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Cheng L, Liu Z, Yu M, Lin L, Xiong L, Dai Q. Hypokalemia and Hyponatremia in Adult Patients Receiving Voriconazole Therapeutic Drug Monitoring. J Clin Pharmacol 2024; 64:461-468. [PMID: 37910022 DOI: 10.1002/jcph.2381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/31/2023] [Indexed: 11/03/2023]
Abstract
Hypokalemia and hyponatremia are common but easily ignored adverse events in treatment with voriconazole (VCZ) that can lead to serious consequences. We intend to investigate the incidence of VCZ-induced hypokalemia and hyponatremia and their risk factors based on real-world data. A prospective study was conducted. A total of 272 patients with 414 VCZ plasma trough concentrations (C0) and VCZ N-oxide concentrations (CN) were included. The incidence of hypokalemia was 18.0% (48/266). A total of 81.2% (39/48) of patients developed hypokalemia within 14 days, whereas 56.2% (27/48) of patients developed hypokalemia within 1 week. The proportion of female patients in the hypokalemia group was higher than that in the nonhypokalemia group, as was the proportion of patients receiving intravenous VCZ. In the multivariate analysis, the independent risk factors for hypokalemia were sex, combined use of antibiotics, and VCZ CN/C0. The incidence of hyponatremia was 7.9% (21/266). The proportion of patients over 47 years of age in the hyponatremia group was 71.4% (15/21). The number of days of VCZ use in the hyponatremia group was greater than that in the nonhyponatremia group. A total of 47.6% (10/21) of patients in the hyponatremia group had supratherapeutic VCZ C0 (>5.0 µg/mL). In conclusion, hypokalemia is more likely to occur in females, in patients receiving intravenous VCZ, and in patients with the combined use of antibiotics. Hyponatremia is more likely to occur in patients older than 47 years who have been using VCZ for a long time and have higher VCZ C0 values.
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Affiliation(s)
- Lin Cheng
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhirui Liu
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Mingjie Yu
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Ling Lin
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Lirong Xiong
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Qing Dai
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
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Chiang YH, Cheng CN, Chuang PJ, Chen YC, Chen YJ, Kuo CH, Lin SW, Chang LC. Enhancing the identification of voriconazole-associated hepatotoxicity by targeted metabolomics. Int J Antimicrob Agents 2024; 63:107028. [PMID: 37931850 DOI: 10.1016/j.ijantimicag.2023.107028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/17/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023]
Abstract
Voriconazole-associated hepatotoxicity is a common condition that generally manifests as elevated liver enzymes and can lead to drug discontinuation. Careful monitoring of voriconazole-associated hepatotoxicity is needed but there are no specific plasma biomarkers for this condition. Metabolomics has emerged as a promising technique for investigating biomarkers associated with drug-induced toxicity. The aim of this study was to use targeted metabolomics to evaluate seven endogenous metabolites as potential biomarkers of voriconazole-associated hepatotoxicity. Patients undergoing therapeutic drug monitoring of voriconazole were classified into a hepatotoxicity group (18 patients) or a control group (153 patients). Plasma samples were analysed using ultra-high-performance liquid chromatography coupled to mass spectrometry. Metabolite concentrations in the two groups were compared. Areas under the receiver operating characteristic (AUROC) curves generated from logistic regressions were used to correlate the concentrations of these seven metabolites with voriconazole trough concentrations and conventional liver biochemistry tests. Glycocholate and α-ketoglutarate levels were significantly higher in the hepatotoxicity group compared with the control group (false discovery rate-corrected P < 0.001 and P = 0.024, respectively). The metabolites glycocholate (AUROC = 0.795) and α-ketoglutarate (AUROC = 0.696) outperformed voriconazole trough concentrations (AUROC = 0.555) and approached the performance of alkaline phosphatase (AUROC = 0.876) and total bilirubin (AUROC = 0.815). A panel of glycocholate combined with voriconazole trough concentrations (AUROC = 0.827) substantially improved the performance of voriconazole trough concentrations alone in predicting hepatotoxicity. In conclusion, the panel integrating glycocholate with voriconazole trough concentrations has great potential for identifying voriconazole-associated hepatotoxicity.
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Affiliation(s)
- Yi-Hsuan Chiang
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Ning Cheng
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Pei-Jiun Chuang
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Jing Chen
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ching-Hua Kuo
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan; Metabolomics Core Laboratory, Centers of Genomic and Precision Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Shu-Wen Lin
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Cancer Center, Taipei, Taiwan.
| | - Lin-Chau Chang
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Li G, Li Q, Zhang C, Yu Q, Li Q, Zhou X, Yang R, Yang X, Liu H, Yang Y. The impact of gene polymorphism and hepatic insufficiency on voriconazole dose adjustment in invasive fungal infection individuals. Front Genet 2023; 14:1242711. [PMID: 37693307 PMCID: PMC10484623 DOI: 10.3389/fgene.2023.1242711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Voriconazole (VRZ) is a broad-spectrum antifungal medication widely used to treat invasive fungal infections (IFI). The administration dosage and blood concentration of VRZ are influenced by various factors, posing challenges for standardization and individualization of dose adjustments. On the one hand, VRZ is primarily metabolized by the liver, predominantly mediated by the cytochrome P450 (CYP) 2C19 enzyme. The genetic polymorphism of CYP2C19 significantly impacts the blood concentration of VRZ, particularly the trough concentration (Ctrough), thereby influencing the drug's efficacy and potentially causing adverse drug reactions (ADRs). Recent research has demonstrated that pharmacogenomics-based VRZ dose adjustments offer more accurate and individualized treatment strategies for individuals with hepatic insufficiency, with the possibility to enhance therapeutic outcomes and reduce ADRs. On the other hand, the security, pharmacokinetics, and dosing of VRZ in individuals with hepatic insufficiency remain unclear, making it challenging to attain optimal Ctrough in individuals with both hepatic insufficiency and IFI, resulting in suboptimal drug efficacy and severe ADRs. Therefore, when using VRZ to treat IFI, drug dosage adjustment based on individuals' genotypes and hepatic function is necessary. This review summarizes the research progress on the impact of genetic polymorphisms and hepatic insufficiency on VRZ dosage in IFI individuals, compares current international guidelines, elucidates the current application status of VRZ in individuals with hepatic insufficiency, and discusses the influence of CYP2C19, CYP3A4, CYP2C9, and ABCB1 genetic polymorphisms on VRZ dose adjustments and Ctrough at the pharmacogenomic level. Additionally, a comprehensive summary and analysis of existing studies' recommendations on VRZ dose adjustments based on CYP2C19 genetic polymorphisms and hepatic insufficiency are provided, offering a more comprehensive reference for dose selection and adjustments of VRZ in this patient population.
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Affiliation(s)
- Guolin Li
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Qinhui Li
- Department of Medical, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Changji Zhang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Qin Yu
- College of Pharmacy, Southwest Medical University, Luzhou, China
| | - Qi Li
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoshi Zhou
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Rou Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xuerong Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Hailin Liu
- Department of Pharmacy, The People’s Hospital of Chongqing Liangjiang New Area, Chongqing, China
| | - Yong Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Wang T, Miao L, Shao H, Wei X, Yan M, Zuo X, Zhang J, Hai X, Fan G, Wang W, Hu L, Zhou J, Zhao Y, Xie Y, Wang J, Guo S, Jin L, Li H, Liu H, Wang Q, Chen J, Li S, Dong Y. Voriconazole therapeutic drug monitoring and hepatotoxicity in critically ill patients: A nationwide multi-centre retrospective study. Int J Antimicrob Agents 2022; 60:106692. [PMID: 36372345 DOI: 10.1016/j.ijantimicag.2022.106692] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 10/01/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To characterize trough concentrations (Cmin) of voriconazole and associated hepatotoxicity, and to determine predictors of hepatotoxicity and identify high-risk groups in critically ill patients. METHODS This was a nationwide, multi-centre, retrospective study. Cmin and hepatotoxicity were studied from 2015 to 2020 in 363 critically ill patients who received voriconazole treatment. Logistic regression and classification and regression tree (CART) models were used to identify high-risk patients. RESULTS Large interindividual variability was observed in initial voriconazole Cmin and concentrations ranged from 0.1 mg/L to 18.72 mg/L. Voriconazole-related grade ≥2 hepatotoxicity developed in 101 patients, including 48 patients with grade ≥3 hepatotoxicity. The median time to hepatotoxicity was 3 days (range 1-24 days), and 83.2% of cases of hepatotoxicity occurred within 7 days of voriconazole initiation. Voriconazole Cmin was significantly associated with hepatotoxicity. The CART model showed that significant predictors of grade ≥2 hepatotoxicity were Cmin >3.42 mg/L, concomitant use of trimethoprim-sulfamethoxazole or tigecycline, and septic shock. The model predicted that the incidence of grade ≥2 hepatotoxicity among these high-risk patients was 48.3-63.4%. Significant predictors of grade ≥3 hepatotoxicity were Cmin >6.87 mg/L, concomitant use of at least three hepatotoxic drugs, and septic shock; the predictive incidence among these high-risk patients was 22.7-36.8%. CONCLUSION Higher voriconazole Cmin, septic shock and concomitant use of hepatotoxic drugs were the strongest predictors of hepatotoxicity. Plasma concentrations of voriconazole should be monitored early (as soon as steady state is achieved) to avoid hepatotoxicity.
