1
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Sabanci R, Saeed M, Watat K, Wilcox M. Cardiac Implications of Itraconazole Therapy in Histoplasmosis Patients. Cureus 2024; 16:e59076. [PMID: 38803747 PMCID: PMC11129802 DOI: 10.7759/cureus.59076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2024] [Indexed: 05/29/2024] Open
Abstract
A male patient in his 60s, with a history of tobacco use, presented with fever, weight loss, and cough, and was ultimately diagnosed with histoplasmosis. Initial treatment with itraconazole (ITZ) led to symptom improvement. However, two months later, he returned with lower extremity swelling and dyspnea. Imaging showed pleural effusions and reduced ejection fraction, suggesting itraconazole-induced cardiac toxicity. Transition to voriconazole and initiation of guideline-directed medical therapy improved symptoms. This case report delves into the cardiac side effects of itraconazole, notably heart failure, and elucidates the potential underlying mechanisms. Our goal is to emphasize the importance of monitoring patients on itraconazole for potential cardiac complications, necessitating timely intervention to mitigate adverse outcomes.
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Affiliation(s)
- Rand Sabanci
- Internal Medicine, Michigan State University, East Lansing, USA
| | - Moiz Saeed
- Internal Medicine, Michigan State University, East Lansing, USA
| | - Kevin Watat
- Internal Medicine, Michigan State University College of Human Medicine, East Lansing, USA
| | - Matthew Wilcox
- Cardiology, Sparrow Hospital Thoracic and Cardiovascular Institute, Lansing, USA
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2
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Antic O, Koshman YE, Bird BM, Jasiek G, Wilsey AS, Mittelstadt SW, Foley CM. Evaluation of the translation of multiple cardiovascular regulatory mechanisms in the anesthetized dog. J Pharmacol Toxicol Methods 2024; 126:107497. [PMID: 38479593 DOI: 10.1016/j.vascn.2024.107497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/19/2023] [Accepted: 02/29/2024] [Indexed: 03/17/2024]
Abstract
The strategic and targeted use of an anesthetized canine cardiovascular model early in drug discovery enables a comprehensive cardiovascular and electrophysiological assessment of potential safety liabilities and guides compound selection prior to initiation of chronic toxicological studies. An ideal model would enable exposure-response relationships to guide safety margin calculations, have a low threshold to initiate, and have quick delivery of decision quality data. We have aimed to profile compounds with diverse mechanism of actions (MoAs) of "non-QT" cardiovascular drug effects and evaluate the ability of nonclinical in vivo cardiovascular models to detect clinically reported effects. The hemodynamic effects of 11 drugs (atropine, itraconazole, atenolol, ivabradine, milrinone, enalaprilat, fasudil, amlodipine, prazosin, amiloride, and hydrochlorothiazide) were profiled in an anesthetized dog cardiovascular model. Derived parameters included: heart rate, an index of left ventricular contractility, mean arterial pressure, systemic vascular resistance, and cardiac output. Species specific plasma protein data was generated (human, dog) and utilized to calculate free drug concentrations. Using the anesthetized dog cardiovascular model, 10 of the 11 drugs displayed the predicted changes in CV parameters based on their primary MoAs and corresponding clinically described effects. Interestingly but not unexpected, 1 of 11 failed to display their predicted CV pattern which is likely due to a delay in pharmacodynamic effect that is beyond the duration of the experimental model (hydrochlorothiazide). The analysis from the current study supports the strategic use of the anesthetized dog model early in the drug discovery process for a comprehensive cardiovascular evaluation with good translation to human.
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Affiliation(s)
- Olivera Antic
- AbbVie Inc., 1 North Waukegan Rd., North Chicago, IL 60064, United States of America.
| | - Yevgeniya E Koshman
- AbbVie Inc., 1 North Waukegan Rd., North Chicago, IL 60064, United States of America
| | - Brandan M Bird
- AbbVie Inc., 1 North Waukegan Rd., North Chicago, IL 60064, United States of America
| | - Geena Jasiek
- AbbVie Inc., 1 North Waukegan Rd., North Chicago, IL 60064, United States of America
| | - Amanda S Wilsey
- AbbVie Inc., 1 North Waukegan Rd., North Chicago, IL 60064, United States of America
| | - Scott W Mittelstadt
- AbbVie Inc., 1 North Waukegan Rd., North Chicago, IL 60064, United States of America
| | - C Michael Foley
- AbbVie Inc., 1 North Waukegan Rd., North Chicago, IL 60064, United States of America
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3
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Axler E, Lipner SR. Antifungal Selection for the Treatment of Onychomycosis: Patient Considerations and Outcomes. Infect Drug Resist 2024; 17:819-843. [PMID: 38463386 PMCID: PMC10922011 DOI: 10.2147/idr.s431526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/24/2024] [Indexed: 03/12/2024] Open
Abstract
Onychomycosis, a common fungal nail infection, affects >20% of adults over age 60 and >50% of people over age 70. Onychomycosis may cause pain, psychosocial problems, and secondary infections, therefore meriting treatment. This review describes the range of treatment modalities, including FDA-approved systemic drugs and topical therapies. Additionally, new and emerging oral and topical therapies are discussed. We emphasize the importance of tailoring onychomycosis therapy to individual patient characteristics, comorbidities, preferences, extent of nail involvement, and fungal species, such that physicians may optimize treatment outcomes, patient satisfaction, and safety.
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Affiliation(s)
- Eden Axler
- Weill Cornell Medicine, Department of Dermatology, New York, NY, 10021, USA
| | - Shari R Lipner
- Weill Cornell Medicine, Department of Dermatology, New York, NY, 10021, USA
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4
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Abstract
The population of older adults continues to increase in the United States, leading to a concomitant increase in cutaneous disease. Fungal disease, specifically, commonly affects this population but often goes undiagnosed for too long. It is therefore important that providers be aware of common fungal pathogens, recognizable symptoms of disease, and treatment options. This article discusses 3 groups of pathogens: dermatophytes, Candida species, and Pityrosporum species, all of which cause a host of conditions that can be debilitating for older adults.
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Affiliation(s)
- Saniya Shaikh
- Department of Dermatology, SSM Health SLU Care Physician Group Saint Louis University School of Medicine, 1225 S Grand Boulevard, Saint Louis, MO 63104, USA.
| | - Aditya Nellore
- Department of Internal Medicine, St. Luke's Hospital, 232 S Woods Mill Road, Chesterfield, MO 63017, USA
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5
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Higgins E, Yuan J, Lange S, Boilson BA, Pritt BS, Rizza SA. Fever, Cough, and Pancytopenia in a Transplant Recipient. Clin Infect Dis 2023; 77:1065-1067. [PMID: 37796055 DOI: 10.1093/cid/ciad167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Affiliation(s)
- Eibhlin Higgins
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ji Yuan
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sawyer Lange
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Barry A Boilson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Bobbi S Pritt
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Stacey A Rizza
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
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6
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Ashok A, Mangalore RP, Morrissey CO. Azole Therapeutic Drug Monitoring and its Use in the Management of Invasive Fungal Disease. CURRENT FUNGAL INFECTION REPORTS 2022. [DOI: 10.1007/s12281-022-00430-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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7
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Nishimatsu K, Minami S, Ikuta S, Ihara S, Komuta K. Successful Treatment of Allergic Bronchopulmonary Aspergillosis Using a Combination of Inhaled Fluticasone Furoate/Vilanterol and Oral Voriconazole. J Med Cases 2021; 11:348-351. [PMID: 34434345 PMCID: PMC8383500 DOI: 10.14740/jmc3567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/29/2020] [Indexed: 11/30/2022] Open
Abstract
Systemic corticosteroids are considered to be the standard treatment for allergic bronchopulmonary aspergillosis (ABPA). However, there is controversy regarding use of inhaled corticosteroid (ICS) therapy for ABPA. Here we report a case of ABPA that was successfully treated with inhaled fluticasone furoate/vilanterol (FF/VI) and oral voriconazole (VRCZ). The patient was a 62-year-old Japanese man with bronchiectasis and diabetes mellitus who presented with fever, cough, and purulent sputum. Computed tomography scans of the chest showed consolidation in the left upper and lower lobes. Laboratory investigations revealed an abnormal increase in the number of eosinophils (3,340/mm3) and elevated levels of C-reactive protein (3.04 mg/dL) and serum immunoglobulin E (IgE) (763 U/mL). Eight days after admission, he experienced a sudden attack of asthma. Aspergillus-precipitating antibodies were positive and Aspergillus fumigatus was detected in sputum culture. These results were consistent with a diagnosis of ABPA, and he was started on inhaled FF/VI and oral VRCZ. Systemic corticosteroids were not used because of the patient’s history of diabetes mellitus and left atrial thrombus. His symptoms and consolidation improved significantly after treatment. He has not experienced an exacerbation for more than 3 years. In mild cases of ABPA in which total IgE is relatively low, inhaled FF/VI in combination with oral VRCZ can be considered as an alternative treatment to systemic corticosteroids in patients with ABPA.
