Application of bootstrap f2 to dissolution data from biorelevant media and evidence of the conservative nature of bootstrap f2

f2 with or without bootstrapping is the most common method to compare in vitro dissolution profiles, but methods to compare dissolution profiles have become less harmonized. The objective was to compare outcomes from bootstrap f2 and f2 (i.e. not-bootstrapped f2) using a large set of in vitro dissolution data. Non-parametric bootstrapping was performed on the 104 profile comparisons that did not meet the percent coefficient of variation (CV%) criteria to use average dissolution data. Bootstrap f2 was taken as the lower 90 % confidence interval of bootstrapped samples. There was concordance between bootstrap f2 and f2 in 92 of the 104 comparisons (88 %). There were no false positives. However, 12 % were false negative. Inspection of these discordance pairs suggests that bootstrap f2 serves as a conservative approach to assess profile similarity, particularly when a value of 50 is being used as decision criteria.

Interaction of the antifungal ketoconazole and its diphenylphosphine derivatives with lipid bilayers: Insights into their antifungal action

Ketoconazole (Ke) is an important antifungal drug, and two of its diphenylphosphinemethyl derivatives (KeP: Ph2PCH2-Ke and KeOP: Ph2P(O)CH2-Ke) have shown improved antifungal activity, namely against a yeast strain lacking ergosterol, suggesting alternative modes of action for azole compounds. In this context, the interactions of these compounds with a model of the cell membrane were investigated, using POPC (1-palmitoyl-2-oleoyl-sn-glycero-3-phosphocholine) large unilamellar vesicles and taking advantage of the intrinsic fluorescence of Ke, KeP and KeOP. Steady-state fluorescence spectra and anisotropy, including partition and aggregation studies, as well as fluorescence lifetime measurements, were carried out. In addition, the ability of the compounds to increase membrane permeability was assessed through carboxyfluorescein leakage. The membrane/water mole fraction partition coefficients (Kp,x): (3.31 ± 0.36) x105, (8.31 ± 1.60) x105 and (4.66 ± 0.72) x106, for Ke, KeP and KeOP, respectively, show that all three compounds have moderate to high affinity for the lipid bilayer. Moreover, KeP, and particularly KeOP interact more efficiently with POPC bilayers than Ke, which correlates well with their in vitro antifungal activity. Furthermore, although the three compounds disturb the lipid bilayer, KeOP is the quickest and most efficient one. Hence, the higher affinity and ability to permeabilize the membrane of KeOP when compared to that of KeP, despite the higher lipophilicity of the latter, points to an important role of Ph2P(O)CH2- oxygen. Overall, this work suggests that membrane interactions are important for the antifungal activity of these azoles and should be considered in the design of new therapeutic agents.

Preparation, characterization, and evaluation of ketoconazole-loaded pineapple cellulose green nanofiber gel

The present study involves the isolation of cellulose nanofibers from pineapple crown waste by a combined alkali-acid treatment method. The extracted pineapple nanofibers were characterized by Fourier-transform infrared spectroscopy, differential scanning calorimetry, X-ray diffraction, scanning electron microscopy, nuclear magnetic resonance, high-resolution transmission electron microscopy, and dynamic light scattering. The extracted pineapple nanofibers were then incorporated in Carbopol 934P containing ketoconazole to prepare a ketoconazole-loaded pineapple nanofibrous gel. The prepared gel formulation was evaluated for viscosity, spreadability, extrudibility, pH, drug content, and texture profile analysis. The anticipated gel formulation was further evaluated by in vitro drug release (98.57 ± 0.58 %), ex vivo drug permeation, cytotoxicity, and histopathological studies. The permeation of the drug through skin determined by the ex-vivo diffusion study was found to be 38.27 % with a flux rate of 4.06 ± 0.26 μg/cm2/h. Further, the cytotoxicity study of pineapple nanofiber and ketoconazole-loaded nanofiber gel displayed no cytotoxic on healthy vero cells in the concentration range from 10 to 80 μg/ml. The histopathological analysis exhibited no signs of distress and inflammation. In conclusion, ketoconazole-loaded pineapple nanofiber gel could be considered as a promising delivery system for topical applications.

Across-species benefits of adrenalectomy on congenital generalized lipoatrophic diabetes: a review

Two adrenalectomies py -45erformed fourteen years apart notoriously alleviated insulin resistance in a female teenager with Congenital Generalized Lipoatrophy (CGL, 1988) and in a murine model of CGL (2002). Following a successful therapeutic trial with anti-glucocorticoids, we performed the first surgical procedure on an 18-year-old girl. Before surgery, the anti-glucocorticoid therapy produced a rapid and striking drop in fasting serum insulin levels (from over 400 to 7.0 mU/L) and a slower -but impressive- fall in fasting serum triglycerides from 7,400 to 220-230 mg/dL. In contrast, fasting serum glucose levels dropped more slowly, from 225-290 to 121-138 mg/dL. Two weeks following total adrenalectomy, the fasting serum glucose level was 98 mg/dL, with a corresponding serum insulin level of 10 mU/L. During an Oral Glucose Tolerance Test, the 2-hour serum glucose was 210 mg/dL, and serum insulin values during the test did not exceed 53 mU/L. In 2002, the A-ZIP/F1 hypoleptinemic mouse had its adrenal glands removed. Even though this CGL model does not respond well to leptin replacement, an infusion of recombinant leptin reduced the characteristic hypercorticosteronemia of this murine model of CGL. Adrenalectomy in this transgenic mouse improved insulin sensitivity in the liver and muscle. In summary, adrenalectomy -in both a human and a mouse case of CGL- limited adipose tissue exposure to corticosteroid action and led to a notorious metabolic improvement. On a broader scenario, given that leptin restrains the adrenal axis, the reduced leptin activity of the leptin resistance displayed by obese subjects should lead to adrenal axis overactivity. This overactivity should result in elevated serum levels of free cortisol, free fatty acids, and glycerol. In this manner, leptin resistance should lead to peripheral (adipose tissue, liver, and muscle) insulin resistance and islet beta-cell apoptosis, paving the way to Type 2 diabetes.

Pharmacological Treatment of Cushing's Syndrome

The 1st line treatment of Cushing's syndrome is surgery, whatever the aetiology. The role of pharmacological treatment is clear in cases where surgery fails or is impossible, in cases of metastases, or while awaiting the delayed effects of radiotherapy. However, certain situations remain controversial, in particular the possible role of pharmacological treatment as a preparation for surgery. This situation must be divided into 2 parts, severe hypercortisolism with immediate vital risk and non-severe hypercortisolism with diagnostic delay. The initiation and adjustment of treatment doses is also controversial, with the possibility of titration by gradual dose increase based on biological markers, or a more radical "block and replace" approach in which the ultimate goal is to achieve hypocortisolism, which can then be supplemented. Each of these approaches has its advantages and drawbacks and should probably be reserved for different patient profiles depending on the severity of hypercortisolism. In this review, we will focus specifically on these 2 points, namely the potential role of preoperative pharmacological treatment and, more generally, the optimal way to initiate and monitor drug treatment to ensure that eucortisolism or hypocortisolism is achieved. We will define for each part which profiles of patients should be the most adapted to try to give advice on the optimal management of patients with hypercortisolism.

seed kernel oil as pharmaceutical oil base: Physicochemical characterization and ketoconazole soap formulation

Ziziphus mauritiana Lam. (Rhamnaceae) is a large spiny shrub or small tree, native to the Indian subcontinent that can reach a maximum height of 9-15 m. This plant stands as a renowned tropical fruit variety, commonly recognized as the Indian plum, Desert apple, or Indian Jujube. The objective of this study was to examine the standard physicochemical parameters of Z. mauritiana seed kernel oil and to formulate the ketoconazole soap (2 % w/w), using the obtained oil, as a base. The oil was obtained through hexane extraction from the seed kernels. To formulate pharmaceutical ketoconazole soap, Z. mauritiana seed kernel oil was subjected to a basic saponification reaction using potassium hydroxide. All the examined physicochemical parameters, namely acid value (4.71 mg KOH/g), saponification value (229.18 mg KOH/g), peroxide value (4.15 milliequivalents KOH/g), ester value (224.47 mg KOH/g), iodine value (11.19 mg KOH/g), refractive index (1.448), pH (5.93), viscosity (89 cP), and specific gravity (0.912 g/mL) were within the acceptable range for industrial purposes. The examination of quality control parameters, namely drug content (99.49 %), total fatty matter (71.13 %), foam retention time (17.21 min), foam height (18.56 cm), moisture content (9.14 %), and pH (7.16) indicated that the newly formulated ketoconazole soap complied with the acceptable limits. In summary, our research demonstrated the excellent physicochemical stability of Z. mauritiana seed kernel oil and its suitability as a soap base, supporting its promising prospects for cost-effective production of cosmetics, soaps, and shampoos in the pharmaceutical and cosmeceutical industries, reducing reliance on synthetic bases.