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Affiliation(s)
- Taotao Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Liyan Miao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hua Shao
- Department of Pharmacy, Zhongda Hospital, Southeast University, Nanjing, China
| | - Xiaohua Wei
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Miao Yan
- Department of Pharmacy, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xiaocong Zuo
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Jun Zhang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xin Hai
- Department of Pharmacy, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Guangjun Fan
- Department of Pharmacy, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Wei Wang
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Linlin Hu
- Department of Pharmacy, Zhongda Hospital, Southeast University, Nanjing, China
| | - Jian Zhou
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yichang Zhao
- Department of Pharmacy, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Yueliang Xie
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Jingjing Wang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Sixun Guo
- Department of Pharmacy, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Liu Jin
- Department of Pharmacy, The Second Affiliated Hospital of Dalian Medical University, Dalian, China; Department of Pharmacy, Liyang Hospital of Chinese Medicine, Changzhou, China
| | - Hao Li
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Hui Liu
- Department of Biobank, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Quanfang Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jiaojiao Chen
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Sihan Li
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
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5
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Takesue Y, Hanai Y, Oda K, Hamada Y, Ueda T, Mayumi T, Matsumoto K, Fujii S, Takahashi Y, Miyazaki Y, Kimura T. Clinical Practice Guideline for the Therapeutic Drug Monitoring of Voriconazole in Non-Asian and Asian Adult Patients: Consensus Review by the Japanese Society of Chemotherapy and the Japanese Society of Therapeutic Drug Monitoring. Clin Ther 2022; 44:1604-1623. [DOI: 10.1016/j.clinthera.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/18/2022] [Accepted: 10/28/2022] [Indexed: 11/23/2022]
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6
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Shilpy N, Pushker N, Meel R, Agrawal S, Bajaj MS, Sharma S, Thakar A, Satapathy G, Velpandian T. Voriconazole in the treatment of invasive aspergillosis of orbit. Med J Armed Forces India 2022. [DOI: 10.1016/j.mjafi.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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7
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Jiang Z, Wei Y, Huang W, Li B, Zhou S, Liao L, Li T, Liang T, Yu X, Li X, Zhou C, Cao C, Liu T. Population pharmacokinetics of voriconazole and initial dosage optimization in patients with talaromycosis. Front Pharmacol 2022; 13:982981. [PMID: 36225581 PMCID: PMC9549404 DOI: 10.3389/fphar.2022.982981] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/30/2022] [Indexed: 01/08/2023] Open
Abstract
The high variability and unpredictability of the plasma concentration of voriconazole (VRC) pose a major challenge for clinical administration. The aim of this study was to develop a population pharmacokinetics (PPK) model of VRC and identify the factors influencing VRC PPK in patients with talaromycosis. Medical records and VRC medication history of patients with talaromycosis who were treated with VRC as initial therapy were collected. A total of 233 blood samples from 69 patients were included in the study. A PPK model was developed using the nonlinear mixed-effects models (NONMEM). Monte Carlo simulation was applied to optimize the initial dosage regimens with a therapeutic range of 1.0–5.5 mg/L as the target plasma trough concentration. A one-compartment model with first-order absorption and elimination adequately described the data. The typical voriconazole clearance was 4.34 L/h, the volume of distribution was 97.4 L, the absorption rate constant was set at 1.1 h-1, and the bioavailability was 95.1%. Clearance was found to be significantly associated with C-reactive protein (CRP). CYP2C19 polymorphisms had no effect on voriconazole pharmacokinetic parameters. Monte Carlo simulation based on CRP levels showed that a loading dose of 250 mg/12 h and a maintenance dose of 100 mg/12 h are recommended for patients with CRP ≤ 96 mg/L, whereas a loading dose of 200 mg/12 h and a maintenance dose of 75 mg/12 h are recommended for patients with CRP > 96 mg/L. The average probability of target attainment of the optimal dosage regimen in CRP ≤ 96 mg/L and CRP > 96 mg/L groups were 61.3% and 13.6% higher than with empirical medication, and the proportion of Cmin > 5.5 mg/L decreased by 28.9%. In conclusion, the VRC PPK model for talaromycosis patients shows good robustness and predictive performance, which can provide a reference for the clinical individualization of VRC. Adjusting initial dosage regimens based on CRP may promote the rational use of VRC.
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Affiliation(s)
- Zhiwen Jiang
- Department of Dermatology and Venereology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Health Commission Key Lab of Fungi and Mycosis Research and Prevention, Nanning, China
| | - Yinyi Wei
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Weie Huang
- Department of Infectious Diseases, Baise People’s Hospital, Baise, China
| | - Bingkun Li
- Department of Dermatology and Venereology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Health Commission Key Lab of Fungi and Mycosis Research and Prevention, Nanning, China
| | - Siru Zhou
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Liuwei Liao
- Department of Dermatology and Venereology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Health Commission Key Lab of Fungi and Mycosis Research and Prevention, Nanning, China
| | - Tiantian Li
- Guangxi Health Commission Key Lab of Fungi and Mycosis Research and Prevention, Nanning, China
| | - Tianwei Liang
- Department of Dermatology and Venereology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Health Commission Key Lab of Fungi and Mycosis Research and Prevention, Nanning, China
| | - Xiaoshu Yu
- Department of Infectious Diseases, Baise People’s Hospital, Baise, China
| | - Xiuying Li
- Department of Dermatology and Venereology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Health Commission Key Lab of Fungi and Mycosis Research and Prevention, Nanning, China
| | - Changjing Zhou
- Department of Infectious Diseases, Baise People’s Hospital, Baise, China
- *Correspondence: Changjing Zhou, ; Cunwei Cao, ; TaoTao Liu,
| | - Cunwei Cao
- Department of Dermatology and Venereology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Health Commission Key Lab of Fungi and Mycosis Research and Prevention, Nanning, China
- *Correspondence: Changjing Zhou, ; Cunwei Cao, ; TaoTao Liu,
| | - TaoTao Liu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- *Correspondence: Changjing Zhou, ; Cunwei Cao, ; TaoTao Liu,
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Maeda Y, Tanaka R, Tatsuta R, Takano K, Hashimoto T, Ogata M, Hiramatsu K, Itoh H. Impact of Inflammation on Intra-individual Variation in Trough Voriconazole Concentration in Patients with Hematological Malignancies. Biol Pharm Bull 2022; 45:1084-1090. [DOI: 10.1248/bpb.b22-00097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Yu Maeda
- Department of Clinical Pharmacy, Oita University Hospital
| | - Ryota Tanaka
- Department of Clinical Pharmacy, Oita University Hospital
| | | | | | - Takehiro Hashimoto
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Masao Ogata
- Department of Hematology, Oita University Hospital
| | - Kazufumi Hiramatsu
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Hiroki Itoh
- Department of Clinical Pharmacy, Oita University Hospital
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9
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Ashok A, Mangalore RP, Morrissey CO. Azole Therapeutic Drug Monitoring and its Use in the Management of Invasive Fungal Disease. Curr Fungal Infect Rep 2022. [DOI: 10.1007/s12281-022-00430-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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10
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Akçay Ö, Gümüştekin M. Voriconazole-Induced Hepatotoxicity Concise up-to-date review. Journal of Basic and Clinical Health Sciences. [DOI: 10.30621/jbachs.1051669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Suetsugu K, Muraki S, Fukumoto J, Matsukane R, Mori Y, Hirota T, Miyamoto T, Egashira N, Akashi K, Ieiri I. Effects of Letermovir and/or Methylprednisolone Coadministration on Voriconazole Pharmacokinetics in Hematopoietic Stem Cell Transplantation: A Population Pharmacokinetic Study. Drugs R D 2021; 21:419-429. [PMID: 34655050 PMCID: PMC8602551 DOI: 10.1007/s40268-021-00365-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 11/26/2022] Open
Abstract
Objective The aim of this study was to identify factors affecting blood concentrations of voriconazole following letermovir coadministration using population pharmacokinetic (PPK) analysis in allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients. Methods The following data were retrospectively collected: voriconazole trough levels, patient characteristics, concomitant drugs, and laboratory information. PPK analysis was performed with NONMEM® version 7.4.3, using the first-order conditional estimation method with interaction. We collected data on plasma voriconazole steady-state trough concentrations at 216 timepoints for 47 patients. A nonlinear pharmacokinetic model with the Michaelis–Menten equation was applied to describe the relationship between steady-state trough concentration and daily maintenance dose of voriconazole. After stepwise covariate modeling, the final model was evaluated using a goodness-of-fit plot, case deletion diagnostics, and bootstrap methods. Results The maximum elimination rate (Vmax) of voriconazole in patients coadministered letermovir and methylprednisolone was 1.72 and 1.30 times larger than that in patients not coadministered these drugs, respectively, resulting in decreased voriconazole trough concentrations. The developed PPK model adequately described the voriconazole trough concentration profiles in allo-HSCT recipients. Simulations clearly showed that increased daily doses of voriconazole were required to achieve an optimal trough voriconazole concentration (1–5 mg/L) when patients received voriconazole with letermovir and/or methylprednisolone. Conclusions The development of individualized dose adjustment is critical to achieve optimal voriconazole concentration, especially among allo-HSCT recipients receiving concomitant letermovir and/or methylprednisolone. Supplementary Information The online version contains supplementary material available at 10.1007/s40268-021-00365-0.
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Affiliation(s)
- Kimitaka Suetsugu
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Shota Muraki
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Junshiro Fukumoto
- Department of Clinical Pharmacology and Biopharmaceutics, The Pharmaceutical College, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Ryosuke Matsukane
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yasuo Mori
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takeshi Hirota
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.,Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Toshihiro Miyamoto
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Nobuaki Egashira
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.,Department of Clinical Pharmacology and Biopharmaceutics, The Pharmaceutical College, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Ichiro Ieiri
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. .,Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. .,Department of Clinical Pharmacology and Biopharmaceutics, The Pharmaceutical College, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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12
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Taghvaye-Masoumi H, Hadjibabaie M, Ghadimi M, Zarif-Yeganeh M, Vaezi M, Ghavamzadeh A. Association of Voriconazole Trough Plasma Concentration with Efficacy and Incidence of Hepatotoxicity in Iranian Patients with Hematological Malignancies. Iran J Pharm Res 2021; 20:62-71. [PMID: 34400941 PMCID: PMC8170753 DOI: 10.22037/ijpr.2020.112330.13688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
There are conflicting data regarding the association between plasma concentration of voriconazole (VCZ) and both efficacy and safety. This study investigates the association of VCZ trough plasma level with clinical efficacy and hepatotoxicity in the Iranian population suffering hematological malignancies. This cross-sectional study was performed on adult Iranian patients (age ≥ 18 years) with hematological malignancies undergoing treatment with oral or intravenous VCZ for proven or probable invasive aspergillosis. Plasma concentrations of VCZ were measured at two time points on day 4 and 14 during the study period. A total of 60 VCZ trough concentrations of 30 patients were drawn on days 4 and 14 after the initiation of treatment. There was no definite correlation between the mean plasma concentration of VCZ and VCZ dosage (p = 0.134, r = 0.280). In multivariable model, only plasma concentration of VCZ on day 14 was associated with the incidence of hepatotoxicity (p = 0.013; OR = 1.42, 95% CI = 1.07-3.24). Plasma trough concentration neither on day 4 nor on day 14 was related to the treatment response. No significant association was observed between the mean plasma concentration of VCZ and 3-month patients’ survival (p = 0.696). To conclude, VCZ trough concentration may not be a predictor of treatment response or 3-month patients’ survival. However, the wide inter- and intra-patient variability of VCZ plasma concentration coupled with the observed association between VCZ trough level and the incidence of hepatotoxicity would pose the question regarding the potential benefit of VCZ concentration monitoring.
