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Hu L, Huang J, Li Y, He G. Clinical application of voriconazole in pediatric patients: a systematic review. Ital J Pediatr 2024; 50:113. [PMID: 38853280 PMCID: PMC11163776 DOI: 10.1186/s13052-024-01684-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/30/2024] [Indexed: 06/11/2024] Open
Abstract
The purpose of this study was to review the literature on the clinical use of voriconazole (VRC) in pediatric patients. MEDLINE, Embase, PubMed, Web of Science, and Cochrane Library were searched from January 1, 2000, to August 15, 2023 for relevant clinical studies on VRC use in pediatric patients. Data were collected based on inclusion and exclusion criteria, and a systematic review was performed on recent research related to the use of VRC in pediatric patients. This systematic review included a total of 35 observational studies among which there were 16 studies investigating factors influencing VRC plasma trough concentrations (Ctrough) in pediatric patients, 14 studies exploring VRC maintenance doses required to achieve target range of Ctrough, and 11 studies focusing on population pharmacokinetic (PPK) research of VRC in pediatric patients. Our study found that the Ctrough of VRC were influenced by both genetic and non-genetic factors. The optimal dosing of VRC was correlated with age in pediatric patients, and younger children usually required higher VRC doses to achieve target Ctrough compared to older children. Establishing a PPK model for VRC can assist in achieving more precise individualized dosing in children.
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Affiliation(s)
- Lin Hu
- Department of Pharmacy, The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China.
- Department of Pharmacy, The First Hospital of Changsha, Changsha, Hunan, China.
| | - Juanjuan Huang
- Department of Pharmacy, The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China
- Department of Pharmacy, The First Hospital of Changsha, Changsha, Hunan, China
| | - Yanfei Li
- Department of Pharmacy, The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China
- Department of Pharmacy, The First Hospital of Changsha, Changsha, Hunan, China
| | - Gefei He
- Department of Pharmacy, The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China.
- Department of Pharmacy, The First Hospital of Changsha, Changsha, Hunan, China.
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Lewis R, Niazi-Ali S, McIvor A, Kanj SS, Maertens J, Bassetti M, Levine D, Groll AH, Denning DW. Triazole antifungal drug interactions-practical considerations for excellent prescribing. J Antimicrob Chemother 2024; 79:1203-1217. [PMID: 38629250 DOI: 10.1093/jac/dkae103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024] Open
Abstract
Systemic antifungal therapy is critical for reducing the mortality from many invasive and chronic fungal infections. Triazole antifungals are the most frequently prescribed antifungals but require attention to dosing and drug interactions. Nearly 600 severe drug-drug interactions and over 1100 moderate interactions requiring dose modifications are described or anticipated with systemic antifungal agents (see https://www.aspergillus.org.uk/antifungal-drug-interactions/). In this article, we address the common and less common, but serious, drug interactions observed in clinical practice with triazole antifungals, including a group of drugs that cannot be prescribed with all or most triazole antifungals (ivabradine, ranolazine, eplerenone, fentanyl, apomorphine, quetiapine, bedaquiline, rifampicin, rifabutin, sirolimus, phenytoin and carbamazepine). We highlight interactions with drugs used in children and new agents introduced for the treatment of haematological malignancies or graft versus host disease (midostaurin, ibrutinib, ruxolitinib and venetoclax). We also summarize the multiple interactions between oral and inhaled corticosteroids and triazole antifungals, and the strategies needed to optimize the therapeutic benefits of triazole antifungal therapy while minimizing potential harm to patients.
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Affiliation(s)
- Russell Lewis
- Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Saarah Niazi-Ali
- Antifungal Database Consultancy Pharmacist, Fungal Infection Trust, PO Box 482, Macclesfield, Cheshire SK10 9AR, UK
| | - Andrew McIvor
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Souha S Kanj
- Division of Infectious Diseases, Department of Internal Medicine and Center for Infectious Diseases Research, American University of Beirut Medical Center, Beirut, Lebanon
| | - Johan Maertens
- Department of Microbiology, Immunology, and Transplantation, Department of Haematology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Matteo Bassetti
- Department of Health Sciences, Infectious Diseases Clinic, University of Genoa and Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Deborah Levine
- Lung Transplant Program, Division of Pulmonary Critical Care and Allergy, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital, Albert-Schweitzer-Campus 1, Building A1, Münster, 48149, Germany
| | - David W Denning
- Manchester Fungal Infection Group, The University of Manchester and Manchester Academic Health Science Centre, Manchester, UK
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Dinh A, Savoy JM, Kontoyiannis DP, Takahashi K, Issa GC, Kantarjian HM, DiNardo CD, Rausch CR. Ivosidenib significantly reduces triazole levels in patients with acute myeloid leukemia and myelodysplastic syndrome. Cancer 2024; 130:1964-1971. [PMID: 38340331 DOI: 10.1002/cncr.35251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/20/2023] [Accepted: 01/12/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Ivosidenib is primarily metabolized by CYP3A4; however, it induces CYP450 isozymes, including CYP3A4 and CYP2C9, whereas it inhibits drug transporters, including P-glycoprotein. Patients with acute myeloid leukemia are at risk of invasive fungal infections, and therefore posaconazole and voriconazole are commonly used in this population. Voriconazole is a substrate of CYP2C9, CYP2C19, and CYP3A4; therefore, concomitant ivosidenib may result in decreased serum concentrations. Although posaconazole is a substrate of P-glycoprotein, it is metabolized primarily via UDP glucuronidation; thus, the impact of ivosidenib on posaconazole exposure is unknown. METHODS Patients treated with ivosidenib and concomitant triazole with at least one serum trough level were included. Subtherapeutic levels were defined as posaconazole <700 ng/mL and voriconazole <1.0 µg/mL. The incidences of breakthrough invasive fungal infections and QTc prolongation were identified at least 5 days after initiation of ivosidenib with concomitant triazole. RESULTS Seventy-eight serum triazole levels from 31 patients receiving ivosidenib-containing therapy and concomitant triazole were evaluated. Of the 78 concomitant levels, 47 (60%) were subtherapeutic (posaconazole: n = 20 of 43 [47%]; voriconazole: n = 27 of 35 [77%]). Compared to levels drawn while patients were off ivosidenib, median triazole serum levels during concomitant ivosidenib were significantly reduced. There was no apparent increase in incidence of grade 3 QTc prolongation with concomitant azole antifungal and ivosidenib 500 mg daily. CONCLUSIONS This study demonstrated that concomitant ivosidenib significantly reduced posaconazole and voriconazole levels. Voriconazole should be avoided, empiric high-dose posaconazole (>300 mg/day) may be considered, and therapeutic drug monitoring is recommended in all patients receiving concomitant ivosidenib.
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Affiliation(s)
- Ashley Dinh
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - J Michael Savoy
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Caitlin R Rausch
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Matsumoto K, Takagi S, Asano-Mori Y, Yamaguchi K, Yuasa M, Kageyama K, Kaji D, Nishida A, Ishiwata K, Yamamoto H, Araoka H, Miyazaki Y, Uchida N, Taniguchi S, Morita K. Evaluation of the pharmacokinetics of liposomal amphotericin B and analysis of the relationship between pharmacokinetics, efficacy and safety in patients with hematological diseases. J Infect Chemother 2024; 30:504-510. [PMID: 38097040 DOI: 10.1016/j.jiac.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 11/20/2023] [Accepted: 12/08/2023] [Indexed: 01/07/2024]
Abstract
INTRODUCTION This study aimed to identify factors responsible for changes in blood concentrations of a liposomal formulation of amphotericin B (AMPH-B, L-AMB) and analyze the relationships between blood concentrations and efficacy or toxicity. METHODS L-AMB was administered to 30 patients being treated for hematological diseases. AMPH-B plasma concentrations were determined right before the initiation (Cmin) and at the end (Cmax) of infusion on at least 1 day, beginning on Day 3 of L-AMB treatment. The relationships of Cmin divided by dose (C/D ratio) to body weight, age, hepatic function, renal function, serum albumin, C-reactive protein (CRP), response, hypokalemia, and renal impairment were evaluated. RESULTS C/D ratio was not correlated with age, hepatic function, renal function, or serum albumin. Body weight adjusted C/D ratio was negatively correlated with CRP. Cmax and Cmin were compared between responders and non-responders, those with or without hypokalemia, and those with or without renal impairment. A higher Cmax in patients with hypokalemia was the only significant difference seen. CONCLUSIONS The negative correlation between CRP and plasma concentrations was likely caused by higher distribution of L-AMB from the blood to infected tissue in patients with a greater degree of infection, with a resulting decrease in plasma concentrations. AMPH-B plasma concentrations were not related to response. Higher Cmax of AMPH-B were observed in patients with hypokalemia, but no relationship between plasma concentration and renal toxicity was observed, suggesting that AMPH-B plasma concentrations appear to be minimally related to PD when used as L-AMB.
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Affiliation(s)
- Kana Matsumoto
- Department of Clinical Pharmaceutics, Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, Japan.
| | | | | | | | | | | | - Daisuke Kaji
- Department of Hematology, Toranomon Hospital, Japan
| | - Aya Nishida
- Department of Hematology, Toranomon Hospital, Japan
| | | | | | - Hideki Araoka
- Department of Infectious Diseases, Toranomon Hospital, Japan
| | - Yoshitsugu Miyazaki
- Department of Fungal Infection, National Institute of Infectious Diseases, Japan
| | - Naoyuki Uchida
- Department of Hematology, Toranomon Hospital, Japan; Okinaka Memorial Institute for Medical Research, Japan
| | | | - Kunihiko Morita
- Department of Clinical Pharmaceutics, Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, Japan
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Almutairy R, Khan MA, Shahbar A, Aseeri M, Alshamrani M, Almarhabi H, Naeem D. Posaconazole versus voriconazole as antifungal prophylaxis for invasive fungal diseases in patients with hematological malignancies. J Oncol Pharm Pract 2024:10781552241246119. [PMID: 38656201 DOI: 10.1177/10781552241246119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
INTRODUCTION The incidence of invasive fungal diseases (IFDs) has risen in hematologic malignancy patients due to neutropenia. While posaconazole is recommended as the first-line antifungal prophylaxis in acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) patients and voriconazole is an alternative, there is currently no direct comparison data available to assess their relative effectiveness. METHOD We retrospectively reviewed eligible patient charts from January 2017 to February 2019 to identify breakthrough IFD rates, drug adverse event frequency, and drug acquisition cost in AML/MDS patients. RESULTS Forty-eight patients received 130 chemo cycles, with 50 (38%) cycles prescribed posaconazole and 80 (62%) prescribed voriconazole as primary IFD prophylaxis. The incidence rates of IFD in the posaconazole group were 8% (4 out of 50), of which two were probable and two were possible infections, while 6.26% (5 out of 80) of patients in the voriconazole group developed IFD, with four possible infections and one probable infection (p = 0.73). A higher percentage of patients in the voriconazole group discontinued prophylaxis due to adverse events, with six patients compared to two patients in the posaconazole group (p = 0.15). The drug acquisition cost of posaconazole is 5.62 times more expensive than voriconazole. CONCLUSION The use of voriconazole instead of posaconazole for 130 chemo cycles would save $166,584.6. Posaconazole and voriconazole have comparable efficacy and safety in preventing IFD in AML and MDS patients receiving chemotherapy. However, posaconazole is more costly than voriconazole.
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Affiliation(s)
- Reem Almutairy
- Pharmaceutical Care, King Abdul-Aziz Medical City, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- Pharmaceutical Care Department, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
- Department of Pharmaceutical Sciences, Fakeeh College for Medical Sciences, Jeddah, Saudi Arabia
| | - Mansoor Ahmed Khan
- Pharmaceutical Care, King Abdul-Aziz Medical City, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Alaa Shahbar
- Faculty of Pharmacy, Pharmacy Practices Department, Umm Al-Qura University, Mecca, Saudi Arabia
| | - Mohammed Aseeri
- Pharmaceutical Care, King Abdul-Aziz Medical City, Jeddah, Saudi Arabia
- King Saud Bin Abdul-Aziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Majed Alshamrani
- Pharmaceutical Care, King Abdul-Aziz Medical City, Jeddah, Saudi Arabia
| | - Hassan Almarhabi
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- King Saud Bin Abdul-Aziz University for Health Sciences, Jeddah, Saudi Arabia
- Department of Infectious Diseases, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
- Department of Internal Medicine, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Doaa Naeem
- Pharmaceutical Care, King Abdul-Aziz Medical City, Jeddah, Saudi Arabia
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Weerdenburg H, Walker H, Curtis N, Duffull S, Haeusler G, Cole T, Gwee A. Posaconazole in paediatric malignancy and haematopoietic stem cell transplant: dosing to achieve therapeutic concentration. J Antimicrob Chemother 2024:dkae099. [PMID: 38637310 DOI: 10.1093/jac/dkae099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/05/2024] [Indexed: 04/20/2024] Open
Abstract
OBJECTIVES Posaconazole is increasingly used for the treatment and prophylaxis of invasive fungal infections in immunocompromised children. We aimed to review evidence for paediatric posaconazole dosing regimens focusing on attainment of target concentrations and frequency of adverse effects. METHODS In May 2023, the Cochrane, Embase, MEDLINE and PubMed databases were searched for articles reporting posaconazole dosing in children with malignancy or post-haematopoietic stem cell transplantation. Studies reporting the attainment of target serum concentrations were included. RESULTS Overall, 24 studies were included. Eighteen studies of the oral suspension consistently reported poor attainment of target concentrations for prophylaxis (≥0.7 µg/mL, 12%-78%) despite high daily doses of 14-23 mg/kg/day (max. 1200 mg/day). Target attainment was significantly affected by gastric pH and food intake. Six studies of the delayed-release tablet (DRT) reported 58%-94% achieved concentrations ≥0.7 µg/mL, with the majority using lower doses of 4-12 mg/kg/day (max. 300 mg/day). Similarly, one study of powder for oral suspension found 67%-100% achieved target concentrations with a dose of 6 mg/kg/day (max. 300 mg/day). As expected, the IV formulation had high attainment of prophylaxis targets (81%-90%) with 6-10 mg/kg/day (max. 400 mg/day). All formulations were well tolerated, and no relationship between adverse effects and posaconazole concentrations was identified. CONCLUSIONS The required posaconazole dose in immunocompromised children varies depending on the formulation. The IV infusion had the highest attainment of therapeutic concentration followed by the DRT and powder for suspension. By contrast, the oral suspension had low attainment of target concentrations despite higher daily doses.