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Affiliation(s)
- Kanako Nishimatsu
- Department of Respiratory Medicine, Osaka Police Hospital, 10-31 Kitayama-cho, Tennoji-ku, Osaka 543-0035, Japan
| | - Seigo Minami
- Department of Respiratory Medicine, Osaka Police Hospital, 10-31 Kitayama-cho, Tennoji-ku, Osaka 543-0035, Japan
| | - Shoko Ikuta
- Department of Respiratory Medicine, Osaka Police Hospital, 10-31 Kitayama-cho, Tennoji-ku, Osaka 543-0035, Japan
| | - Shoichi Ihara
- Department of Respiratory Medicine, Osaka Police Hospital, 10-31 Kitayama-cho, Tennoji-ku, Osaka 543-0035, Japan.,Department of Respiratory Medicine, Daini Osaka Police Hospital, 2-6-40 Karasuga-tuji, Tennoji-ku, Osaka 543-0042, Japan
| | - Kiyoshi Komuta
- Department of Respiratory Medicine, Osaka Police Hospital, 10-31 Kitayama-cho, Tennoji-ku, Osaka 543-0035, Japan.,Department of Respiratory Medicine, Daini Osaka Police Hospital, 2-6-40 Karasuga-tuji, Tennoji-ku, Osaka 543-0042, Japan
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8
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Kroon S, Snijder R, Hosman A, Vorselaars V, Disch F, Post M, Mager J. Oral itraconazole for epistaxis in hereditary hemorrhagic telangiectasia: a proof of concept study. Angiogenesis 2021; 24:379-386. [PMID: 33211216 PMCID: PMC7615075 DOI: 10.1007/s10456-020-09758-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 11/09/2020] [Indexed: 10/23/2022]
Abstract
The inhibiting effects of itraconazole, an antifungal drug on vascular endothelial growth factor (VEGF) have recently been discovered. By inhibiting VEGF, itraconazole has shown potential in clinical trials as anti-cancer treatment. In hereditary hemorrhagic telangiectasia (HHT) patients, VEGF levels are elevated and inhibition of VEGF can decrease bleeding. Itraconazole could potentially serve as anti-angiogenic therapy for HHT-related bleeding. We report a proof of concept study with HHT patients and severe epistaxis. Patients were treated with daily 200 mg orally administered itraconazole for sixteen weeks. Twenty-one HHT patients, 8 females (38%), 13 males (62%), median age of 59 years (interquartile range (IQR) 55-69) were enrolled. Of these patients, 13 (62%) were diagnosed with HHT type 1, seven (33%) with HHT type 2 and in one patient (5%), no pathognomonic HHT mutation was found. Four patients (19%) prematurely terminated the study (3 due to mild or moderate side-effects) resulting in 17 patients included in the analyses. The median epistaxis severity score significantly decreased during treatment from 6.0 (IQR 5.1-7.2) to 3.8 (IQR 3.1-5.2) (p = 0.006). The monthly epistaxis frequency decreased from 56 to 38 epistaxis episodes (p = 0.004) and the monthly duration from 407 to 278 minutes (p = 0.005). Hemoglobin levels did not significantly change. The quality of life showed a small but significant improvement. In conclusion, oral itraconazole significantly improved epistaxis in HHT patients. The potential benefit of itraconazole in HHT should be further investigated.
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Affiliation(s)
- S. Kroon
- Departments of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - R.J. Snijder
- Departments of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - A.E. Hosman
- Departments of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - V.M.M Vorselaars
- Department of Cardiology and Ear, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - F.J.M. Disch
- Department of Nose and Throat, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - M.C. Post
- Department of Cardiology and Ear, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - J.J. Mager
- Departments of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
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9
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Hortigon-Vinagre MP, Zamora V, Burton FL, Smith GL. The Use of Voltage Sensitive Dye di-4-ANEPPS and Video-Based Contractility Measurements to Assess Drug Effects on Excitation-Contraction Coupling in Human-Induced Pluripotent Stem Cell-Derived Cardiomyocytes. J Cardiovasc Pharmacol 2021; 77:280-290. [PMID: 33109927 DOI: 10.1097/fjc.0000000000000937] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/09/2020] [Indexed: 12/21/2022]
Abstract
ABSTRACT Because cardiotoxicity is one of the leading causes of drug failure and attrition, the design of new protocols and technologies to assess proarrhythmic risks on cardiac cells is in continuous development by different laboratories. Current methodologies use electrical, intracellular Ca2+, or contractility assays to evaluate cardiotoxicity. Increasingly, the human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) are the in vitro tissue model used in commercial assays because it is believed to recapitulate many aspects of human cardiac physiology. In this work, we demonstrate that the combination of a contractility and voltage measurements, using video-based imaging and fluorescence microscopy, on hiPSC-CMs allows the investigation of mechanistic links between electrical and mechanical effects in an assay design that can address medium throughput scales necessary for drug screening, offering a view of the mechanisms underlying drug toxicity. To assess the accuracy of this novel technique, 10 commercially available inotropic drugs were tested (5 positive and 5 negative). Included were drugs with simple and specific mechanisms, such as nifedipine, Bay K8644, and blebbistatin, and others with a more complex action such as isoproterenol, pimobendan, digoxin, and amrinone, among others. In addition, the results provide a mechanism for the toxicity of itraconazole in a human model, a drug with reported side effects on the heart. The data demonstrate a strong negative inotropic effect because of the blockade of L-type Ca2+ channels and additional action on the cardiac myofilaments. We can conclude that the combination of contractility and action potential measurements can provide wider mechanistic knowledge of drug cardiotoxicity for preclinical assays.
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MESH Headings
- Action Potentials/drug effects
- Arrhythmias, Cardiac/chemically induced
- Arrhythmias, Cardiac/metabolism
- Arrhythmias, Cardiac/physiopathology
- Calcium Channels, L-Type/drug effects
- Calcium Channels, L-Type/metabolism
- Cardiotoxicity
- Cell Differentiation
- Cells, Cultured
- Excitation Contraction Coupling/drug effects
- Fluorescent Dyes/chemistry
- Humans
- Induced Pluripotent Stem Cells/drug effects
- Induced Pluripotent Stem Cells/metabolism
- Induced Pluripotent Stem Cells/pathology
- Microscopy, Fluorescence
- Microscopy, Video
- Myocardial Contraction/drug effects
- Myocytes, Cardiac/drug effects
- Myocytes, Cardiac/metabolism
- Myocytes, Cardiac/pathology
- Myofibrils/drug effects
- Myofibrils/metabolism
- Myofibrils/pathology
- Pyridinium Compounds/chemistry
- Risk Assessment
- Time Factors
- Toxicity Tests
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Affiliation(s)
- Maria Pura Hortigon-Vinagre
- Departamento de Bioquímica y Biología Molecular y Genética, Facultad de Ciencias, Universdad de Extremadura, Badajoz, Spain
| | - Victor Zamora
- Departamento de Ingeniería Mecánica, Energética y de los Materiales, Escuela de Ingerierias Industriales, Universidad de Extremadura, Badajoz, Spain
| | - Francis L Burton
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Science, University of Glasgow, Glasgow, United Kingdom ; and
- Clyde Biosciences Ltd, BioCity Scotland, Newhouse, United Kingdom
| | - Godfrey L Smith
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Science, University of Glasgow, Glasgow, United Kingdom ; and
- Clyde Biosciences Ltd, BioCity Scotland, Newhouse, United Kingdom
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10
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Mohamed AW, Elbassiouny M, Elkhodary DA, Shawki MA, Saad AS. The effect of itraconazole on the clinical outcomes of patients with advanced non-small cell lung cancer receiving platinum-based chemotherapy: a randomized controlled study. Med Oncol 2021; 38:23. [PMID: 33559053 DOI: 10.1007/s12032-021-01475-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/26/2021] [Indexed: 12/25/2022]
Abstract
Itraconazole is an oral antifungal that has a been reported to have anticancer effect in non-small cell lung cancer (NSCLC) through inhibition of angiogenesis. The aim is to evaluate the effect of using itraconazole on the clinical outcome of metastatic NSCLC. This was a prospective randomized controlled open-label study conducted on 60 chemotherapy-naive metastatic NSCLC. Patients were simply randomized to either Control group who received platinum-based chemotherapy for a maximum of six cycles or Itraconazole group who received the same chemotherapy regimen in addition to itraconazole 200 mg daily for 21 days starting from day 1 in each cycle. Primary outcome was 1-year progression-free survival (PFS) while secondary outcomes included overall response rate (ORR), 1-year overall survival (OS) and tolerability. The two groups were comparable at baseline with no significant difference between groups regarding demographics and clinical characteristics. The ORR in Control group was 66.7% versus 90% in Itraconazole group (p value 0.028). There was a significant difference between groups regarding PFS where the mean 1-year PFS was 5.415 months in Control group versus 6.556 months in Itraconazole group (p value = 0.002). However, there was no significant difference between groups with respect to 1-year OS. All adverse effects reported were tolerable except for one patient who developed grade 2 cardiotoxicity in Itraconazole group requiring itraconazole discontinuation. Itraconazole use was beneficial in NSCLC in terms of 1-year PFS and ORR which was not reflected by improvement in 1-year OS.Clinical trial.gov registration number: NCT03664115, date of registration: September 10, 2018.