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Affiliation(s)
- Hamidreza Taghvaye-Masoumi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Guilan University of Medical Sciences, Rasht, Iran
| | - Molouk Hadjibabaie
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Ghadimi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Morvarid Zarif-Yeganeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Vaezi
- Hematology-Oncology and Stem Cell Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ardeshir Ghavamzadeh
- Hematology-Oncology and Stem Cell Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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13
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Tanaka R, Eto D, Goto K, Ohchi Y, Yasuda N, Suzuki Y, Tatsuta R, Kitano T, Itoh H. Pharmacokinetic and Adsorptive Analyses of Administration of Oral Voriconazole Suspension via Enteral Feeding Tube in Intensive Care Unit Patients. Biol Pharm Bull 2021; 44:737-741. [PMID: 33952830 DOI: 10.1248/bpb.b20-00796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
For intensive care unit (ICU) patients, injectable voriconazole (VRCZ) is difficult to use because the patients often develop acute kidney injury. Since many ICU patients have consciousness disturbance, oral ingestion of tablet formulation is also difficult, and administration of a suspension via enteral feeding tube is required when using VRCZ. In this study, we investigated the in vitro adsorption property of oral VRCZ to feeding tube and performed pharmacokinetic analysis of VRCZ prepared by powdering and simple suspension for ICU patients. VRCZ was tube-administered to five ICU patients at a loading dose of 300 mg and plasma VRCZ concentrations before and at 1, 2, 4, 8, 12 h after the first dose were measured using HPLC. Pharmacokinetic parameters were calculated by non-compartmental model analysis. The recovery rate of VRCZ after infusion of the suspension through feeding tube was 89.8 ± 8.3%, but the cumulative rates after the first and second re-infusion were 102.7 ± 20.7 and 99.3 ± 10.3%, respectively, suggesting almost no residual drug in the tube after re-infusion. Metabolic phenotype was extensive metabolizer (EM) in two patients and intermediate metabolizer (IM) in three patients. The values of total clearance (CLtot/F) calculated by moment analysis were 0.51 and 0.55 L/h/kg in two EM patients, and 0.09, 0.29 and 0.31 L/h/kg in three IM patients. The CLtot/F was apparently lower in IM patients compared to EM. In conclusion, powdered and suspended VRCZ administered via enteral feeding tube showed pharmacokinetics depending on CYP2C19 gene polymorphism, similar to that observed in usual oral administration.
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Affiliation(s)
- Ryota Tanaka
- Department of Clinical Pharmacy, Oita University Hospital
| | - Daiki Eto
- Department of Clinical Pharmacy, Oita University Hospital
| | - Koji Goto
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Oita University
| | - Yoshifumi Ohchi
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Oita University
| | - Norihisa Yasuda
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Oita University
| | - Yosuke Suzuki
- Department of Clinical Pharmacy, Oita University Hospital
| | | | - Takaaki Kitano
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Oita University
| | - Hiroki Itoh
- Department of Clinical Pharmacy, Oita University Hospital
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14
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Hanai Y, Hamada Y, Kimura T, Matsumoto K, Takahashi Y, Fujii S, Nishizawa K, Miyazaki Y, Takesue Y. Favorable Effects of Voriconazole Trough Concentrations Exceeding 1 μg/mL on Treatment Success and All-Cause Mortality: A Systematic Review and Meta-Analysis. J Fungi (Basel) 2021; 7:306. [PMID: 33923727 DOI: 10.3390/jof7040306] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 12/23/2022] Open
Abstract
This systematic review and meta-analysis examined the optimal trough concentration of voriconazole for adult patients with invasive fungal infections. We used stepwise cutoffs of 0.5-2.0 μg/mL for efficacy and 3.0-6.0 μg/mL for safety. Studies were included if they reported the rates of all-cause mortality and/or treatment success, hepatotoxicity, and nephrotoxicity according to the trough concentration. Twenty-five studies involving 2554 patients were included. The probability of mortality was significantly decreased using a cutoff of ≥1.0 μg/mL (odds ratio (OR) = 0.34, 95% confidence interval (CI) = 0.15-0.80). Cutoffs of 0.5 (OR = 3.48, 95% CI = 1.45-8.34) and 1.0 μg/mL (OR = 3.35, 95% CI = 1.52-7.38) also increased the treatment success rate. Concerning safety, significantly higher risks of hepatotoxicity and neurotoxicity were demonstrated at higher concentrations for all cutoffs, and the highest ORs were recorded at 4.0 μg/mL (OR = 7.39, 95% CI = 3.81-14.36; OR = 5.76, 95% CI 3.14-10.57, respectively). Although further high-quality trials are needed, our findings suggest that the proper trough concentration for increasing clinical success while minimizing toxicity is 1.0-4.0 μg/mL for adult patients receiving voriconazole therapy.
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15
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Li H, Zhang D, Cheng X, Sultan MFA, Xiong L, Ma Y, Wang M, Feng W. Application of the Westgard Multi-rule Theory to Internal Quality Control Evaluation of Voriconazole for Therapeutic Drug Monitoring. CURR PHARM ANAL 2021. [DOI: 10.2174/1573412916999200818104337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
There is no worldwide recognized reference internal quality control method
for Therapeutic Drug Monitoring (TDM) of voriconazole (VCZ) by Liquid Chromatography (LC). In
this study, we aimed to develop an internal quality control method for TDM of VCZ, evaluate it by the
Westgard multi-rule theory, and guarantee the analytical quality of the assays.
Methods:
The plasma concentration of VCZ was detected by two-dimensional liquid chromatography
with ultraviolet detection (2D-LC-UV) method. The internal quality control results accompanying with
TDM of VCZ in our laboratory from July 2019 to January 2020 were collected and retrospectively
studied. The Levey-Jennings quality chart and Z-score quality chart were drawn and Westgard multirules
of 12s/13s/22s/R4s/41s/10x were applied to assess the suitable quality control method for TDM of
VCZ.
Results:
The 2D-LC-UV method was well suited to monitor the plasma concentration of VCZ and increase
the real-time capability of TDM for VCZ. Combined with Westgard multi-rules, the quality control
charts of Levery-Jennings and Z-score both can timely discover and judge the systematic errors
and random errors for the internal quality control results. 86 batches of quality control products were
assessed and 7 times warnings and 6 times out of control were detected.
Conclusion:
The Westgard multi-rules, with high efficacy in determining detection errors, has important
application value in the internal quality control for TDM of VCZ. The developed quality control
method can improve the accuracy and reliability for VCZ measurement by the 2D-LC-UV method
and further promote the clinical rational use of the drug.
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Affiliation(s)
- Houli Li
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Di Zhang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiaoliang Cheng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | | | - Lilong Xiong
- School of Chemistry, Xi’an Jiaotong University, Xi’an, China
| | - Ying Ma
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Maoyi Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Weiyi Feng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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16
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Chen TC, Wang RC, Lin YH, Chang KH, Hung LY, Teng CLJ. Posaconazole for the prophylaxis of invasive aspergillosis in acute myeloid leukemia: Is it still useful outside the clinical trial setting? Ther Adv Hematol 2020; 11:2040620720965846. [PMID: 33194163 PMCID: PMC7607783 DOI: 10.1177/2040620720965846] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 09/14/2020] [Indexed: 02/02/2023] Open
Abstract
Background: Posaconazole prophylaxis during remission induction chemotherapy not only decreases the incidence of invasive aspergillosis (IA) but also improves the overall survival rate among patients with acute myeloid leukemia (AML). However, it remains debatable whether this result applies to patients in a real-world setting. Methods: We retrospectively assessed 208 adult patients with newly diagnosed AML who underwent remission induction therapy. These 208 patients were stratified into the posaconazole prophylaxis group (n = 58) and no antifungal prophylaxis group (n = 150). Results: Multivariate analyses showed that induction failure significantly increased the risk of proven or probable IA during the first induction chemotherapy [hazard ratio (HR), 10.47; 95% confidence interval (CI), 1.73–63.45; p = 0.011] and the entire course of AML treatment (HR, 4.48; 95% CI, 1.71–11.75; p = 0.002). However, posaconazole prophylaxis did not reduce the risk of IA during the first induction chemotherapy (HR, 1.47; 95% CI, 0.14–15.04; p = 0.746) and during the entire course of AML treatment (HR, 1.09; 95% CI, 0.29–4.09; p = 0.896). Furthermore, there was no significant difference in overall survival between these two groups of patients (514 versus 689 days; p = 0.454). Conclusion: Successful induction remains fundamental to reducing the risk of IA among AML patients undergoing remission induction chemotherapy.
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Affiliation(s)
- Tsung-Chih Chen
- Department of Medicine, Division of Hematology/Medical Oncology, Taichung Veterans General Hospital, Taiwan
| | - Ren Ching Wang
- Department of Pathology, Taichung Veterans General Hospital, Taiwan
| | - Yu-Hui Lin
- Department of Medicine, Division of Infectious Disease, Taichung Veterans General Hospital, Taiwan
| | - Kuang-Hsi Chang
- Department of Medical Research, Tungs' Taichung Metroharbor Hospital, Taiwan
| | - Li-Ya Hung
- Section of Medical Records, Taichung Veterans General Hospital, Taiwan
| | - Chieh-Lin Jerry Teng
- Department of Medicine, Division of Hematology/Medical Oncology, Taichung Veterans General Hospital, No. 1650, Sec. 4, Taiwan Blvd., Taichung, 40705, Taiwan
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17
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Tanaka R, Fujioka T, Suzuki Y, Iwao M, Itoh H. A Prospective Study on the Usefulness of Initial Voriconazole Dose Adjustment Based on CYP2C19 Gene Polymorphism Analysis. Chemotherapy 2020; 65:59-64. [PMID: 32877905 DOI: 10.1159/000509970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/27/2020] [Indexed: 11/19/2022]
Abstract
Genetic polymorphism exists for CYP2C19, a dominant metabolic enzyme of voriconazole (VRCZ), and VRCZ pharmacokinetics has been shown to fluctuate according to the CYP2C19 phenotype. Although dosages for different phenotypes have been recommended in various retrospective studies, few reports have adjusted the initial VRCZ dose based on CYP2C19 phenotype determined prior to administration. In this study, we prospectively evaluated the usefulness of CYP2C19 polymorphism analysis in adjusting the initial VRCZ maintenance dose. The study enrolled 19 patients who underwent analysis of CYP2C19 polymorphism prior to VRCZ administration. Subjects were classified into 3 phenotype subgroups: extensive metabolizer (EM), intermediate metabolizer (IM), and poor metabolizer (PM). The initial VRCZ maintenance doses given twice daily were proposed as follows: approximately 8, 6, and 4 mg/kg/day for EM, IM and PM, respectively, according to previous reports. In EM, the initial maintenance dose was 8.0 ± 0.5 mg/kg/day, and trough level was 6.6 ± 2.4 μg/mL. By contrast, the initial maintenance doses in IM and PM were 5.5 ± 0.7 and 4.1 ± 0.3 mg/kg/day, and the initial trough concentrations were 2.9 ± 1.2 and 2.6 ± 0.4 μg/mL, respectively. The attainment rate of target trough concentration of 1-6 μg/mL was 50% in EM, and was 100% in IM and PM. Determining the initial dose of VRCZ only by phenotype based on CYP2C19 gene polymorphism was found to be challenging. However, decreasing the initial maintenance dose in IM and PM may be important for adjusting the initial trough level to target range.