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Affiliation(s)
- Heather Weerdenburg
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Hannah Walker
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nigel Curtis
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Gabrielle Haeusler
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- The Victorian Paediatric Integrated Cancer Service, Victoria State Government, Melbourne, Victoria, Australia
| | - Theresa Cole
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Amanda Gwee
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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Sugimoto M, Yonezawa A, Kanda J, Itohara K, Hira D, Yamagiwa T, Taniguchi R, Hanyu Y, Watanabe M, Arai Y, Mizumoto C, Kitawaki T, Kondo T, Yamashita K, Takaori-Kondo A, Terada T. Population Pharmacokinetic Modeling of Posaconazole in Japanese Patients Receiving Fungal Prophylaxis. Ther Drug Monit 2024:00007691-990000000-00207. [PMID: 38648638 DOI: 10.1097/ftd.0000000000001198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 01/26/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Posaconazole is a vital drug to treat and prevent invasive fungal infections. Several factors, such as sex, body weight, total serum proteins, dietary intake, and severe mucositis, affect posaconazole pharmacokinetics (PKs). However, the relevance of other factors that affect the PKs of posaconazole in hematopoietic stem cell transplantation (HSCT) is unknown. This study explored factors influencing the PKs of posaconazole in HSCT recipients and nontransplant patients with hematological diseases. METHODS The authors conducted a single-institution, retrospective study. Forty-two Japanese inpatients receiving oral posaconazole tablets as prophylaxis for fungal infections were enrolled in this study. A one-compartment model with first-order absorption was used as the structural pharmacokinetic model. A population PK (PopPK) analysis was performed using a nonlinear mixed-effects modeling program, using a first-order conditional estimation method with interactions. Perl-speaks-NONMEM and R were used to evaluate the goodness of fit and visualize the output. RESULTS In 29% of the enrolled patients, the serum concentration of posaconazole was <0.5 mcg/mL, considered the effective range. PopPK analysis revealed that the patient had undergone HSCT within 1 year, diarrhea occurred more than 5 times a day, and aspartate aminotransferase were covariates that influenced apparent clearance (CL/F). The CL/F of posaconazole was 1.43-fold higher after HSCT and 1.26-fold higher during diarrhea. CONCLUSIONS PopPK analysis revealed that HSCT, diarrhea, and aspartate aminotransferase were factors associated with the CL/F of posaconazole. The trough concentration of posaconazole may be below the therapeutic range in a few patients with diarrhea and/or after HSCT. As invasive fungal infections in patients with hematologic diseases can be life-threatening, therapeutic drug monitoring of posaconazole is strongly recommended, and patients should be carefully monitored.
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Affiliation(s)
- Mitsuhiro Sugimoto
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
- Division of Integrative Clinical Pharmacology, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Kotaro Itohara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Daiki Hira
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Takeo Yamagiwa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Risa Taniguchi
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Yuta Hanyu
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Mizuki Watanabe
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Chisaki Mizumoto
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Toshio Kitawaki
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kouhei Yamashita
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; and
| | - Tomohiro Terada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
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Khurana A, Sharath S, Sardana K, Chowdhary A. Clinico-mycological and therapeutic updates on cutaneous dermatophytic infections in the era of Trichophyton indotineae. J Am Acad Dermatol 2024:S0190-9622(24)00535-8. [PMID: 38574764 DOI: 10.1016/j.jaad.2024.03.024] [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: 11/12/2023] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 04/06/2024]
Abstract
Trichophyton indotineae has emerged as a novel dermatophyte species resulting in treatment recalcitrant skin infections. While the earliest reports came from India, T. indotineae has now spread to many parts of the world and is rapidly becoming a global health concern. Accurate identification of T. indotineae requires elaborate mycological investigations which is beyond the domain of routine microbiology testing. Extensive, non-inflammatory and atypical presentations are commonly seen with this novel species. T. indotineae shows an alarmingly high rate of mutations in the squalene epoxidase gene leading to lowered in vitro susceptibility to terbinafine. This has also translated into a lowered clinical response and requirement of a higher dose and much longer durations of treatment with the drug. Although the species remains largely susceptible to itraconazole, prolonged treatment durations are required to achieve cure with itraconazole. Fluconazole and griseofulvin do not have satisfactory in vitro or clinical activity. Apart from requirement of prolonged treatment durations, relapse postsuccessful treatment is a distressing and yet unexplained consequence of this "species-shift." Use of third generation azoles and combinations of systemic antifungals is unwarranted as both have not demonstrated clear superiority over itraconazole given alone, and the former is an important class of drugs for invasive mycoses.
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Affiliation(s)
- Ananta Khurana
- Department of Dermatology, Venereology and Leprosy, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India.
| | - Savitha Sharath
- Department of Dermatology, Venereology and Leprosy, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Kabir Sardana
- Department of Dermatology, Venereology and Leprosy, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Anuradha Chowdhary
- Medical Mycology Unit, Department of Microbiology, National Reference Laboratory for Antimicrobial Resistance in Fungal Pathogens, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi, India
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Lai T, Yeo CY, Rockliff B, Stokes M, Kim HY, Marais BJ, McLachlan AJ, Alffenaar JWC. Therapeutic drug monitoring of liposomal amphotericin B in children. Are we there yet? A systematic review. J Antimicrob Chemother 2024; 79:703-711. [PMID: 38252921 PMCID: PMC10984953 DOI: 10.1093/jac/dkae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/22/2023] [Indexed: 01/24/2024] Open
Abstract
INTRODUCTION Therapeutic drug monitoring (TDM) is a tool that supports personalized dosing, but its role for liposomal amphotericin B (L-amb) is unclear. This systematic review assessed the evidence for L-amb TDM in children. OBJECTIVES To evaluate the concentration-efficacy relationship, concentration-toxicity relationship and pharmacokinetic/pharmacodynamic (PK/PD) variability of L-amb in children. METHODS We systematically reviewed PubMed and Embase databases following PRISMA guidelines. Eligible studies included L-amb PK/PD studies in children aged 0-18 years. Review articles, case series of RESULTS In total, 4220 studies were screened; 6 were included, presenting data on 195 children. Invasive candidiasis and aspergillosis were the two most common infections treated with L-amb. Studies showed significant PK variability due to age (mean age ranged from 14 days to 17 years), body weight, non-linear PK and changes in the volume of distribution. Limited evidence supported a peak concentration/MIC (Cmax/MIC) of 25-50 for optimal efficacy and an AUC24 of >600 mg·h/L for nephrotoxicity. L-amb doses of 2.5-10 mg/kg/day were reported to achieve Cmax/MIC > 25 using an MIC of 1 mg/L. CONCLUSIONS While significant PK variability was observed in children, evidence to support routine L-amb TDM was limited. Further studies on efficacy and toxicity benefits are required before routine TDM of L-amb can be recommended.
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Affiliation(s)
- Tony Lai
- Pharmacy Department, The Children’s Hospital at Westmead, Sydney, NSW, Australia
- The University of Sydney Infectious Diseases Institute (Sydney ID), Sydney, NSW, Australia
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Chin-Yen Yeo
- Pharmacy Department, Concord Hospital, Sydney, Australia
| | - Bradley Rockliff
- Pharmacy Department, The Children’s Hospital at Westmead, Sydney, NSW, Australia
| | - Michael Stokes
- Pharmacy Department, The Children’s Hospital at Westmead, Sydney, NSW, Australia
- The University of Sydney Infectious Diseases Institute (Sydney ID), Sydney, NSW, Australia
| | - Hannah Yejin Kim
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Pharmacy Department, Westmead Hospital, Sydney, Australia
| | - Ben J Marais
- The University of Sydney Infectious Diseases Institute (Sydney ID), Sydney, NSW, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jan-Willem C Alffenaar
- The University of Sydney Infectious Diseases Institute (Sydney ID), Sydney, NSW, Australia
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Pharmacy Department, Westmead Hospital, Sydney, Australia
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10
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Boyer J, Hoenigl M, Kriegl L. Therapeutic drug monitoring of antifungal therapies: do we really need it and what are the best practices? Expert Rev Clin Pharmacol 2024; 17:309-321. [PMID: 38379525 DOI: 10.1080/17512433.2024.2317293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/07/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Despite advancements, invasive fungal infections (IFI) still carry high mortality rates, often exceeding 30%. The challenges in diagnosis, coupled with limited effective antifungal options, make managing IFIs complex. Antifungal drugs are essential for IFI management, but their efficacy can be diminished by drug-drug interactions and pharmacokinetic variability. Therapeutic Drug Monitoring (TDM), especially in the context of triazole use, has emerged as a valuable strategy to optimize antifungal therapy. AREAS COVERED This review provides current evidence regarding the potential benefits of TDM in IFI management. It discusses how TDM can enhance treatment response, safety, and address altered pharmacokinetics in specific patient populations. EXPERT OPINION TDM plays a crucial role in achieving optimal therapeutic outcomes in IFI management, particularly for certain antifungal agents. Preclinical studies consistently show a link between therapeutic drug levels and antifungal efficacy. However, clinical research in mycology faces challenges due to patient heterogeneity and the diversity of fungal infections. TDM's potential advantages in guiding Echinocandin therapy for critically ill patients warrant further investigation. Additionally, for drugs like Posaconazole, assessing whether serum levels or alternative markers like saliva offer the best measure of efficacy is an intriguing question.
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Affiliation(s)
- Johannes Boyer
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed, Graz, Austria
- Translational Mycology Working Group, ECMM Excellence Center for Clinical Mycology, Medical University of Graz, Graz, Austria
| | - Lisa Kriegl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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11
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Boppana M, Sengar M, Jain H, Gurjar M, Ambotkar M, Gota V, Bonda A, Bagal B, Thorat J, Gokarn A, Nayak L, Shetty N, Baheti A, Mokal S, Kannan S, Shetty A, Eipe T. A Prospective Study to Evaluate the Effect of Therapeutic Drug Monitoring-Based Posaconazole Prophylaxis on Invasive Fungal Infection Rate During Acute Myeloid Leukemia Induction Therapy. Indian J Hematol Blood Transfus 2024; 40:204-212. [PMID: 38708158 PMCID: PMC11065854 DOI: 10.1007/s12288-023-01709-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 10/04/2023] [Indexed: 05/07/2024] Open
Abstract
Invasive fungal infections (IFIs) are a significant cause of morbidity and mortality in de-novo acute myeloid leukemia patients receiving induction chemotherapy. Despite using posaconazole, a broad-spectrum antifungal, for IFI prophylaxis, the breakthrough IFI rate is high in the real-world setting. One of the reasons could be frequent suboptimal plasma posaconazole levels. In the present study, we evaluated if therapeutic drug monitoring (TDM) guided posaconazole prophylaxis can reduce the IFI rates in comparison to a historical cohort. We enrolled 90 patients, > / = 16 years of age, without baseline IFIs, planned for remission induction therapy. All patients were started on posaconazole suspension 200 mg TDS and the dose was increased in a stepwise manner if trough levels were found to be suboptimal (< 350 ng/ml for day 2 or < 700 ng/ml subsequently). The TDM based approach resulted in a significant decline in breakthrough IFI rates (18% versus 52%, P < 0.0001) A total of 69 patients (78%) required dose escalation. Thirty-one patients required change in antifungals due to either suboptimal levels, persistent fever, diarrhoea or vomiting. We could not demonstrate an exposure-response relationship but the difference in IFI rates in patients with a median posaconazole level > / = 700 ng/ml (0%) and < 700 ng/ml (21.6%) was clinically meaningful. Posaconazole levels were found to be significantly lower in patients on antacids and prokinetics. The incidence of posaconazole-related grade 3 toxicity was low (2.3%). Thus TDM-based dosing of posaconazole helps reduce breakthrough IFI rate and should be a part of posaconazole prophylaxis. Supplementary Information The online version contains supplementary material available at 10.1007/s12288-023-01709-3.
