Amphotericin B lipid complex in the treatment of invasive fungal infections in liver transplant patients

Adverse Drug Reaction of Antifungals in the Management of Black Fungus: A Tertiary Care Centre Experience

In India, COVID-19 has led to a surge in cases of a potentially fatal fungal infection called mucormycosis, popularly known as “black fungus.” Intravenous amphotericin B is the only available drug for salvage therapy. Efforts to improve its therapeutic efficacy and decrease its nephrotoxicity have focussed on the reformulation of AmB in three new lipid formulations such amphotericin B lipid complex (Abelcet), amphotericin B colloidal dispersion (Amphotec), and liposomal amphotericin B (AmBisome). The aim of this study is (1) to evaluate the adverse drug reaction of various formulations of amphotericin B used for the treatment of rhinooculocerebralmucormycosis in Indian population. (2) to evaluate the adverse drug reaction of injectable form of posaconazole. This prospective observational study was done on a random sample of 110 patients who got admitted for the management of rhinooculocerebral mucormycosis in a tertiary care centre of middle india… The patients were assessed for the adverse reactions following the administration of various antifungal medication and the findings were analysed. All the 110 patients had received two forms of Amphotericin B (liposomal Amphotericin B and Amphotericin B lipid complex) and Posaconazole injection. 60 patients had received all three forms of Amphotericin B. Out of the 110 patients who received Liposomal amphotericin B, only 2 patients developed adverse drug reaction while in 110 patients who received Amphotericin B Lipid complex, 7 patients had adverse drug effects. Lyophilised amphotericin B had been administered to 60 patients in which 51 patients developed adverse drug reaction and in them one patient went to congestive cardiac failure. Injection posaconazole had been administered to 110 patients in which 72 patients developed drug reaction. In spite of its proven track record of Amphotericin B, its well-known side effects and toxicity will sometimes require discontinuation of therapy despite a life-threatening systemic fungal infection. Lipid formulations of AmB are better tolerated than AmB deoxycholate but infusional drug reactions have been reported in lipid formulation too. So improved strategies for the management of infusion related adverse events are required.

Theranostics Based on Liposome: Looking Back and Forward

Liposome is one of the oldest yet most successful nanomedicine platforms. Doxil®, PEGylated liposome loaded with doxorubicin (DOX), was approved by the FDA in 1995 for the treatment of AIDS-related Kaposi's sarcoma, and it was the first approval for nanomedicine. Since then, liposome-based therapeutics were approved for the treatment of various diseases and many clinical trials are underway. The success of the liposome-based therapeutics was due to following factors: (1) ease of synthesis, (2) biocompatibility, (3) the ability to load both hydrophilic and hydrophobic agents, and (4) long circulation property after application of polyethylene glycol (PEG). Recently, more functionalities are introduced to liposome platform, which are (1) in vivo imaging probes for optical, magnetic resonance imaging (MRI), positron emission tomography (PET), and single-photon emission computed tomography (SPECT), (2) pH and temperature-sensitive lipid moiety, and (3) novel agents for photodynamic and photothermal therapies (PDT, PTT). These conventional and newly tested advantages make the liposome to be one of the most promising nanoplatforms for theranostics.

Atualização no uso de agentes antifúngicos

Aborda-se sumariamente o espectro de ação, aspectos farmacológicos e toxicológicos e eficácia clínica de anfotericina B lipossomal, anfotericina B em dispersão coloidal, complexo lipídico de anfotericina B, voriconazol e caspofungina. Discute-se o uso desses antifúngicos mais recentes considerando a segurança, a eficiência e o custo da terapia. Sugestões para o uso clínico dessas drogas em infecções pulmonares e sistêmicas são apresentadas, destacando-se a menor toxicidade das formulações lipídicas da anfotericina B em relação à medicação convencional, a possibilidade de terapia primária da aspergilose invasiva, scedosporiose e fusariose com voriconazol e a caspofungina como opção terapêutica na candidíase disseminada e na aspergilose invasiva.

Efficacy, safety and cost-effectiveness of Amphotericin B Lipid Complex (ABLC): a review of the literature

Amphotericin B Lipid Complex (ABLC) was the first lipid-based formulation of amphotericin B (AmB) to be developed, it was designed to provide a less toxic alternative to conventional AmB without compromising efficacy. Preclinical and early clinical data relating to ABLC have been presented in previous reviews. This paper reviews more recent published data on the efficacy, safety and cost-effectiveness of ABLC. All published manuscripts and conference abstracts were searched on MEDLINE, BIOL and SCIN for the period between January 1997 and August 2003. Comparative and non-comparative studies of ABLC are usually mild or moderate and are manageable were considered. Comparative studies and additional data from non-comparative studies suggest that ABLC 5 mg/kg/day is safe and effective for the treatment of documented or suspected systemic fungal infections in adults and children who are refractory to or intolerant of conventional AmB. ABLC is effective against a wide range of pathogens and efficacy is at least as good as conventional AmB or the other lipid-based formulations. The safety profile of ABLC is improved compared with conventional AmB; ABLC is less nephrotoxic than conventional AmB and can be given safely to patients with pre-existing renal impairment. The most commonly reported adverse effects are transient infusion-related events, including chills, fever, nausea and vomiting, which with premedication. Comparative studies suggest that ABLC is a cost-effective treatment option compared with conventional AmB or other lipid-based formulations of amphotericin B.