The pipeline for drugs for control and elimination of neglected tropical diseases: 2. Oral anti-infective drugs and drug combinations for off-label use

In its 'Road map for neglected tropical diseases 2021-2030', the World Health Organization outlined its targets for control and elimination of neglected tropical diseases (NTDs) and research needed to achieve them. For many NTDs, this includes research for new treatment options for case management and/or preventive chemotherapy. Our review of small-molecule anti-infective drugs recently approved by a stringent regulatory authority (SRA) or in at least Phase 2 clinical development for regulatory approval showed that this pipeline cannot deliver all new treatments needed. WHO guidelines and country policies show that drugs may be recommended for control and elimination for NTDs for which they are not SRA approved (i.e. for 'off-label' use) if efficacy and safety data for the relevant NTD are considered sufficient by WHO and country authorities. Here, we are providing an overview of clinical research in the past 10 years evaluating the anti-infective efficacy of oral small-molecule drugs for NTD(s) for which they are neither SRA approved, nor included in current WHO strategies nor, considering the research sponsors, likely to be registered with a SRA for that NTD, if found to be effective and safe. No such research has been done for yaws, guinea worm, Trypanosoma brucei gambiense human African trypanosomiasis (HAT), rabies, trachoma, visceral leishmaniasis, mycetoma, T. b. rhodesiense HAT, echinococcosis, taeniasis/cysticercosis or scabies. Oral drugs evaluated include sparfloxacin and acedapsone for leprosy; rifampicin, rifapentin and moxifloxacin for onchocerciasis; imatinib and levamisole for loiasis; itraconazole, fluconazole, ketoconazole, posaconazole, ravuconazole and disulfiram for Chagas disease, doxycycline and rifampicin for lymphatic filariasis; arterolane, piperaquine, artesunate, artemether, lumefantrine and mefloquine for schistosomiasis; ivermectin, tribendimidine, pyrantel, oxantel and nitazoxanide for soil-transmitted helminths including strongyloidiasis; chloroquine, ivermectin, balapiravir, ribavirin, celgosivir, UV-4B, ivermectin and doxycycline for dengue; streptomycin, amoxicillin, clavulanate for Buruli ulcer; fluconazole and isavuconazonium for mycoses; clarithromycin and dapsone for cutaneous leishmaniasis; and tribendimidine, albendazole, mebendazole and nitazoxanide for foodborne trematodiasis. Additional paths to identification of new treatment options are needed. One promising path is exploitation of the worldwide experience with 'off-label' treatment of diseases with insufficient treatment options as pursued by the 'CURE ID' initiative.

CYP51-mediated cholesterol biosynthesis is required for the proliferation of CD4+ T cells in Sjogren's syndrome

CYtochrome P450, family 51 (CYP51) is an important enzyme for de novo cholesterol synthesis in mammalian cells. In the present study, we found that the expression of CYP51 positively correlated with CD4+ T cell activation both in vivo and in vitro. The addition of ketoconazole, a pharmacological inhibitor of CYP51, prevented the proliferation and activation of anti-CD3/CD28-expanded mouse CD4+ T cells in a dose-dependent fashion. Liquid chromatography-tandem mass spectrometry indicated an increase in levels of lanosterol in T cells treated with ketoconazole during activation. Ketoconazole-induced blockade of the cholesterol synthesis pathway also caused Sterol regulatory element binding protein 2 (SREBP2) activation in CD4+ T cells. Additionally, ketoconazole treatment elicited an integrated stress response in T cells that up-regulated activating transcription factor 4 (ATF4) and DNA-damage inducible transcript 3 (DDIT3/CHOP) at the translational level. Furthermore, treatment with ketoconazole significantly decreased the amount of CD4+ T cells infiltrating lesions in the submandibular glands of NOD/Ltj mice. In summary, our results suggest that CYP51 plays an essential role in the proliferation and survival of CD4+ T cells, which makes ketoconazole an inhibitor of CD4+ T cell proliferation and of the SS-like autoimmune response through regulating the biosynthesis of cholesterol and inducing the integrated stress response.

Silver(I) complexes containing N-heterocyclic carbene azole drugs: Synthesis, characterization, cytotoxic activity, and their BSA interactions

Cancer is one of the main public health problems globally, there is a public demand for better drugs. Rational strategies or approaches are used to improve the success of drug discovery. Our strategy was to the repurposing of well-known antifungal agents as potential anticancer drugs, such as Clotrimazole (CTZ) and Ketoconazole (KTZ). We prepared the respective iodide imidazolium salt L1: (CTZ-Me)I and L2: (KTZ-Me)I to be the intermediates toward the synthesis of its respective NHC ligand and achieve the respective silver(I)-monoNHC and silver(I)-bisNHC derivatives: [Ag(L1)I] (1), [AgI(L2)] (2) [Ag(L1)2]I. (3), [Ag(L2)2]I. (4), as well as their corresponding coordination compounds [Ag(CTZ)2]NO3 (5) and [Ag(KTZ)2]NO3 (6) where these ligands (CTZ and KTZ) coordinate to silver through the N-imidazole atom. These compounds (L1, L2 and complexes 1-6) exhibited significant activity against the tested cancer cell lines (B16-F1, murine melanoma strains and CT26WT, murine colon carcinoma). The silver(I) complexes were more active than the free ligands, complexes 2 and 4 being the most selective in B16-F1 cancer cell line. Two possibles biological targets such as DNA and albumin were examined for the observed anticancer activity. Results show that DNA is not the main target, however, the interactions with albumin suggest it can transport/delivery the metal complexes.

Antifungal medicines in the terrestrial environment: Levels in biosolids from England and Wales

Antifungals are used widely in clinical and agricultural practice to control fungal growth, either treating or preventing infection. There are reports of increasing prevalence of resistance to antifungals in human pathogens and concern that their use in agriculture is driving clinical resistance in patients. While crop protection products are the most obvious source in agriculture, a further source may be biosolids from wastewater treatment. In the UK, these are applied to land to provide nutrients and improve soil structure for crops. In this study, biosolids from ten sites in England and one in Wales were analysed for clinical antifungals. Ketoconazole and miconazole were detected in all samples with a median concentration of 0.87 and 0.54 mg kg^-1 dry weight (DW), respectively. Clotrimazole was detected at seven of eleven sites at a median level of 1.32 mg kg^-1 DW and its absence at four others was considered treatment related. Two prescription-only and systemic medications, itraconazole and posaconazole, were frequently detected with median concentrations of 0.14 mg kg^-1 DW and 0.09 mg kg^-1 DW, respectively. The biosolid levels of itraconazole found in this study were two orders of magnitude higher than an indicative Predicted No Effect Concentration for resistance selection (PNEC-R) in soil. Neither fluconazole, griseofulvin, and voriconazole nor flucytosine and nystatin were found above the limit of detection of 0.01 or 0.1 mg kg^-1 as received, respectively. The findings show that biosolids represent a viable pathway for antifungal agents to reach soil.

Activity and safety of KEES - an oral multi-drug chemo-hormonal metronomic combination regimen in metastatic castration-resistant prostate cancer

BACKGROUND

Metastatic castration-resistant prostate cancer (mCRPC) remains a therapeutic challenge and evidence for late-line treatments in real-life is limited. The present study investigates the efficacy and safety of an oral metronomic chemo-hormonal regimen including cyclophosphamide, etoposide, estramustine, ketoconazole and prednisolone (KEES) administered in a consecutive biweekly schedule.

METHODS

A retrospective cohort study in two Swedish regions was conducted. Overall (OS) and progression-free survival (PFS), biochemical response rate (bRR) and toxicities were analyzed.

RESULTS

One hundred and twenty-three patients treated with KEES after initial treatment with at least a taxane or an androgen-receptor targeting agents (ARTA) were identified. Of those, 95 (77%) had received both agents and were the primary analysis population. Median (95% CI) OS and PFS in the pre-treated population were 12.3 (10.1-15.0) and 4.4 (3.8-5.5) months, respectively. Biochemical response, defined as ≥ 50% prostate-specific antigen (PSA) reduction, occurred in 26 patients (29%), and any PSA reduction in 59 (65%). PFS was independent of prior treatments used, and KEES seemed to be effective in late treatment lines. The bRR was higher compared to historical data of metronomic treatments in docetaxel and ARTA pre-treated populations. In multivariable analyses, performance status (PS) ≥ 2 and increasing alkaline phosphatase (ALP) predicted for worse OS. Nausea, fatigue, thromboembolic events and bone marrow suppression were the predominant toxicities.

CONCLUSIONS

KEES demonstrated meaningful efficacy in heavily pre-treated CRPC patients, especially those with PS 0-1 and lower baseline ALP, and had an acceptable toxicity profile.

Formulation and Development of Hyaluronic Acid based gel with Ketoconazole -Loaded Nanostructured Lipid Carriers in Fungal Infection

BACKGROUND

Ketoconazole is an imidazole ring containing antifungal agent used in the treatment of systemic fungal infections. It acts by blocking the synthesis of ergosterol, an essential component of the fungal cell membrane.

OBJECTIVE

The purpose of this work is to construct skin targeting ketoconazole nanostructured lipid carriers (NLCs) loaded hyaluronic acid (HA) modified gel to minimize side effects and provide a controlled release.

METHODS

The NLCs were prepared using emulsion sonication method and their optimized batches were characterized for X-ray diffraction, scanning electron microscopy and fourier transform infrared spectroscopy study. These batches were then incorporated into HA containing gel for convenient application. The final formulation was compared with the marketed formulation for studying its antifungal activity and drug diffusion.

RESULTS

Ketoconazole NLCs loaded hyaluronic acid formulation was successfully developed with desirable formulation parameters by using 23 Factorial design. In-vitro release study of developed formulation showed prolonged drug release (up to 5 hrs) while ex-vivo drug diffusion study on human cadaver skin showed better drug diffusion as compared with marketed formulation. Moreover, the release study and diffusion study results reflected the improvement of antifungal activity of the developed formulation against Candida albicans.

CONCLUSION

The work suggests that ketoconazole NLCs loaded HA modified gel provides prolonged release. The formulation also has good drug diffusion and antifungal activity and thus can act as a promising carrier for topical delivery of ketoconazole.

Open-label phase II clinical trial of ketoconazole as CYP17 inhibitor in metastatic or advanced non-resectable granulosa cell ovarian tumors: the GREKO (GRanulosa Et KetOconazole) trial, GETHI 2011-03

BACKGROUND

Granulosa cell ovarian tumor (GCT) is characterized by a pathognomonic mutation in the FOXL2 gene (402 C > G) that leads to an overactivation of steroidogenesis. CYP17 is a key enzyme in such process and can be inhibited by ketoconazole.

METHODS

We designed a phase II clinical trial to assess the efficacy of ketoconazole in advanced GCT and conducted several in vitro studies to support the clinical findings.