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Affiliation(s)
- Mounika Boppana
- Department of Medical Oncology, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
- Present Address: Department of Medical Oncology, Krishna Institute of Medical Sciences, Minister Road, Secunderabad, Telangana 500003, India
| | - Manju Sengar
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National University, Earnest Borges Road, Parel, Mumbai 400012 India
| | - Hasmukh Jain
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Murari Gurjar
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Madhavi Ambotkar
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Vikram Gota
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Avinash Bonda
- Department of Medical Oncology, Asian Institute of Gastroenterology (AIG) Hospitals, Mindspace Road, P Janardhan Reddy Nagar, Gachibowli, Hyderabad, Telangana 500032, India
| | - Bhausaheb Bagal
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Jayashree Thorat
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Anant Gokarn
- Adult Hematolymphoid Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Lingaraj Nayak
- Adult Hematolymphoid Unit, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Nitin Shetty
- Department of Radiodiagnosis, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Akshay Baheti
- Department of Radiodiagnosis, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Smruti Mokal
- Clinical Research Secretariat, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Sadhana Kannan
- Clinical Research Secretariat, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Alok Shetty
- Department of Medical Oncology, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Thomas Eipe
- Department of Medical Oncology, Tata Memorial Centre, Affiliated to Homi Bhabha National Institute, E Borges Road, Mumbai, Maharashtra 400 012 India
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12
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Cimino C, Rivera CG, Pearson JC, Colton B, Slain D, Mahoney MV. Pharmacotherapeutic Considerations in the Treatment of Nontuberculous Mycobacterial Infections: A Primer for Clinicians. Open Forum Infect Dis 2024; 11:ofae128. [PMID: 38560605 PMCID: PMC10977864 DOI: 10.1093/ofid/ofae128] [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] [Indexed: 04/04/2024] Open
Abstract
Nontuberculous mycobacteria (NTM) can cause a variety of infections, including serious pulmonary disease. Treatment encompasses polypharmacy, with a targeted regimen of 2-5 active medications, depending on site of infection, species, and clinical characteristics. Medications may include oral, intravenous, and inhalational routes. Medication acquisition can be challenging for numerous reasons, including investigational status, limited distribution models, and insurance prior authorization. Additionally, monitoring and managing adverse reactions and drug interactions is a unique skill set. While NTM is primarily medically managed, clinicians may not be familiar with the intricacies of medication selection, procurement, and monitoring. This review offers insights into the pharmacotherapeutic considerations of this highly complex disease state, including regimen design, medication acquisition, safety monitoring, relevant drug-drug interactions, and adverse drug reactions.
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Affiliation(s)
- Christo Cimino
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Jeffrey C Pearson
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Benjamin Colton
- Pharmacy Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Douglas Slain
- Department of Clinical Pharmacy, School of Pharmacy and Section of Infectious Diseases, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Monica V Mahoney
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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13
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Agarwal R, Sehgal IS, Muthu V, Denning DW, Chakrabarti A, Soundappan K, Garg M, Rudramurthy SM, Dhooria S, Armstrong-James D, Asano K, Gangneux JP, Chotirmall SH, Salzer HJF, Chalmers JD, Godet C, Joest M, Page I, Nair P, Arjun P, Dhar R, Jat KR, Joe G, Krishnaswamy UM, Mathew JL, Maturu VN, Mohan A, Nath A, Patel D, Savio J, Saxena P, Soman R, Thangakunam B, Baxter CG, Bongomin F, Calhoun WJ, Cornely OA, Douglass JA, Kosmidis C, Meis JF, Moss R, Pasqualotto AC, Seidel D, Sprute R, Prasad KT, Aggarwal AN. Revised ISHAM-ABPA working group clinical practice guidelines for diagnosing, classifying and treating allergic bronchopulmonary aspergillosis/mycoses. Eur Respir J 2024; 63:2400061. [PMID: 38423624 PMCID: PMC10991853 DOI: 10.1183/13993003.00061-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND The International Society for Human and Animal Mycology (ISHAM) working group proposed recommendations for managing allergic bronchopulmonary aspergillosis (ABPA) a decade ago. There is a need to update these recommendations due to advances in diagnostics and therapeutics. METHODS An international expert group was convened to develop guidelines for managing ABPA (caused by Aspergillus spp.) and allergic bronchopulmonary mycosis (ABPM; caused by fungi other than Aspergillus spp.) in adults and children using a modified Delphi method (two online rounds and one in-person meeting). We defined consensus as ≥70% agreement or disagreement. The terms "recommend" and "suggest" are used when the consensus was ≥70% and <70%, respectively. RESULTS We recommend screening for A. fumigatus sensitisation using fungus-specific IgE in all newly diagnosed asthmatic adults at tertiary care but only difficult-to-treat asthmatic children. We recommend diagnosing ABPA in those with predisposing conditions or compatible clinico-radiological presentation, with a mandatory demonstration of fungal sensitisation and serum total IgE ≥500 IU·mL-1 and two of the following: fungal-specific IgG, peripheral blood eosinophilia or suggestive imaging. ABPM is considered in those with an ABPA-like presentation but normal A. fumigatus-IgE. Additionally, diagnosing ABPM requires repeated growth of the causative fungus from sputum. We do not routinely recommend treating asymptomatic ABPA patients. We recommend oral prednisolone or itraconazole monotherapy for treating acute ABPA (newly diagnosed or exacerbation), with prednisolone and itraconazole combination only for treating recurrent ABPA exacerbations. We have devised an objective multidimensional criterion to assess treatment response. CONCLUSION We have framed consensus guidelines for diagnosing, classifying and treating ABPA/M for patient care and research.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | - Kathirvel Soundappan
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandeep Garg
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Darius Armstrong-James
- Faculty of Medicine, Department of Infectious Disease, Imperial College London, London, UK
| | - Koichiro Asano
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Jean-Pierre Gangneux
- Université Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail), UMR_S 1085, Rennes, France
- CHU Rennes, Laboratoire de Parasitologie-Mycologie, ECMM Excellence Center in Medical Mycology, Rennes, France
- National Reference Center on Mycoses and Antifungals (CNRMA LA-Asp C), Rennes, France
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University (NTU) and Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Helmut J F Salzer
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine-Pneumology, Kepler University Hospital and Medical Faculty, Johannes Kepler University, Linz, Austria
| | | | - Cendrine Godet
- Université Paris Sorbonne, AP-HP, Hôpital Tenon, Service de Pneumologie et Oncologie Thoracique, Centre Constitutif Maladies Pulmonaires Rares Paris, Paris, France
| | | | - Iain Page
- NHS Lothian, Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, UK
| | - Parameswaran Nair
- McMaster University, McGill University, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - P Arjun
- KIMS Hospital, Trivandrum, India
| | - Raja Dhar
- Department of Pulmonology, CK Birla Hospitals, Kolkata, India
| | - Kana Ram Jat
- Division of Pediatric Pulmonology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Joseph L Mathew
- Pediatric Pulmonology Division, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Alok Nath
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute, Lucknow, India
| | - Dharmesh Patel
- City Clinic and Bhailal Amin General Hospital, Vadodara, India
| | - Jayanthi Savio
- Department of Microbiology, St John's Medical College and Hospital, Bengaluru, India
| | - Puneet Saxena
- Pulmonary and Critical Care Medicine, Army Hospital (R&R), New Delhi, India
| | - Rajeev Soman
- Department of Infectious Diseases, Jupiter Hospital, Pune, India
| | | | - Caroline G Baxter
- Department of Respiratory Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
- Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - William J Calhoun
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Oliver A Cornely
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
| | - Jo A Douglass
- University of Melbourne, Royal Melbourne Hospital, Parkville, Australia
| | - Chris Kosmidis
- Division of Evolution, Infection and Genomics, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jacques F Meis
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
- Center of Expertise in Mycology Radboudumc/CWZ Nijmegen, Nijmegen, The Netherlands
| | - Richard Moss
- Center of Excellence in Pulmonary Biology, Division of Pulmonary, Asthma and Sleep Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Alessandro C Pasqualotto
- Molecular Biology Laboratory, Santa Casa de Misericordia de Porto Alegre, Porto Alegre, Brazil
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Danila Seidel
- Department of Internal Medicine, University Hospital, Cologne, Germany
| | - Rosanne Sprute
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Hinze CA, Fuge J, Grote-Koska D, Brand K, Slevogt H, Cornberg M, Simon S, Joean O, Welte T, Rademacher J. Factors influencing voriconazole plasma level in intensive care patients. JAC Antimicrob Resist 2024; 6:dlae045. [PMID: 38500519 PMCID: PMC10946233 DOI: 10.1093/jacamr/dlae045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/22/2024] [Indexed: 03/20/2024] Open
Abstract
Background In clinical routine, voriconazole plasma trough levels (Cmin) out of target range are often observed with little knowledge about predisposing influences. Objectives To determine the distribution and influencing factors on voriconazole blood levels of patients treated on intensive- or intermediate care units (ICU/IMC). Patients and methods Data were collected retrospectively from patients with at least one voriconazole trough plasma level on ICU/IMC (n = 153) to determine the proportion of sub-, supra- or therapeutic plasma levels. Ordinal logistic regression analysis was used to assess factors hindering patients to reach voriconazole target range. Results Of 153 patients, only 71 (46%) reached the target range at the first therapeutic drug monitoring, whereas 66 (43%) patients experienced too-low and 16 (10%) too-high plasma levels. Ordinal logistic regression analysis identified the use of extra corporeal membrane oxygenation (ECMO), low international normalized ratio (INR) and aspartate-aminotransferase (AST) serum levels as predictors for too-low plasma levels. Conclusion Our data highlight an association of ECMO, INR and AST levels with voriconazole plasma levels, which should be considered in the care of critically ill patients to optimize antifungal therapy with voriconazole.
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Affiliation(s)
| | - Jan Fuge
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Denis Grote-Koska
- Institute of Clinical Chemistry, Hannover Medical School, Hannover, Germany
| | - Korbinian Brand
- Institute of Clinical Chemistry, Hannover Medical School, Hannover, Germany
| | - Hortense Slevogt
- Department of Respiratory Medicine and Infectious Disease, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
- Respiratory Infection Dynamics Group, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Centre for Individualized Infection Medicine, Hannover, Germany
- German Center for Infection Research (DZIF), partner-site Hannover-Braunschweig, Hannover, Germany
| | - Susanne Simon
- Department of Respiratory Medicine and Infectious Disease, Hannover Medical School, Hannover, Germany
| | - Oana Joean
- Department of Respiratory Medicine and Infectious Disease, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine and Infectious Disease, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Jessica Rademacher
- Department of Respiratory Medicine and Infectious Disease, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
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Gupta AK, Mann A, Polla Ravi S, Wang T. Navigating fungal infections and antifungal stewardship: drug resistance, susceptibility testing, therapeutic drug monitoring and future directions. Ital J Dermatol Venerol 2024; 159:105-117. [PMID: 38088126 DOI: 10.23736/s2784-8671.23.07694-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/24/2024]
Abstract
Antifungal stewardship refers to the rational use of antifungal agents. Historically, in some instances, the misuse or overuse of antifungal agents has predisposed patients to an elevated risk of systemic side-effects and treatment resistance, as well as increased healthcare costs. Superficial mycoses, such as onychomycosis, are sometimes treated without any diagnostic testing and is associated with a high likelihood of self-diagnosis and self-treatment, potentially leading to the emergence of resistance against commonly used antifungals like terbinafine. Practitioners need to ensure that a proper clinical diagnosis is backed up by appropriate testing. This may include the traditional light microscopy and culture; additionally, molecular techniques (such as polymerase chain reaction, terbinafine gene mutational analysis) and antifungal susceptibility testing are considerations as appropriate. The choice of antifungal agent should be guided by what is the standard of care in the location where the clinician practices as well as more broadly state and national prescription patterns. Recently, reports of treatment resistance concerning both superficial and deep fungal infections have added another layer of difficulty to clinical practice. This review aims to explore the phenomenon of antifungal drug resistance, and highlights the importance of adopting antifungal stewardship programs. We provide an overview of treatment resistance and mechanisms of resistance reported thus far in dermatophytes. Challenges of performing antifungal susceptibility testing and therapeutic drug monitoring are discussed, as well as principles, recommendations and future directions of antifungal stewardship programs.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada -
- Mediprobe Research Inc, London, ON, Canada -
| | | | | | - Tong Wang
- Mediprobe Research Inc, London, ON, Canada
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16
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Pungprasert T, Dhirachaikulpanich D, Phutthasakda W, Tantai N, Maneeon S, Nganthavee V, Atipas K, Tanpong S, Krithin S, Tanglitanon S, Jutidamrongphan W, Chayakulkeeree M, Srinonprasert V, Phikulsod P. The cost-utility analysis of antifungal prophylaxis for invasive fungal infections in acute myeloid leukaemia patients receiving chemotherapy: a study from a middle-income country. J Hosp Infect 2024; 145:118-128. [PMID: 38219835 DOI: 10.1016/j.jhin.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 12/15/2023] [Accepted: 12/25/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Invasive fungal infections (IFIs) contribute to morbidity and mortality during acute myeloid leukaemia (AML) treatment. Without prophylaxis, IFI rate during AML treatment in Thailand is high and results in a high mortality rate and a prolonged hospital stay. AIM To evaluate the cost-utility of antifungal therapy (AFT) prophylaxis during AML treatment. METHODS We assessed the cost-utility of AFT available in Thailand, including posaconazole (solution), itraconazole (solution and capsule), and voriconazole. A hybrid model consisting of a decision tree and the Markov model was established. RESULTS The costs to prevent overall IFI using any AFT were all lower than the treatment cost of a non-prophylaxis group, resulting in a saving of 808-1507 USD per patient. Prevention with voriconazole prophylaxis showed the highest quality-adjusted life years (QALYs = 3.51, incremental QALYs = 0.23), followed by posaconazole (QALYs = 3.46, incremental QALY = 0.18) and itraconazole solution (QALYs = 3.45, incremental QALYs = 0.17). Itraconazole capsule reduced QALY in the model. For invasive aspergillosis prevention, posaconazole and voriconazole both resulted in better QALYs and life year savings compared with no prophylaxis. However, posaconazole prophylaxis was the only cost-saving option (976 USD per patient). CONCLUSION Posaconazole, itraconazole solution and voriconazole were all cost saving compared with no prophylaxis for overall IFI prophylaxis, with voriconazole being the most cost-effective option. Posaconazole and voriconazole were both cost effective for invasive aspergillosis prevention but only posaconazole was cost saving. A change in reimbursement policy for the use of AFT prophylaxis during intensive AML treatment could provide both clinical benefits to patients and substantial economic benefits to healthcare systems.