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Affiliation(s)
- Ryota Tanaka
- Department of Clinical Pharmacy, Oita University Hospital, Oita, Japan,
| | - Takashi Fujioka
- Department of Clinical Pharmacy, Oita University Hospital, Oita, Japan
| | - Yosuke Suzuki
- Department of Clinical Pharmacy, Oita University Hospital, Oita, Japan
| | - Motoshi Iwao
- Department of Clinical Pharmacy, Oita University Hospital, Oita, Japan
| | - Hiroki Itoh
- Department of Clinical Pharmacy, Oita University Hospital, Oita, Japan
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18
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Lee J, Ng P, Hamandi B, Husain S, Lefebvre MJ, Battistella M. Effect of Therapeutic Drug Monitoring and Cytochrome P450 2C19 Genotyping on Clinical Outcomes of Voriconazole: A Systematic Review. Ann Pharmacother 2020; 55:509-529. [DOI: 10.1177/1060028020948174] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objectives To examine current knowledge on the clinical utility of therapeutic drug monitoring (TDM) in voriconazole therapy, the impact of CYP2C19 genotype on voriconazole plasma concentrations, and the role of CYP2C19 genotyping in voriconazole therapy. Data Sources Three literature searches were conducted for original reports on (1) TDM and voriconazole outcomes and (2) voriconazole and CYP2C19 polymorphisms. Searches were conducted through EMBASE, MEDLINE/PubMed, Scopus, and Cochrane Central Register of Controlled Trials from inception to June 2020. Study Selection and Data Extraction Randomized controlled trials, cohort studies, and case series with ≥10 patients were included. Only full-text references in English were eligible. Data Synthesis A total of 63 studies were reviewed. TDM was recommended because of established concentration and efficacy/toxicity relationships. Voriconazole trough concentrations ≥1.0 mg/L were associated with treatment success; supratherapeutic concentrations were associated with increased neurotoxicity; and hepatotoxicity associations were more prevalent in Asian populations. CYP2C19 polymorphisms significantly affect voriconazole metabolism, but no relationship with efficacy/safety were found. Genotype-guided dosing with TDM was reported to increase chances of achieving therapeutic range. Relevance to Patient Care and Clinical Practice Genotype-guided dosing with TDM is a potential solution to optimizing voriconazole efficacy while avoiding treatment failures and common toxicities. Conclusions Voriconazole plasma concentrations and TDM are treatment outcome predictors, but research is needed to form a consensus target therapeutic range and dosage adjustment guidelines based on plasma concentrations. CYP2C19 polymorphisms are a predictor of voriconazole concentrations and metabolism, but clinical implications are not established. Large-scale, high-methodological-quality trials are required to investigate the role for prospective genotyping and establish CYP2C19-guided voriconazole dosing recommendations.
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Affiliation(s)
| | - Patrick Ng
- University Health Network, Toronto, ON, Canada
| | - Bassem Hamandi
- University of Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Shahid Husain
- University of Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | | | - Marisa Battistella
- University of Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
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19
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Abdul-Aziz MH, Alffenaar JWC, Bassetti M, Bracht H, Dimopoulos G, Marriott D, Neely MN, Paiva JA, Pea F, Sjovall F, Timsit JF, Udy AA, Wicha SG, Zeitlinger M, De Waele JJ, Roberts JA. Antimicrobial therapeutic drug monitoring in critically ill adult patients: a Position Paper .. Intensive Care Med 2020; 46:1127-1153. [PMID: 32383061 PMCID: PMC7223855 DOI: 10.1007/s00134-020-06050-1] [Citation(s) in RCA: 450] [Impact Index Per Article: 112.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/10/2020] [Indexed: 12/12/2022]
Abstract
Purpose This Position Paper aims to review and discuss the available data on therapeutic drug monitoring (TDM) of antibacterials, antifungals and antivirals in critically ill adult patients in the intensive care unit (ICU). This Position Paper also provides a practical guide on how TDM can be applied in routine clinical practice to improve therapeutic outcomes in critically ill adult patients.
Methods Literature review and analysis were performed by Panel Members nominated by the endorsing organisations, European Society of Intensive Care Medicine (ESICM), Pharmacokinetic/Pharmacodynamic and Critically Ill Patient Study Groups of European Society of Clinical Microbiology and Infectious Diseases (ESCMID), International Association for Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT) and International Society of Antimicrobial Chemotherapy (ISAC). Panel members made recommendations for whether TDM should be applied clinically for different antimicrobials/classes. Results TDM-guided dosing has been shown to be clinically beneficial for aminoglycosides, voriconazole and ribavirin. For most common antibiotics and antifungals in the ICU, a clear therapeutic range has been established, and for these agents, routine TDM in critically ill patients appears meritorious. For the antivirals, research is needed to identify therapeutic targets and determine whether antiviral TDM is indeed meritorious in this patient population. The Panel Members recommend routine TDM to be performed for aminoglycosides, beta-lactam antibiotics, linezolid, teicoplanin, vancomycin and voriconazole in critically ill patients. Conclusion Although TDM should be the standard of care for most antimicrobials in every ICU, important barriers need to be addressed before routine TDM can be widely employed worldwide. Electronic supplementary material The online version of this article (10.1007/s00134-020-06050-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia
| | - Jan-Willem C Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Westmead Hospital, Westmead, NSW, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa, Genoa and Hospital Policlinico San Martino - IRCCS, Genoa, Italy
| | - Hendrik Bracht
- Department of Anaesthesiology, University Ulm, Ulm, Germany
| | - George Dimopoulos
- Department of Critical Care, University Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
| | - Deborah Marriott
- Department of Microbiology and Infectious Diseases, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Michael N Neely
- Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Division of Infectious Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jose-Artur Paiva
- Department of Medicine, Faculty of Medicine of Porto, Porto, Portugal.,Department of Emergency and Intensive Care Medicine, Centro Hospitalar Universitario de São João, Porto, Portugal
| | - Federico Pea
- Institute of Clinical Pharmacology, SM Misericordia University Hospital, ASUFC, Udine, Italy
| | - Fredrik Sjovall
- Department of Perioperative Medicine, Skåne University Hospital, Malmö, Sweden
| | - Jean F Timsit
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, Paris, France.,Infection, Antimicrobials, Modelling, Evolution (IAME), Paris Diderot University, Paris, France
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia. .,Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia. .,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia. .,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
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20
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Lempers VJ, Meuwese E, Mavinkurve-Groothuis AM, Henriet S, van der Sluis IM, Hanff LM, Warris A, Koch BCP, Brüggemann RJ. Impact of dose adaptations following voriconazole therapeutic drug monitoring in pediatric patients. Med Mycol 2019; 57:937-943. [PMID: 30759261 DOI: 10.1093/mmy/myz006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/08/2019] [Accepted: 01/11/2019] [Indexed: 12/16/2022] Open
Abstract
Voriconazole is the mainstay of treatment for invasive aspergillosis in immunocompromised pediatric patients. Although Therapeutic Drug Monitoring (TDM) of voriconazole is recommended, it remains unknown if TDM-based dose adaptations result in target attainment. Patients <19 years from two pediatric hematologic-oncology wards were retrospectively identified based on unexplained high voriconazole trough concentrations (Cmin > 6 mg/l). Patient demographics, clinical characteristics, treatment, voriconazole dosing information, voriconazole Cmin before and after adjustment based on TDM were obtained. Twenty-one patients, median (range) age 7.0 (1.2-18.5) years, were identified in two centers. First Cmin (3.1 mg/l [0.1-13.5]) was obtained after 3 days (1-27) of treatment. The median of all Cmin (n = 485, median 11 per patient) was 2.16 mg/l (0.0 (undetectable)-28.0), with 24.1% of Cmin < 1 mg/l, 48.9% 1-4 mg/l, 9.3% 4-6 mg/l, and 17.7% > 6 mg/l. Intrapatient variability was large (94.1% for IV, 88.5% for PO). Dose increases at Cmin < 1 mg/l resulted in an increased Cmin in 76.4%, with 60% between 1 and 4 mg/l. Dose decreases at Cmin > 6 mg/l resulted in a decreased Cmin in 80%, with 51% between 1 and 4 mg/l. Overall, in 45% of the cases (33 out of 55 and 12 out of 45) therapeutic targets were attained after dose adjustment. Fifty-five percent of initial Cmin was outside the therapeutic target of 1-4 mg/l, with multiple dose adaptations required to achieve therapeutic concentrations. Only 60% and 51% of dose adaptations following sub- and supra-therapeutic Cmin, respectively, did result in target attainment. Intensive and continuous TDM of voriconazole is a prerequisite for ensuring adequate exposure in pediatric patients.