The direct cost and incidence of systemic fungal infections

OBJECTIVES

In this study we determined the incidence and direct inpatient and outpatient costs of systemic fungal infections (candidiasis, aspergillosis, cryptococcosis, histoplasmosis) in 1998.

METHODS

Using primarily the National Hospital Discharge Survey (NHDS) for incidence and the Maryland Hospital Discharge Data Set (MDHDDS) for costs, we surveyed four systemic fungal infections in patients who also had HIV/AIDS, neoplasia, transplant, and all other concomitant diagnoses. Using a case-control method, we compared the cases with controls (those without fungal infections with the same underlying comorbidity) to obtain the incremental hospitalization costs. We used the Student's t-test to determine significance of incremental hospital costs. We modeled outpatient costs on the basis of discharge status to calculate the total annual cost for systemic fungal infections in 1998.

RESULTS

For 1998, the projected average incidence was 306 per million US population, with candidiasis accounting for 75% of cases. The estimated total direct cost was $2.6 billion and the average per-patient attributable cost was $31,200. The most commonly reported comorbid diagnoses with fungal infections (HIV/AIDS, neoplasms, transplants) accounted for only 45% of all infections.

CONCLUSIONS

The cost burden is high for systemic fungal infections. Additional attention should be given to the 55% with fungal disease and other comorbid diagnoses.

Efficacy and safety of amphotericin B lipid complex injection (ABLC) in solid-organ transplant recipients with invasive fungal infections

BACKGROUND

Fungal infections following solid-organ transplantation are a major source of morbidity and mortality. This report describes the efficacy and safety of Amphotericin B Lipid Complex Injection (ABLC) in solid-organ transplant recipients.

METHODS

Three open-label, second-line treatment studies evaluated ABLC as a treatment for severe, life-threatening mycoses in patients who were refractory to or intolerant to conventional antifungal (mostly amphotericin B [AmB]) therapy or had pre-existing renal disease.

RESULTS

The 79 solid-organ transplant recipients (25 heart, 20 liver, 17 kidney, 11 lung, 5 multiple, 1 pancreas) who received ABLC in these studies had the following fungal infections: aspergillosis (n = 39); candidiasis (n = 20); zygomycosis (n = 8); cryptococcosis and histoplasmosis (n = 3 each); and blastomycosis, cladosporiosis, fusariosis, Bipolaris hawaiiensis, Dactylaria gallopava, and an unspecified fungal infection (n = 1 each). The median duration of ABLC therapy was 28 d (1-178 d). The daily dose ranged between 1.6 and 7.4 mg/kg (median, 4.6 mg/kg). The clinical response rate for the patients who could be assessed was 58% (39/67). Clinical response rates for heart, liver, kidney, and lung recipients were 59, 60, 67, and 40%, respectively; response rates for aspergillosis and candidiasis were 47 and 71%, respectively. Forty-six of the 79 patients (58%) survived for more than 28 d after the last dose of ABLC. Mean baseline serum creatinine was 3.2 mg/dL; 64 patients (81%) had stable (n = 37) or improved (n = 27) serum creatinine at the end of treatment.

CONCLUSIONS

ABLC is safe and effective treatment for fungal infections in solid-organ transplant recipients. Its renal-sparing properties are particularly suited for this high-risk population for renal failure.

A comparative review of conventional and lipid formulations of amphotericin B

Over the past 15 years, factors suh as corticosteroid treatment, cytotoxic chemotherapy, excessive use of broad spectrum antibiotics and HIV have led to an increased risk of serious fungal infections in both adults and pediatric patients. This increase in invasive fungal infections poses increasing difficulty in their treatment. Three new lipid formulations of amphotericin B are now available in the U.S.: amphotericin B lipid complex (Abelcet), amphotericin B colloidal dispersion (Amphotec), and liposomal amphotericin B (AmBisome). These newer formulations are substantially more expensive, but allow patients to receive higher doses for longer periods of time with decreased renal toxicity than conventional amphotericin B. The properties of these new agents are summarized in this review. Discussion of current national guidelines as well as those used at our institution are presented to provide guidance for the development of institution specific guidelines for the most cost-effective drug for most patients, some may benefit more from one of the newer lipid formulations.