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Affiliation(s)
- T Pungprasert
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - W Phutthasakda
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - N Tantai
- Siriaj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Department of Pharmacy, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - S Maneeon
- Siriaj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Department of Pharmacy, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - V Nganthavee
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - K Atipas
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - S Tanpong
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - S Krithin
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - S Tanglitanon
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - W Jutidamrongphan
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - M Chayakulkeeree
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - V Srinonprasert
- Siriaj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - P Phikulsod
- Division of Haematology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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17
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Wei XC, Zhao MF, Xiao X. Supratherapeutic posaconazole concentrations associated with hyperlipidemia in a patient with HSCT. J Infect Chemother 2024; 30:255-257. [PMID: 37832823 DOI: 10.1016/j.jiac.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 10/15/2023]
Abstract
Posaconazole is a potent, extended-spectrum triazole antifungal used for the treatment and prophylaxis of serious fungal infections. Previous reports have demonstrated hyperlipidemia resulted in significant changes in posaconazole pharmacokinetics and tissue distribution in rats. However, the effect of hyperlipidemia on the pharmacokinetics of posaconazole in patients has not yet been reported. We report a case of a 34-year-old woman who experienced a supratherapeutic posaconazole trough concentration (PTC) associated with hyperlipidemia after haploidentical hematopoietic stem cell transplantation (HSCT). The patient was admitted 13 months after HSCT for recurrent cough and sputum. She was treated with caspofungin due to developing invasive fungal infection of Candida tropicalis. After 10 days, caspofungin was discontinued due to the poor therapeutic efficacy and replaced with amphotericin B. Afterwards, the condition of the patient improved significantly and she was switched to daily oral posaconazole tablet. Therapeutic drug monitoring (TDM) of posaconazole showed a PTC was 3.2 mg/L. After discharge, she continued to receive posaconazole tablet as antifungal treatment. Two months later, laboratory tests at outpatient showed her blood lipid levels were significantly elevated and PTC was increased to 9.38 mg/L. Therefore, the posaconazole tablet was discontinued and she received lipid-lowering therapy. A few days later, the PTC was down to 5.22 mg/L. No medication errors and significant drug interactions were found. Hence, supratherapeutic PTC for this patient may be caused by hyperlipidemia which altered pharmacokinetics of posaconazole. Our findings highlight the need for close TDM in order to avoid supratherapeutic PTC if hyperlipidimia occurs during posaconazole use.
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Affiliation(s)
- Xiao-Chen Wei
- Department of Pharmacy, Tianjin First Central Hospital, Tianjin, PR China.
| | - Ming-Feng Zhao
- Department of Hematology, Tianjin First Central Hospital, Tianjin, PR China
| | - Xia Xiao
- Department of Hematology, Tianjin First Central Hospital, Tianjin, PR China
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18
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Géraud A, Combarel D, Funck-Brentano C, Beaulieu Q, Zahr N, Broutin S, Spano JP, Massard C, Besse B, Gougis P. A Score to Predict the Clinical Usefulness of Therapeutic Drug Monitoring: Application to Oral Molecular Targeted Therapies in Cancer. Clin Pharmacol Ther 2024. [PMID: 38389482 DOI: 10.1002/cpt.3193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/22/2024] [Indexed: 02/24/2024]
Abstract
Therapeutic drug monitoring (TDM) involves measuring and interpreting drug concentrations in biological fluids to adjust drug dosages. In onco-hematology, TDM guidelines for oral molecular targeted therapies (oMTTs) are varied. This study evaluates a quantitative approach with a score to predict the clinical usefulness of TDM for oMTTs. We identified key parameters for an oMTT's suitability for TDM from standard TDM recommendations. We gathered oMTT pharmacological data, which covered exposure variability (considering pharmacokinetic (PK) impact of food and proton pump inhibitors), technical intricacy (PK linearity and active metabolites), efficacy (exposure-response relationship), and safety (maximum tolerated dose, and exposure-safety relationship). To assess the validity and the relevance of the score and define relevant thresholds, we evaluated molecules with prospective validation or strong recommendations for TDM, both in oncology and in other fields. By September 1, 2021, the US Food and Drug Administration (FDA) approved 67 oMTTs for onco-hematological indications. Scores ranged from 15 (acalabrutinib) to 80 (sunitinib) with an average of 48.3 and a standard deviation of 15.6. Top scorers included sunitinib, sorafenib, cabozantinib, nilotinib, and abemaciclib. Based on scores, drugs were categorized into low (< 40), intermediate (≥ 40 and < 60), and high (≥ 60) relevance for TDM. Notably, negative controls generally scored around or under 40, whereas positive controls had a high score across different indications. In this work, we propose a quantitative and reproducible score to compare the potential usefulness of TDM for oMTTs. Future guidelines should prioritize the TDM for molecules with the highest score.
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Affiliation(s)
- Arthur Géraud
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
- Early Drug Development Department (DITEP), Gustave Roussy, Villejuif, France
- Paris-Saclay University, Orsay, France
| | - David Combarel
- Pharmacology Department, Gustave Roussy, Villejuif, France
- Faculty of Pharmacy, Paris-Saclay University, Chatenay-Malabry, France
| | - Christian Funck-Brentano
- Department of Pharmacology and Clinical Investigation Center (CIC-1901), AP-HP.Sorbonne Université, Pitié-Salpêtrière Hospital, INSERM, CIC-1901 and UMR-S 1166, Sorbonne Université Médecine, Paris, France
| | - Quentin Beaulieu
- Department of Pharmacology and Clinical Investigation Center (CIC-1901), AP-HP.Sorbonne Université, Pitié-Salpêtrière Hospital, INSERM, CIC-1901 and UMR-S 1166, Sorbonne Université Médecine, Paris, France
| | - Noël Zahr
- Department of Pharmacology and Clinical Investigation Center (CIC-1901), AP-HP.Sorbonne Université, Pitié-Salpêtrière Hospital, INSERM, CIC-1901 and UMR-S 1166, Sorbonne Université Médecine, Paris, France
| | - Sophie Broutin
- Pharmacology Department, Gustave Roussy, Villejuif, France
| | - Jean-Philippe Spano
- Oncology Department, APHP-Sorbonne Université, Cancer Institute (IUC), Paris, France
- INSERM, UMRS 1136, Paris, France
| | - Christophe Massard
- Early Drug Development Department (DITEP), Gustave Roussy, Villejuif, France
- Centre Eugène Marquis, Rennes, France
| | - Benjamin Besse
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
- Paris-Saclay University, Orsay, France
| | - Paul Gougis
- Department of Pharmacology and Clinical Investigation Center (CIC-1901), AP-HP.Sorbonne Université, Pitié-Salpêtrière Hospital, INSERM, CIC-1901 and UMR-S 1166, Sorbonne Université Médecine, Paris, France
- Oncology Department, APHP-Sorbonne Université, Cancer Institute (IUC), Paris, France
- Residual Tumor & Response to Treatment Laboratory, RT2Lab, INSERM, U932 Immunity and Cancer, Curie Institute, Université Paris, Paris, France
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19
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Bewersdorf TN, Hofmann J, Findeisen S, Schamberger C, Lingner T, Sommer U, Schmidmaier G, Grossner T. Impact of Anti-Mycotic Drugs on the Osteogenic Response of Bone Marrow Mesenchymal Stem Cells In Vitro. Antibiotics (Basel) 2024; 13:186. [PMID: 38391572 PMCID: PMC10886247 DOI: 10.3390/antibiotics13020186] [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: 12/28/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
The treatment of fungal bone infections and infected non-unions is a huge challenge in modern trauma and orthopedics, which normally contain the local and systemic administration of anti-fungal drugs. Although frequently used, little is known about the impact of systemic and locally administered fungicides on the osteogenic regenerative capabilities of infected bone tissue, especially upon the osteogenesis of human bone marrow mesenchymal stem cells (BM-hMSCs). This study evaluates the effects of the three most common fungicides for the systemic treatment of bone infections, Voriconazole (VOR), liposomal Amphotericin B (LAMB), and Fluconazole (FLU), as well as the effects of VOR and LAMB-loaded Polymethylmethacrylate (PMMA) cement chips in different concentrations upon the osteogenic response of BM-hMSCs in vitro. Within this study, we compared the ability of BM-hMSC to differentiate into osteoblast-like cells and synthesize hydroxyapatite as assessed by radioactive 99mTechnetium-Hydroxydiphosphonate (99mTc-HDP) labeling, cell proliferation, and analyses of supernatants upon various osteogenic parameters. Our results revealed that VOR added to the cell culture medium affects the osteogenic potential of BM-hMSC negatively, while there were no detectable effects of LAMB and FLU. Moreover, we showed dose-dependent negative effects of high- and extended-dose fungicide-loaded PMMA cement due to cytotoxicity, with a higher cytotoxic potential of VOR than LAMB, while low-dose fungicide-loaded PMMA had no significant effect on the osteogenic potential of BM-hMSC in vitro.
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Affiliation(s)
- Tim Niklas Bewersdorf
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Jakob Hofmann
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Sebastian Findeisen
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Christian Schamberger
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Thomas Lingner
- Genevention GmbH, Rudolf-Wissell-Str. 28A, 37079 Göttingen, Germany
| | - Ulrike Sommer
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Gerhard Schmidmaier
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Tobias Grossner
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
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20
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Barros N, Wheat LJ. Histoplasmosis in Solid Organ Transplantation. J Fungi (Basel) 2024; 10:124. [PMID: 38392796 PMCID: PMC10890191 DOI: 10.3390/jof10020124] [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: 12/20/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/24/2024] Open
Abstract
Histoplasma capsulatum, the etiological agent for histoplasmosis, is a dimorphic fungus that grows as a mold in the environment and as a yeast in human tissues. It has a broad global distribution with shifting epidemiology during recent decades. While in immunocompetent individuals infection is usually self-resolving, solid organ transplant recipients are at increased risk of symptomatic disease with dissemination to extrapulmonary tissue. Diagnosis of histoplasmosis relies on direct observation of the pathogen (histopathology, cytopathology, and culture) or detection of antigens, antibodies, or nucleic acids. All transplant recipients with histoplasmosis warrant therapy, though the agent of choice and duration of therapy depends on the severity of disease. In the present article, we describe the pathogenesis, epidemiology, clinical manifestations and management of histoplasmosis in solid organ transplant recipients.
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Affiliation(s)
- Nicolas Barros
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Division of Infectious Diseases, Indiana University Health, Indianapolis, IN 46202, USA
- Miravista Diagnostics, Indianapolis, IN 46241, USA
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21
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Jendoubi A, Pressiat C, De Roux Q, Hulin A, Ghaleh B, Tissier R, Kohlhauer M, Mongardon N. The impact of extracorporeal membrane oxygenation on antifungal pharmacokinetics: A systematic review. Int J Antimicrob Agents 2024; 63:107078. [PMID: 38161046 DOI: 10.1016/j.ijantimicag.2023.107078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/09/2023] [Accepted: 12/26/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND AND OBJECTIVE The use of extracorporeal membrane oxygenation (ECMO) as a cardiocirculatory or respiratory support has tremendously increased in critically ill patients. In the setting of ECMO support, invasive fungal infections are a severe cause of morbidity and mortality. This vulnerable population is at risk of suboptimal antifungal exposure due to an increased volume of distribution (Vd), drug sequestration and decreased clearance. Here, we aimed to summarize ex-vivo and clinical studies on the potential impact of ECMO on the pharmacokinetics (PK) of antifungal agents and dosing requirements. METHODS A systematic search of the literature within electronic databases PubMed and EMBASE was conducted from database inception to 30 April 2023. Inclusion criteria were as follows: critically ill patients receiving ECMO regardless of age and reporting at least one PK parameter. RESULTS Thirty-six studies met inclusion criteria, including seven ex-vivo experiments and 29 clinical studies evaluating three classes of antifungals: polyenes, triazoles and echinocandins. Based on the available ex-vivo PK data, we found a significant sequestration of highly lipophilic and protein-bound antifungals within the ECMO circuit such as voriconazole, posaconazole and micafungin but the PK of several antifungals remains to be addressed such as amphotericin B, isavuconazole and anidulafungin. Most clinical studies have shown increased Vd of some antifungals like fluconazole and micafungin, particularly in the pediatric population. Conflicting data exist about caspofungin exposure. CONCLUSIONS The available literature on the antifungal PK changes in ECMO setting is scarce. Whenever possible, therapeutic drug monitoring is highly advised to personalize antifungal therapy.
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Affiliation(s)
- Ali Jendoubi
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Service d'Anesthésie-Réanimation Chirurgicale, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Claire Pressiat
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Faculté de Santé, Université Paris Est Créteil, Créteil, France; Laboratoire de Pharmacologie, DMU Biologie-Pathologie, Assistance Publique des Hôpitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Quentin De Roux
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Service d'Anesthésie-Réanimation Chirurgicale, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Anne Hulin
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Faculté de Santé, Université Paris Est Créteil, Créteil, France; Laboratoire de Pharmacologie, DMU Biologie-Pathologie, Assistance Publique des Hôpitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Bijan Ghaleh
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Faculté de Santé, Université Paris Est Créteil, Créteil, France; Laboratoire de Pharmacologie, DMU Biologie-Pathologie, Assistance Publique des Hôpitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Renaud Tissier
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France
| | - Matthias Kohlhauer
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France
| | - Nicolas Mongardon
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Service d'Anesthésie-Réanimation Chirurgicale, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France; Faculté de Santé, Université Paris Est Créteil, Créteil, France.