RESULTS

From October 1st 2012 to January 31st 2014, six evaluable patients were recruited in ten hospitals of the Spanish Group for Transversal Oncology and Research in Orphan and Infrequent Tumors" (GETTHI). FOXL2 (402C > G) mutation was confirmed in three; two cases were wild type and it could not be assessed in one. No objective response by RECIST was observed, but five cases achieved stable disease longer than 12 months. Median progression-free survival was 14.06 months (CI 95% 5.43-22.69) for the whole study population (3.38 and 13.47 months for wild-type cases and 14.06, 20.67 and 26.51 for those with confirmed FOXL2 mutation). Median overall survival was 22·99 months (CI 95% 8.99-36.99). In vitro assays confirmed the activity of ketoconazole in this tumor and suggested potential synergisms with other hormone therapies.

CONCLUSION

Ketoconazole has shown activity in advanced GCT in clinical and in vitro studies. Based on these data, an orphan designation was granted by the European Medicines Agency for ketoconazole in GCT (EU/3/17/1857).

CLINICALTRIALS

GOV IDENTIFIER

NCT01584297.

Cushing's disease: adrenal steroidogenesis inhibitors

Cushing's disease (CD), caused by an adrenocorticotropic hormone (ACTH)-secreting pituitary tumor, is the most common form of Cushing's syndrome (CS), accounting for approximately 70% of cases. CD requires a prompt diagnosis, an adequate treatment selection, and long-term management to limit hypercortisolism duration and long-term complications and improve patient outcomes. Pituitary surgery is the first-line option, which is non-curative in one third of patients, therefore requiring additional treatments. Medical therapy has recently acquired an emerging role, with the availability of several drugs with different therapeutic targets, efficacy and safety profiles. The current review focuses on efficacy and safety of steroidogenesis inhibitors, and particularly the historical drugs, ketoconazole and metyrapone, and the novel drugs levoketoconazole and osilodrostat, which seem to offer a rapid, sustained, and effective disease control. Ketoconazole should be preferred in females and in patients without severe liver disease; levoketoconazole may offer an alternative to classical ketoconazole, appearing characterized by a higher potency and potential lower hepatotoxicity compared to ketoconazole. Metyrapone should be preferred in males and in patients without severe or uncontrolled hypokalemia. Both ketoconazole and metyrapone may be preferred for short-term more than for long-term treatment. Osilodrostat may represent the best choice for long-term treatment, in patients with poor compliance to the multiple daily administration schedule, and in patients without severe or uncontrolled hypokalemia. Steroidogenesis inhibitors may be used alone or in combination, and associated with pituitary directed drugs, to improve the efficacy of the single drugs, allowing a potential use of lower doses for each drug, and hypothetically reducing the rate of adverse events associated with the single drugs. Clinicians may tailor medical therapy on the specific clinical scenario, considering disease history together with patients' characteristics and hypercortisolism's degree, addressing the needs of each patient in order to improve the therapeutic outcome and to reduce the burden of illness, particularly in patients with persistent or recurrent CD.

Cushing's disease: role of preoperative and primary medical therapy

Transsphenoidal surgery is the first-line treatment for Cushing's disease. However, some situations may require the use of a primary medical treatment, such as in patients with severe life-threatening hypercortisolism, a situation which can be handled by fast-acting steroidogenesis inhibitors, instead of classical bilateral adrenalectomy. Primary medical treatment could also be considered in patients with non-severe hypercortisolism, but the evidence is far less convincing for its systematic use. The aim of this short review is to explain briefly the different circumstances in which primary medical therapy could be considered, the limits of this approach, and the way in which to initiate and monitor the treatment.

Distinct effects of form selective cytochrome P450 inhibitors on cytochrome P450-mediated monooxygenase and hydrogen peroxide generating NADPH oxidase

A characteristic of cytochrome P450 (CYP) enzymes is their ability to generate H₂O₂, either directly or indirectly via superoxide anion, a reaction referred to as "NADPH oxidase" activity. H₂O₂ production by CYPs can lead to the accumulation of cytotoxic reactive oxygen species which can compromise cellular functioning and contribute to tissue injury. Herein we determined if form selective CYP inhibitors could distinguish between the activities of the monooxygenase and NADPH oxidase activities of rat recombinant CYP1A2, CYP2E1, CYP3A1 and CYP3A2 and CYP1A1/2-enriched β-naphthoflavone-induced rat liver microsomes, CYP2E1-enriched isoniazide-induced rat liver microsomes and CYP3A subfamily-enriched dexamethasone-induced rat liver microsomes. In the presence of 7,8-benzoflavone (2.0 μM) for CYP1A2 and 4-methylpyrazole (32 μM) or DMSO (16 mM) for CYP2E1, monooxygenase activity was blocked without affecting NADPH oxidase activity for both the recombinant enzymes and microsomal preparations. Ketoconazole (1.0 μM), a form selective inhibitor for CYP3A subfamily enzymes, completely inhibited monooxygenase activity of rat recombinant CYP3A1/3A2 and CYP3A subfamily in rat liver microsomes; it also partially inhibited NADPH oxidase activity. 7,8-benzoflavone is a type I ligand, which competes with substrate binding, while 4-methylpyrazole and DMSO are type II heme binding ligands. Interactions of heme with these type II ligands was not sufficient to interfere with oxygen activation, which is required for NADPH oxidase activity. Ketoconazole, a type II ligand known to bind multiple sites on CYP3A subfamily enzymes in close proximity to heme, also interfered, at least in part, with oxygen activation. These data indicate that form specific inhibitors can be used to distinguish between monooxygenase reactions and H₂O₂ generating NADPH oxidase of CYP1A2 and CYP2E1. Mechanisms by which ketoconazole inhibits CYP3A NADPH oxidase remain to be determined.

Functionalized PEG-PLA nanoparticles for brain targeted delivery of ketoconazole contribute to pregnane X receptor overexpressing in drug-resistant epilepsy

OBJECTIVE

To develop a functionalized PEG-PLA nanoparticle system containing ketoconazole (KCZ) to overcome the overactivity of pregnane X receptor (PXR) for the treatment of drug-resistant epilepsy (DRE).

SIGNIFICANCE

KCZ was developed as a therapy strategy for DRE limited by its lethal hepatotoxicity and minute brain concentration. KCZ-incorporated nanoparticles modified with angiopep-2 (NPs/KCZ) could reduce adverse effects of KCZ and achieve epileptic foci-targeted drug delivery.

METHODS

NPs/KCZ was prepared by thin-film hydration method and characterized in vitro and in vivo. The efficacy evaluation of NPs/KCZ was evaluated in a kainic acid (KA)-induced mice model of epilepsy with carbamazepine (CBZ) treatment.

RESULTS

The mean particle size and Zeta potential of NPs/KCZ were 17.84 ± 0.33 nm and - 2.28 ± 0.12 mV, respectively. The drug-loading (DL%) of KCZ in nanoparticles was 8.96 ± 0.12 % and the entrapment efficiency (EE%) was 98.56 ± 0.02 %. The critical value of critical micelle concentration was 10^-3.3 mg/ml. No obvious cytotoxicity was found in vitro. The behavioral and electrographic seizure activities were obviously attenuated in NPs/KCZ+CBZ group. The CBZ concentration of brain tissues in mice treated with NPs/KCZ+CBZ was significantly increased than those treated with CBZ alone (P = 0.0028). A significantly decreased expression level of PXR and its downstream proteins was observed in NPs/KCZ+CBZ group compared with that in the control and CBZ group (All P < 0.05).

CONCLUSION

Our results showed that NPs/KCZ achieved the epileptic foci-targeted delivery of KCZ and ameliorated the efficacy of CBZ on DRE by attenuating the overactivity of PXR.

Molecular exploration of hidden pleiotropic activities of azoles on dermatophytes in human tinea corporis infection

Dermatophyte infections are widespread worldwide and are the most prevalent cause of fungal infection of the skin, hair, and nails. Tinea corporis is most commonly caused by dermatophytes belonging to three genera: Trichophyton , Microsporum , and Epidermophyton. The disease may be acquired through person-to-person transmission, typically by direct communication with an infected individual. Since dermatophytes causing tinea corporis infection are restricted to superficial keratinized tissue, topical treatments are most effective in patients with naïve tinea corporis unless the disease is widespread. Dermatophyte adherence to a keratinized structure is an essential step in dermatophytosis pathogenesis, whereby proteolytic enzyme activity is converted into a particular keratolytic activity that encourages the dermatophyte to use keratin as the sole source of carbon. Despite increasing dermatophytosis worldwide, particularly in the tropics, this research has often been neglected, appears to predominate globally, and presents practitioners with a therapeutic challenge. However, experts supported the use of allylamines in the pleiotropic molecular exploration of azoles, including reactive oxygen species (ROS) inducer, anti-inflammatory, antibacterial, and wide-spectrum antimycotic effects. Therefore, the current review aims to update and reform this essential subject and illustrate the recent advancement of the hidden pleiotropic activity of azoles at the molecular level on dermatophytes in human tinea corporis infection.

Xanthan and alginate-matrix used as transdermal delivery carrier for piroxicam and ketoconazole

This study presents new drug delivery systems based on xanthan, unmodified or modified by esterification with oleic acid, and alginate for controlled release of bioactive substances with anti-inflammatory (piroxicam) and antifungal properties (ketoconazole). The mechanical properties of the developed drug carriers showed that their compressive strength was affected by the encapsulation of the bioactive principles. When ketoconazole was added into the xanthan/alginate matrix, an increment in the mechanical strength was recorded (66.68% compression). The release of the active principles from the materials was best described by the Korsmeyer-Peppas model, with non-Fickian or Fickian diffusion (the values of the exponent of release are between 0.29 and 0.75), depending on the composition of the polymeric matrix. The release rate constant presents smaller values for the materials based on chemically modified xanthan (between 0.89 and 20.11) as compared with materials based on the unmodified form (between 4.27 and 25.00). All materials were characterized by Fourier Transform Infrared Spectroscopy (FTIR) and Scanning Electron Microscopy (SEM). The designed systems prove to have antimicrobial and anti-inflammatory activity. The findings make prone these biomaterials for the manufacture of transdermal drug delivery systems.

