aim of the present study was to determine the frequency of adverse drug reactions (ADRs) associated with the use of systemic antifungal drugs in patients hospitalized at a high-complexity hospital. In addition, factors associated with ADRs were investigated. This cross-sectional retrospective study involved the investigation of 183 medical records of patients receiving systemic antifungal therapy. Antifungal drugs were classified using the fourth level of the Anatomical Therapeutic Chemical System. ADR causality was classified using the Naranjo algorithm. Drug interactions were assessed using DRUG-REAX software. Data were analyzed with descriptive statistics and univariate and multivariate logistic regression. A total of 53 patients (29.0%) had at least 1 ADR involving antifungals. Ninety-six ADRs were detected. The main ADRs observed were an infusion reaction in 24 patients (25.0%), hypokalemia in 22 (22.9%), nephrotoxicity in 18 (18.7%), and hepatotoxicity in 15 (15.6%). Amphotericin B and voriconazole were associated with ADRs of major clinical impact. Eleven of the ADRs (11.4%) were related to drug interactions. The following 3 factors were contributors to the multivariate model for the occurrence of ADRs caused by antifungal drug use: neoplasm diagnosis (odds ratio [OR], 3.9; 1.9-7.9), length of hospital stay (OR, 2.2; 1.1-4.5), and the use of ≥13 drugs (OR, 3.4; 1.6-7.2). Our study revealed positive associations between the occurrence of ADRs and diagnosis of a neoplasm, the length of stay, and the use of multiple drugs concomitant with antifungals. These risk factors should be considered in antifungal stewardship, among other actions, to promote the rational use of antifungal agents.
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Affiliation(s)
- Maria Clara Padovani de Souza
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil.,Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil
| | - Andrezza Gouvêa Dos Santos
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil.,Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil
| | - Adriano Max Moreira Reis
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil.,Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil
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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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Mahdi ZM, Synal-Hermanns U, Yoker A, Locher KP, Stieger B. Role of Multidrug Resistance Protein 3 in Antifungal-Induced Cholestasis. Mol Pharmacol 2016; 90:23-34. [DOI: 10.1124/mol.116.103390] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 04/20/2016] [Indexed: 12/18/2022] Open
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Characterization of chemical-induced sterile inflammation in vitro: application of the model compound ketoconazole in a human hepatic co-culture system. Arch Toxicol 2016; 91:799-810. [PMID: 26965496 DOI: 10.1007/s00204-016-1686-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 02/22/2016] [Indexed: 12/31/2022]
Abstract
Liver injury as a result of a sterile inflammation is closely linked to the activation of immune cells, including macrophages, by damaged hepatocytes. This interaction between immune cells and hepatocytes is as yet not considered in any of the in vitro test systems applied during the generation of new drugs. Here, we established and characterized a novel in vitro co-culture model with two human cell lines, HepG2 and differentiated THP-1. Ketoconazole, an antifungal drug known for its hepatotoxicity, was used as a model compound in the testing of the co-culture. Single cultures of HepG2 and THP-1 cells were studied as controls. Different metabolism patterns of ketoconazole were observed for the single and co-culture incubations as well as for the different cell types. The main metabolite N-deacetyl ketoconazole was found in cell pellets, but not in supernatants of cell cultures. Global proteome analysis showed that the NRF2-mediated stress response and the CXCL8 (IL-8) pathway were induced by ketoconazole treatment under co-culture conditions. The upregulation and ketoconazole-induced secretion of several pro-inflammatory cytokines, including CXCL8, TNF-α and CCL3, was observed in the co-culture system only, but not in single cell cultures. Taking together, we provide evidence that the co-culture model applied might be suitable to serve as tool for the prediction of chemical-induced sterile inflammation in liver tissue in vivo.