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Affiliation(s)
- Vincent J Lempers
- Radboud university medical center, Department of Pharmacy and Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Edmé Meuwese
- Erasmus Medical Center, Department of Pharmacy, Rotterdam, The Netherlands
| | | | - Stefanie Henriet
- Radboud university medical center, Department of Pediatric Infectious Diseases & Immunology, Nijmegen, The Netherlands
| | - Inge M van der Sluis
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Erasmus Medical Center-Sophia Children's Hospital, Department of Pediatric Haematology-Oncology, Rotterdam, The Netherlands
| | - Lidwien M Hanff
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Adilia Warris
- MRC Centre for Medical Mycology, Aberdeen Fungal Group, Institute of Medical Sciences, University of Aberdeen, United Kingdom
| | - Birgit C P Koch
- Erasmus Medical Center, Department of Pharmacy, Rotterdam, The Netherlands
| | - Roger J Brüggemann
- Radboud university medical center, Department of Pharmacy and Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
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21
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Wei X, Zhao M, Fu P, Xiao X. Risk factors associated with insufficient and potentially toxic voriconazole plasma concentrations: an observational study. J Chemother 2019; 31:401-7. [PMID: 31359851 DOI: 10.1080/1120009X.2019.1646974] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The aim of this study was to identify potential factors associated with insufficient/toxic voriconazole trough concentrations (VTCs) in patients in order to screen the high-risk population. A total of 119 VTCs were obtained from 67 patients. Multivariate regression analysis suggested that insufficient VTCs (<1.0 mg/L) were significantly associated with younger age and underlying hematological malignancy, and toxic VTCs (>5.5 mg/L) were significantly associated with lower serum albumin (ALB) level. Receiver operating characteristic curve analysis indicated that patients whose age < 47 years were the high-risk population of insufficient VTCs, and patients whose ALB <27 g/L were the high-risk population of toxic VTCs. Younger age and underlying hematological malignancy were significant predictors of insufficient VTCs, and lower ALB level was found to be a significant predictor of toxic VTCs. Therefore, we recommend to increase the monitoring on these high-risk population to avoid treatment failure and to prevent toxic adverse events.
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Ries F, Alflen A, Aranda Lopez P, Beckert H, Theobald M, Schild H, Teschner D, Radsak MP. Antifungal Drugs Influence Neutrophil Effector Functions. Antimicrob Agents Chemother 2019; 63:e02409-18. [PMID: 30910895 DOI: 10.1128/AAC.02409-18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/17/2019] [Indexed: 12/14/2022] Open
Abstract
There is a growing body of evidence for immunomodulatory side effects of antifungal agents on different immune cells, e.g., T cells. Therefore, the aim of our study was to clarify these interactions with regard to the effector functions of polymorphonuclear neutrophils (PMN). Human PMN were preincubated with fluconazole (FLC), voriconazole (VRC), posaconazole (POS), isavuconazole (ISA), caspofungin (CAS), micafungin (MFG), conventional amphotericin B (AMB), and liposomal amphotericin B (LAMB). PMN then were analyzed by flow cytometry for activation, degranulation, and phagocytosis and by dichlorofluorescein assay to detect reactive oxygen species (ROS). Additionally, interleukin-8 (IL-8) release was measured by enzyme-linked immunosorbent assay. POS led to enhanced activation, degranulation, and generation of ROS, whereas IL-8 release was reduced. In contrast, ISA-pretreated PMN showed decreased activation signaling, impaired degranulation, and lower generation of ROS. MFG caused enhanced expression of activation markers but impaired degranulation, phagocytosis, generation of ROS, and IL-8 release. CAS showed increased phagocytosis, whereas degranulation and generation of ROS were reduced. AMB led to activation of almost all effector functions besides impaired phagocytosis, whereas LAMB did not alter any effector functions. Independent from class, antifungal agents show variable influence on neutrophil effector functions in vitro Whether this is clinically relevant needs to be clarified.
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Schwartz IS, Wiederhold NP. Update on Therapeutic Drug Monitoring of Antifungals for the Prophylaxis and Treatment of Invasive Fungal Infections. Curr Fungal Infect Rep 2017; 11:75-83. [DOI: 10.1007/s12281-017-0287-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Warrilow AGS, Parker JE, Price CL, Nes WD, Garvey EP, Hoekstra WJ, Schotzinger RJ, Kelly DE, Kelly SL. The Investigational Drug VT-1129 Is a Highly Potent Inhibitor of Cryptococcus Species CYP51 but Only Weakly Inhibits the Human Enzyme. Antimicrob Agents Chemother 2016; 60:4530-8. [PMID: 27161631 PMCID: PMC4958158 DOI: 10.1128/aac.00349-16] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 05/04/2016] [Indexed: 01/07/2023] Open
Abstract
Cryptococcosis is a life-threatening disease often associated with HIV infection. Three Cryptococcus species CYP51 enzymes were purified and catalyzed the 14α-demethylation of lanosterol, eburicol, and obtusifoliol. The investigational agent VT-1129 bound tightly to all three CYP51 proteins (dissociation constant [Kd] range, 14 to 25 nM) with affinities similar to those of fluconazole, voriconazole, itraconazole, clotrimazole, and ketoconazole (Kd range, 4 to 52 nM), whereas VT-1129 bound weakly to human CYP51 (Kd, 4.53 μM). VT-1129 was as effective as conventional triazole antifungal drugs at inhibiting cryptococcal CYP51 activity (50% inhibitory concentration [IC50] range, 0.14 to 0.20 μM), while it only weakly inhibited human CYP51 activity (IC50, ∼600 μM). Furthermore, VT-1129 weakly inhibited human CYP2C9, CYP2C19, and CYP3A4, suggesting a low drug-drug interaction potential. Finally, the cellular mode of action for VT-1129 was confirmed to be CYP51 inhibition, resulting in the depletion of ergosterol and ergosta-7-enol and the accumulation of eburicol, obtusifolione, and lanosterol/obtusifoliol in the cell membranes.
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Affiliation(s)
- Andrew G S Warrilow
- Centre for Cytochrome P450 Biodiversity, Institute of Life Science, Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Josie E Parker
- Centre for Cytochrome P450 Biodiversity, Institute of Life Science, Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Claire L Price
- Centre for Cytochrome P450 Biodiversity, Institute of Life Science, Swansea University Medical School, Swansea, Wales, United Kingdom
| | - W David Nes
- Center for Chemical Biology, Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, Texas, USA
| | | | | | | | - Diane E Kelly
- Centre for Cytochrome P450 Biodiversity, Institute of Life Science, Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Steven L Kelly
- Centre for Cytochrome P450 Biodiversity, Institute of Life Science, Swansea University Medical School, Swansea, Wales, United Kingdom
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Wang Y, Wang T, Xie J, Yang Q, Zheng X, Dong W, Xing J, Wang X, Dong Y. Risk Factors for Voriconazole-Associated Hepatotoxicity in Patients in the Intensive Care Unit. Pharmacotherapy 2016; 36:757-65. [PMID: 27284960 DOI: 10.1002/phar.1779] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVES To determine the incidence of hepatotoxicity in critically ill patients who were treated with voriconazole and to identify potential risk factors for voriconazole-associated hepatotoxicity in these patients. DESIGN Single-center prospective observational study. SETTING Intensive care unit (ICU) in a university-affiliated hospital in Xi'an, China. PATIENTS Sixty-three adults, admitted to the ICU between January 2010 and July 2015, who had an ICU length of stay longer than 3 days, had received voriconazole treatment for at least 3 days, and had at least one trough voriconazole plasma concentration (VPC) measurement. INTERVENTION All patients received CYP2C19 genotyping and were evaluated for the development of hepatotoxicity by assessing liver function tests performed before, during, and after voriconazole therapy. MEASUREMENTS AND MAIN RESULTS Hepatotoxicity was classified according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) grade scores and was defined as a CTCAE grade score that had increased by at least 2 grade scores over the baseline score. Hepatotoxicity occurred in 12 (19%) of the 63 patients. Characteristics of the patients who developed hepatotoxicity were compared with those of the patients who did not develop hepatotoxicity by univariate and multivariate Cox regression analyses. In the univariate analysis, Acute Physiology and Chronic Health Evaluation II score, invasive fungal infection classification, CYP2C19 genotype, and trough VPC were identified as the variables, and they were subsequently combined in the multivariate regression analysis. Multivariate Cox regression analysis revealed that hepatotoxicity was independently associated with trough VPC (hazard ratio 1.76, p<0.001). The relationships between trough VPCs and probability of hepatotoxicity were explored by using logistic regression analysis, and a target VPC upper limit of 4 mg/L was identified. The Kaplan-Meier method for the cumulative incidence of hepatotoxicity showed a significant difference between patients with trough VPCs of 4 mg/L or higher and those with VPCs lower than 4 mg/L (p<0.001). CONCLUSION Trough VPC was an independent risk factor associated with a greater risk of developing hepatotoxicity in critically ill patients, with a potentially toxic target trough concentration threshold of 4 mg/L identified for this complex population.
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Affiliation(s)
- Yan Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Taotao Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jiao Xie
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Qianting Yang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiaowei Zheng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Weihua Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jianfeng Xing
- School of Pharmacy, Health Science Center, Xi'an Jiaotong University, Xi'an, China
| | - Xue Wang
- Central Intensive Care Unit, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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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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Matsumoto K, Abematsu K, Shigemi A, Kanazawa N, Watanabe E, Yokoyama Y, Ikawa K, Morikawa N, Takeda Y. Therapeutic drug monitoring of voriconazole in Japanese patients: analysis based on clinical practice data. J Chemother 2016; 28:198-202. [PMID: 26187373 DOI: 10.1179/1973947815y.0000000057] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The aim of this study was to investigate whether routine therapeutic drug monitoring (TDM) of voriconazole (VRCZ) reduced discontinuation due to hepatotoxicity. Hepatotoxicity was observed in 15 (51.7%) out of 29 patients. The percentages of patients who developed hepatotoxicity within 4 days and 1 week were 26.7 and 46.7%, respectively. The drug trough concentrations in patients with and without hepatotoxicity were 5.55 ± 2.73 and 2.36 ± 1.67 μg/ml (P < 0.01, the two-sided Student's t-test), respectively. Trough concentrations reached the target of 1-5 μg/ml in patients with gradual dose reductions based on TDM, and, consequently, liver enzyme levels returned to the original levels before the VRCZ treatment. All patients eventually continued effective VRCZ therapy despite its hepatotoxicity. Thus, dose adjustments by TDM to achieve the target trough concentrations is useful in order to avoid hepatotoxicity and enable continued effective VRCZ therapy for Japanese patients with invasive fungal infections.