Oxysterols profiles in zebrafish (Danio rerio) embryos exposed to bisphenol A

INTRODUCTION

Oxysterols are cholesterol oxidation products and bioactive lipids involved in developmental signaling pathways, embryonic and postembryonic tissue patterning and homeostasis. The embryonic period is a very sensitive window of exposure to bisphenol A (BPA), hence the role of BPA on the levels of oxysterols in the very early stages of zebrafish embryogenesis is a relevant novel field of investigation.

OBJECTIVES

To compare the role of BPA on oxysterols levels in zebrafish embryos at 8 and 24 hours post fertilization (hpf) with cytochromes P450 (CYPs)-modulating chemicals (carbamazepine, ketoconazole, and hydrogen peroxide).

METHODS

Upon a dose range finding, zebrafish embryos were exposed to environmentally relevant (0.04μM) and toxicological (17.5 μM) BPA concentrations. Seven oxysterols were profiled by high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS).

RESULTS

Similarly to the CYPs-modulating chemicals, BPA caused: i) no significant changes at 8 hpf and ii) a dose-dependent increase of total oxysterols at 24 hpf, with 27-hydroxycholesterol as the most regulated oxysterol.

DISCUSSION

In the first day post-fertilization of the zebrafish embryos, the role of BPA alike a CYPs-modulating chemical was confirmed by the similar oxysterol changes observed with the already known CYPs-modulating chemicals.

Pharmacological assessment of the heartwood of Acacia raddiana Willd for antifungal potential

As COVID-19 suppresses the immune system and those who have recovered from COVID-19 are at risk of developing mucormycosis or black fungus so there is a need to develop new antifungal strategies by the use of medicinal plants. Medicinal plants have always been a subject of interest for drug discovery, ethno-botany, traditional and indigenous medicines. One of the successful strategies for the investigation of new bioactive compounds from medicinal plants includes the screening of plant extract, fractions followed by the purification of the constituents and screening for biological activity. In the present study, the heartwood of desert plant Acacia raddiana Willd was screened for antifungal activity by Agar-well diffusion method against Aspergillus flavus, Aspergillus niger, Candida albicans, Penicillium chrysogenum and Trichophyton rubrum. The result obtained shows that heartwood extract and their fractions serve as an effective agent against selected fungi and efficiency is dependent upon the nature of fraction and vary with respect to specific fungi. The extract and fractions shows a wide antifungal potential against C. albicans. The findings suggest that the medicinal plant under investigation might be a reasonable solution for fungal infections especially against C. albicans.

In vitro selection of ketoconazole-pentamidine-resistant Leishmania (Viannia) braziliensis strains

The use of ketoconazole (KTZ) plus pentamidine (PMD) could be an interesting treatment option for New World cutaneous leishmaniasis. The aim of this work was to generate KTZ- and PMD-resistant strains and to determine some characteristics of the selection process and the resulting parasites. Resistance to one or two drugs was selected on promastigotes by progressively increasing drug concentrations for eleven months. The resistance levels (IC₅₀) to one or two drugs (synergism assay) were determined using a colorimetric resazurin methodology. The stability of the resistance phenotype (without drug pressure or after mouse passage), cross resistance with paromomycin and miltefosine, and resistance transference to intracellular amastigotes were determined. In addition, some parasite attributes compared with WT, such as growth kinetics, amastigogenesis, THP-1 cells, and mouse infection, were determined. Promastigotes resistant to KTZ or PMD were obtained three times earlier than the combined KTZ + PMD-resistant strains. Resistant parasites (promastigotes and intracellular amastigotes) were three to twelve times less susceptible to KTZ and PMD than WT parasites. The resistance phenotype on parasites was unstable, and no cross resistance was observed. Similar parasite fitness related to our evaluated characteristics was observed except for in vivo infection, where a delay of the onset of cutaneous lesions was observed after KTZ + PMD-resistant parasite infection. CONCLUSION: Combined treatment with KTZ and PMD delayed the onset of parasite resistance and was more effective in vitro than each drug separately for WT and all resistant strains. Parasites resistant to KTZ and PMD acquired similar in vitro behaviour to WT parasites, were less virulent to mice and maintained their resistance phenotype on intracellular amastigotes but not without drug pressure or after mouse infection.

A supramolecular thermosensitive gel of ketoconazole for ocular applications: In silico, in vitro, and ex vivo studies

The incidence of corneal fungal infections continues to be a growing concern worldwide. Ocular delivery of anti-fungal drugs is challenging due to the anatomical and physiological barriers of the eye. The ocular bioavailability of ketoconazole (KTZ), a widely prescribed antifungal agent, is hampered by its limited aqueous solubility and permeation. In the study, the physicochemical properties of KTZ were improved by complexation with sulfobutylether-β-cyclodextrin (SBE-β-CD).KTZ-SBE-β-CD complex was studied in silico with docking and dynamics simulations, followed by wet-lab experiments.The optimized KTZ-SBE-β-CD complex was loaded into a thermosensitivein situ gel to increase corneal bioavailability. The supramolecular complex increased the solubility of KTZ by 5-folds and exhibited a 10-fold increment in drug release compared to the pure KTZ. Owing to the diffusion, thein situ gel exhibited a more sustained drug release profile. Theex vivocorneal permeation studies showed higher permeation from KTZ-SBE-β-CD in situ gel (flux of ∼19.11 µg/cm²/h) than KTZin situ gel (flux of ∼1.17 µg/cm²/h). The cytotoxicity assays and the hen's egg chorioallantoic membrane assay (HET-CAM) confirmed the formulations' safety and non-irritancy. In silico guided design of KTZ-SBE-β-CD inclusion complexes successfully modified the physicochemical properties of KTZ. In addition, the loading of the KTZ-SBE-β-CD complex into an in situ gel significantly increased the precorneal retention and permeation of KTZ, indicating that the developed formulation is a viable modality to treat fungal keratitis.

Predicting the Drug-Drug Interaction Mediated by CYP3A4 Inhibition: Method Development and Performance Evaluation

The prediction of drug-drug interactions (DDIs) plays critical roles for the estimation of DDI risk caused by inhibition of CYP3A4. The aim of this paper is to develop a physiologically based pharmacokinetic (PBPK)-DDI model for prediction of the DDI co-administrated with ketoconazole in humans and evaluate the predictive performance of the model. The pharmacokinetic and biopharmaceutical properties of 35 approved drugs, as victims, were collected for the development of a PBPK model, which were linked to the PBPK model of ketoconazole for the DDI prediction. The PBPK model of victims and ketoconazole were validated by matching actual in vivo pharmacokinetic data. The predicted results of DDI were compared with actual data to evaluate the predictive performance. The percentage of predicted ratio of AUC (AUCR), C_max (C_maxR), and T_max (T_maxR) was 75%, 69%, and 91%, respectively, which were within the twofold threshold (range, 0.5-2.0×) of the observed values. Only 3% of the predicted AUCRs are obviously underestimated. After integration of the reported fraction of metabolism (f_m) into the PBPK-DDI model for limited four cases, the model-predicted AUCRs were improved from the twofold range of the observed AUCRs to the 90% confidence interval. The developed method could reasonably predict drug-drug interaction with a low risk of underestimation. The present accuracy of the prediction was improved compared with that of static mechanistic models. The evaluation of predictive performance increases the confidence using the model to evaluate the risk of DDIs co-administrated with ketoconazole before the in vivo DDI study.

Functional evaluation of vandetanib metabolism by CYP3A4 variants and potential drug interactions in vitro

AIM

To investigate the enzymatic properties of cytochrome P450 3A4 (CYP3A4) variants and their ability to metabolize vandetanib (VNT) in vitro, and to study potential drug interactions in combination with VNT.

METHOD

Recombinant CYP3A4 cell microsomes were prepared using a Bac-to-Bac baculovirus expression system. Enzymatic reactions were carried out, and the metabolites were determined by ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS).

RESULTS

The activities of 27 CYP3A4 variants were determined to assess the degree of VNT metabolism that occurred. Analysis indicated that there was enhanced intrinsic clearance (V_max/K_m, CLint) for eight variants (CYP3A4.2, 3, 9, 15, 16, 29, 32, and 33), while there was a significant decrease in CYP3A4.5, 7, 8, 10-14, 17-20, 23, 24, 28, 31, and 34. Compared with CYP3A4.1, no significant differences were found for CYP3A4.6 and 30. Furthermore, the relative clearances were compared between VNT and cabozantinib, which were all metabolized by CYP3A4 with the same indications. When combined with ketoconazole, which is a CYP inhibitor, obvious differences were observed in the potency of VNT between different variants, including CYP3A4.2, 15, and 18.

CONCLUSION

This comprehensive assessment of CYP3A4 variants provides significant insights into the allele-specific metabolism of VNT and drug interactions in vitro. We hope that these comprehensive data will provide references and predictions for the clinical application of VNT.

Does the circulating ketoconazole metabolite N-deacetyl ketoconazole contribute to the drug-drug interaction potential of the parent compound?