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Affiliation(s)
- Asmaa Waheed Mohamed
- Clinical Oncology and Nuclear Medicine Department Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed Elbassiouny
- Clinical Oncology and Nuclear Medicine Department Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Dalia Abdelghany Elkhodary
- Clinical Oncology and Nuclear Medicine Department Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - May Ahmed Shawki
- Clinical Pharmacy Department Faculty of Pharmacy, Ain Shams University, African Union Organization Street, Cairo, 11566, Egypt.
| | - Amr Shafik Saad
- Clinical Oncology and Nuclear Medicine Department Faculty of Medicine, Ain Shams University, Cairo, Egypt
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11
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Chaves AFA, Xander P, Romera LMD, Fonseca FLA, Batista WL. What is the elephant in the room when considering new therapies for fungal diseases? Crit Rev Microbiol 2021; 47:275-289. [PMID: 33513315 DOI: 10.1080/1040841x.2021.1876632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The global scenario of antimicrobial resistance is alarming, and the development of new drugs has not appeared to make substantial progress. The constraints on drug discovery are due to difficulties in finding new targets for therapy, the high cost of development, and the mismatch between the time of drug introduction in a clinic and microorganism adaptation to a drug. Policies to address neglected diseases miss the broad spectrum of mycosis. Society is not aware of the actual threat represented by fungi to human health, food security, and biodiversity. The evidence discussed here is critical for warning governments to establish effective surveillance policies for fungi.HIGHLIGHTSFungal diseases are ignored even among neglected disease classifications.There are few options to treat mycoses, which is an increasing concern regarding fungal resistance to drugs, as evidenced by the spread of Candida auris.Fungal diseases represent a real threat to human health and food security.Investment in research to investigate the potential of repurposing drugs already in use could obtain results in the short term.
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Affiliation(s)
| | - Patricia Xander
- Department of Pharmaceutical Sciences, Federal University of São Paulo, São Paulo, Brazil
| | | | | | - Wagner Luiz Batista
- Department of Microbiology, Immunology and Parasitology, Federal University of São Paulo, São Paulo, Brazil.,Department of Pharmaceutical Sciences, Federal University of São Paulo, São Paulo, Brazil
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12
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Abstract
INTRODUCTION Onychomycosis is the most common nail disease seen in clinical practice. Treatment options include systemic and topical therapies, as well as devices. Following clinical and mycologic diagnosis, treatment must be individualized, accounting for disease severity, infecting organism(s), comorbidities, patient characteristics and drug/device efficacy. Safety is the most important consideration in choosing the most appropriate therapeutic modality. AREAS COVERED This review covers currently available treatments for onychomycosis, with an emphasis on safety and tolerability. Medications and devices were analyzed for side effects, drug-drug interactions, and safety during pregnancy and breastfeeding. EXPERT OPINION Systemic antifungals offer greater efficacy for onychomycosis treatment but are limited by risks of systemic toxicity and drug-drug interactions. The risk of terbinafine-induced hepatotoxicity is negligible in healthy patients. Systemic therapies, especially azole antifungals, are associated with numerous drug-drug interactions, some of which are life-threatening and fatal. Thus, a detailed medication history is critical before prescribing these medications. Topical antifungals are well tolerated and generally safe, with only potential local side effects. Systemic and topical onychomycosis treatments should not be prescribed during pregnancy and breastfeeding. Laser therapy is likely less effective than systemic and topical therapies, but may be safely used during pregnancy and breastfeeding.
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Affiliation(s)
- Jose W Ricardo
- Department of Dermatology, Weill Cornell Medicine , NY, NY, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine , NY, NY, USA
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13
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El Hadidi S, Rosano G, Tamargo J, Agewall S, Drexel H, Kaski JC, Niessner A, Lewis BS, Coats AJS. Potentially Inappropriate Prescriptions in Heart Failure with Reduced Ejection Fraction (PIP-HFrEF). EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 8:187-210. [PMID: 32941594 DOI: 10.1093/ehjcvp/pvaa108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/12/2020] [Accepted: 09/04/2020] [Indexed: 12/13/2022]
Abstract
Heart failure (HF) is a chronic debilitating and potentially life-threatening condition. Heart Failure patients are usually at high risk of polypharmacy and consequently, potentially inappropriate prescribing leading to poor clinical outcomes. Based on the published literature, a comprehensive HF-specific prescribing review tool is compiled to avoid medications that may cause HF or harm HF patients and to optimize the prescribing practice of HF guideline-directed medical therapies. Recommendations are made in line with the last versions of ESC guidelines, ESC position papers, scientific evidence, and experts' opinions.
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Affiliation(s)
- Seif El Hadidi
- Faculty of Pharmaceutical Sciences and Pharmaceutical Industries, Future University in Egypt, New Cairo, Egypt
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy.,Cardiovascular Clinical Academic Group, St George's Hospitals NHS Trust University of London, London, UK
| | - Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, Madrid, Spain
| | - Stefan Agewall
- Department of Cardiology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Heinz Drexel
- VIVIT Institute, Landeskrankenhaus Feldkirch, Austria
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London
| | - Alexander Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, Technion-IIT, Haifa, Israel
| | - Andrew J S Coats
- Centre of Clinical and Experimental Medicine, IRCCS San Raffaele Pisana, Rome, Italy
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14
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Madurella mycetomatis causing eumycetoma medical treatment: The challenges and prospects. PLoS Negl Trop Dis 2020; 14:e0008307. [PMID: 32853199 PMCID: PMC7452721 DOI: 10.1371/journal.pntd.0008307] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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15
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Rengasamy M, Shenoy MM, Dogra S, Asokan N, Khurana A, Poojary S, Jayaraman J, Valia AR, Sardana K, Kolalapudi S, Marfatia Y, Rao PN, Bhat RM, Kura M, Pandhi D, Barua S, Kaushal V. Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Task Force against Recalcitrant Tinea (ITART) Consensus on the Management of Glabrous Tinea (INTACT). Indian Dermatol Online J 2020; 11:502-519. [PMID: 32832435 PMCID: PMC7413465 DOI: 10.4103/idoj.idoj_233_20] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/30/2020] [Accepted: 06/22/2020] [Indexed: 01/12/2023] Open
Abstract
Background and Aims: Dermatophytosis has always been a common superficial mycosis in India. However, the past 6-7 years have seen an unprecedented increase in the number of patients affected by recurrent, chronic, recalcitrant and steroid modified dermatophytosis involving the glabrous skin (tinea corporis, tinea cruris and tinea faciei). Importantly, there has been a notable decrease in clinical responsiveness to commonly used antifungals given in conventional doses and durations resulting in difficult-to-treat infections. Considering that scientific data on the management of the current epidemic of dermatophytosis in India are inadequate, the Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Task force Against Recalcitrant Tinea (ITART) has formulated a consensus statement on the management of dermatophytosis in India. Methods: Seventeen dermatologists with a focussed interest in dermatophytosis participated in a Delphi consensus method, conducted in three rounds. They responded as either “agree” or “disagree” to 132 statements prepared by the lead experts and gave their comments. Consensus was defined as an agreement of 80% or higher concurrence. Statements on which there was no consensus were modified based on the comments and were then recirculated. The results were finally analysed in a face-to-face meeting and the responses were further evaluated. A draft of the consensus was circulated among the participants and modified based on their inputs. Results: Consensus was achieved on 90 of the 132 statements. Direct microscopy using potassium hydroxide mount was recommended in case of diagnostic difficulty on clinical examination. Counselling of patients about strict adherence to general measures and compliance to treatment was strongly recommended as the key to successful management of dermatophytosis. A combination of systemic and topical antifungal drugs was recommended for the treatment of glabrous tinea in the current scenario. Topical corticosteroid use, whether used alone or in combination with other components, was strongly discouraged by all the experts. It was suggested that topical antifungals may be continued for 2 weeks beyond clinical resolution. Itraconazole and terbinafine were recommended to be used as the first line options in systemic therapy, whereas griseofulvin and fluconazole are alternatives. Terbinafine was agreed to be used as a first line systemic agent in treatment naïve and terbinafine naïve patients with glabrous tinea. Regular follow-up of patients to ensure compliance and monitoring of clinical response was recommended by the experts, both during treatment and for at least 4 weeks after apparent clinical cure. Longer duration of treatment was recommended for patients with chronic, recurrent and steroid modified dermatophytosis. Conclusion: Consensus in the management of dermatophytosis is necessary in the face of conventional regimens proving ineffective and dearth of clinical trials re-evaluating the role of available antifungals in the wake of evolving epidemiology of the infection in the country. It needs to be backed by more research to provide the required level of evidence. It is hoped that this consensus statement improves the quality of care for patients with dermatophytosis, which has emerged as a huge public health problem, imposing considerable financial burden on the country.