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22
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Wu Z, Jiang M, Yan M, Li G, Zeng Z, Zhang X, Li N, Jiang Y, Gong G, Zhang M. Therapeutic Drug Monitoring of Voriconazole in Patients with End-Stage Liver Disease. Ther Drug Monit 2024; 46:89-94. [PMID: 38192036 DOI: 10.1097/ftd.0000000000001139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND This study aimed to identify the factors that influence voriconazole (VCZ) plasma concentrations and optimize the doses of VCZ in patients with end-stage liver disease (ESLD). METHODS Patients with ESLD who received a VCZ maintenance dose of 100 mg twice daily (group A, n = 57) or the VCZ maintenance dose of 50 mg twice daily (group B, n = 37), orally or intravenously, were enrolled in this study. Trough plasma concentrations (Cmin) of VCZ between 1 and 5 mg/L were considered within the therapeutic target range. RESULTS The VCZ Cmin was determined in 94 patients with ESLD. The VCZ Cmin of patients in group A was remarkably higher than those in group B (4.85 ± 2.53 mg/L vs 2.75 ± 1.40 mg/L; P < 0.001). Compared with group A, fewer patients in group B had VCZ Cmin outside the therapeutic target (23/57 vs. 6/37, P = 0.021). Univariate and multivariate analyses suggested that both body weight and Model for End-Stage Liver Disease scores were closely associated with the VCZ Cmin in group B. CONCLUSIONS These data indicate that dose optimization based on body weight and Model for End-Stage Liver Disease scores is required to strike an efficacy-safety balance during VCZ treatment in patients with ESLD.
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Affiliation(s)
- Zhenyu Wu
- Department of Infectious Diseases, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Min Jiang
- Department of Infectious Diseases, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Miao Yan
- Department of Pharmacy, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China; and
| | - Guangdi Li
- Hunan Provincial Key Laboratory of Clinical Epidemiology, Xiangya School of Public Health, Central South University, Changsha, Hunan, China
| | - Zhihao Zeng
- Department of Infectious Diseases, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Xiangling Zhang
- Department of Infectious Diseases, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Naiping Li
- Department of Infectious Diseases, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yongfang Jiang
- Department of Infectious Diseases, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Guozhong Gong
- Department of Infectious Diseases, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Min Zhang
- Department of Infectious Diseases, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
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23
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Vena A, Bassetti M, Mezzogori L, Marchesi F, Hoenigl M, Giacobbe DR, Corcione S, Bartoletti M, Stemler J, Pagano L, Cornely OA, Salmanton-García J. Laboratory and clinical management capacity for invasive fungal infections: the Italian landscape. Infection 2024; 52:197-208. [PMID: 37656348 PMCID: PMC10811091 DOI: 10.1007/s15010-023-02084-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND We assessed the laboratory diagnosis and treatment of invasive fungal disease (IFD) in Italy to detect limitations and potential for improvement. METHODS The survey was available online at www.clinicalsurveys.net/uc/IFI management capacity/, and collected variables such as (a) institution profile, (b) perceptions of IFD in the respective institution, (c) microscopy, (d) culture and fungal identification, (e) serology, (f) antigen detection, (g) molecular tests, (h) susceptibility testing and (i) therapeutic drug monitoring (TDM). RESULTS The laboratory capacity study received responses from 49 Italian centres, with an equitable geographical distribution of locations. The majority of respondents (n = 36, 73%) assessed the occurrence of IFD as moderate-high, with Aspergillus spp. being the pathogen of highest concern, followed by Candida spp. and Mucorales. Although 46 (94%) of the institutions had access to microscopy, less than half of them performed direct microscopy on clinical specimens always when IFD was suspected. Cultures were available in all assessed laboratories, while molecular testing and serology were available in 41 (83%), each. Antigen detection tests and antifungal drugs were also generally accessible (> 90%) among the participating institutions. Nevertheless, access to TDM was limited (n = 31, 63%), with a significant association established between therapeutic drug monitoring availability and higher gross domestic product per capita. CONCLUSIONS Apart from TDM, Italy is adequately prepared for the diagnosis and treatment of IFD, with no significant disparities depending on gross domestic product. Future efforts may need to focus on enhancing the availability and application of direct microscopic methods, as well as TDM, to promote optimal treatment and better patient outcomes.
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Affiliation(s)
- Antonio Vena
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
- Clinica Malattie Infettive, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
- Infectious Diseases Unit, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Largo Rosanna Benzi, 10, 16132, Genoa, Italy.
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Clinica Malattie Infettive, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Infectious Diseases Unit, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | - Laura Mezzogori
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Clinica Malattie Infettive, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Infectious Diseases Unit, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | | | - Martin Hoenigl
- Division of Infectious Diseases, Excellence Center for Medical Mycology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Division of Infectious Diseases, ECMM Center of Excellence for Medical Mycology, Medical University of Graz, Graz, Austria
- BioTechMed, Graz, Austria
| | - Daniele Roberto Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Clinica Malattie Infettive, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Infectious Diseases Unit, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
- Tufts University School of Medicine, Boston, MA, USA
| | - Michele Bartoletti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Infectious Disease Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Jannik Stemler
- Faculty of Medicine, Institute of Translational Research, Cologne Excellence Cluster On Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, University Hospital Cologne, Cologne, Germany
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology, University of Cologne, Herderstraße 52-54, 50931, Cologne, Germany
- Partner Site Bonn-Cologne, German Centre for Infection Research (DZIF), Cologne, Germany
| | - Livio Pagano
- Hematology Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
- Hematology Unit, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Oliver A Cornely
- Faculty of Medicine, Institute of Translational Research, Cologne Excellence Cluster On Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, University Hospital Cologne, Cologne, Germany
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology, University of Cologne, Herderstraße 52-54, 50931, Cologne, Germany
- Partner Site Bonn-Cologne, German Centre for Infection Research (DZIF), Cologne, Germany
- Faculty of Medicine, Center for Molecular Medicine Cologne (CMMC), University of Cologne, University Hospital Cologne, Cologne, Germany
- Faculty of Medicine, University of Cologne, University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany
| | - Jon Salmanton-García
- Faculty of Medicine, Institute of Translational Research, Cologne Excellence Cluster On Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, University Hospital Cologne, Cologne, Germany.
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology, University of Cologne, Herderstraße 52-54, 50931, Cologne, Germany.
- Partner Site Bonn-Cologne, German Centre for Infection Research (DZIF), Cologne, Germany.
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24
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Melhem MSC, Leite Júnior DP, Takahashi JPF, Macioni MB, Oliveira LD, de Araújo LS, Fava WS, Bonfietti LX, Paniago AMM, Venturini J, Espinel-Ingroff A. Antifungal Resistance in Cryptococcal Infections. Pathogens 2024; 13:128. [PMID: 38392866 PMCID: PMC10891860 DOI: 10.3390/pathogens13020128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/20/2024] [Accepted: 01/22/2024] [Indexed: 02/25/2024] Open
Abstract
Antifungal therapy, especially with the azoles, could promote the incidence of less susceptible isolates of Cryptococcus neoformans and C. gattii species complexes (SC), mostly in developing countries. Given that these species affect mostly the immunocompromised host, the infections are severe and difficult to treat. This review encompasses the following topics: 1. infecting species and their virulence, 2. treatment, 3. antifungal susceptibility methods and available categorical endpoints, 4. genetic mechanisms of resistance, 5. clinical resistance, 6. fluconazole minimal inhibitory concentrations (MICs), clinical outcome, 7. environmental influences, and 8. the relevance of host factors, including pharmacokinetic/pharmacodynamic (PK/PD) parameters, in predicting the clinical outcome to therapy. As of now, epidemiologic cutoff endpoints (ECVs/ECOFFs) are the most reliable antifungal resistance detectors for these species, as only one clinical breakpoint (amphotericin B and C. neoformans VNI) is available.
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Affiliation(s)
- Marcia S C Melhem
- Graduate Program in Sciences, Secretary of Health, São Paulo 01246-002, SP, Brazil
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
- Graduate Program in Tropical Diseases, State University of São Paulo, Botucatu 18618-687, SP, Brazil
| | | | - Juliana P F Takahashi
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
- Pathology Division, Adolfo Lutz Institute, São Paulo 01246-002, SP, Brazil
| | | | | | - Lisandra Siufi de Araújo
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
- Central Public Health Laboratory-LACEN, Mycology Unit, Adolfo Lutz Institut, São Paulo 01246-002, SP, Brazil
| | - Wellington S Fava
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
| | - Lucas X Bonfietti
- Central Public Health Laboratory-LACEN, Mycology Unit, Adolfo Lutz Institut, São Paulo 01246-002, SP, Brazil
| | - Anamaria M M Paniago
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
| | - James Venturini
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
| | - Ana Espinel-Ingroff
- Central Public Health Laboratory-LACEN, Campo Grande 79074-460, MS, Brazil
- VCU Medical Center, Richmond, VA 23284, USA
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25
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Chiang YH, Cheng CN, Chuang PJ, Chen YC, Chen YJ, Kuo CH, Lin SW, Chang LC. Enhancing the identification of voriconazole-associated hepatotoxicity by targeted metabolomics. Int J Antimicrob Agents 2024; 63:107028. [PMID: 37931850 DOI: 10.1016/j.ijantimicag.2023.107028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/17/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023]
Abstract
Voriconazole-associated hepatotoxicity is a common condition that generally manifests as elevated liver enzymes and can lead to drug discontinuation. Careful monitoring of voriconazole-associated hepatotoxicity is needed but there are no specific plasma biomarkers for this condition. Metabolomics has emerged as a promising technique for investigating biomarkers associated with drug-induced toxicity. The aim of this study was to use targeted metabolomics to evaluate seven endogenous metabolites as potential biomarkers of voriconazole-associated hepatotoxicity. Patients undergoing therapeutic drug monitoring of voriconazole were classified into a hepatotoxicity group (18 patients) or a control group (153 patients). Plasma samples were analysed using ultra-high-performance liquid chromatography coupled to mass spectrometry. Metabolite concentrations in the two groups were compared. Areas under the receiver operating characteristic (AUROC) curves generated from logistic regressions were used to correlate the concentrations of these seven metabolites with voriconazole trough concentrations and conventional liver biochemistry tests. Glycocholate and α-ketoglutarate levels were significantly higher in the hepatotoxicity group compared with the control group (false discovery rate-corrected P < 0.001 and P = 0.024, respectively). The metabolites glycocholate (AUROC = 0.795) and α-ketoglutarate (AUROC = 0.696) outperformed voriconazole trough concentrations (AUROC = 0.555) and approached the performance of alkaline phosphatase (AUROC = 0.876) and total bilirubin (AUROC = 0.815). A panel of glycocholate combined with voriconazole trough concentrations (AUROC = 0.827) substantially improved the performance of voriconazole trough concentrations alone in predicting hepatotoxicity. In conclusion, the panel integrating glycocholate with voriconazole trough concentrations has great potential for identifying voriconazole-associated hepatotoxicity.
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Affiliation(s)
- Yi-Hsuan Chiang
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Ning Cheng
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Pei-Jiun Chuang
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Jing Chen
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ching-Hua Kuo
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan; Metabolomics Core Laboratory, Centers of Genomic and Precision Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Shu-Wen Lin
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Cancer Center, Taipei, Taiwan.
| | - Lin-Chau Chang
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.
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26
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Carter C, Kahai R, Cunningham J, Kilduff J, Hough N, Baxter C, Connell D, Shah A. Chronic pulmonary aspergillosis - a guide for the general physician. Clin Med (Lond) 2024; 24:100019. [PMID: 38281665 PMCID: PMC11024841 DOI: 10.1016/j.clinme.2024.100019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
This collaborative article presents a review of chronic pulmonary aspergillosis (CPA) from the perspective of a multidisciplinary team comprising of respiratory physicians, radiologists, mycologists, dietitians, pharmacists, physiotherapists and palliative care specialists. The review synthesises current knowledge on CPA, emphasising the intricate interplay between clinical, radiological, and microbiological aspects. We highlight the importance of assessing each patient as multidisciplinary team to ensure personalised treatment strategies and a holistic approach to patient care.
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Affiliation(s)
- Charlotte Carter
- Registrar in respiratory medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Rasleen Kahai
- Respiratory dietitian, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Josie Cunningham
- Pharmacist independent prescriber, Frimley Park NHS Foundation Trust, Frimley, UK
| | - Jennifer Kilduff
- Physiotherapist in respiratory medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Natasha Hough
- Consultant physician in respiratory medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Caroline Baxter
- Consultant physician in respiratory medicine, National Aspergillosis Centre, Manchester NHS Foundation Trust, Manchester, UK
| | - David Connell
- Consultant physician in respiratory medicine, NHS Tayside, Dundee, UK
| | - Anand Shah
- Consultant physician in respiratory medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK, and MRC Centre of Global Infectious Disease Analysis, Imperial College London, London, UK
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27
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Girton M, Tomsig J, Bazydlo L. Triazole Antifungal Quantification for Therapeutic Drug Monitoring in Serum by Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS): Posaconazole, Voriconazole, Itraconazole, and Hydroxyitraconazole. Methods Mol Biol 2024; 2737:55-65. [PMID: 38036810 DOI: 10.1007/978-1-0716-3541-4_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Antifungal therapy with triazole drugs including posaconazole, voriconazole, itraconazole, and its active metabolite hydroxyitraconazole is routinely accompanied by therapeutic drug monitoring to ensure optimal dosing. The method presented here simultaneously quantitates these compounds in serum by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Specimen preparation includes protein precipitation with a methanol and acetonitrile mixture, centrifugation, and filtration. Analyte separation is achieved by reverse-phase chromatography using a dC18 column and a linear gradient of methanol in water. Analytes are detected by multiple reaction monitoring mass spectrometry and quantitated by comparison to a standard curve.