Ketoconazole is a strong inhibitor of cytochrome P450 3A4 (CYP3A4) and of P-glycoprotein (P-gp) and is often used as an index inhibitor especially for CYP3A4-mediated drug metabolism. A preliminary physiologically based pharmacokinetic (PBPK) model for drug-drug interactions indicated possible involvement of a metabolite to the perpetrator potential of ketoconazole. Still unknown for humans, in rodents, N-deacetyl ketoconazole (DAK) has been identified as the major ketoconazole metabolite. We therefore investigated in vitro, whether DAK also inhibits the human CYPs and drug transporters targeted by ketoconazole and quantified DAK in human plasma from healthy volunteers after receiving a single oral dose of 400 mg ketoconazole. Our data demonstrated that DAK also inhibits CYP3A4 (2.4-fold less potent than ketoconazole), CYP2D6 (13-fold more potent than ketoconazole), CYP2C19 (equally potent), P-gp (3.4-fold less potent than ketoconazole), breast cancer resistance protein (more potent than ketoconazole) and organic anion transporting polypeptide 1B1 and 1B3 (7.8-fold and 2.6-fold less potent than ketoconazole). After a single oral dose of 400 mg ketoconazole, maximum concentrations of DAK in human plasma were only 3.1 ‰ of the parent compound. However, assuming that DAK also highly accumulates in the human liver as demonstrated for rodents, inhibition of the proteins investigated could also be conceivable in vivo. In conclusion, DAK inhibits several CYPs and drug transporters, which might contribute to the perpetrator potential of ketoconazole.

[Effects of ketoconazole on physiological function of liver and testis in mice]

Objective: To investigate the effects of different doses of ketoconazole (KCZ) on the physiological functions of the liver and testis in Kunming mice. Methods: Forty male Kunming mice were randomly divided into four groups (n=10): normal group, KCZ low-dose group (30 mg/kg), medium-dose group (50 mg/kg), and high-dose group (70 mg/kg). The mice in the drug groups were injected subcutaneously (0.1 ml/10 g) with the corresponding dose of KCZ once a day, and the concentrations of KCZ in the KCZ low, middle, and high dose groups were 3 mg/ml, 5 mg/ml and 7 mg/ml respectively, and the normal group was injected with the same amount of normal saline for 3 weeks. The activities of aspartate transaminase (AST) and alanine aminotransferase (ALT) in serum, and γ-glutamyl transpeptidase (γ-GT), lactate dehydrogenase (LDH) and acid phosphatase (ACP) in testicular tissue were measured. HE staining was used to observe the pathological changes of the liver and testis. Results: Compared with the normal group, the activities of AST and ALT were increased significantly (P＜0.01), and the activities of γ-GT, ACP and LDH were decreased markedly in KCZ groups (P＜0.01). KCZ could affect the above indexes in a dose-dependent manner. HE staining showed that the hepatocytes were denatured, arranged loosely, and the cytoplasm was light in color. The lumen of the seminiferous tubules of the testis were enlarged, and the number of spermatogenic cells and sperm at all levels were decreased. Conclusion: KCZ could cause physiological function damage and pathological histological changes of the liver and testis, increase the levels of liver transaminase, reduce the activities of testicular specific enzymes of mice. Besides, the degree of damage was increased with the increase of dose.

Comparative assessment of interventions for treating cutaneous leishmaniasis: A network meta-analysis of randomized clinical trials

INTRODUCTION

Various interventions including laser therapy, heat therapy, and several drugs have been trialed in patients with cutaneous leishmaniasis. Due to the lack of an evidence-based comparison of all these interventions, we carried out the present network meta-analysis.

METHODS

Electronic databases were searched for randomized clinical trials evaluating the efficacy and safety of any interventions in patients with cutaneous leishmaniasis. The proportion of patients with complete cure was the primary outcome. The proportion of lesions cured at the end of treatment, the proportion of lesions with minimal/no response to treatment, and proportion of wounds with minimal/no change were the secondary outcomes. Random-effects modeling was used for generating pooled estimates. Rankogram plot was used for identifying the 'best intervention'. For interventions containing a combination of treatments, backslash (/) has been used for depicting the same.

RESULTS

One-hundred and thirty-one studies were included. Intralesional meglumine, topical paromomycin/gentamicin, topical paromomycin, parenteral sodium stibogluconate, topical honey/intralesional meglumine, topical liposomal amphotericin B, oral zinc sulphate, oral miltefosine, parenteral meglumine, heat therapy, topical liposomal azithromycin, intralesional meglumine/silver dressing, intralesional sodium stibogluconate, parenteral meglumine/intralesional meglumine, oral allopurinol/parenteral meglumine, topical trichloroacetic acid/heat therapy, oral zinc sulphate/oral ketoconazole, topical imiquimod/cryotherapy, intralesional meglumine/cryotherapy, topical herbal extract of Z-HE, parenteral pentamidine, topical trichloroacetic acid/intralesional meglumine, carbon-dioxide laser, topical recombinant granulocyte-macrophage colony-stimulating factor/parenteral meglumine, intralesional dapsone, carbon-dioxide laser/intralesional meglumine, moist wet dressing with sodium hypochlorite, parenteral sodium stibogluconate/intralesional recombinant granulocyte-macrophage colony-stimulating factor, oral dapsone, intralesional sodium stibogluconate/oral ketoconazole, intralesional sodium stibogluconate/parenteral sodium stibogluconate and electrocautery/moist wet dressing with sodium hypochlorite were observed with significantly greater proportion of patients with complete cure compared to placebo/untreated controls. Rankogram analysis revealed that parenteral pentamidine has the highest statistical probability of being the best in the pool.

CONCLUSION

We observed several interventions to be effective for treating cutaneous leishmaniasis. However, greater caution is required in interpreting the results as the estimates are likely to change with the advent of results from future studies.

Sterol Biosynthesis in Four Green Algae: A Bioinformatic Analysis of the Ergosterol Versus Phytosterol Decision Point

Animals and fungi produce cholesterol and ergosterol, respectively, while plants produce the phytosterols stigmasterol, campesterol, and β-sitosterol in various combinations. The recent sequencing of many algal genomes allows the detailed reconstruction of the sterol metabolic pathways. Here, we characterized sterol synthesis in two sequenced Chlorella spp., the free-living C. sorokiniana, and symbiotic C. variabilis NC64A. Chlamydomonas reinhardtii was included as an internal control and Coccomyxa subellipsoidea as a plant-like outlier. We found that ergosterol was the major sterol produced by Chlorella spp. and C. reinhardtii, while C. subellipsoidea produced the three phytosterols found in plants. In silico analysis of the C. variabilis NC64A, C. sorokiniana, and C. subellipsoidea genomes identified 22 homologs of sterol biosynthetic genes from Arabidopsis thaliana, Saccharomyces cerevisiae, and C. reinhardtii. The presence of CAS1, CPI1, and HYD1 in the four algal genomes suggests the higher plant cycloartenol branch for sterol biosynthesis, confirming that algae and fungi use different pathways for ergosterol synthesis. Phylogenetic analysis for 40 oxidosqualene cyclases (OSCs) showed that the nine algal OSCs clustered with the cycloartenol cyclases, rather than the lanosterol cyclases, with the OSC for C. subellipsoidea positioned in between the higher plants and the eight other algae. With regard to why C. subellipsoidea produced phytosterols instead of ergosterol, we identified 22 differentially conserved positions where C. subellipsoidea CAS and A. thaliana CAS1 have one amino acid while the three ergosterol producing algae have another. Together, these results emphasize the position of the unicellular algae as an evolutionary transition point for sterols.

Functional assessment of the effects of CYP3A4 variants on acalabrutinib metabolism in vitro

AIM

We aimed (i) to study the effects of genetic polymorphism of cytochrome P450 3A4 (CYP3A4) and drug interactions on acalabrutinib (ACA) metabolism and (ii) to investigate the mechanisms underlying the effects of CYP3A4 variants on the differential kinetic profiles of ACA and ibrutinib.

METHOD

Recombinant human CYP3A4 and variants were expressed using a Bac-to-Bac baculovirus expression system. The cell microsome was prepared and subjected to kinetic study. The analyte concentrations were determined by UPLC-MS/MS. A molecular docking assay was employed to investigate the mechanisms leading to differences in kinetic profiles.

RESULTS

The kinetic parameters of ACA, catalyzed by CYP3A4 and 28 of its variants, were determined, including V_max, K_m, and K_si. CYP3A4.6-8, 12, 13, 17, 18, 20, and 30 lost their catalytic function. No significant differences were found for CYP3A4.4, 5, 10, 15, 31, and 34 compared with CYP3A4.1 with respect to intrinsic clearance (V_max/K_m, Clint). However, the Clint values of CYP3A4.9, 14, 16, 19, 23, 24, 28, 32 were obviously decreased, ranging from 0.02 to 0.05 μL/min/pmol. On the contrary, the catalytic activities of CYP3A4.2, 3, 11, 29, and 33 were increased dramatically. The Clint value of CYP3A4.11 was 5.95 times as high as that of CYP3A4.1. Subsequently, CYP3A4.1, 3, 11, 23, and 28 were chosen to study the kinetic changes in combination with ketoconazole. Interestingly, we found the inhibitory potency of ketoconazole varied in different variants. In addition, the kinetic parameters of ibrutinib and ACA were accordingly compared in different CYP3A4 variants. Significant differences in relative clearance were observed among variants, which would probably influence the distance between the redox site and the heme iron atom.

CONCLUSION

Genetic polymorphism of CYP3A4 extensively changes its ACA-metabolizing enzymatic activity. In combination with a CYP inhibitor, its inhibitory potency also varied among different variants. Even the same variants exhibited different capabilities catalyzing ACA. Its enzymatic capabilities are probably determined by the distance between the substrate and the heme iron atom, which could be impacted by mutation.