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Affiliation(s)
- Madhu Rengasamy
- Department of Dermatology, Venereology and Leprosy, Madras Medical College, Chennai, Tamil Nadu, India
| | - Manjunath M Shenoy
- Department of Dermatology, Venereology and Leprosy, Yenepoya Medical College, Deralakatte, Deralakatte, Mangalore, Karanataka, India
| | - Sunil Dogra
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neelakandhan Asokan
- Department of Dermatology, Venereology and Leprosy, Government Medical College, Thrissur, Kerala, India
| | - Ananta Khurana
- Department of Dermatology, Venereology and Leprosy, Dr Ram Manohar Lohia Hospital and Postgraduate Institute of Medical Education and Research, New Delhi, India
| | - Shital Poojary
- Department of Dermatology, Venereology and Leprosy, K. J. Somaiya Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Jyothi Jayaraman
- Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Mangalore, Karnataka, India
| | - Ameet R Valia
- Consultant Dermatologist, Harganga Mahal Annexe, Dadar TT, India
| | - Kabir Sardana
- Department of Dermatology, Venereology and Leprosy, Dr Ram Manohar Lohia Hospital and Postgraduate Institute of Medical Education and Research, New Delhi, India
| | | | - Yogesh Marfatia
- Department of Dermatology, Venereology and Leprosy, SBKS Medical College, Piparia, Vadodara, Gujarat, India
| | - P Narasimha Rao
- Consultant Dermatologist, Masab Tank, Hyderabad, Telangana, India
| | - Ramesh M Bhat
- Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Mangalore, Karnataka, India
| | - Mahendra Kura
- Department of Dermatology, Venereology and Leprosy, Grant Medical College, Mumbai, Maharashtra, India
| | - Deepika Pandhi
- Department of Dermatology, Venereology and Leprosy, University College of Medical Sciences and GTBH, New Delhi, India
| | - Shyamanta Barua
- Department of Dermatology, Venereology and Leprosy, Assam Medical College and Hospital, Dibrugarh, Assam, India
| | - Vibhor Kaushal
- Consultant Dermatologist, Dr. Kaushal's Skin Clinic, Agra, Uttar Pradesh, India
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Teaford HR, Abu Saleh OM, Villarraga HR, Enzler MJ, Rivera CG. The Many Faces of Itraconazole Cardiac Toxicity. Mayo Clin Proc Innov Qual Outcomes 2020; 4:588-594. [PMID: 33083707 PMCID: PMC7557188 DOI: 10.1016/j.mayocpiqo.2020.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/21/2020] [Accepted: 05/04/2020] [Indexed: 01/03/2023] Open
Abstract
Itraconazole is well known for carrying a black-box warning for new or worsening congestive heart failure. Single cases of other cardiac- and fluid-related disturbances have been reported periodically since its issuance. We describe a large cohort of patients on itraconazole experiencing a breadth of cardiac- and fluid-related toxicities, ranging from new-onset hypertension to cardiac arrest. A retrospective, single-center, large case series at a large tertiary medical center was conducted. Patients with itraconazole and cardiac toxicity—including hypertension, cardiomyopathy, reduced ejection fraction, and edema—in medical record between January 1, 1999, and May 21, 2019, were identified and assigned a Naranjo score; 31 patients were included with a Naranjo score of 5 or higher. There were slightly more male subjects than female subjects, average age was 66, and all subjects were Caucasian. Median time until presentation of adverse effects was 4 weeks (range: 0.3 to 104 weeks). Most common symptom was edema (74% of patients), followed by heart failure without and with preserved ejection fraction (19.4% and 22.6% of patients, respectively). Worsening or new hypertension was also common (25.8% of patients). Rarer were pulmonary edema, pericardial effusion, and cardiac arrest that occurred in 1 patient. In most cases, clinicians stopped itraconazole (74%) or decreased itraconazole dose (19%), resulting in improvement or resolution of symptoms. In 4 cases, the adverse effect did not resolve. Itraconazole can cause a range of possible serious cardiac and fluid-associated adverse events. Dose decrease or cessation usually resulted in symptomatic improvement or reversal.
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Affiliation(s)
| | | | | | - Mark J Enzler
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
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17
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Dockrell DH, O’Shea D, Cartledge JD, Freedman AR. British HIV Association guidelines on the management of opportunistic infection in people living with HIV: The clinical management of Candidiasis 2019. HIV Med 2020; 20 Suppl 8:2-24. [PMID: 31670458 DOI: 10.1111/hiv.12806] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- D H Dockrell
- University of Edinburgh, Edinburgh, UK and Regional Infectious Diseases Unit, NHS Lothian Infection Service, Edinburgh, UK
| | - D O’Shea
- University of Edinburgh, Edinburgh, UK and Regional Infectious Diseases Unit, NHS Lothian Infection Service, Edinburgh, UK
| | | | - A R Freedman
- Cardiff University School of Medicine, Cardiff, UK
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18
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Rodriguez JA, Ivancic S, Eckardt PA, Lemos-Ramirez JC, Niu J. A Case of Pulmonary Histoplasmosis Presenting with Hypercalcemia and Altered Mental Status in a Patient Following Allogeneic Hematopoietic Stem Cell Transplantation. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e919724. [PMID: 31955178 PMCID: PMC6993276 DOI: 10.12659/ajcr.919724] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Patient: Male, 75-year-old Final Diagnosis: Pulmonary histoplasmosis Symptoms: Altered mental status • cough • shortness of breath Medication: — Clinical Procedure: — Specialty: Pulmonology
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Affiliation(s)
- Jose A Rodriguez
- Department of Internal Medicine, Memorial Hospital West, Memorial Healthcare System, Pembroke Pines, FL, USA
| | - Stipe Ivancic
- Department of Internal Medicine, Memorial Hospital West, Memorial Healthcare System, Pembroke Pines, FL, USA
| | - Paula A Eckardt
- Division of Infectious Disease, Memorial Regional Hospital, Memorial Healthcare System, Hollywood, FL, USA
| | - Juan C Lemos-Ramirez
- Division of Infectious Disease, Memorial Regional Hospital, Memorial Healthcare System, Hollywood, FL, USA
| | - Jianli Niu
- Office of Human Research, Memorial Healthcare System, Hollywood, FL, USA
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19
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Gaspar GG, Cocio TA, Guioti-Puga F, Nascimento E, Fabro AT, Kress MRVZ, Bagagli E, Martinez R. Paracoccidioidomycosis due to Paracoccidioides lutzii complicated with adrenal injury and pulmonary arterial hypertension. Rev Inst Med Trop Sao Paulo 2020; 62:e89. [PMID: 33206863 PMCID: PMC7669275 DOI: 10.1590/s1678-9946202062089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/22/2020] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Eduardo Bagagli
- Universidade Estadual Paulista 'Júlio de Mesquita Filho', Brazil
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20
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Alkeswani A, Cantrell W, Elewski B. Treatment of Tinea Capitis. Skin Appendage Disord 2019; 5:201-210. [PMCID: PMC6615323 DOI: 10.1159/000495909] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 11/29/2018] [Indexed: 11/26/2023] Open
Abstract
Tinea capitis is a common fungal infection of the hair of the scalp affecting predominately prepubertal children. In the US, griseofulvin has been considered a first-line therapy agent for tinea capitis since the 1960s. However, it has been falling out of favor due to significant treatment failure, high cost, and long duration of treatment. Other antifungal agents have been researched as an alternative to griseofulvin. This paper will review the relevant pharmacologic properties, dosing, cost, efficacy, and adverse events profile for griseofulvin, terbinafine, itraconazole, fluconazole, and some adjuvant therapy options such as selenium sulfide shampoos and topical ketoconazole.