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Affiliation(s)
- Kazuaki Matsumoto
- a Department of Clinical Pharmacy and Pharmacology, Graduate School of Medical and Dental Sciences , Kagoshima University , Kagoshima , Japan
| | - Kazuko Abematsu
- a Department of Clinical Pharmacy and Pharmacology, Graduate School of Medical and Dental Sciences , Kagoshima University , Kagoshima , Japan
| | - Akari Shigemi
- a Department of Clinical Pharmacy and Pharmacology, Graduate School of Medical and Dental Sciences , Kagoshima University , Kagoshima , Japan
| | - Naoko Kanazawa
- a Department of Clinical Pharmacy and Pharmacology, Graduate School of Medical and Dental Sciences , Kagoshima University , Kagoshima , Japan
| | - Erika Watanabe
- a Department of Clinical Pharmacy and Pharmacology, Graduate School of Medical and Dental Sciences , Kagoshima University , Kagoshima , Japan
| | - Yuta Yokoyama
- a Department of Clinical Pharmacy and Pharmacology, Graduate School of Medical and Dental Sciences , Kagoshima University , Kagoshima , Japan.,b Department of Clinical Pharmacotherapy , Hiroshima University , Hiroshima , Japan
| | - Kazuro Ikawa
- b Department of Clinical Pharmacotherapy , Hiroshima University , Hiroshima , Japan
| | - Norifumi Morikawa
- b Department of Clinical Pharmacotherapy , Hiroshima University , Hiroshima , Japan
| | - Yasuo Takeda
- a Department of Clinical Pharmacy and Pharmacology, Graduate School of Medical and Dental Sciences , Kagoshima University , Kagoshima , Japan
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Luong ML, Al-Dabbagh M, Groll AH, Racil Z, Nannya Y, Mitsani D, Husain S. Utility of voriconazole therapeutic drug monitoring: a meta-analysis. J Antimicrob Chemother 2016; 71:1786-99. [DOI: 10.1093/jac/dkw099] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 02/29/2016] [Indexed: 11/12/2022] Open
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Ceesay MM, Couchman L, Smith M, Wade J, Flanagan RJ, Pagliuca A. Triazole antifungals used for prophylaxis and treatment of invasive fungal disease in adult haematology patients: Trough serum concentrations in relation to outcome. Med Mycol 2016; 54:691-8. [DOI: 10.1093/mmy/myw031] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 03/28/2016] [Indexed: 12/15/2022] Open
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Dote S, Sawai M, Nozaki A, Naruhashi K, Kobayashi Y, Nakanishi H. A retrospective analysis of patient-specific factors on voriconazole clearance. J Pharm Health Care Sci 2016; 2:10. [PMID: 27096102 PMCID: PMC4835838 DOI: 10.1186/s40780-016-0044-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 03/28/2016] [Indexed: 11/19/2022] Open
Abstract
Background Voriconazole concentrations display a large variability, which cannot completely be explained by known factors. We investigated the relationships of voriconazole concentration with patient-specific variables and concomitant medication to identify clinical factors affecting voriconazole clearance. Methods A retrospective chart review of voriconazole trough concentration, laboratory data, and concomitant medication in patients was performed. The concentration/dose ratio (C/D-ratio) was assessed as a surrogate marker of total clearance by dividing voriconazole concentration by daily dose per kg of body weight. Results A total of 77 samples from 63 patients were obtained. In multiple linear regression analysis, increased C-reactive protein (CRP) level (p < 0.05) and decreased albumin (Alb) level (p < 0.05) were associated with significantly increased C/D-ratio of voriconazole, and coadministration with a glucocorticoid was associated with significantly (p < 0.05) decreased C/D-ratio of voriconazole (adjusted r2 = 0.31). Regarding CRP and Alb, receiver operating characteristic curve analysis indicated that increased CRP level and decreased Alb level were significant predictors of toxic trough concentration of voriconazole. For CRP, area under the curve (AUC) and cutoff value were 0.71 (95 % confidence interval (CI), 0.57–0.86, p < 0.01) and 4.7 mg/dl, respectively. For Alb, AUC and cutoff value were 0.68 (95 % CI, 0.53–0.82, p < 0.05) and 2.7 g/dl, respectively. A significant difference was seen in voriconazole trough concentration between patients with hepatotoxicity and those without (5.69 μg/ml vs 3.0 μg/ml, p < 0.001). Conclusion Coadministration of glucocorticoid and inflammation, reflected by elevated CRP level and hypoalbuminemia, are associated with voriconazole clearance. We propose that early measurement of voriconazole concentration before the plateau phase will lead to avoidance of a toxic voriconazole level in patients with elevated CRP level and hypoalbuminemia, although further studies are needed to confirm our findings.
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Affiliation(s)
- Satoshi Dote
- Department of Pharmacy, Kyoto-Katsura Hospital, 17 Yamadahirao-cho, Nishikyo-ku, Kyoto 615-8256 Japan
| | - Maki Sawai
- Department of Pharmacy, Kyoto-Katsura Hospital, 17 Yamadahirao-cho, Nishikyo-ku, Kyoto 615-8256 Japan
| | - Ayumu Nozaki
- Department of Pharmacy, Kyoto-Katsura Hospital, 17 Yamadahirao-cho, Nishikyo-ku, Kyoto 615-8256 Japan
| | - Kazumasa Naruhashi
- Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, Kodo, Kyotanabe-shi, Kyoto 610-0395 Japan
| | - Yuka Kobayashi
- Department of Pharmacy, Kyoto-Katsura Hospital, 17 Yamadahirao-cho, Nishikyo-ku, Kyoto 615-8256 Japan
| | - Hirokazu Nakanishi
- Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, Kodo, Kyotanabe-shi, Kyoto 610-0395 Japan
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Jin H, Wang T, Falcione BA, Olsen KM, Chen K, Tang H, Hui J, Zhai S. Trough concentration of voriconazole and its relationship with efficacy and safety: a systematic review and meta-analysis. J Antimicrob Chemother 2016; 71:1772-85. [PMID: 26968880 PMCID: PMC4896404 DOI: 10.1093/jac/dkw045] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 01/29/2016] [Indexed: 01/12/2023] Open
Abstract
This meta-analysis showed trough concentrations of 0.5 mg/L to be the lower limit of voriconazole during treatment, whereas trough concentrations of 3.0 mg/L were associated with an increased risk of moderate to severe hepatotoxicity, particularly for the Asian population. Objectives The optimum trough concentration of voriconazole for clinical response and safety is controversial. The objective of this review was to determine the optimum trough concentration of voriconazole and evaluate its relationship with efficacy and safety. Methods MEDLINE, EMBASE, ClinicalTrials.gov, the Cochrane Library and three Chinese literature databases were searched. Observational studies that compared clinical outcomes below and above the trough concentration cut-off value were included. We set the trough concentration cut-off value for efficacy as 0.5, 1.0, 1.5, 2.0 and 3.0 mg/L and for safety as 3.0, 4.0, 5.0, 5.5 and 6.0 mg/L. The efficacy outcomes were invasive fungal infection-related mortality, all-cause mortality, rate of successful treatment and rate of prophylaxis failure. The safety outcomes included incidents of hepatotoxicity, neurotoxicity and visual disorders. Results A total of 21 studies involving 1158 patients were included. Compared with voriconazole trough concentrations of >0.5 mg/L, levels of <0.5 mg/L significantly decreased the rate of treatment success (risk ratio = 0.46, 95% CI 0.29–0.74). The incidence of hepatotoxicity was significantly increased with trough concentrations >3.0, >4.0, >5.5 and >6.0 mg/L. The incidence of neurotoxicity was significantly increased with trough concentrations >4.0 and >5.5 mg/L. Conclusions A voriconazole level of 0.5 mg/L should be considered the lower threshold associated with efficacy. A trough concentration >3.0 mg/L is associated with increased hepatotoxicity, particularly for the Asian population, and >4.0 mg/L is associated with increased neurotoxicity.
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Affiliation(s)
- Haiying Jin
- Department of Pharmacy, Peking University Third Hospital, Beijing, China Department of Pharmacy, The Affiliated Hospital of Medical College, Ningbo University, Ningbo, Zhejiang, China
| | - Tiansheng Wang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China Department of Pharmacy Administration and Clinical Pharmacy, Peking University School of Pharmaceutical Sciences, Beijing, China
| | - Bonnie A Falcione
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Keith M Olsen
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ken Chen
- Department of Pharmacy, Peking University Third Hospital, Beijing, China Department of Pharmacy Administration and Clinical Pharmacy, Peking University School of Pharmaceutical Sciences, Beijing, China
| | - Huilin Tang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - John Hui
- Department of Pharmacy, Stanford University Hospital and Clinics, Palo Alto, CA, USA
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
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Implications of Pharmacogenetics for Antimicrobial Prescribing. Mol Microbiol 2016. [DOI: 10.1128/9781555819071.ch43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
While the pace of discovery of new agents, mechanisms and risk factors involved in drug-induced liver injury (DILI) remains brisk, advances in the treatment of acute DILI seems slow by comparison. In general, the key to treating suspected DILI is to stop using the drug prior to developing irreversible liver failure. However, predicting when to stop is an inexact science, and commonly used ALT monitoring is an ineffective strategy outside of clinical trials. The only specific antidote for acute DILI remains N-acetylcysteine (NAC) for acetaminophen poisoning, although NAC is proving to be beneficial in some cases of non-acetaminophen DILI in adults. Corticosteroids can be effective for DILI associated with autoimmune or systemic hypersensitivity features. Ursodeoxycholic acid, silymarin and glycyrrhizin have been used to treat DILI for decades, but success remains anecdotal. Bile acid washout regimens using cholestyramine appear to be more evidenced based, in particular for leflunomide toxicity. For drug-induced acute liver failure, the use of liver support systems is still investigational in the United States and emergency liver transplant remains limited by its availability. Primary prevention appears to be the key to avoiding DILI and the need for acute treatment. Pharmacogenomics, including human leukocyte antigen genotyping and the discovery of specific DILI biomarkers offers significant promise for the future. This article describes and summarizes the numerous and diverse treatment and prevention modalities that are currently available to manage DILI.