Ketoconazole-p aminobenzoic cocrystal, an improved antimycotic drug formulation, does not induce skin sensitization on the skin of BALBc mice

Fungal infections are a growing global health problem. Therefore, our group has synthetized and characterized an improved antimycotic by co-crystallization of ketoconazole and para-amino benzoic acid, named KET-PABA. The aim was to increase bioavailability, biocompatibility, and efficiency of the parent drug-ketoconazole. Based on our previous results showing the cocrystal improved physical properties, such as stability in suspension, solubility, as well as antimycotic efficiency compared to ketoconazole, the current study investigated the local possible side effects induced on the skin of BALBc mice by the application of KET-PABA cocrystal, in view of a further use as a topically applied antimycotic drug. A specific test (mouse ear-swelling test) was used, combined with the histopathological examination and the measurement of pro and anti-inflammatory cytokines and inflammation mediators. KET-PABA application was safe, without signs of skin sensitization shown by the mouse ear sensitization test, or histopathology. KET-PABA strongly inhibited proinflammatory cytokines such as IL1 α, IL1 β, IL6 and TNF α, and other proinflammatory inducers such as NRF2, compared to vehicle. KET-PABA had no effect on the levels of the anti-inflammatory cytokine IL10, or proinflammatory enzyme COX2 and had minimal effects on the activation of the NF-κB pathway. Overall, KET-PABA application induced no sensitization, moreover, it decreased the skin levels of proinflammatory molecules. The lack of skin sensitization effects on BALBc mice skin along with the inhibition of the proinflammatory markers show a good safety profile for topical applications of KET-PABA and show promise for a further clinical use in the treatment of cutaneous mycosis.

Classical toxicity endpoints in female rats are insensitive to the human endocrine disruptors diethylstilbestrol and ketoconazole

Developmental exposure to endocrine disrupting chemicals can have negative consequences for reproductive health in both men and women. Our knowledge about how chemicals can cause adverse health outcomes in females is, however, poorer than our knowledge in males. This is possibly due to lack of sensitive endpoints to evaluate endocrine disruption potential in toxicity studies. To address this shortcoming we carried out rat studies with two well-known human endocrine disruptors, diethylstilbestrol (DES) and ketoconazole (KTZ), and evaluated the sensitivity of a series of endocrine related endpoints. Sprague-Dawley rats were exposed orally from gestational day 7 until postnatal day 22. In a range-finding study, disruption of pregnancy-related endpoints was seen from 0.014 mg/kg bw/day for DES and 14 mg/kg bw/day for KTZ, so doses were adjusted to 0.003; 0.006; and 0.0012 mg/kg bw/day DES and 3; 6; or 12 mg/kg bw/day KTZ in the main study. We observed endocrine disrupting effects on sensitive endpoints in male offspring: both DES and KTZ shortened anogenital distance and increased nipple retention. In female offspring, 0.0012 mg/kg bw/day DES caused slightly longer anogenital distance. We did not see effects on puberty onset when comparing average day of vaginal opening; however, we saw a subtle delay after exposure to both chemicals using a time-curve analysis. No effects on estrous cycle were registered. Our study shows a need for more sensitive test methods to protect the reproductive health of girls and women from harmful chemicals.

Development, Optimization, and Antifungal Assessment of Ocular Gel Loaded With Ketoconazole Cubic Liquid Crystalline Nanoparticles

Ketoconazole is a drug that belongs to azole antifungal group. The current available marketed products of ketoconazole are accompanied with potential drawbacks such as short retention time at the eye surface and eye irritation. The aim of this research is to find a solution for the previously mentioned limitations through loading of ketoconazole within cubosomes (KZ-Cub) to be used as ophthalmic drug delivery systems. Cubosomes properties will help to keep the encapsulated drug in the solubilized form. Further incorporation of cubosomes into biodegradable polymer based gel could prolong the ocular retention time of the drug. Three studied independent variables included glyceryl-mono-oleate, Pluronic-F127 and Polyvinyl alcohol percentage with respect to the dispersion media, while particle size, entrapment efficiency and stability index were the dependent variables that have been evaluated. The optimized cubosomes was assessed for its in-vitro and in-vivo antifungal activity. The prepared gel loaded with KZ-Cub formula had an enhanced permeability, ocular availability, antifungal activity and significant decrease in MIC values compared to commercial one, which reflected the strong impact on the activity of KZ in the management of eye infection.

Antifungal promising agents of zinc(II) and copper(II) derivatives based on azole drug

A series of new metal complexes, [Zn(KTZ)₂(Ac)₂]·H₂O (1)_, [Zn(KTZ)₂Cl₂]·0.4CH₃OH (2), [Zn(KTZ)₂(H₂O)(NO₃)](NO₃) (3), [Cu(KTZ)₂(Ac)₂]·H₂O (4)_, [Cu(KTZ)₂Cl₂]·3.2H₂O (5), [Cu(KTZ)₂(H₂O)(NO₃)](NO₃)·H₂O (6), were synthesized by a reaction of ketoconazole (KTZ) with their respective zinc or copper salts under mild conditions. Similarly, six corresponding metal-CTZ (clotrimazole) complexes [Zn(CTZ)₂(Ac)₂]·4H₂O (7)_, [Zn(CTZ)₂Cl₂] (8), [Zn(CTZ)₂(H₂O)(NO₃)](NO₃)·4H₂O (9), [Cu(CTZ)₂(Ac)₂]·H₂O (10)_, [Cu(CTZ)₂Cl₂]·2H₂O (11), [Cu(CTZ)₂(H₂O)(NO₃)](NO₃)·2H₂O (12), were obtained. These metal complexes were characterized by elemental analyses, molar conductivity, ¹H and ¹³C{¹H} nuclear magnetic resonance, UV/Vis, and infrared spectroscopies. Further, the crystal structure for complexes 7 and 10 was determined by single-crystal X-ray diffraction. The antifungal activity of these metal complexes was evaluated against three fungal species of medical relevance: Candida albicans, Cryptococcus neoformans, and Sporothrix brasiliensis. Complexes 1 and 3 exhibited the greatest antifungal activity with a broad spectrum of action at low concentrations and high selectivity. Some morphological changes induced by these metal complexes in S. brasiliensis cells included yeast-hyphae conversion, an increase in cell size and cell wall damage. The strategy of coordination of clinic drugs (KTZ and CTZ) to zinc and copper was successful, since the corresponding metal complexes were more effective than the parent drug. Particularly, the promising antifungal activities displayed by Zn-KTZ complexes make them potential candidates for the development of an alternative drug to treat mycoses.

Exploring the safety and efficacy of adding ketoconazole to tacrolimus in pediatric renal transplant immunosuppression

BACKGROUND

Guatemala is a developing country in Central America with limited health resources. In order to expand successful renal transplant care to children and adolescents at the lowest possible cost, our pediatric renal transplant clinic uses a post-transplant tacrolimus-sparing strategy via inhibition of CYP3A4.

AIM

To study the safety, efficacy and the associated cost reduction of ketoconazole in combination with tacrolimus in this pediatric population.

METHODS

A retrospective chart review was carried out among the cohort of pediatric renal transplant recipients treated at the Foundation for pediatric renal patients (Fundación para el Niño Enfermo Renal - FUNDANIER), a pediatric tertiary care renal transplant center in Guatemala City, Guatemala. Patient charts were reviewed to ascertain the number of transplant recipients who were transitioned from tacrolimus based immunosuppression to combination therapy with ketoconazole and tacrolimus. Twenty-five post-transplant patients that used ketoconazole combined with tacrolimus were identified. Anthropometric, clinical and laboratory data was collected from patient charts before and after the transition.

RESULTS

Of the 25 patient charts reviewed 12 (48%) patients were male and the average patient age was 13 years. Twenty-four (96%) transplants were from living donors. There was a non-significant difference between the mean tacrolimus doses six months and two months prior to ketoconazole: -0.10 ± 0.04 (95%CI: 0.007, -0.029), P = 0.23. However, the difference between the mean tacrolimus doses six months prior to ketoconazole initiation and six months after ketoconazole addition was significant: 0.06 ± 0.05 (95%CI: -0.034, -0.086) P < 0.001. All tacrolimus doses were reduced by 45% after the addition of ketoconazole. Therapeutic levels of tacrolimus ranged between 6.8-8.8 ng/mL during the study period and patients demonstrated an increase in estimated glomerular filtration rate. The combination of tacrolimus and ketoconazole resulted in a 21% reduction in cost.

CONCLUSION

Patients experienced an effective dose-reduction of tacrolimus with the administration of ketoconazole. There was no relevant variations in tacrolimus serum levels, number of rejections, or significant liver toxicity. The strategy allowed a cost reduction in pediatric immunosuppressive therapy.

Interdigitale infection by synergistic action

This study aimed to exert the synergistic action of ketoconazole (KCZ) and ionic liquids (ILs) for improving antifungal effect. Various ILs were engineered and demonstrated different solubilization capacity for KCZ. Among them, the IL formed by choline and geranic acid ([Ch][Ger]) was the optimal one and able to imporve the solubility of KCZ by around 100-fold. The in vitro antifungal test revealed the [Ch][Ger] significantly inhibited the activity of T. Interdigitale and exerted the synergistic action with KCZ. Compared to Daktarin®, the [Ch][Ger] not only promoted KCZ to penetrate into deep skin layer but also improved in vivo anti-T. Interdigitale activity significantly. Besides, the [Ch][Ger] was able to strip the skin of the lesion site in a flaky manner to remove fungi more thoroughly. However, the skin can recover to be normal state after treatment and there was no evident skin irritation found in [Ch][Ger] group. The ILs may offer promising opportunities to deliver anti-fungal drugs to treat inner skin fungal infections by synergistic action.