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Affiliation(s)
- Amena Alkeswani
- University of Alabama Birmingham, School of Medicine, Birmingham, Alabama, USA
| | - Wendy Cantrell
- UAB Department of Dermatology, Dermatology at the Whitaker Clinic, Birmingham, Alabama, USA
| | - Boni Elewski
- University of Alabama Birmingham, Department of Dermatology, Birmingham, Alabama, USA
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21
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Mourad A, Perfect JR. Tolerability profile of the current antifungal armoury. J Antimicrob Chemother 2019; 73:i26-i32. [PMID: 29304209 DOI: 10.1093/jac/dkx446] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The tolerability of available antifungal agents is essential to the final outcome of the management of invasive mycoses. There are limited classes of antifungal agents for use, and they can have serious direct toxicities and/or drug-drug interactions. In this review, we examine the common toxicities noted for antifungal agents and attempt to both identify the issues around the adverse events and provide clinical context for their occurrence in these fragile patients.
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Affiliation(s)
- Ahmad Mourad
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - John R Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, USA
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22
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Weber GC, Firouzi P, Baran AM, Bölke E, Schrumpf H, Buhren BA, Homey B, Gerber PA. Treatment of onychomycosis using a 1064-nm diode laser with or without topical antifungal therapy: a single-center, retrospective analysis in 56 patients. Eur J Med Res 2018; 23:53. [PMID: 30355363 PMCID: PMC6199788 DOI: 10.1186/s40001-018-0340-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 09/07/2018] [Indexed: 11/10/2022] Open
Abstract
Background Currently available treatment options for onychomycosis such as topical and systemic antifungals are often of limited efficacy, difficult to administer or associated with relevant side effects. Non-ablative laser therapy is proposed to represent a safe alternative without the disadvantages of drugs. Yet, to date, the efficacy of laser therapy for onychomycosis is discussed controversially. Against this background, we performed a systematic retrospective analysis of our clinical experience of 4 years of onychomycosis treatment applying a long-pulsed 1.064-nm diode laser. Methods We retrospectively evaluated the records of 56 patients with microscopic and culturally proven onychomycosis affecting a toenail of the hallux and other toes, who had been treated with a long-pulsed 1.064-nm diode laser (FOX, A.C.R. Laser GmbH, Nuremberg) during the time period of July 2013–December 2016 with or without concomitant topical antifungals. Thereof, 27 patients received laser treatment and 29 patients received laser treatment in combination with local antifungals. We conducted a mean of 3.9 laser treatments at 2–6-week intervals. The primary endpoint of our analysis was clinical improvement; secondary endpoints were complete remission of fungal pathogens in fungal culture and in microscopy. Results Clinical improvement was achieved in 56% of patients treated with laser only after a mean of 4.5 treatments and in 69% of patients treated with laser in combination with topical antifungals after a mean of 3.6 treatments. Cultural healing was detected in 63% of patients treated with laser only after a mean of 5.4 treatments, vs. 86% of patients treated with laser and concomitant topical antifungals after a mean of 4.8 treatments. Microscopic healing (complete healing) with the absence of fungal pathogens was achieved in 11% of patients after a mean of 4.7 treatments with laser only, vs. 21% of patients treated with laser and concomitant topical antifungals after a mean of 4 treatments. No relevant adverse effects were observed. Conclusions The 1.064-nm diode laser is an effective and safe option for the treatment of onychomycosis. Of note, the combination with topical antifungals will increase overall treatment efficacy and reduce the time to healing. Particularly, patients with contraindications against systemic antifungals may benefit from this multimodal therapeutic approach. Our data, moreover, suggest that treatment efficacy is positively correlated with the total number of laser treatments.
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Affiliation(s)
- G C Weber
- Department of Dermatology, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - P Firouzi
- Department of Dermatology, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - A M Baran
- Department of Dermatology, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - E Bölke
- Department of Radiation Oncology, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - H Schrumpf
- Department of Dermatology, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - B A Buhren
- Department of Dermatology, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - B Homey
- Department of Dermatology, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - P A Gerber
- Department of Dermatology, Heinrich-Heine-University, 40225, Düsseldorf, Germany.
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Xie P, Lefrançois P. Efficacy, safety, and comparison of sonic hedgehog inhibitors in basal cell carcinomas: A systematic review and meta-analysis. J Am Acad Dermatol 2018; 79:1089-1100.e17. [PMID: 30003981 DOI: 10.1016/j.jaad.2018.07.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 06/27/2018] [Accepted: 07/03/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sonic hedgehog inhibitors (SHHis) provide an additional treatment option for basal cell carcinomas (BCCs), especially for metastatic or locally advanced BCC. However, studies have been heterogeneous and lacked direct comparisons between molecules. OBJECTIVE To determine the efficacy and safety of the class of molecules SHHi for treating BCC and to compare them individually. METHODS We performed a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)-compliant systematic review of studies followed by a meta-analysis. RESULTS Eighteen articles were included in our meta-analysis; 16 articles were combined for efficacy and 16 for safety. In locally advanced BCC, overall response rates (ORRs) were similar for vismodegib and sonidegib (69% vs 57%, respectively) but not complete response rates (31% vs 3%, respectively). In metastatic disease, the ORR of vismodegib was 2.7-fold higher than the ORR of sonidegib (39% vs 15%, respectively). For side effects affecting a majority of patients, prevalences for muscle spasms (67.1%), dysgeusia (54.1%), and alopecia (57.7%) were in similar proportions for sonidegib and vismodegib. Patients receiving sonidegib experienced more upper gastrointestinal distress than patients receiving vismodegib. CONCLUSION SHHis induce a partial response to locally advanced BCC disease. Side effects are common, similar across molecules, associated with high discontinuation rates, and warrant discussion beforehand.
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Affiliation(s)
- Pingxing Xie
- Division of Dermatology, Department of Medicine, McGill University, Montreal, Canada
| | - Philippe Lefrançois
- Division of Dermatology, Department of Medicine, McGill University, Montreal, Canada.
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25
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The evaluation of drug-induced changes in left ventricular function in pentobarbital-anesthetized dogs. J Pharmacol Toxicol Methods 2018; 91:27-35. [DOI: 10.1016/j.vascn.2018.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 12/06/2017] [Accepted: 01/09/2018] [Indexed: 11/18/2022]
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Bellmann R, Smuszkiewicz P. Pharmacokinetics of antifungal drugs: practical implications for optimized treatment of patients. Infection 2017; 45:737-779. [PMID: 28702763 PMCID: PMC5696449 DOI: 10.1007/s15010-017-1042-z] [Citation(s) in RCA: 196] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 06/25/2017] [Indexed: 02/08/2023]
Abstract
Introduction Because of the high mortality of invasive fungal infections (IFIs), appropriate exposure to antifungals appears to be crucial for therapeutic efficacy and safety. Materials and methods This review summarises published pharmacokinetic data on systemically administered antifungals focusing on co-morbidities, target-site penetration, and combination antifungal therapy. Conclusions and discussion Amphotericin B is eliminated unchanged via urine and faeces. Flucytosine and fluconazole display low protein binding and are eliminated by the kidney. Itraconazole, voriconazole, posaconazole and isavuconazole are metabolised in the liver. Azoles are substrates and inhibitors of cytochrome P450 (CYP) isoenzymes and are therefore involved in numerous drug–drug interactions. Anidulafungin is spontaneously degraded in the plasma. Caspofungin and micafungin undergo enzymatic metabolism in the liver, which is independent of CYP. Although several drug–drug interactions occur during caspofungin and micafungin treatment, echinocandins display a lower potential for drug–drug interactions. Flucytosine and azoles penetrate into most of relevant tissues. Amphotericin B accumulates in the liver and in the spleen. Its concentrations in lung and kidney are intermediate and relatively low myocardium and brain. Tissue distribution of echinocandins is similar to that of amphotericin. Combination antifungal therapy is established for cryptococcosis but controversial in other IFIs such as invasive aspergillosis and mucormycosis.
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Affiliation(s)
- Romuald Bellmann
- Clinical Pharmacokinetics Unit, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Piotr Smuszkiewicz
- Department of Anesthesiology, Intensive Therapy and Pain Treatment, University Hospital, Poznań, Poland
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Abstract
The causal agents of blastomycosis, Blastomyces dermatitidis and Blastomyces gilchristii, belong to a group of thermally dimorphic fungi that can infect healthy and immunocompromised individuals. Following inhalation of mycelial fragments and spores into the lungs, Blastomyces spp convert into pathogenic yeast and evade host immune defenses to cause pneumonia and disseminated disease. The clinical spectrum of pulmonary blastomycosis is diverse. The diagnosis of blastomycosis requires a high degree of clinical suspicion and involves culture-based and non-culture-based fungal diagnostic tests. The site and severity of infection, and the presence of underlying immunosuppression or pregnancy, influence the selection of antifungal therapy.