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Affiliation(s)
- Mark Girton
- Department of Pathology, University of Virginia, Charlottesville, VA, USA
| | - Jose Tomsig
- Medical Laboratories, UVA Health, Charlottesville, VA, USA
| | - Lindsay Bazydlo
- Department of Pathology, University of Virginia, Charlottesville, VA, USA.
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28
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McHale TC, Boulware DR, Kasibante J, Ssebambulidde K, Skipper CP, Abassi M. Diagnosis and management of cryptococcal meningitis in HIV-infected adults. Clin Microbiol Rev 2023; 36:e0015622. [PMID: 38014977 PMCID: PMC10870732 DOI: 10.1128/cmr.00156-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
Cryptococcal meningitis is a leading cause of morbidity and mortality globally, especially in people with advanced HIV disease. Cryptococcal meningitis is responsible for nearly 20% of all deaths related to advanced HIV disease, with the burden of disease predominantly experienced by people in resource-limited countries. Major advancements in diagnostics have introduced low-cost, easy-to-use antigen tests with remarkably high sensitivity and specificity. These tests have led to improved diagnostic accuracy and are essential for screening campaigns to reduce the burden of cryptococcosis. In the last 5 years, several high-quality, multisite clinical trials have led to innovations in therapeutics that have allowed for simplified regimens, which are better tolerated and result in less intensive monitoring and management of medication adverse effects. One trial found that a shorter, 7-day course of deoxycholate amphotericin B is as effective as the longer 14-day course and that flucytosine is an essential partner drug for reducing mortality in the acute phase of disease. Single-dose liposomal amphotericin B has also been found to be as effective as a 7-day course of deoxycholate amphotericin B. These findings have allowed for simpler and safer treatment regimens that also reduce the burden on the healthcare system. This review provides a detailed discussion of the latest evidence guiding the clinical management and special circumstances that make cryptococcal meningitis uniquely difficult to treat.
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Affiliation(s)
- Thomas C. McHale
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David R. Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Caleb P. Skipper
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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29
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Yu M, Yang J, Xiong L, Zhan S, Cheng L, Chen Y, Liu F. Comparison of ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) and enzyme-multiplied immunoassay technique (EMIT) for quantification of voriconazole plasma concentration from Chinese patients. Heliyon 2023; 9:e22015. [PMID: 38045154 PMCID: PMC10692776 DOI: 10.1016/j.heliyon.2023.e22015] [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: 07/12/2023] [Revised: 09/15/2023] [Accepted: 11/01/2023] [Indexed: 12/05/2023] Open
Abstract
Introduction Voriconazole (VRZ) is the recommended standard treatment for life-threatening invasive aspergillosis. The plasma concentration of VRZ should be determined to optimise treatment results and reduce side effects. This study aimed to compare the correlation and concordance of ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) and enzyme-multiplied immunoassay technique (EMIT) to determine VRZ plasma concentration in clinical practice. Methods An isotopically labelled internal standard UPLC-MS/MS method was established, validated, and subsequently applied to determine VRZ concentration. The UPLC-MS/MS method was also compared with a commercial EMIT method regarding results correlation and concordance. Results The calibration curve of UPLC-MS/MS was linear from 0.1 to 10 mg/L, the inter- and intra-day relative standard deviations (RSDs), and the stability of quality control samples were less than 15 %, satisfying the Bioanalytical Method Validation Guidelines. A total of 122 plasma samples were collected and analyzed using both methods. UPLC-MS/MS and EMIT showed a high correlation (r = 0.9534), and Bland-Altman analysis indicated a mean absolute bias of 1.035 mg/L and an average bias of 27.56 % between UPLC-MS/MS and EMIT. The paired Wilcoxon test and Bland-Altman analysis revealed poor consistency between the two methods. Furthermore, we compared the effects of different methods in clinical applications. Two threshold values for treatment efficacy (1.0 mg/L) and safety (5.5 mg/L) were established, and considerable discordance was observed between the original EMIT and UPLC-MS/MS results at both thresholds (p < 0.05). Nevertheless, the adjusted EMIT results were not inconsistent with the UPLC-MS/MS results regarding the efficacy (p = 0.125) and safety (p = 1.0) thresholds. Conclusions The isotopically labelled internal standard UPLC-MS/MS method is established and well applied in the clinical setting. A strong correlation but discordance was found between UPLC-MS/MS and EMIT, indicating that switching from UPLC-MS/MS to EMIT was unsuitable. However, the adjusted EMIT results may serve as a reliable surrogate when UPLC-MS/MS results cannot be obtained when necessary.
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Affiliation(s)
| | | | - Lirong Xiong
- Pharmacy Department, Southwest Hospital of Army Medical University, Chongqing, 400038, People's Republic of China
| | - Shipeng Zhan
- Pharmacy Department, Southwest Hospital of Army Medical University, Chongqing, 400038, People's Republic of China
| | - Lin Cheng
- Pharmacy Department, Southwest Hospital of Army Medical University, Chongqing, 400038, People's Republic of China
| | - Yongchuan Chen
- Pharmacy Department, Southwest Hospital of Army Medical University, Chongqing, 400038, People's Republic of China
| | - Fang Liu
- Pharmacy Department, Southwest Hospital of Army Medical University, Chongqing, 400038, People's Republic of China
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30
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Pattanaik S, Gota V, Tripathi SK, Kshirsagar NA. Therapeutic drug monitoring in India: A strength, weakness, opportunity and threats analysis. Br J Clin Pharmacol 2023; 89:3247-3261. [PMID: 37259249 DOI: 10.1111/bcp.15808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 04/25/2023] [Accepted: 05/09/2023] [Indexed: 06/02/2023] Open
Abstract
Over the last three to four decades, Therapeutic Drug Monitoring (TDM) has shaped itself as therapeutic drug management, an integral component of precision medicine. The practice of TDM is not extensive in India, despite being one of the fastest-growing economies in the world. It is currently limited to a few academic medical centres and teaching hospitals. Apart from the immunosuppressive drugs, several other therapeutic areas, such as anticancer, antifungal, antibiotic and antitubercular, have demonstrated great potential to improve patient outcomes in Indian settings. Factors such as the higher prevalence of nutritional deficiencies, tropical diseases, widespread use of alternative medicines, unalike pharmacogenomics and sparse population-specific data available on therapeutic ranges of several drugs make the population of this subcontinent unique regarding the relevance of TDM. Despite the impact of TDM in clinical science and its widespread application, TDM has failed to receive the attention it deserves in India. This review intends to bring out a strength, weakness, opportunity and threats (SWOT) analysis for TDM in India so that appropriate steps for fostering the growth of TDM could be envisioned. The need of the hour is the creation of a cooperative group including all the stakeholders, such as TDM professionals, clinicians and the government and devising a National Action Plan to strengthen TDM. Nodal TDM centres should be established, and pilot programmes should be rolled out to identify the thrust areas for TDM in the country, capacity building and creating awareness to integrate TDM into mainstream clinical medicine.
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Affiliation(s)
- Smita Pattanaik
- Clinical Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikram Gota
- Advanced Centre for Treatment Education and Research in Cancer, Tata Memorial Centre, Kharghar Navi Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | | | - Nilima A Kshirsagar
- Clinical Pharmacology, Indian Council of Medical Research, New Delhi, India
- Seth Gordhandas Sunderdas, Medical College and King Edward Memorial Hospital, Mumbai, India
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31
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Moni BM, Wise BL, Loots GG, Weilhammer DR. Coccidioidomycosis Osteoarticular Dissemination. J Fungi (Basel) 2023; 9:1002. [PMID: 37888258 PMCID: PMC10607509 DOI: 10.3390/jof9101002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/27/2023] [Accepted: 10/07/2023] [Indexed: 10/28/2023] Open
Abstract
Valley fever or coccidioidomycosis is a pulmonary infection caused by species of Coccidioides fungi that are endemic to California and Arizona. Skeletal coccidioidomycosis accounts for about half of disseminated infections, with the vertebral spine being the preferred site of dissemination. Most cases of skeletal coccidioidomycosis progress to bone destruction or spread to adjacent structures such as joints, tendons, and other soft tissues, causing significant pain and restricting mobility. Manifestations of such cases are usually nonspecific, making diagnosis very challenging, especially in non-endemic areas. The lack of basic knowledge and research data on the mechanisms defining susceptibility to extrapulmonary infection, especially when it involves bones and joints, prompted us to survey available clinical and animal data to establish specific research questions that remain to be investigated. In this review, we explore published literature reviews, case reports, and case series on the dissemination of coccidioidomycosis to bones and/or joints. We highlight key differential features with other conditions and opportunities for mechanistic and basic research studies that can help develop novel diagnostic, prognostic, and treatment strategies.
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Affiliation(s)
- Benedicte M. Moni
- Biosciences and Biotechnology Division, Lawrence Livermore National Laboratory, Livermore, CA 94550, USA
| | - Barton L. Wise
- Lawrence J. Ellison Musculoskeletal Research Center, Department of Orthopaedic Surgery, University of California Davis Health, 2700 Stockton Blvd., Sacramento, CA 95817, USA; (B.L.W.)
| | - Gabriela G. Loots
- Biosciences and Biotechnology Division, Lawrence Livermore National Laboratory, Livermore, CA 94550, USA
- Lawrence J. Ellison Musculoskeletal Research Center, Department of Orthopaedic Surgery, University of California Davis Health, 2700 Stockton Blvd., Sacramento, CA 95817, USA; (B.L.W.)
| | - Dina R. Weilhammer
- Biosciences and Biotechnology Division, Lawrence Livermore National Laboratory, Livermore, CA 94550, USA
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32
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de Oliveira VF, Taborda M, Arcieri VC, Kruschewsky WLL, Costa AN, Duarte NJC, Romano P, de Almeida Rezende Ebner P, Magri ASGK, Abdala E, Levin AS, Magri MMC. Itraconazole Serum Trough Concentrations Using Oral Capsules for the Treatment of Chronic Pulmonary Aspergillosis: What is the Target? Mycopathologia 2023; 188:693-698. [PMID: 37526790 DOI: 10.1007/s11046-023-00781-7] [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: 02/18/2023] [Accepted: 07/23/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND In regions where there is only itraconazole capsule as a therapeutic option for treatment of chronic pulmonary aspergillosis (CPA), measuring the serum concentrations becomes even more important for therapeutic success. OBJECTIVE Evaluate the initial itraconazole serum trough concentrations after the administration of oral capsule of itraconazole for the treatment of CPA. METHODS The measurement was performed at least 7-days after initiation of therapy. The standard treatment at our institution was a 200 mg capsule every 12 h. We defined that an adequate serum trough concentration of itraconazole during treatment was 1-4 mg/L. RESULTS This study recruited 28 patients. The median value was 0.30 mg/L (IQR 0.01-0.70). Only 11% (n = 3) had adequate serum concentrations based on guideline recommendation. All patients with clinical deterioration had itraconazole serum levels ≤ 0.8 mg/L. CONCLUSION The initial serum concentrations of itraconazole after capsule formulation administration were low. Increasing the dose should be considered when the itraconazole concentration is low, especially if it is ≤ 0.8 mg/L, and the patient presents with clinical deterioration. Larger studies are needed to evaluate the adequate concentrations recommended for CPA.
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Affiliation(s)
- Vítor Falcão de Oliveira
- Department of Infectious and Parasitic Diseases, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil.
| | - Mariane Taborda
- Department of Infectious and Parasitic Diseases, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Vitor Ciampone Arcieri
- Department of Infectious and Parasitic Diseases, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Wdson Luis Lima Kruschewsky
- Department of Infectious and Parasitic Diseases, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Andre Nathan Costa
- Department of Pneumology, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Nilo José Coêlho Duarte
- Central Laboratory Division, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Paschoalina Romano
- Central Laboratory Division, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Edson Abdala
- Department of Infectious and Parasitic Diseases, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Anna S Levin
- Department of Infectious and Parasitic Diseases, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
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Menna P, Marchesi F, Cattaneo C, Candoni A, Delia M, Nadali G, Vatteroni A, Pasciolla C, Perrone S, Verga L, Armiento D, Del Principe MI, Fracchiolla NS, Salvatorelli E, Lupisella S, Terrenato I, Busca A, Minotti G, Pagano L. Posaconazole and midostaurin in patients with FLT3-mutated acute myeloid leukemia: Pharmacokinetic interactions and clinical facts in a real life study. Clin Transl Sci 2023; 16:1876-1885. [PMID: 37515369 PMCID: PMC10582652 DOI: 10.1111/cts.13595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023] Open
Abstract
Midostaurin is used in combination with chemotherapy to treat patients with newly diagnosed FLT3-mutated acute myeloid leukemia. Chemotherapy-induced neutropenia exposes these patients to a significant risk of invasive fungal infections (IFIs). International guidelines recommend primary antifungal prophylaxis with posaconazole (PCZ) but nested analysis of a phase III trial showed that strong PCZ inhibition of CYP3A4 diminished midostaurin metabolism and increased midostaurin plasma levels; however, midostaurin-related adverse events (AEs) were only moderately exacerbated. We conducted a prospective multicenter real-life study to evaluate (i) how often concerns around PCZ-midostaurin interactions made the hematologist prescribe antifungals other than PCZ, (ii) how remarkably PCZ increased midostaurin plasma levels, and (iii) how significantly PCZ-midostaurin interactions influenced hematologic and safety outcomes of induction therapy. Although the hematologists were blinded to pharmacokinetic findings, as many as 16 of 35 evaluable patients were prescribed antifungal prophylaxis with micafungin, weak CYP3A4 inhibitor, in place of PCZ (p < 0.001 for deviation from guidelines). In the 19 patients managed as per guidelines, PCZ-midostaurin interactions were more remarkable than previously characterized, such that at the end of induction therapy midostaurin minimum plasma concentration (Cmin ) was greater than three times higher than reported; moreover, midostaurin Cmin , maximum plasma concentration, and area under the curve were more than or equal to four times higher with PCZ than micafungin. Hematologic outcomes (complete remission and duration of severe neutropenia) and safety outcomes (midostaurin-related any grade or grade ≥3 AEs) were nonetheless similar for patients exposed to PCZ or micafungin, as was the number of breakthrough IFIs. In waiting for randomized phase III trials of new prophylaxis regimens, these findings show that PCZ should remain the antifungal of choice for the midostaurin-treated patient.