Colloidal lipid nanodispersion enriched hydrogel of antifungal agent for management of fungal infections: Comparative in-vitro, ex-vivo and in-vivo evaluation for oral and topical application

Ketoconazole (KZ) is broad spectrum antifungal drug, used for the treatment of fungal infections. KZ's clinical topical use has been associated with some adverse effects in healthy adults particularly local reactions, such as stinging, severe irritation, and pruritus. However, bioavailability of KZ after oral administration is low from tablets due to its low aqueous solubility. The objective of this investigation was development and characterization of KZ-containing solid lipid nanoparticles (KZ-SLNs) and SLN-containing hydrogel (KZ-SLN-H) for oral and topical delivery of KZ. KZ-SLNs were prepared using homogenization-sonication method. Optimal KZ-SLN formulation was selected based on physicochemical and in-vitro release studies. Optimized KZ-SLN converted to KZ-SLN hydrogel (KZ-SLN-H) using gelling polymers and optimized with rheological and in-vitro studies. Further, optimized KZ-SLN and KZ-SLN-H formulations evaluated for crystallinity, morphology, stability, ex-vivo and in-vivo pharmacokinetic (PK) studies in rats, comparison with KZ suspension (KZ-S) and KZ-S hydrogel (KZ-SH). Optimized KZ-SLN formulation showed desirable characters. KZ-SLN and KZ-SLN-H formulations exhibited spherical shape, converted to amorphous, sustained release behaviour and enhanced permeability (p < 0.05). Moreover, both formulations were stable for three months at 4 °C and 25 °C. PK studies revealed 1.9 and 1.5-folds, 3.5 and 2.8-folds enhancement of bioavailability of optimized KZ-SLN and KZ-SLN-H formulations (p < 0.05) compared with KZ-S and KZ-SH formulations, respectively. Overall, SLN and SLN-H formulations could be considered as an efficient delivery vehicles for KZ through oral and topical administration for better control over topical and systemic fungal infections.

Similarity of dissolution profiles from biorelevant media: Assessment of interday repeatability, interanalyst repeatability, and interlaboratory reproducibility using ibuprofen and ketoconazole tablets

Biorelevant media are increasingly being employed as dissolution media in drug development, including in smaller volumes than 900ml and under non-sink conditions. The objectives were to assess interday repeatability, interanalyst repeatability, and interlaboratory reproducibility of dissolution profiles from biorelevant media, as well as to assess the impacts of biorelevant media production method and biorelevant medium volume on dissolution profiles. Ibuprofen and ketoconazole tablets were subjected to dissolution testing in 500ml, 300ml, and 40ml of fasted state simulated gastric fluid (FaSSGF), fed state simulated gastric fluid (FeSSGF), fasted state simulated intestinal fluid version 2 (FaSSIF-V2), and fed state simulated intestinal fluid version 2 (FeSSIF-V2). f₂ was used to assess repeatability and reproducibility of dissolution profiles. Results indicate favorable interday repeatability (83 of 88 comparisons were similar), favorable interanalyst repeatability (19 of 21 comparisons were similar), and favorable interlaboratory reproducibility (10 of 14 comparisons were similar) of dissolution profiles from biorelevant media, with commercial media showing greater interlaboratory reproducibility than 'from scratch' media. However, biorelevant medium production had low impact on profiles when one analyst conducted all medium preparations and study procedures at one location. Additionally, biorelevant media detected differences when products were not similar. Overall, biorelevant media showed favorable repeatability and reproducibility performance.

Lecithins-Zein nanoparticles for antifungal treatment: Enhancement and prolongation of drug retention in skin with reduced toxicity

Fungal infections are one of the major skin healthcare issues and cause significant morbidity. Ketoconazole (KC) as a broad-spectrum antifungal drug is widely used to treat skin fungal diseases. However, its therapeutic effects are limited by low concentration, short duration of drug efficacy in the skin and severe systemic toxicity. Here, the ketoconazole loaded Lecithins-Zein nanoparticles (KLZ-NPs) with core-shell structure were designed to resolve above problems. In vitro penetration test confirmed that the ketoconazole concentration of the KLZ-NPs group in the stratum corneum and deeper layers increased significantly (2.98-fold, 1.51-fold higher to free ketoconazole, respectively). Meanwhile, follicular closing technique showed the formed nanoparticles via follicle pathway into the skin had been significantly enhanced, and the results of the visual fluorescent images also confirmed it. Additionally, in the in vivo imaging experiment, the fluorescence intensity of the single applying of the DiR-LZ-NPs was higher than that of the thrice usage of the free DiR. More importantly, the results also indicated that the accumulation of nanoparticles in the liver and spleen was significantly reduced. Hence, Lecithins-Zein nanoparticles are a promising strategy to enhance the drug concentration, prolong efficacy and reduce systemic toxicity in the topical administration for antifungal treatment.

The Introduction of a New Flexible In Vivo Predictive Dissolution Apparatus, GIS-Alpha (GIS-α), to Study Dissolution Profiles of BCS Class IIb Drugs, Dipyridamole and Ketoconazole

The physiological pH changes and peristalsis activities in gastrointestinal (GI) tract have big impact on the dissolution of oral drug products, when those oral drug products include APIs with pH-dependent solubility. It is well documented that predicting the bioperformance of those oral drug products can be challenging using compendial methods. To overcome this limitation, in vivo predictive dissolution apparatuses, such as the transfer model, have been developed to predict bioperformance of oral formulation candidates and drug products. In this manuscript we utilize a new transfer-model dissolution apparatus, the gastrointestinal simulator-α (GIS-α), to characterize its behavior in terms of transfer kinetics and pH, assess its reproducibility and adaptability to mimic different transfer conditions, as well as study dissolution of ketoconazole and dipyridamole as model BCS class IIb compounds. Availability of commercially available dissolution transfer systems with similar configuration to compendial dissolution apparatus, may be helpful to simplify and standardize in vivo predictive dissolution methodologies for BCS class IIb compounds in the future.

Simultaneous determination the concentration change of ketoconazole and dexamethasone acetate: application to drug-drug interaction in human keratinocyte

BACKGROUND

The combination of ketoconazole and dexamethasone acetate is one of the commonly used treatments in dermatology regiment for skin inflammation accompanied by fungal infections. This interaction of ketoconazole and dexamethasone may make the drug much effective, decrease the adverse reaction or toxic effects. At present, there was no information about the interaction of these two external drugs. Therefore, it was necessary to build a model to measure the levels and evaluate the interaction of ketoconazole and dexamethasone acetate in skin cells.

METHODS

In our study, the determination methodology of ketoconazole and dexamethasone acetate in human keratinocyte (HaCaT cells) was established and the interaction of these two drugs in cells was explored. HaCaT cells were cultured in medium containing ketoconazole, then they were sequentially cultured with or without dexamethasone acetate treatment for another 1, 2, 4, 8 and 12 h. The samples were then harvested and the concentrations were quantified by enhanced BCA (the bicinchoninic acid) protein assay. Furthermore, the analytes in the cell suspension were also prepared and analyzed by LC-MS method.

RESULTS

As a result, ketoconazole and dexamethasone acetate were detected at the concentration range of 0.02 to 5 μg/mL and 0.2 to 100 μg/mL, respectively. The RSD (relative standard deviation) and RE (relative error) of precision and accuracy of the two analytes in the cell suspension were all less than 15 %. The matrix effect values variations were all less than 15%. The results showed that there was no significant difference in the concentration of ketoconazole with or without dexamethasone acetate treatment within 12 h.

CONCLUSIONS

A simple, sensitive and rapid LC-MS method which could quantify these two analytes in cells simultaneously was developed for the first time. The results of the concentration changes meant that no interaction occurred when dexamethasone sequentially administrated for 12 h after ketoconazole treatment. This method was successfully applied to establish the cell pharmacokinetics methodology and preliminary studied the metabolism of drug-drug interaction of ketoconazole and dexamethasone acetate.

Advances in the Medical Treatment of Cushing Disease

Medical therapy has an adjunctive role in management of Cushing disease. Medical therapy is recommended for patients who received pituitary radiotherapy and are awaiting its salutary effects. Medications are used preoperatively to stabilize the condition of seriously ill patients before surgery. Medical therapy is used to control hypercortisolism in patients with uncertain tumor location. Medical therapies available for management of patients with Cushing disease include steroidogenesis inhibitors, centrally acting agents, and glucocorticoid receptor antagonists. All agents require careful monitoring to optimize clinical effectiveness and manage adverse effects. Novel agents in development may expand the armamentarium for management of this condition.

Molecular diagnosis and therapy for cutaneous leishmaniasis of a returned traveler from Mexico

Leishmaniasis is prevalent in Southern Europe, the Middle East, India, Africa, and Central and South America. Cutaneous leishmaniasis may spontaneously heal over time without treatment; however, risk of visceral dissemination and the impact of cosmetic defect are important concerns. We report a Case of cutaneous leishmaniasis in a patient who ever traveled to Mexico before the onset of a deteriorating wound around the swollen left eyebrow. A diagnosis of infection with Leishmania mexicana was made based on histopathological examination and molecular identification. Systemic treatment with liposomal amphotericin B and ketoconazole were administered with gradual healing of the lesion. Also, this traveler case implicates that the spread of endemic parasitic diseases may be a concealed risk on the public health for Taiwan underlying globalization.

Fatal high-grade skull osteosarcoma 30 years following radiotherapy for Cushing's disease

SUMMARY

Cushing's disease is a rare disorder characterised by excessive cortisol production as a consequence of a corticotroph pituitary tumour. While the primary treatment is surgical resection, post-operative radiation therapy may be used in cases of ongoing inadequate hormonal control or residual or progressive structural disease. Despite improved outcomes, radiotherapy for pituitary tumours is associated with hypopituitarism, visual deficits and, rarely, secondary malignancies. We describe an unusual case of a 67-year-old female with presumed Cushing's disease diagnosed at the age of 37, treated with transsphenoidal resection of a pituitary tumour with post-operative external beam radiotherapy (EBRT), ketoconazole for steroidogenesis inhibition, and finally bilateral adrenalectomy for refractory disease. She presented 30 years after her treatment with a witnessed generalised tonic-clonic seizure. Radiological investigations confirmed an extracranial mass infiltrating through the temporal bone and into brain parenchyma. Due to recurrent generalised seizures, the patient was intubated and commenced on dexamethasone and anti-epileptic therapy. Resection of the tumour revealed a high-grade osteoblastic osteosarcoma. Unfortunately, the patient deteriorated in intensive care and suffered a fatal cardiac arrest following a likely aspiration event. We describe the risk factors, prevalence and treatment of radiation-induced osteosarcoma, an exceedingly rare and late complication of pituitary irradiation. To our knowledge, this is the longest reported latency period between pituitary irradiation and the development of an osteosarcoma of the skull.