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Affiliation(s)
- Joseph A McBride
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, USA; Division of Infectious Disease, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 1675 Highland Avenue, Madison, WI 53792, USA
| | - Gregory M Gauthier
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, USA.
| | - Bruce S Klein
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, USA; Division of Infectious Disease, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 1675 Highland Avenue, Madison, WI 53792, USA; Department of Medical Microbiology and Immunology, University of Wisconsin School of Medicine and Public Health, 1550 Linden Drive, Madison, WI 53706, USA.
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THE PHARMACOKINETICS OF TOPICAL ITRACONAZOLE IN PANAMANIAN GOLDEN FROGS (ATELOPUS ZETEKI). J Zoo Wildl Med 2017; 48:344-351. [DOI: 10.1638/2015-0218r2.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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An evaluation of the utility of LVdP/dt 40 , QA interval, LVdP/dt min and Tau as indicators of drug-induced changes in contractility and lusitropy in dogs. J Pharmacol Toxicol Methods 2017; 85:1-21. [DOI: 10.1016/j.vascn.2017.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 12/19/2016] [Accepted: 01/04/2017] [Indexed: 11/19/2022]
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Abstract
Itraconazole is a commonly used antifungal drug. In addition to commonly described adverse effects, there have been few reports of heart failure with its use. We present two cases that developed acute systolic heart failure with Itraconazole use. A man in his early 30s was admitted with worsening leg swelling and dyspnoea on exertion. He had been on Itraconazole for blastomyces skin ulcer. His ejection fraction (EF) was found to be 10%-15%. Another man in his 50s was admitted with similar symptoms; his EF was 40%-45%. He had been on Itraconazole for forearm cellulitis. No other aetiology was identified in both patients despite extensive work-up including cardiac catheterisation. Itraconazole was stopped in both the cases. Our first patient did not improve even months after cessation of therapy and was referred for heart transplant. Our second patient improved after a few weeks, and his ejection fraction had improved on repeat testing.
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Affiliation(s)
- Vishesh Paul
- Univeristy of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Harsh Rawal
- Univeristy of Illinois Urbana-Champaign, Urbana, Illinois, USA
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Rodrigo-Troyano A, Mediavilla MM, Garin N, Güell R. Heart failure induced by itraconazole. Med Clin (Barc) 2016; 148:69-70. [PMID: 27914674 DOI: 10.1016/j.medcli.2016.09.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 11/17/2022]
Abstract
INTRODUCTION AND OBJECTIVE Itraconazole is an antifungal imidazole used for the treatment of aspergillosis. Evidence supporting the association between itraconazole and the onset of congestive heart failure (CHF) is limited and is based on cases reported after drug market release. CASE REPORT We report the case of a 76-year-old man with hypertension and COPD GOLD D who experienced heart failure after receiving a new line of treatment with itraconazole. The patient's symptoms resolved completely after the drug's withdrawal and initiation of treatment with diuretic therapy. Using validated algorithms, we concluded that there was a probable association between itraconazole and the onset of CHF. CONCLUSIONS The association between the administration of itraconazole and the onset of CHF is difficult to prove. Further observational studies are needed to assess this association. However, based on the available evidence, we should consider this possible adverse effect and even contraindicate this treatment in patients with a structural heart disease.
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Affiliation(s)
- Ana Rodrigo-Troyano
- Servicio de Neumología, Hospital de la Santa Creu i Sant Pau, Barcelona, España.
| | - Marta M Mediavilla
- Servicio de Farmacia, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Noé Garin
- Servicio de Farmacia, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Rosa Güell
- Servicio de Neumología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
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Pointon A, Pilling J, Dorval T, Wang Y, Archer C, Pollard C. From the Cover: High-Throughput Imaging of Cardiac Microtissues for the Assessment of Cardiac Contraction during Drug Discovery. Toxicol Sci 2016; 155:444-457. [DOI: 10.1093/toxsci/kfw227] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Page RL, O'Bryant CL, Cheng D, Dow TJ, Ky B, Stein CM, Spencer AP, Trupp RJ, Lindenfeld J. Drugs That May Cause or Exacerbate Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2016; 134:e32-69. [PMID: 27400984 DOI: 10.1161/cir.0000000000000426] [Citation(s) in RCA: 253] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Heart failure is a common, costly, and debilitating syndrome that is associated with a highly complex drug regimen, a large number of comorbidities, and a large and often disparate number of healthcare providers. All of these factors conspire to increase the risk of heart failure exacerbation by direct myocardial toxicity, drug-drug interactions, or both. This scientific statement is designed to serve as a comprehensive and accessible source of drugs that may cause or exacerbate heart failure to assist healthcare providers in improving the quality of care for these patients.
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Hayes GE, Novak-Frazer L. Chronic Pulmonary Aspergillosis-Where Are We? and Where Are We Going? J Fungi (Basel) 2016; 2:jof2020018. [PMID: 29376935 PMCID: PMC5753080 DOI: 10.3390/jof2020018] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 05/19/2016] [Accepted: 06/01/2016] [Indexed: 02/06/2023] Open
Abstract
Chronic pulmonary aspergillosis (CPA) is estimated to affect 3 million people worldwide making it an under recognised, but significant health problem across the globe, conferring significant morbidity and mortality. With variable disease forms, high levels of associated respiratory co-morbidity, limited therapeutic options and prolonged treatment strategies, CPA is a challenging disease for both patients and healthcare professionals. CPA can mimic smear-negative tuberculosis (TB), pulmonary histoplasmosis or coccidioidomycosis. Cultures for Aspergillus are usually negative, however, the detection of Aspergillus IgG is a simple and sensitive test widely used in diagnosis. When a fungal ball/aspergilloma is visible radiologically, the diagnosis has been made late. Sometimes weight loss and fatigue are predominant symptoms; pyrexia is rare. Despite the efforts of the mycology community, and significant strides being taken in optimising the care of these patients, much remains to be learnt about this patient population, the disease itself and the best use of available therapies, with the development of new therapies being a key priority. Here, current knowledge and practices are reviewed, and areas of research priority highlighted.
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Affiliation(s)
- Gemma E Hayes
- The University of Manchester, Oxford Road, Manchester M13 9PL, UK.
- Manchester Academic Health Science Centre, 46 Grafton Street, Manchester M13 9NT, UK.
- National Aspergillosis Centre, 2nd Floor Education and Research Centre, University Hospital of South Manchester, Southmoor Road, Manchester M23 9LT, UK.
| | - Lilyann Novak-Frazer
- The University of Manchester, Oxford Road, Manchester M13 9PL, UK.
- Manchester Academic Health Science Centre, 46 Grafton Street, Manchester M13 9NT, UK.
- The University of Manchester, Manchester Academic Health Science Centre, 2nd Floor Education and Research Centre, University Hospital of South Manchester, Southmoor Road, Manchester M23 9LT, UK.
- Mycology Reference Centre, Manchester, 2nd Floor Education and Research Centre, University Hospital of South Manchester, Southmoor Road, Manchester M23 9LT, UK.
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Lee HJ, Lee B, Park JD, Jeong HJ, Choi YH, Ju HY, Hong CR, Lee JW, Kim H, Suh DI, Park KD, Kang HJ, Shin HY, Ahn HS. Association of systolic blood pressure drop with intravenous administration of itraconazole in children with hemato-oncologic disease. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:6489-95. [PMID: 26719674 PMCID: PMC4687612 DOI: 10.2147/dddt.s95218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose Although few adverse effects have been reported for itraconazole, a widely used antifungal therapy for febrile neutropenia, we found intravenous (IV) itraconazole to be associated with serious cases of blood pressure (BP) drop. We therefore evaluated the incidence and risk factors for BP drop during IV administration of the drug. Materials and methods We reviewed the medical records of children with hemato-oncologic disease who were treated with IV itraconazole from January 2012 to December 2013. By analyzing systolic BP (SBP) measurements made from 4 hours before through to 4 hours after itraconazole administration, we evaluated the changes in SBP and the risk factors for an SBP drop, especially clinically meaningful (≥20%) drops. Results Itraconazole was administered 2,627 times to 180 patients. The SBP during the 4 hours following itraconazole administration was lower than during the 4 hours before administration (104 [53.0–160.33 mmHg] versus 105 [59.8–148.3 mmHg]; P<0.001). The decrease in SBP was associated with the application of continuous renal replacement therapy (CRRT) (P=0.012) and the use of inotropic (P=0.005) and hypotensive drugs (P=0.021). A clinically meaningful SBP drop was seen in 5.37% (141 out of 2,627) of the administrations, and the use of inotropics (odds ratio [OR] 6.70, 95% confidence interval [CI] 3.22–13.92; P<0.001), reducing the dose of inotropics (OR 8.08; 95% CI 1.39–46.94; P=0.02), CRRT (OR 3.10, 95% CI 1.41–6.81; P=0.005), and bacteremia (OR 2.70, 95% CI 1.32–5.51; P=0.007) were risk factors, while age was a protective factor (OR 0.93, 95% CI 0.89–0.97; P<0.001). Conclusion A decrease in SBP was associated with IV administration of itraconazole. It was particularly significant in younger patients with bacteremia using inotropic agents and during application of CRRT. Careful attention to hypotension is warranted during IV administration of itraconazole in this group of patients.