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Affiliation(s)
- Jonathan G. Stine
- University of Virginia Health System, Department of Medicine, Division of Gastroenterology and Hepatology, JPA and Lee Street, MSB 2145, PO Box 800708, Charlottesville VA 22908
| | - James H. Lewis
- Georgetown University Medical Center, Department of Medicine, Division of Gastroenterology and Hepatology, 3800 Reservoir Rd NW, Washington, DC 20007
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Shubitz LF, Trinh HT, Galgiani JN, Lewis ML, Fothergill AW, Wiederhold NP, Barker BM, Lewis ER, Doyle AL, Hoekstra WJ, Schotzinger RJ, Garvey EP. Evaluation of VT-1161 for Treatment of Coccidioidomycosis in Murine Infection Models. Antimicrob Agents Chemother 2015; 59:7249-54. [PMID: 26369964 DOI: 10.1128/AAC.00593-15] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 08/30/2015] [Indexed: 12/27/2022] Open
Abstract
Coccidioidomycosis, or valley fever, is a growing health concern endemic to the southwestern United States. Safer, more effective, and more easily administered drugs are needed especially for severe, chronic, or unresponsive infections. The novel fungal CYP51 inhibitor VT-1161 demonstrated in vitro antifungal activity, with MIC50 and MIC90 values of 1 and 2 μg/ml, respectively, against 52 Coccidioides clinical isolates. In the initial animal study, oral doses of 10 and 50 mg/kg VT-1161 significantly reduced fungal burdens and increased survival time in a lethal respiratory model in comparison with treatment with a placebo (P < 0.001). Oral doses of 25 and 50 mg/kg VT-1161 were similarly efficacious in the murine central nervous system (CNS) model compared to placebo treatment (P < 0.001). All comparisons with the positive-control drug, fluconazole at 50 mg/kg per day, demonstrated either statistical equivalence or superiority of VT-1161. VT-1161 treatment also prevented dissemination of infection from the original inoculation site to a greater extent than fluconazole. Many of these in vivo results can be explained by the long half-life of VT-1161 leading to sustained high plasma levels. Thus, the efficacy and pharmacokinetics of VT-1161 are attractive characteristics for long-term treatment of this serious fungal infection.
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Abstract
Antimicrobial efficacy and toxicity varies between individuals owing to multiple factors. Genetic variants that affect drug-metabolizing enzymes may influence antimicrobial pharmacokinetics and pharmacodynamics, thereby determining efficacy and/or toxicity. In addition, many severe immune-mediated reactions have been associated with HLA class I and class II genes. In the last two decades, understanding of pharmacogenomic factors that influence antimicrobial efficacy and toxicity has rapidly evolved, leading to translational success such as the routine use of HLA-B*57:01 screening to prevent abacavir hypersensitivity reactions. This article examines recent advances in the field of antimicrobial pharmacogenomics that potentially affect treatment efficacy and toxicity, and challenges that exist between pharmacogenomic discovery and translation into clinical use.
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Affiliation(s)
- Ar Kar Aung
- Department of General Medicine & Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
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Abstract
Voriconazole is an azole useful for the prophylaxis and the treatment of aspergillosis and other fungal infections in immunosuppressed subjects, as those found in aplasia after aggressive polychemotherapy treatments, after hematopoietic stem cell, liver or lung transplantation. Its administration in therapeutic doses lead to extremely varied serum levels from patient to patient and even to the same patient. The explanations are varied: nonlinear pharmacokinetics, certain patient-related factors, including genetic polymorphisms in the cytochrome P450 2C19 gene, the kidney and liver function, simultaneous administration with other drugs metabolised by the same cytochrome. It is recommended to maintain the serum concentrations of voriconazole between 1.5 and 4 μg/mL. At lower values its efficacy decreases and at higher values the risk of neurological toxicity increases. Even at these concentrations it is not excluded the possible appearance of a variety of toxic effects, including on the liver, manifested by cholestasis, hepatocytolisis, or their combination. It is recommended to monitor the clinical and laboratory evolution of all patients treated with voriconazole, and of the serum levels of the drug of those who belong to risk groups, even if there is still no consensus on this issue, given the lack of correlation between the serum level and the occurrence of adverse effects in many patients.
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Barr VO, Zdyb EG, Postelnick M. The Clinical Significance of Azole Antifungals’ Effects on the Liver and Transaminase Levels. Curr Fungal Infect Rep 2015; 9:190-5. [DOI: 10.1007/s12281-015-0226-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Moriyama B, Kadri S, Henning SA, Danner RL, Walsh TJ, Penzak SR. Therapeutic Drug Monitoring and Genotypic Screening in the Clinical Use of Voriconazole. Curr Fungal Infect Rep 2015; 9:74-87. [PMID: 26918067 DOI: 10.1007/s12281-015-0219-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Voriconazole is an antifungal triazole that is the first line agent for treatment of invasive aspergillosis. It is metabolized by CYP2C19, CYP2C9, and CYP3A4 and demonstrates wide interpatient variability in serum concentrations. Polymorphisms in CYP2C19 contribute to variability in voriconazole pharmacokinetics. Here, evidence is examined for the use of voriconazole therapeutic drug monitoring (TDM) and the role of CYP2C19 genotyping in voriconazole dosing. The majority of studies exploring the impact of voriconazole TDM on efficacy and safety have found TDM to be beneficial. However, most of these studies are observational, with only one being a randomized controlled trial. High-volume multicenter randomized controlled trials of TDM are currently not available to support definitive guidelines. There is a significant relationship in healthy volunteers between CYP2C19 genotype and voriconazole pharmacokinetics, but this association is markedly less visible in actual patients. While CYP2C19 genotype data may explain variability of voriconazole serum levels, they alone are not sufficient to guide initial dosing. The timeliness of availability of CYP2C19 genotype data in treatment of individual patients also remains challenging. Additional studies are needed before implementation of CYP2C19 genotyping for voriconazole dosing into routine clinical care.
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Affiliation(s)
- Brad Moriyama
- NIH Clinical Center, Pharmacy Department, Bethesda, MD
| | - Sameer Kadri
- NIH Clinical Center, Critical Care Medicine Department, Bethesda, MD
| | | | - Robert L Danner
- NIH Clinical Center, Critical Care Medicine Department, Bethesda, MD
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program, Department of Medicine, Pediatrics, and Microbiology and Infectious Diseases, Weill Cornell Medical Center of Cornell University, New York, NY
| | - Scott R Penzak
- Department of Pharmacotherapy University of North Texas System College of Pharmacy, Fort Worth, TX
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Karthaus M, Lehrnbecher T, Lipp HP, Kluge S, Buchheidt D. Therapeutic drug monitoring in the treatment of invasive aspergillosis with voriconazole in cancer patients--an evidence-based approach. Ann Hematol 2015; 94:547-56. [PMID: 25697592 DOI: 10.1007/s00277-015-2333-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 01/24/2015] [Indexed: 11/28/2022]
Abstract
Invasive aspergillosis (IA) is a life-threatening complication in hematological cancer patients. Voriconazole (VCZ) is the established first-line treatment of IA. VCZ has a nonlinear pharmacokinetic profile and exhibits considerable variability of drug exposure. Therefore, therapeutic drug monitoring (TDM) of VCZ may help to improve treatment results in IA patients, but evidence-based data on the clinical use of TDM in patients treated with VCZ for IA are scarce. Evidence-based guidance is needed to support decisions on the use of TDM in routine VCZ therapy of IA. Our present analysis assessed published studies for evidence-based criteria for TDM of VCZ to improve efficacy and safety of IA therapy in cancer patients. Literature searches of MEDLINE and Cochrane database were performed. We identified 27 clinical studies reporting on the use of plasma level monitoring and/or TDM for VCZ. For each study, strength of recommendation and quality of evidence were categorized according to predefined criteria. A number of studies were published on plasma level monitoring (PLM) and TDM in VCZ therapy of IA. Across studies, VCZ levels >5-5.5 mg/L were found to be associated with toxicity, while reaching minimum levels of >1-2 mg/L appeared to improve efficacy. Timing, frequency, and intervention thresholds and dosage increments of VCZ for adjustment of plasma levels remain to be established. Currently, there is still no conclusive evidence for recommendations in routine clinical practice. More data from prospective randomized studies with TDM are desirable to provide a solid evidence basis for these approaches.
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Affiliation(s)
- Meinolf Karthaus
- Medical Clinic IV, Hematology and Oncology, Neuperlach Hospital, Munich, Germany,
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Vanstraelen K, Wauters J, Vercammen I, de Loor H, Maertens J, Lagrou K, Annaert P, Spriet I. Impact of hypoalbuminemia on voriconazole pharmacokinetics in critically ill adult patients. Antimicrob Agents Chemother 2014; 58:6782-9. [PMID: 25182655 PMCID: PMC4249353 DOI: 10.1128/aac.03641-14] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 08/23/2014] [Indexed: 01/30/2023] Open
Abstract
Setting the adequate dose for voriconazole is challenging due to its variable pharmacokinetics. We investigated the impact of hypoalbuminemia (<35 g/liter) on voriconazole pharmacokinetics in adult intensive care unit (ICU) patients treated with voriconazole (20 samples in 13 patients) as well as in plasma samples from ICU patients that had been spiked with voriconazole at concentrations of 1.5 mg/liter, 2.9 mg/liter, and 9.0 mg/liter (66 samples from 22 patients). Plasma albumin concentrations ranged from 13.8 to 38.7 g/liter. Total voriconazole concentrations in adult ICU patients treated with voriconazole ranged from 0.5 to 8.7 mg/liter. Unbound and bound voriconazole concentrations were separated using high-throughput equilibrium dialysis followed by liquid chromatography-tandem mass spectrometry (LC-MSMS). Multivariate analysis revealed a positive relationship between voriconazole plasma protein binding and plasma albumin concentrations (P < 0.001), indicating higher unbound voriconazole concentrations with decreasing albumin concentrations. The correlation is more pronounced in the presence of elevated bilirubin concentrations (P = 0.05). We therefore propose to adjust the measured total voriconazole concentrations in patients with abnormal plasma albumin and total serum bilirubin plasma concentrations who show adverse events potentially related to voriconazole via a formula that we developed. Assuming 50% protein binding on average and an upper limit of 5.5 mg/liter for total voriconazole concentrations, the upper limit for unbound voriconazole concentrations is 2.75 mg/liter. Alterations in voriconazole unbound concentrations caused by hypoalbuminemia and/or elevated bilirubin plasma concentrations cannot be countered immediately, due to the adult saturated hepatic metabolism. Consequently, increased unbound voriconazole concentrations can possibly cause adverse events, even when total voriconazole concentrations are within the reference range.