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Affiliation(s)
- Pierantonio Menna
- University Campus Bio‐Medico andFondazione Policlinico Universitario Campus Bio‐MedicoRomeItaly
| | - Francesco Marchesi
- Hematology and Stem Cell Transplant UnitIRCCS Regina Elena National Cancer InstituteRomeItaly
| | - Chiara Cattaneo
- Azienda Socio Sanitaria Territoriale and Spedali CiviliBresciaItaly
| | - Anna Candoni
- Azienda Sanitaria Universitaria IntegrataUniversity HospitalUdineItaly
| | - Mario Delia
- Hematology Section, Department of Emergency and Organ TransplantUniveristy of BariBariItaly
| | - Gianpaolo Nadali
- U.O.C. Ematologia, Azienda Ospedaliera Universitaria Integrata di Verona, Ospedale Borgo Roma, Verona, ItalyAzienda Ospedaliera Universitaria IntegrataVeronaItaly
| | - Alessandra Vatteroni
- U.O.C. Ematologia, Azienda Ospedaliera Universitaria Integrata di Verona, Ospedale Borgo Roma, Verona, ItalyAzienda Ospedaliera Universitaria IntegrataVeronaItaly
| | | | | | | | - Daniele Armiento
- University Campus Bio‐Medico andFondazione Policlinico Universitario Campus Bio‐MedicoRomeItaly
| | | | | | | | | | - Irene Terrenato
- Hematology and Stem Cell Transplant UnitIRCCS Regina Elena National Cancer InstituteRomeItaly
| | - Alessandro Busca
- Department of Hematology and Stem Cell Transplant UnitAzienda Ospedaliera Universitaria Citta' della Salute e della ScienzaTorinoItaly
| | - Giorgio Minotti
- University Campus Bio‐Medico andFondazione Policlinico Universitario Campus Bio‐MedicoRomeItaly
| | - Livio Pagano
- Fondazione Policlinico Universitario Agostino Gemelli IRCCSRomeItaly
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Kluwe F, Michelet R, Huisinga W, Zeitlinger M, Mikus G, Kloft C. Towards Model-Informed Precision Dosing of Voriconazole: Challenging Published Voriconazole Nonlinear Mixed-Effects Models with Real-World Clinical Data. Clin Pharmacokinet 2023; 62:1461-1477. [PMID: 37603216 PMCID: PMC10520167 DOI: 10.1007/s40262-023-01274-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Model-informed precision dosing (MIPD) frequently uses nonlinear mixed-effects (NLME) models to predict and optimize therapy outcomes based on patient characteristics and therapeutic drug monitoring data. MIPD is indicated for compounds with narrow therapeutic range and complex pharmacokinetics (PK), such as voriconazole, a broad-spectrum antifungal drug for prevention and treatment of invasive fungal infections. To provide guidance and recommendations for evidence-based application of MIPD for voriconazole, this work aimed to (i) externally evaluate and compare the predictive performance of a published so-called 'hybrid' model for MIPD (an aggregate model comprising features and prior information from six previously published NLME models) versus two 'standard' NLME models of voriconazole, and (ii) investigate strategies and illustrate the clinical impact of Bayesian forecasting for voriconazole. METHODS A workflow for external evaluation and application of MIPD for voriconazole was implemented. Published voriconazole NLME models were externally evaluated using a comprehensive in-house clinical database comprising nine voriconazole studies and prediction-/simulation-based diagnostics. The NLME models were applied using different Bayesian forecasting strategies to assess the influence of prior observations on model predictivity. RESULTS The overall best predictive performance was obtained using the aggregate model. However, all NLME models showed only modest predictive performance, suggesting that (i) important PK processes were not sufficiently implemented in the structural submodels, (ii) sources of interindividual variability were not entirely captured, and (iii) interoccasion variability was not adequately accounted for. Predictive performance substantially improved by including the most recent voriconazole observations in MIPD. CONCLUSION Our results highlight the potential clinical impact of MIPD for voriconazole and indicate the need for a comprehensive (pre-)clinical database as basis for model development and careful external model evaluation for compounds with complex PK before their successful use in MIPD.
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Affiliation(s)
- Franziska Kluwe
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin/Potsdam, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Karl-Liebknecht-Str. 24/25, 14476 Potsdam, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Gerd Mikus
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 419, 69120 Heidelberg, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
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Jackson KD, Achour B, Lee J, Geffert RM, Beers JL, Latham BD. Novel Approaches to Characterize Individual Drug Metabolism and Advance Precision Medicine. Drug Metab Dispos 2023; 51:1238-1253. [PMID: 37419681 PMCID: PMC10506699 DOI: 10.1124/dmd.122.001066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 05/30/2023] [Accepted: 06/05/2023] [Indexed: 07/09/2023] Open
Abstract
Interindividual variability in drug metabolism can significantly affect drug concentrations in the body and subsequent drug response. Understanding an individual's drug metabolism capacity is important for predicting drug exposure and developing precision medicine strategies. The goal of precision medicine is to individualize drug treatment for patients to maximize efficacy and minimize drug toxicity. While advances in pharmacogenomics have improved our understanding of how genetic variations in drug-metabolizing enzymes (DMEs) affect drug response, nongenetic factors are also known to influence drug metabolism phenotypes. This minireview discusses approaches beyond pharmacogenetic testing to phenotype DMEs-particularly the cytochrome P450 enzymes-in clinical settings. Several phenotyping approaches have been proposed: traditional approaches include phenotyping with exogenous probe substrates and the use of endogenous biomarkers; newer approaches include evaluating circulating noncoding RNAs and liquid biopsy-derived markers relevant to DME expression and function. The goals of this minireview are to 1) provide a high-level overview of traditional and novel approaches to phenotype individual drug metabolism capacity, 2) describe how these approaches are being applied or can be applied to pharmacokinetic studies, and 3) discuss perspectives on future opportunities to advance precision medicine in diverse populations. SIGNIFICANCE STATEMENT: This minireview provides an overview of recent advances in approaches to characterize individual drug metabolism phenotypes in clinical settings. It highlights the integration of existing pharmacokinetic biomarkers with novel approaches; also discussed are current challenges and existing knowledge gaps. The article concludes with perspectives on the future deployment of a liquid biopsy-informed physiologically based pharmacokinetic strategy for patient characterization and precision dosing.
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Affiliation(s)
- Klarissa D Jackson
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.D.J., J.L., R.M.G., J.L.B., B.D.L.); and Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island (B.A.)
| | - Brahim Achour
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.D.J., J.L., R.M.G., J.L.B., B.D.L.); and Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island (B.A.)
| | - Jonghwa Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.D.J., J.L., R.M.G., J.L.B., B.D.L.); and Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island (B.A.)
| | - Raeanne M Geffert
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.D.J., J.L., R.M.G., J.L.B., B.D.L.); and Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island (B.A.)
| | - Jessica L Beers
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.D.J., J.L., R.M.G., J.L.B., B.D.L.); and Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island (B.A.)
| | - Bethany D Latham
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.D.J., J.L., R.M.G., J.L.B., B.D.L.); and Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island (B.A.)
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McCreary EK, Davis MR, Narayanan N, Andes DR, Cattaneo D, Christian R, Lewis RE, Watt KM, Wiederhold NP, Johnson MD. Utility of triazole antifungal therapeutic drug monitoring: Insights from the Society of Infectious Diseases Pharmacists: Endorsed by the Mycoses Study Group Education and Research Consortium. Pharmacotherapy 2023; 43:1043-1050. [PMID: 37459118 DOI: 10.1002/phar.2850] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/23/2023] [Accepted: 05/26/2023] [Indexed: 08/15/2023]
Abstract
Triazole antifungals (i.e., fluconazole, itraconazole, voriconazole, posaconazole, and isavuconazole) are commonly used in clinical practice to prevent or treat invasive fungal infections. Most triazole antifungals require therapeutic drug monitoring (TDM) due to highly variable pharmacokinetics, known drug interactions, and established relationships between exposure and response. On behalf of the Society of Infectious Diseases Pharmacists (SIDP), this insight describes the pharmacokinetic principles and pharmacodynamic targets of commonly used triazole antifungals and provides the rationale for utility of TDM within each agent.
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Affiliation(s)
- Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Matthew R Davis
- Infectious Disease Connect, Inc., Pittsburgh, Pennsylvania, USA
| | - Navaneeth Narayanan
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey, USA
| | - David R Andes
- Departments of Medicine and Medical Microbiology & Immunology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, Department of Laboratory Medicine, Luigi Sacco University Hospital, Milan, Italy
| | - Robbie Christian
- Department of Pharmacy, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | - Russell E Lewis
- Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Kevin M Watt
- Division of Pediatric Clinical Pharmacology and Division of Critical Care, University of Utah, Salt Lake City, Utah, USA
| | - Nathan P Wiederhold
- Department of Pathology and Laboratory Medicine, Fungus Testing Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Melissa D Johnson
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Hu L, Huang S, Huang Q, Huang J, Feng Z, He G. Population pharmacokinetics of voriconazole and the role of CYP2C19 genotype on treatment optimization in pediatric patients. PLoS One 2023; 18:e0288794. [PMID: 37695751 PMCID: PMC10495004 DOI: 10.1371/journal.pone.0288794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/04/2023] [Indexed: 09/13/2023] Open
Abstract
The aim of this study was to evaluate factors that impact on voriconazole (VRC) population pharmacokinetic (PPK) parameters and explore the optimal dosing regimen for different CYP2C19 genotypes in Chinese paediatric patients. PPK analysis was used to identify the factors contributing to the variability in VRC plasma trough concentrations. A total of 210 VRC trough concentrations from 91 paediatric patients were included in the study. The median VRC trough concentration was 1.23 mg/L (range, 0.02 to 8.58 mg/L). At the measurement of all the trough concentrations, the target range (1.0~5.5 mg/L) was achieved in 52.9% of the patients, while subtherapeutic and supratherapeutic concentrations were obtained in 40.9% and 6.2% of patients, respectively. VRC trough concentrations were adjusted for dose (Ctrough/D), with normal metabolizers (NMs) and intermediate metabolizers (IMs) having significantly lower levels than poor metabolizers (PMs) (PN-P < 0.001, PI-P = 0.039). A one-compartment model with first-order absorption and elimination was suitable to describe the VRC pharmacokinetic characteristics. The final model of VRC PPK analysis contained CYP2C19 phenotype as a significant covariate for clearance. Dose simulations suggested that a maintenance dose of 9 mg/kg orally or 8 mg/kg intravenously twice daily was appropriate for NMs to achieve the target concentration. A maintenance dose of 9 mg/kg orally or 5 mg/kg intravenously twice daily was appropriate for IMs. Meanwhile, PMs could use lower maintenance dose and an oral dose of 6 mg/kg twice daily or an intravenous dose of 5mg/kg twice daily was appropriate. To increase the probability of achieving the therapeutic range and improving efficacy, CYP2C19 phenotype can be used to predict VRC trough concentrations and guide dose adjustments in Chinese pediatric patients.
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Affiliation(s)
- Lin Hu
- Department of Pharmacy, The First Hospital of Changsha, Changsha, Hunan, China
| | - Shiqiong Huang
- Department of Pharmacy, The First Hospital of Changsha, Changsha, Hunan, China
| | - Qi Huang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Juanjuan Huang
- Department of Pharmacy, The First Hospital of Changsha, Changsha, Hunan, China
| | - Zeying Feng
- Clinical Trial Institution Office, Liuzhou Hospital of Guangzhou Women and Children’s Medical Center, Liuzhou, Guangxi, China
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Gefei He
- Department of Pharmacy, The First Hospital of Changsha, Changsha, Hunan, China
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Barros N, Rosenblatt RE, Phipps MM, Fomin V, Mansour MK. Invasive fungal infections in liver diseases. Hepatol Commun 2023; 7:e0216. [PMID: 37639701 PMCID: PMC10462082 DOI: 10.1097/hc9.0000000000000216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 06/07/2023] [Indexed: 08/31/2023] Open
Abstract
Patients with liver diseases, including decompensated cirrhosis, alcohol-associated hepatitis, and liver transplant recipients are at increased risk of acquiring invasive fungal infections (IFIs). These infections carry high morbidity and mortality. Multiple factors, including host immune dysfunction, barrier failures, malnutrition, and microbiome alterations, increase the risk of developing IFI. Candida remains the most common fungal pathogen causing IFI. However, other pathogens, including Aspergillus, Cryptococcus, Pneumocystis, and endemic mycoses, are being increasingly recognized. The diagnosis of IFIs can be ascertained by the direct observation or isolation of the pathogen (culture, histopathology, and cytopathology) or by detecting antigens, antibodies, or nucleic acid. Here, we provide an update on the epidemiology, pathogenesis, diagnosis, and management of IFI in patients with liver disease and liver transplantation.