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Affiliation(s)
- Hyeong Jin Lee
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University, Seoul, South Korea
| | - Bongjin Lee
- Division of Pediatric Intensive Care, Department of Pediatrics, Seoul National University College of Medicine, Seoul National University, Seoul, South Korea
| | - June Dong Park
- Division of Pediatric Intensive Care, Department of Pediatrics, Seoul National University College of Medicine, Seoul National University, Seoul, South Korea
| | - Hyung Joo Jeong
- Division of Pediatric Intensive Care, Department of Pediatrics, Seoul National University College of Medicine, Seoul National University, Seoul, South Korea
| | - Yu Hyeon Choi
- Division of Pediatric Intensive Care, Department of Pediatrics, Seoul National University College of Medicine, Seoul National University, Seoul, South Korea
| | - Hee Young Ju
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University, Seoul, South Korea
| | - Che Ry Hong
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University, Seoul, South Korea
| | - Ji Won Lee
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University, Seoul, South Korea
| | - Hyery Kim
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University, Seoul, South Korea
| | - Dong In Suh
- Division of Pulmonology, Department of Pediatrics, Seoul National University College of Medicine, Seoul National University, Seoul, South Korea
| | - Kyung Duk Park
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University, Seoul, South Korea
| | - Hyoung Jin Kang
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University, Seoul, South Korea
| | - Hee Young Shin
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University, Seoul, South Korea
| | - Hyo Seop Ahn
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University, Seoul, South Korea
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Cleary JD, Stover KR. Antifungal-Associated Drug-Induced Cardiac Disease. Clin Infect Dis 2015; 61 Suppl 6:S662-8. [DOI: 10.1093/cid/civ739] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Predictivity of in vitro non-clinical cardiac contractility assays for inotropic effects in humans — A literature search. J Pharmacol Toxicol Methods 2015; 75:62-9. [DOI: 10.1016/j.vascn.2015.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 05/09/2015] [Accepted: 05/22/2015] [Indexed: 11/18/2022]
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Abstract
PURPOSE OF REVIEW Despite guideline-based treatment, many patients with severe asthma continue to have uncontrolled disease. Fungal allergy is being increasingly recognized in the pathogenesis of severe asthma. Limited data exist on the approach to treatment of fungal asthma. This review summarizes existing evidence on the use of antifungal agents in allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitization (SAFS), and highlights needed areas of future investigation. RECENT FINDINGS Recent studies evaluating oral triazole therapy in ABPA appear to support triazole use in a carefully considered clinical setting, whereas studies assessing triazole use in SAFS have yielded mixed results. Despite early encouraging findings that oral triazole use may improve asthma symptoms, stabilize lung function, decrease inhaled and systemic corticosteroid requirements, and alter serum biomarkers, overall data are limited. Appropriate patient selection, as well as choice of the optimal drug, dose, frequency, and duration of therapy, remains poorly defined. SUMMARY The role of antifungal therapy in severe asthma remains unclear. Early studies have suggested a possible benefit of some antifungal agents, such as oral triazoles in ABPA and SAFS; however, routine clinical use of these agents in severe asthma without ABPA is not currently recommended. Further research is needed to better delineate the potential utility of antifungal medications in severe asthma and identify the asthma populations who benefit from such treatment.
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Cutaneous Phaeohyphomycosis Caused by Exophiala attenuata in a Domestic Cat. Mycopathologia 2015; 180:281-7. [PMID: 26088340 PMCID: PMC7089347 DOI: 10.1007/s11046-015-9909-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 06/10/2015] [Indexed: 11/25/2022]
Abstract
A 7-year-old female-spayed, domestic short-haired cat was presented to her veterinarian with a mass on the hind paw. Histopathologic examination of a tissue biopsy revealed nodular pyogranulomatous panniculitis with intralesional pigmented fungal hyphae. A dematiaceous fungal isolate was isolated with a micromorphological phenotype consistent with the anamorphic genus Exophiala: budding cells, torulose mycelium and annellidic conidiogenesis from simple conidiophores consisting of terminal and lateral cells that tapered to a short beak at the apex. Sequence homology of the internal transcribed spacer region of the rDNA gene confirmed the identification of the isolate as Exophialaattenuata. Reported here is the first confirmed case of feline phaeohyphomycosis caused by E. attenuata in North America. Similar to historical cases of feline phaeohyphomycosis caused by Exophiala spp., there was no history or postmortem evidence to suggest the patient was in an immunocompromised state (e.g., suffering from FeLV or FIV). Although aggressive surgical excision of local lesions is recommended prior to drug treatment when dealing with subcutaneous phaeohyphomycosis, surgery followed by itraconazole treatment did not resolve the E. attenuata infection in this cat.
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The evaluation of drug-induced changes in cardiac inotropy in dogs: Results from a HESI-sponsored consortium. J Pharmacol Toxicol Methods 2015; 75:70-90. [PMID: 25843226 DOI: 10.1016/j.vascn.2015.02.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 02/12/2015] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Drug-induced effects on the cardiovascular system remain a major cause of drug attrition. While hemodynamic (blood pressure (BP) and heart rate (HR)) and electrophysiological methods have been used in testing drug safety for years, animal models for assessing myocardial contractility are used less frequently and their translation to humans has not been established. The goal of these studies was to determine whether assessment of contractility and hemodynamics, when measured across different laboratories using the same protocol, could consistently detect drug-induced changes in the inotropic state of the heart using drugs known to have clinically relevant positive and negative effects on myocardial contractility. METHODS A 4×4 double Latin square design (n=8) design using Beagle dogs was developed. Drugs were administrated orally. Arterial blood pressure, left ventricular pressure (LVP) and the electrocardiogram were assessed. Each of the six laboratories studied at least 2 drugs (one positive inotrope (pimobendan or amrinone) and one negative inotrope) (itraconazole or atenolol) at 3 doses selected to match clinical exposure data and a vehicle control. Animals were instrumented with an ITS telemetry system, DSI's D70-PCTP system or DSI's Physiotel Digital system. Data acquisition and analysis systems were Ponemah, Notocord or EMKA. RESULTS Derived parameters included: diastolic, systolic and mean arterial BP, peak systolic LVP, HR, end-diastolic LVP, and LVdP/dtmax as the primary contractility index. Blood samples were drawn to confirm drug exposures predicted from independent pharmacokinetic studies. Across the laboratories, a consistent change in LVdP/dtmax was captured despite some differences in the absolute values of some of the hemodynamic parameters prior to treatment. DISCUSSION These findings indicate that this experimental model, using the chronically instrumented conscious dog, can accurately and consistently detect changes in cardiac contractility, across multiple sites and instrumentation systems, and that data obtained in this model may also translate to clinical outcomes.
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Abstract
Background Onychomycosis has several clinical presentations and is caused by various infectious organisms. Objective To provide guidance for selection of appropriate treatment. Methods The literature on onychomycosis management was reviewed to generate an evidence-based decision tree. Results and Conclusion Several options are available: terbinafine, itraconazole, fluconazole, ciclopirox 8% nail lacquer, efinaconazole 10% nail solution, and laser therapy. Further studies on lasers are needed before use can be recommended. Nondermatophyte molds or mixed infection can be managed with terbinafine or itraconazole with or without topicals. Itraconazole, fluconazole, and efinaconazole can be used for Candida infection. For dermatophytes, topicals can be considered for mild to moderate onychomycosis. For moderate to severe cases, any oral monotherapy can be used; however, we suggest terbinafine if there is a possibility of a drug interaction. These recommendations can be applied for all ages, immune function, or metabolic status, but proper monitoring and contraindications should be taken into consideration.