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Lo Re V, Carbonari DM, Lewis JD, Forde KA, Goldberg DS, Reddy KR, Haynes K, Roy JA, Sha D, Marks AR, Schneider JL, Strom BL, Corley DA. Oral Azole Antifungal Medications and Risk of Acute Liver Injury, Overall and by Chronic Liver Disease Status. Am J Med 2016; 129:283-91.e5. [PMID: 26597673 PMCID: PMC5549881 DOI: 10.1016/j.amjmed.2015.10.029] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 09/17/2015] [Accepted: 10/12/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND Reports on associations between azole antifungal medications and acute liver injury are inconsistent and have not been based on liver-related laboratory tests. We evaluated incidence rates of acute liver injury associated with oral azole antifungals. METHODS We conducted a cohort study among Kaiser Permanente Northern California members who initiated an oral azole antifungal in an outpatient setting during 2004-2010. We determined development of: (1) liver aminotransferases >200 U/L, (2) severe acute liver injury (coagulopathy with hyperbilirubinemia), and (3) acute liver failure. We calculated incidence rates of endpoints. Cox regression was used to determine whether chronic liver disease was a risk factor for outcomes. RESULTS Among 195,334 azole initiators (178,879 fluconazole; 14,296 ketoconazole; 1653 itraconazole; 478 voriconazole; 28 posaconazole), incidence rates (events/1000 person-years [95% confidence intervals (CIs)]) of liver aminotransferases >200 U/L were similarly low with fluconazole (13.0 [11.4-14.6]), ketoconazole (19.3 [13.8-26.3]), and itraconazole (24.5 [10.6-48.2]). Rates were higher with voriconazole (181.9 [112.6-278.0]) and posaconazole (191.1 [23.1-690.4]), but comparable. Severe acute liver injury was uncommon with fluconazole (2.0 [1.4-2.7]), ketoconazole (2.9 [1.1-6.3]), and itraconazole (0.0 [0.0-11.2]), but more frequent with voriconazole (16.7 [2.0-60.2]) and posaconazole (93.4 [2.4-520.6]). One patient developed acute liver failure due to ketoconazole. Pre-existing chronic liver disease increased risks of aminotransferases >200 U/L (hazard ratio 4.68 [95% CI, 3.68-5.94]) and severe acute liver injury (hazard ratio 5.62 [95% CI, 2.56-12.35]). CONCLUSIONS Rates of acute liver injury were similarly low for fluconazole, ketoconazole, and itraconazole. Events were more common among voriconazole and posaconazole users but were comparable. Pre-existing chronic liver disease increased risk of azole-induced liver injury.
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Affiliation(s)
- Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
| | - Dena M Carbonari
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - James D Lewis
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kimberly A Forde
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David S Goldberg
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - K Rajender Reddy
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kevin Haynes
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jason A Roy
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Daohang Sha
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Amy R Marks
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Brian L Strom
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Rutgers Biomedical and Health Sciences, Rutgers, the State University of New Jersey, Newark
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland
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Banankhah PS, Garnick KA, Greenblatt DJ. Ketoconazole-Associated Liver Injury in Drug-Drug Interaction Studies in Healthy Volunteers. J Clin Pharmacol 2016; 56:1196-202. [DOI: 10.1002/jcph.711] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/21/2016] [Accepted: 01/22/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Peymaan S. Banankhah
- Master of Science in Biomedical Sciences Program; Tufts University School of Medicine; Boston Massachusetts USA
| | - Kyle A. Garnick
- Graduate Programs in Pharmacology and Drug Development and in Pharmacology and Experimental Therapeutics; Sackler School of Graduate Biomedical Science; Tufts University School of Medicine; Boston Massachusetts USA
| | - David J. Greenblatt
- Master of Science in Biomedical Sciences Program; Tufts University School of Medicine; Boston Massachusetts USA
- Graduate Programs in Pharmacology and Drug Development and in Pharmacology and Experimental Therapeutics; Sackler School of Graduate Biomedical Science; Tufts University School of Medicine; Boston Massachusetts USA
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49
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Greenblatt DJ. Evidence-based choice of ritonavir as index CYP3A inhibitor in drug-drug interaction studies. J Clin Pharmacol 2015; 56:152-6. [PMID: 26239522 DOI: 10.1002/jcph.609] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 07/31/2015] [Indexed: 12/23/2022]
Affiliation(s)
- David J Greenblatt
- Program in Pharmacology and Experimental Therapeutics, Tufts University School of Medicine and Tufts Medical Center, Boston, MA, USA
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