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Affiliation(s)
- Kim Vanstraelen
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, University Hospitals Leuven, Leuven, Belgium
| | - Joost Wauters
- Clinical Department of General Internal Medicine, Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Ine Vercammen
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, University Hospitals Leuven, Leuven, Belgium
| | - Henriette de Loor
- Department of Microbiology and Immunology, Laboratory of Nephrology and Renal Transplantation, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Johan Maertens
- Clinical Department of Haematology, Acute Leukaemia and Stem Cell Transplantation Unit, University Hospitals Leuven, Leuven, Belgium
| | - Katrien Lagrou
- Clinical Department of Laboratory Medicine, Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Annaert
- Department of Pharmaceutical and Pharmacological Sciences, Drug Delivery and Disposition, KU Leuven, Leuven, Belgium
| | - Isabel Spriet
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, University Hospitals Leuven, Leuven, Belgium
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Warrilow AG, Hull CM, Parker JE, Garvey EP, Hoekstra WJ, Moore WR, Schotzinger RJ, Kelly DE, Kelly SL. The clinical candidate VT-1161 is a highly potent inhibitor of Candida albicans CYP51 but fails to bind the human enzyme. Antimicrob Agents Chemother 2014; 58:7121-7. [PMID: 25224009 DOI: 10.1128/AAC.03707-14] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The binding and cytochrome P45051 (CYP51) inhibition properties of a novel antifungal compound, VT-1161, against purified recombinant Candida albicans CYP51 (ERG11) and Homo sapiens CYP51 were compared with those of clotrimazole, fluconazole, itraconazole, and voriconazole. VT-1161 produced a type II binding spectrum with Candida albicans CYP51, characteristic of heme iron coordination. The binding affinity of VT-1161 for Candida albicans CYP51 was high (dissociation constant [Kd], ≤ 39 nM) and similar to that of the pharmaceutical azole antifungals (Kd, ≤ 50 nM). In stark contrast, VT-1161 at concentrations up to 86 μM did not perturb the spectrum of recombinant human CYP51, whereas all the pharmaceutical azoles bound to human CYP51. In reconstitution assays, VT-1161 inhibited Candida albicans CYP51 activity in a tight-binding fashion with a potency similar to that of the pharmaceutical azoles but failed to inhibit the human enzyme at the highest concentration tested (50 μM). In addition, VT-1161 (MIC = 0.002 μg ml(-1)) had a more pronounced fungal sterol disruption profile (increased levels of methylated sterols and decreased levels of ergosterol) than the known CYP51 inhibitor voriconazole (MIC = 0.004 μg ml(-1)). Furthermore, VT-1161 weakly inhibited human CYP2C9, CYP2C19, and CYP3A4, suggesting a low drug-drug interaction potential. In summary, VT-1161 potently inhibited Candida albicans CYP51 and culture growth but did not inhibit human CYP51, demonstrating a >2,000-fold selectivity. This degree of potency and selectivity strongly supports the potential utility of VT-1161 in the treatment of Candida infections.
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Chen GY, Chiu HH, Lin SW, Tseng YJ, Tsai SJ, Kuo CH. Development and application of a comparative fatty acid analysis method to investigate voriconazole-induced hepatotoxicity. Clin Chim Acta. 2015;438:126-134. [PMID: 25150729 DOI: 10.1016/j.cca.2014.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 08/08/2014] [Accepted: 08/11/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND As fatty acids play an important role in biological regulation, the profiling of fatty acid expression has been used to discover various disease markers and to understand disease mechanisms. This study developed an effective and accurate comparative fatty acid analysis method using differential labeling to speed up the metabolic profiling of fatty acids. METHODS Fatty acids were derivatized with unlabeled (D0) or deuterated (D3) methanol, followed by GC-MS analysis. The comparative fatty acid analysis method was validated using a series of samples with different ratios of D0/D3-labeled fatty acid standards and with mouse liver extracts. RESULTS Using a lipopolysaccharide (LPS)-treated mouse model, we found that the fatty acid profiles after LPS treatment were similar between the conventional single-sample analysis approach and the proposed comparative approach, with a Pearson's correlation coefficient of approximately 0.96. We applied the comparative method to investigate voriconazole-induced hepatotoxicity and revealed the toxicity mechanism as well as the potential of using fatty acids as toxicity markers. CONCLUSIONS In conclusion, the comparative fatty acid profiling technique was determined to be fast and accurate and allowed the discovery of potential fatty acid biomarkers in a more economical and efficient manner.
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Dolton MJ, McLachlan AJ. Voriconazole pharmacokinetics and exposure-response relationships: assessing the links between exposure, efficacy and toxicity. Int J Antimicrob Agents 2014; 44:183-93. [PMID: 25106074 DOI: 10.1016/j.ijantimicag.2014.05.019] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 05/19/2014] [Indexed: 11/15/2022]
Abstract
The triazole antifungal voriconazole (VCZ) exhibits broad-spectrum antifungal activity and is the first-line treatment for invasive aspergillosis. Highly variable, non-linear pharmacokinetics, metabolism via the polymorphic drug-metabolising enzyme CYP2C19, and a range of serious adverse events (AEs) including hepatotoxicity and neurotoxicity complicate the clinical utility of VCZ. As interest in optimising VCZ treatment has increased, a growing number of studies have examined the relationships between VCZ exposure and efficacy in the treatment and prevention of invasive fungal infections, as well as associations with VCZ-related AEs. This review provides a critical analysis of VCZ pharmacokinetics and exposure-response (E-R) relationships, assessing the links between VCZ exposure, efficacy and toxicity. Low VCZ exposure has frequently been associated with a higher incidence of treatment failure; fewer studies have addressed E-R relationships with prophylactic VCZ. VCZ-related neurotoxicity appears common at high VCZ concentrations and can be minimised by maintaining concentrations below the recommended upper concentration thresholds; hepatotoxicity appears to be associated with increased VCZ exposure but is also prevalent at low concentrations. Further research should aim to inform and optimise the narrow therapeutic range of VCZ as well as develop interventions to individualise VCZ dosing to achieve maximal efficacy with minimal toxicity.
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Affiliation(s)
- Michael J Dolton
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Andrew J McLachlan
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia; Centre for Education and Research on Ageing, Concord Repatriation General Hospital, Sydney, NSW, Australia.
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Autmizguine J, Guptill JT, Cohen-Wolkowiez M, Benjamin DK, Capparelli EV. Pharmacokinetics and pharmacodynamics of antifungals in children: clinical implications. Drugs 2014; 74:891-909. [PMID: 24872147 PMCID: PMC4073603 DOI: 10.1007/s40265-014-0227-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Invasive fungal disease (IFD) remains life threatening in premature infants and immunocompromised children despite the recent development of new antifungal agents. Optimal dosing of antifungals is one of the few factors clinicians can control to improve outcomes of IFD. However, dosing in children cannot be extrapolated from adult data because IFD pathophysiology, immune response, and drug disposition differ from adults. We critically examined the literature on pharmacokinetics (PK) and pharmacodynamics (PD) of antifungal agents and highlight recent developments in treating pediatric IFD. To match adult exposure in pediatric patients, dosing adjustment is necessary for almost all antifungals. In young infants, the maturation of renal and metabolic functions occurs rapidly and can significantly influence drug exposure. Fluconazole clearance doubles from birth to 28 days of life and, beyond the neonatal period, agents such as fluconazole, voriconazole, and micafungin require higher dosing than in adults because of faster clearance in children. As a result, dosing recommendations are specific to bracketed ranges of age. PD principles of antifungals mostly rely on in vitro and in vivo models but very few PD studies specifically address IFD in children. The exposure-response relationship may differ in younger children compared with adults, especially in infants with invasive candidiasis who are at higher risk of disseminated disease and meningoencephalitis, and by extension severe neurodevelopmental impairment. Micafungin is the only antifungal agent for which a specific target of exposure was proposed based on a neonatal hematogenous Candida meningoencephalitis animal model. In this review, we found that pediatric data on drug disposition of newer triazoles and echinocandins are lacking, dosing of older antifungals such as fluconazole and amphotericin B products still need optimization in young infants, and that target PK/PD indices need to be clinically validated for almost all antifungals in children. A better understanding of age-specific PK and PD of new antifungals in infants and children will help improve clinical outcomes of IFD by informing dosing and identifying future research areas.
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Affiliation(s)
- Julie Autmizguine
- Duke Clinical Research Institute, 2400 Pratt St, Durham, NC 27705, USA
| | | | | | | | - Edmund V. Capparelli
- Department of Pediatric Pharmacology, University of California, 9500 Gilman Drive, La Jolla, CA 92093-0831, USA
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Wiederhold NP, Pennick GJ, Dorsey SA, Furmaga W, Lewis JS, Patterson TF, Sutton DA, Fothergill AW. A reference laboratory experience of clinically achievable voriconazole, posaconazole, and itraconazole concentrations within the bloodstream and cerebral spinal fluid. Antimicrob Agents Chemother 2013; 58:424-31. [PMID: 24189246 PMCID: PMC3910734 DOI: 10.1128/aac.01558-13] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 10/25/2013] [Indexed: 11/20/2022] Open
Abstract
Interest in antifungal therapeutic-drug monitoring has increased due to studies demonstrating associations between concentrations and outcomes. We reviewed the antifungal drug concentration database at our institution to gain a better understanding of achievable triazole drug levels. Antifungal concentrations were measured by high-performance liquid chromatography (HPLC), ultraperformance liquid chromatography and single-quadrupole mass spectrometry (UPLC/MS), or a bioassay. For this study, only confirmed human bloodstream (serum or plasma) and cerebral spinal fluid (CSF) concentrations of voriconazole, posaconazole, and itraconazole were analyzed. The largest numbers of bloodstream and CSF samples were found for voriconazole (14,370 and 173, respectively). Voriconazole bloodstream concentrations within the range of 1 to 5.5 μg/ml represented 50.6% of samples. Levels below the lower limit of quantification (0.2 μg/ml) were observed in 14.6% of samples, and 10.4% of samples had levels of ≥5.5 μg/ml. CSF voriconazole levels ranged from undetectable to 15.3 μg/ml and were <0.2 μg/ml in 11% of samples. Posaconazole bloodstream concentrations were ≥0.7 and ≥1.25 μg/ml in 41.6% and 18.9% of samples, respectively. Posaconazole was detected in only 4 of 22 CSF samples (undetectable to 0.56 μg/ml). Itraconazole levels, as measured by UPLC/MS, were ≥0.5 μg/ml in 43.3% and were undetectable in 33.9% of bloodstream samples. In contrast, when measured by a bioassay, itraconazole/hydroxyitraconazole bloodstream concentrations were ≥1.0 μg/ml in 72.9% of samples and were undetectable in 18% of samples. These results indicate that there is marked variability in bloodstream concentrations achieved with these three azoles. In addition, many levels within the bloodstream for each azole and for voriconazole and posaconazole in the CSF were undetectable or below thresholds associated with efficacy.
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Affiliation(s)
- Nathan P. Wiederhold
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Gennethel J. Pennick
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Sheryl A. Dorsey
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Wieslaw Furmaga
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - James S. Lewis
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- University Health System, San Antonio, Texas, USA
| | - Thomas F. Patterson
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Deanna A. Sutton
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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