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Affiliation(s)
- Aditya K. Gupta
- From the Department of Medicine, University of Toronto, Toronto, ON, and Mediprobe Research Inc., London, ON
| | - Maryse Paquet
- From the Department of Medicine, University of Toronto, Toronto, ON, and Mediprobe Research Inc., London, ON
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Therapeutic drug monitoring for triazoles: A needs assessment review and recommendations from a Canadian perspective. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2015; 25:327-43. [PMID: 25587296 PMCID: PMC4277162 DOI: 10.1155/2014/340586] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Invasive fungal infections cause significant morbidity and mortality in patients with concomitant underlying immunosuppressive diseases. The recent addition of new triazoles to the antifungal armamentarium has allowed for extended-spectrum activity and flexibility of administration. Over the years, clinical use has raised concerns about the degree of drug exposure following standard approved drug dosing, questioning the need for therapeutic drug monitoring (TDM). Accordingly, the present guidelines focus on TDM of triazole antifungal agents. A review of the rationale for triazole TDM, the targeted patient populations and available laboratory methods, as well as practical recommendations based on current evidence from an extended literature review are provided in the present document.
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Soares JR, Nunes MCP, Leite AF, Falqueto EB, Lacerda BERA, Ferrari TCA. Reversible dilated cardiomyopathy associated with amphotericin B therapy. J Clin Pharm Ther 2014; 40:333-5. [PMID: 25487534 DOI: 10.1111/jcpt.12237] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 11/07/2014] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Amphotericin B (AmB) is commonly used to treat a broad spectrum of fungal infections and leishmaniasis. Its use is limited by numerous adverse effects. Reversible dilated cardiomyopathy associated with AmB is a rare disorder with only four previously reported cases, and all of them referring to patients who presented with a predisposing factor for heart failure. CASE SUMMARY A previously healthy 45-year-old man with visceral leishmaniasis treated with AmB developed acute dilated cardiomyopathy. Other causes of heart failure as well-known predisposing factors for this condition were ruled out. As with previously reported cases, the cardiac function of our patient returned to normal shortly after. WHAT IS NEW AND CONCLUSION We describe the first case of dilated cardiomyopathy associated with the administration of AmB in a patient without any known predisposing factor for developing cardiac dysfunction. Available evidence suggests that AmB may induce cardiotoxicity. Further investigations are needed to clarify this issue.
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Affiliation(s)
- J R Soares
- Hospital das Clinicas of the Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
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Eldridge ML, Chambers CJ, Sharon VR, Thompson GR. Fungal infections of the skin and nail: new treatment options. Expert Rev Anti Infect Ther 2014; 12:1389-405. [DOI: 10.1586/14787210.2014.960849] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Gøtzsche PC, Johansen HK. Routine versus selective antifungal administration for control of fungal infections in patients with cancer. Cochrane Database Syst Rev 2014; 2014:CD000026. [PMID: 25188768 PMCID: PMC6457640 DOI: 10.1002/14651858.cd000026.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Systemic fungal infection is considered to be an important cause of morbidity and mortality in cancer patients, particularly those with neutropenia. Antifungal drugs are often given prophylactically, or empirically to patients with persistent fever. OBJECTIVES To assess whether commonly used antifungal drugs decrease mortality in cancer patients with neutropenia. SEARCH METHODS We searched PubMed from 1966 to 7 July 2014 and the reference lists of identified articles. SELECTION CRITERIA Randomised clinical trials of amphotericin B, fluconazole, ketoconazole, miconazole, itraconazole or voriconazole compared with placebo or no treatment in cancer patients with neutropenia. DATA COLLECTION AND ANALYSIS The two review authors independently assessed trial eligibility and risk of bias, and abstracted data. MAIN RESULTS Thirty-two trials involving 4287 patients were included. Prophylactic or empirical treatment with amphotericin B significantly decreased total mortality (relative risk (RR) 0.69, 95% confidence interval (CI) 0.50 to 0.96), whereas the estimated RRs for fluconazole, ketoconazole, miconazole, and itraconazole were close to 1.00. No eligible trials were found with voriconazole. Amphotericin B and fluconazole decreased mortality ascribed to fungal infection (RR 0.45, 95% CI 0.26 to 0.76 and RR 0.42, 95% CI 0.24 to 0.73, respectively). The incidence of invasive fungal infection decreased significantly with administration of amphotericin B (RR 0.41, 95% CI 0.24 to 0.73), fluconazole (RR 0.39, 95% CI 0.27 to 0.57) and itraconazole (RR 0.53, 95% CI 0.29 to 0.97), but not with ketoconazole or miconazole. Effect estimates were similar for those 13 trials that had adequate allocation concealment and were blinded. The reporting of harms was far too variable from trial to trial to allow a meaningful overview. For the 2011 and 2014 updates no additional trials were identified for inclusion. AUTHORS' CONCLUSIONS Intravenous amphotericin B was the only antifungal agent that reduced total mortality. It should therefore be preferred when prophylactic or empirical antifungal therapy is introduced in cancer patients with neutropenia.
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Affiliation(s)
- Peter C Gøtzsche
- RigshospitaletNordic Cochrane CentreBlegdamsvej 9, 7811CopenhagenDenmarkDK‐2100
| | - Helle Krogh Johansen
- RigshospitaletThe Nordic Cochrane CentreBlegdamsvej 9, 3343CopenhagenDenmarkDK 2100
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Abstract
Understanding the tissue penetration of systemically administered antifungal agents is critical for a proper appreciation of their antifungal efficacy in animals and humans. Both the time course of an antifungal drug and its absolute concentrations within tissues may differ significantly from those observed in the bloodstream. In addition, tissue concentrations must also be interpreted within the context of the pathogenesis of the various invasive fungal infections, which differ significantly. There are major technical obstacles to the estimation of concentrations of antifungal agents in various tissue subcompartments, yet these agents, even those within the same class, may exhibit markedly different tissue distributions. This review explores these issues and provides a summary of tissue concentrations of 11 currently licensed systemic antifungal agents. It also explores the therapeutic implications of their distribution at various sites of infection.
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Denolle T, Azizi M, Massart C, Zennaro MC. [Itraconazole: a new drug-related cause of hypertension]. Ann Cardiol Angeiol (Paris) 2014; 63:213-215. [PMID: 24952675 DOI: 10.1016/j.ancard.2014.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 05/14/2014] [Indexed: 06/03/2023]
Abstract
Itraconazole is a triazole agent used in the treatment of fungal infections and in some metastatic cancers. Its use has been associated with cardiovascular adverse events and particularly heart failure with preserved ejection fraction. We report the case of a 68-year-old male patient with a well-controlled hypertension treated with irbesartan 150mg/day since 2007. He developed a pulmonary aspergillosis on post-tuberculosis cavitary lesions treated in July 2011 with itraconazole 200mg/day. Early 2012, his antihypertensive treatment had to be gradually increased to a quadritherapy and his blood pressure was at 157/78mmHg at home. Hypokalemia was observed on several occasions as well as edema of the lower limbs. Plasma renin and plasma and urine aldosterone concentrations on treatment not interfering with the renin angiotensin system were low, associated with normal serum and urine cortisol, ACTH, SDHA and DOC, BNP and creatinine concentrations. Plasma itraconazole values were much above the therapeutic range. Left ventricular ejection fraction was preserved. There were no adrenal or renal artery abnormalities at the CT scan. Three months after stopping itraconazole, hypokalemia and edema disappeared and blood pressure was normalized with less treatment. Plasma renin and aldosterone concentrations were normalized. He had a pulmonary lobectomy for his pulmonary aspergillosis. Itraconazole may induce a resistant hypertension with low renin. The mechanisms of this adverse effect of itraconazole remain unknown.
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Affiliation(s)
- T Denolle
- Hôpital Arthur-Gardiner, 1, rue Henri-Dunant, 35800 Dinard, France.
| | - M Azizi
- Unité d'HTA, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 75015 Paris, France
| | - C Massart
- Hôpital Pontchaillou, 35000 Rennes, France
| | - M C Zennaro
- Inserm U 970, service de génétique, hôpital européen Georges-Pompidou, université Paris Descartes, 75015 Paris, France
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Okuyan H, Altın C. Heart failure induced by itraconazole. Indian J Pharmacol 2014; 45:524-5. [PMID: 24130392 PMCID: PMC3793528 DOI: 10.4103/0253-7613.117751] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 05/14/2013] [Accepted: 07/12/2013] [Indexed: 11/04/2022] Open
Abstract
Itraconazole is a broad-spectrum antifungal agent. It rarely leads to adverse the cardiovascular effects, especially heart failure. We present here a case of a 60-year-old female patient with itraconazole induced heart failure.
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Affiliation(s)
- Hızır Okuyan
- Department of Cardiology, Sakarya Education and Research Hospital, Adapazari, Sakarya, Turkey
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