LEARNING POINTS

Cushing's disease is treated with transsphenoidal resection as first-line therapy, with radiotherapy used in cases of incomplete resection, disease recurrence or persistent hypercortisolism. The most common long-term adverse outcome of pituitary tumour irradiation is hypopituitarism occurring in 30-60% of patients at 10 years, and less commonly, vision loss and oculomotor nerve palsies, radiation-induced brain tumours and sarcomas. Currently proposed characteristics of radiation-induced osteosarcomas include: the finding of a different histological type to the primary tumour, has developed within or adjacent to the path of the radiation beam, and a latency period of at least 3 years. Treatment of osteosarcoma of the skull include complete surgical excision, followed by systemic chemotherapy and/or radiotherapy. Overall prognosis in radiation-induced sarcoma of bone is poor. Newer techniques such as stereotactic radiosurgery may reduce the incidence of radiation-induced malignancies.

Ketoconazole-loaded poly-(lactic acid) nanoparticles: Characterization and improvement of antifungal efficacy in vitro against Candida and dermatophytes

OBJECTIVE

In order to improve the effect of ketoconazole, poly-lactic acid (PLA) nanoparticles containing ketoconazole were prepared, characterized and tested against dermatophytes and Candida spp planktonic and biofilm cells.

METHODS

The ketoconazole-PLA nanoparticles obtained by nanoprecipitation were characterized using dynamic light scattering, scanning electron microscopy, transmission electron microscopy, and differential scanning calorimetry. In addition, quantification of encapsulated ketoconazole and the in vitro release profile were determined. Antifungal susceptibility tests against dermatophytes Trichophyton rubrum, Trichophyton mentagrophytes, and Microsporum gypseum and yeasts Candida albicans, C. dubliniensis, C. krusei, C. parapsilosis, and C. tropicalis were performed.

RESULTS

Spherical nanoparticles, with a mean diameter of 188.5nm and an encapsulation efficiency of 45% ketoconazole, were obtained. The nanoparticles containing ketoconazole had superior antifungal activity against all tested fungi strains than free ketoconazole. Inhibition of yeast biofilm formation was also achieved.

CONCLUSION

Ketoconazole-PLA nanoparticles resulted in better antifungal activity of ketoconazole nanoparticles than free drug against dermatophytes and Candida species, indicating a promising tool for the development of therapeutic strategies.

A Novel GNAS Mutation Causing Isolated Infantile Cushing's Syndrome

Infantile Cushing's syndrome is potentially found as part of McCune-Albright syndrome (MAS) which is caused by postzygotic somatic mutations of the GNAS gene. MAS is typically characterized by a triad of polyostotic fibrous dysplasia, café-au-lait skin pigmentation, and precocious puberty or other endocrine hyperfunction. Here, we describe a 2-month-old female infant with features of Cushing's syndrome without café au lait spots, polyostotic fibrous dysplasia, and clinical evidence of other endocrine hyperfunction. Investigations demonstrated adrenocorticotropic hormone-independent Cushing's syndrome with bilateral adrenal gland enlargement. Whole-exome sequencing of leukocytes identified a de novo heterozygous novel missense mutation (c.521G>A, p.Cys174Tyr) in the GNAS gene. The patient experienced clinical improvement of Cushing's syndrome during ketoconazole treatment. Her clinical course was complicated by Pneumocystis jiroveci pneumonia. She also had shortened activated partial thromboplastin time indicating a hypercoagulable state and resulting in pulmonary embolism. She eventually manifested gonadotropin-independent precocious puberty at the age of 13 months after ketoco-nazole was discontinued. This patient demonstrated that Cushing syndrome can be the presenting sign of MAS in infancy. A high index of suspicion followed by genetic analysis is essential in order to establish a diagnosis.

Effects of repeated oral doses of ketoconazole on a sequential ascending single oral dose of fedratinib in healthy subjects

PURPOSE

Fedratinib is an orally administered Janus kinase 2-selective inhibitor that is indicated for the treatment of adult patients with intermediate-2 or high-risk myelofibrosis in the United States. Fedratinib is metabolized by multiple cytochrome P450s (CYPs) in vitro, with the predominant contribution from CYP3A4. The primary objective of this study was to evaluate the effects of 14-day repeated 200 mg twice daily (BID) oral doses of a strong CYP3A4 inhibitor, ketoconazole, on a sequential ascending single oral dose of fedratinib in healthy male subjects.

METHODS

An open-label, fixed-sequence, two-treatment cross-over study was conducted. Two cohorts of healthy adult males received two single doses of fedratinib (50 mg in Cohort 1 and 300 mg in Cohort 2) with one dose administered alone on Day 1 of Period 1 and the other dose coadministered with ketoconazole in the morning of Day 6 of Period 2. Subjects in both cohorts received 200-mg BID (Days 1-14) ketoconazole during Period 2.

RESULTS

Coadministration of repeated 200-mg BID oral doses of ketoconazole for 14 days increased fedratinib exposure by 3.85- and 3.06-fold for area under the plasma concentration-time curve from time zero to infinity following a single oral dose of fedratinib of 50 and 300 mg, respectively. Oral administration of a single dose of 50 or 300 mg of fedratinib, administered alone or coadministered with steady-state ketoconazole, was safe and tolerable in the healthy male subjects.

CONCLUSIONS

These results serve as the basis for fedratinib dose reduction when fedratinib is coadministered with strong CYP3A4 inhibitors.

Photocatalytic degradation of ketoconazole by Z-scheme Ag3PO4/graphene oxide: response surface modeling and optimization

Ketoconazole is an imidazole fungicide which is commonly used as pharmaceutical and healthcare products. Residual amount of this compound can cause adverse ecological health problems. The present study investigated ketoconazole photocatalytic degradation using Ag₃PO₄/graphene oxide (GO). Ag₃PO₄/GO and Ag₃PO₄ as visible light-driven photocatalysts was synthesized using the in situ growth method. Degradation of ketoconazole at the concentration of 1-20 mg/L in aqueous solutions was optimized in the presence of Ag₃PO₄/GO nanocomposite with the dosage of 0.5-2 g/L, contact time of 15-20 min, and pH of 5-9 using response surface methodology. A second-order model was selected as the best fitted model with R² value and lack of fit as 0.935 and 0.06, respectively. Under the optimized conditions, the Ag₃PO₄/GO catalyst achieved a photocatalytic efficiency of 96.53% after 93.34 min. The photocatalytic activity, reaction kinetics, and stability were also investigated. The results indicated that the Ag₃PO₄/GO nanocomposite exhibited higher photocatalytic activity for ketoconazole degradation, which was 2.4 times that of pure Ag₃PO₄. Finally, a direct Z-scheme mechanism was found to be responsible for enhanced photocatalytic activity in the Ag₃PO₄/GO nanocomposite. The high photocatalytic activity, acceptable reusability, and good aqueous stability make the Ag₃PO₄/GO nanocomposite a promising nanophotocatalyst for photocatalytic degradation of azoles contaminants.

Co-exposure to ketoconazole alters effects of bisphenol A in Danio rerio and H295R cells

Chemicals are present in combination in ambient water, however toxicities of their mixtures are not well understood. This study investigated the effects of ketoconazole (KCZ) on the responses induced by bisphenol A (BPA) in zebrafish and in human adrenocarcinoma (H295R) cells. After exposure to BPA alone or mixed with KCZ for 21 d, egg production, relative tissue weights, sex hormone levels, cytochrome P450 (CYP)3a activity, and transcriptions of genes related to CYP metabolism, vitellogenesis, and steroidogenesis were determined in zebrafish. Male fish were more sensitive to the adverse effects of BPA than females, and the presence of KCZ potentiated the BPA-induced estrogenic responses in the male and anti-estrogenic responses in the female fish. In male zebrafish exposed to BPA, a significant reduction in egg number and relative gonad weight, an increase in 17β-estradiol (E2) to testosterone (T) ratio, and an upregulation of vtg, erα, and cyp19a genes were observed. Under KCZ, BPA exposure resulted in a significant downregulation of cyp3a65 and pxr genes and an increase in estrogenic responses in males. In female fish, anti-estrogenic effects, such as a decrease in E2 concentration, were observed following the combined exposure. These results indicate that KCZ could increase the toxicity of the chemicals that depend on the given CYP metabolism for their elimination or other crucial functions such as steroidogenesis. Co-exposure to BPA and KCZ in H295R cells also increased E2 and decreased T production. Release and presence of this azole compound warrant caution, because it could modify adverse effects of BPA.

Somatostatin analog challenge test in the pre-surgical management of ACTH-secreting pheochromocytoma

SUMMARY

ACTH-secreting pheochromocytoma is a very rare cause of Cushing's syndrome, with a high morbidity and mortality risk due to both cortisol and catecholamines excess. We report the case of a 45-year-old female patient with a 3 cm, high-density, left adrenal mass, diagnosed as an ACTH-secreting pheochromocytoma. The biochemical sensitivity of the tumor to somatostatin analogues was tested by a 100 μg s.c. octreotide administration, which led to an ACTH and cortisol reduction of 50 and 25% respectively. In addition to alpha and beta blockers, preoperative approach to laparoscopic adrenalectomy included octreotide, a somatostatin analogue, together with ketoconazole, in order to achieve an adequate pre-surgical control of cortisol release. Histopathological assessment confirmed an ACTH-secreting pheochromocytoma expressing type 2 and 5 somatostatin receptors (SSTR-2 and -5).

LEARNING POINTS

ACTH-secreting pheochromocytomas represent a rare and severe condition, characterized by high morbidity and mortality risk. Surgical removal of the adrenal mass is the gold standard treatment, but adequate medical therapy is required preoperatively to improve the surgical outcome and to avoid major complications. Somatostatin analogs, in addition to other medications, may represent a useful therapeutic option for the presurgical management of selected patients. In this sense, the octreotide challenge test is a useful tool to predict favorable therapeutic response to the treatment.