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Affiliation(s)
- Nicolas Barros
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Division of Infectious Diseases, Department of Medicine, Indiana University Health, Indianapolis, Indiana, USA
| | - Russell E. Rosenblatt
- Department of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Meaghan M. Phipps
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Vladislav Fomin
- Department of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Michael K. Mansour
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Roy M, Karhana S, Shamsuzzaman M, Khan MA. Recent drug development and treatments for fungal infections. Braz J Microbiol 2023; 54:1695-1716. [PMID: 37219748 PMCID: PMC10484882 DOI: 10.1007/s42770-023-00999-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 04/27/2023] [Indexed: 05/24/2023] Open
Abstract
Fungal infections are now becoming a hazard to individuals which has paved the way for research to expand the therapeutic options available. Recent advances in drug design and compound screening have also increased the pace of the development of antifungal drugs. Although several novel potential molecules are reported, those discoveries have yet to be translated from bench to bedside. Polyenes, azoles, echinocandins, and flucytosine are among the few antifungal agents that are available for the treatment of fungal infections, but such conventional therapies show certain limitations like toxicity, drug interactions, and the development of resistance which limits the utility of existing antifungals, contributing to significant mortality and morbidity. This review article focuses on the existing therapies, the challenges associated with them, and the development of new therapies, including the ongoing and recent clinical trials, for the treatment of fungal infections. Advancements in antifungal treatment: a graphical overview of drug development, adverse effects, and future prospects.
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Affiliation(s)
- Madhura Roy
- Centre for Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
| | - Sonali Karhana
- Centre for Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
| | - Md Shamsuzzaman
- Department of Pharmaceutical Sciences, College of Pharmacy, Shaqra University, Sahqra, Kingdom of Saudi Arabia
| | - Mohd Ashif Khan
- Centre for Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India.
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Benedict K, Gold JAW, Beekmann SE, Polgreen PM, Toda M, Smith DJ. Antifungal Therapeutic Drug Monitoring Practices: Results of an Emerging Infections Network Survey. Open Forum Infect Dis 2023; 10:ofad468. [PMID: 37771852 PMCID: PMC10533201 DOI: 10.1093/ofid/ofad468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/08/2023] [Indexed: 09/30/2023] Open
Abstract
In a survey of 523 infectious disease specialists, a moderate to high percentage reported using any antifungal therapeutic drug monitoring (TDM) during itraconazole (72%), posaconazole (72%), and voriconazole (90%) treatment, and a low to moderate percentage reported using any antifungal TDM during prophylaxis (32%, 55%, and 65%, respectively). Long turnaround times for send-out TDM testing and logistical difficulties were frequent barriers.
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Affiliation(s)
- Kaitlin Benedict
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jeremy A W Gold
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Susan E Beekmann
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Philip M Polgreen
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Mitsuru Toda
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Dallas J Smith
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Khurana A, Sharath S, Sardana K, Chowdhary A, Panesar S. Therapeutic Updates on the Management of Tinea Corporis or Cruris in the Era of Trichophyton Indotineae: Separating Evidence from Hype-A Narrative Review. Indian J Dermatol 2023; 68:525-540. [PMID: 38099117 PMCID: PMC10718250 DOI: 10.4103/ijd.ijd_832_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023] Open
Abstract
The emergence and spread of Trichophyton indotineae (T. indotineae) has led to a sea change in the prescription practices of clinicians regarding the management of dermatophytic skin infections. An infection easily managed with a few weeks of antifungals, tinea corporis or cruris, is now often chronic and recurrent and requires prolonged treatment. Rising resistance to terbinafine, with documented squalene epoxidase (SQLE) gene mutations, and slow clinical response to itraconazole leave clinicians with limited treatment choices. However, in these testing times, it is essential that the tenets of antifungal stewardship be followed in making therapeutic decisions, and that the existing armamentarium of antifungals be used in rationale ways to counter this extremely common cutaneous infection, while keeping the growing drug resistance among dermatophytes in check. This review provides updated evidence on the use of various systemic antifungals for dermatophytic infection of the glabrous skin, especially with respect to the emerging T. indotineae species, which is gradually becoming a worldwide concern.
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Affiliation(s)
- Ananta Khurana
- From the Department of Dermatology, Venereology and Leprosy, ABVIMS and Dr. RML Hospital, New Delhi, India
| | - Savitha Sharath
- From the Department of Dermatology, Venereology and Leprosy, ABVIMS and Dr. RML Hospital, New Delhi, India
| | - Kabir Sardana
- From the Department of Dermatology, Venereology and Leprosy, ABVIMS and Dr. RML Hospital, New Delhi, India
| | - Anuradha Chowdhary
- Medical Mycology Unit, Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Sanjeet Panesar
- Department of Community Medicine, ABVIMS and Dr. RML Hospital, New Delhi, India
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Yi ZM, Li X, Wang Z, Qin J, Jiang D, Tian P, Yang P, Zhao R. Status and Quality of Guidelines for Therapeutic Drug Monitoring Based on AGREE II Instrument. Clin Pharmacokinet 2023; 62:1201-1217. [PMID: 37490190 DOI: 10.1007/s40262-023-01283-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND With the progress of therapeutic drug monitoring (TDM) technology and the development of evidence-based medicine, many guidelines were developed and implemented in recent decades. OBJECTIVE The aim was to evaluate the current status of TDM guidelines and provide suggestions for their development and updates based on Appraisal of Guidelines for Research and Evaluation (AGREE) II. METHODS The TDM guidelines were systematically searched for among databases including PubMed, Embase, China National Knowledge Infrastructure, Wanfang Data, and the Chinese biomedical literature service system and the official websites of TDM-related associations. The search period was from inception to 6 April 2023. Four researchers independently screened the literature and extracted data. Any disagreement was discussed and reconciled by another researcher. The quality of guidelines was assessed using the AGREE II instrument. RESULTS A total of 92 guidelines were included, including 57 technical guidelines, three management guidelines, and 32 comprehensive guidelines. The number of TDM guidelines has gradually increased since 1979. The United States published the most guidelines (20 guidelines), followed by China (15 guidelines) and the United Kingdom (ten guidelines), and 23 guidelines were developed by international organizations. Most guidelines are aimed at adult patients only, while 28 guidelines include special populations. With respect to formulation methods, there are 23 evidence-based guidelines. As for quality evaluation results based on AGREE II, comprehensive guidelines scored higher (58.16%) than technical guidelines (51.36%) and administrative guidelines (50.00%). CONCLUSION The number of TDM guidelines, especially technical and comprehensive ones, has significantly increased in recent years. Most guidelines are confronted with the problems of unclear methodology and low quality of evidence according to AGREE II. More evidence-based research on TDM and high-quality guideline development is recommended to promote individualized therapy.
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Affiliation(s)
- Zhan-Miao Yi
- Department of Pharmacy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, China
| | - Xinya Li
- Department of Pharmacy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Zhitong Wang
- Department of Pharmacy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, China
| | - Jiguang Qin
- Department of Pharmacy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Dan Jiang
- Department of Pharmacy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Panhui Tian
- Department of Pharmacy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Ping Yang
- Department of Pharmacy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, China
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China.
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China.
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, China.
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Li G, Li Q, Zhang C, Yu Q, Li Q, Zhou X, Yang R, Yang X, Liu H, Yang Y. The impact of gene polymorphism and hepatic insufficiency on voriconazole dose adjustment in invasive fungal infection individuals. Front Genet 2023; 14:1242711. [PMID: 37693307 PMCID: PMC10484623 DOI: 10.3389/fgene.2023.1242711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Voriconazole (VRZ) is a broad-spectrum antifungal medication widely used to treat invasive fungal infections (IFI). The administration dosage and blood concentration of VRZ are influenced by various factors, posing challenges for standardization and individualization of dose adjustments. On the one hand, VRZ is primarily metabolized by the liver, predominantly mediated by the cytochrome P450 (CYP) 2C19 enzyme. The genetic polymorphism of CYP2C19 significantly impacts the blood concentration of VRZ, particularly the trough concentration (Ctrough), thereby influencing the drug's efficacy and potentially causing adverse drug reactions (ADRs). Recent research has demonstrated that pharmacogenomics-based VRZ dose adjustments offer more accurate and individualized treatment strategies for individuals with hepatic insufficiency, with the possibility to enhance therapeutic outcomes and reduce ADRs. On the other hand, the security, pharmacokinetics, and dosing of VRZ in individuals with hepatic insufficiency remain unclear, making it challenging to attain optimal Ctrough in individuals with both hepatic insufficiency and IFI, resulting in suboptimal drug efficacy and severe ADRs. Therefore, when using VRZ to treat IFI, drug dosage adjustment based on individuals' genotypes and hepatic function is necessary. This review summarizes the research progress on the impact of genetic polymorphisms and hepatic insufficiency on VRZ dosage in IFI individuals, compares current international guidelines, elucidates the current application status of VRZ in individuals with hepatic insufficiency, and discusses the influence of CYP2C19, CYP3A4, CYP2C9, and ABCB1 genetic polymorphisms on VRZ dose adjustments and Ctrough at the pharmacogenomic level. Additionally, a comprehensive summary and analysis of existing studies' recommendations on VRZ dose adjustments based on CYP2C19 genetic polymorphisms and hepatic insufficiency are provided, offering a more comprehensive reference for dose selection and adjustments of VRZ in this patient population.
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Affiliation(s)
- Guolin Li
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Qinhui Li
- Department of Medical, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Changji Zhang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Qin Yu
- College of Pharmacy, Southwest Medical University, Luzhou, China
| | - Qi Li
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoshi Zhou
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Rou Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xuerong Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Hailin Liu
- Department of Pharmacy, The People’s Hospital of Chongqing Liangjiang New Area, Chongqing, China
| | - Yong Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Gomez-Lopez A, Sanchez Galiano S, Ortega Madueño S, Carballo Gonzalez C. Observed isavuconazole exposure: 5-year experience of azole TDM from a Spanish reference laboratory. Med Mycol 2023; 61:myad086. [PMID: 37580172 DOI: 10.1093/mmy/myad086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/28/2023] [Accepted: 08/12/2023] [Indexed: 08/16/2023] Open
Abstract
We aimed to assess patient exposure to isavuconazole (ISZ) from samples received in our laboratory for therapeutic antifungal monitoring. We used liquid chromatography coupled with ultraviolet (UV) absorbance detection adapted from a multiplex-validated method with photodiode array (PDA) detection to monitor the analytes. The latter device allows the characterization of the azoles UV spectra. The method was validated according to international guidelines for efficient ISZ monitoring. The assay exhibited linearity between 0.25 and 16 mg/l for ISZ. Accuracy and intra- and inter-day precision were within acceptable ranges, and the method was successfully applied to quantify azoles and major metabolites from clinical samples collected from treated patients. We focus on ISZ blood concentrations and compared them to those of voriconazole, posaconazole, and itraconazole for a period of 5 years (2017-2021). Median ISZ concentration was 2.92 mg/l (interquartile range 1.82-5.33 mg/l) with 89% of measurements classified as adequate exposure (> 1 mg/l). Additionally, 71% of samples reach concentration values > 2 mg/l. Different ISZ exposure between adults to children were found. In conclusion, ISZ achieves excellent blood concentrations compared to other azole drugs, they are almost identical to those previously described, they exceed the MICs of most fungi for which its use was recommended and they differ depending on the patient's age. The method we describe for antifungal monitoring is simple, robust, and efficient. It simultaneously analyzes azoles and metabolites, and can be used for tailored interventions, achieve exposures associated with therapeutic success, decrease treatment-related toxicity, and help prevent resistance emergence due to continuous azole sub-optimal concentrations.
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Affiliation(s)
- Alicia Gomez-Lopez
- Mycology Reference and Research Laboratory (National Centre for Microbiology CNM-ISCIII), Instituto de Salud Carlos III Carretera Majadahonda-Pozuelo Km 2 28220 Madrid, Spain
- Center for Biomedical Research in Network in Infectious Diseases (CIBERINFEC-CB21/13/00105), Instituto de Salud Carlos III. Carretera Majadahonda-Pozuelo Km 2 Madrid, Spain
| | - Susana Sanchez Galiano
- Mycology Reference and Research Laboratory (National Centre for Microbiology CNM-ISCIII), Instituto de Salud Carlos III Carretera Majadahonda-Pozuelo Km 2 28220 Madrid, Spain
| | - Sheila Ortega Madueño
- Mycology Reference and Research Laboratory (National Centre for Microbiology CNM-ISCIII), Instituto de Salud Carlos III Carretera Majadahonda-Pozuelo Km 2 28220 Madrid, Spain
| | - Cristina Carballo Gonzalez
- Mycology Reference and Research Laboratory (National Centre for Microbiology CNM-ISCIII), Instituto de Salud Carlos III Carretera Majadahonda-Pozuelo Km 2 28220 Madrid, Spain
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Benedict K, Gold JAW, Toda M, Thompson GR, Wiederhold NP, Smith DJ. Low Rates of Antifungal Therapeutic Drug Monitoring Among Inpatients Who Received Itraconazole, Posaconazole, or Voriconazole, United States, 2019-2021. Open Forum Infect Dis 2023; 10:ofad389. [PMID: 37539059 PMCID: PMC10394719 DOI: 10.1093/ofid/ofad389] [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: 05/19/2023] [Accepted: 07/19/2023] [Indexed: 08/05/2023] Open
Abstract
Antifungal therapeutic drug monitoring (TDM) is recommended for hospitalized patients receiving itraconazole, posaconazole, or voriconazole for treatment or prophylaxis. In this analysis of hospital-based data, TDM was uncommonly performed (15.8%) in a large cohort of eligible patients, suggesting missed opportunities to avoid subtherapeutic drug levels and minimize toxicity.
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Affiliation(s)
- Kaitlin Benedict
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jeremy A W Gold
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mitsuru Toda
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases, University of California, Davis Medical Center, Sacramento, California, USA
- Department of Medical Microbiology and Immunology, University of California, Davis, California, USA
| | - Nathan P Wiederhold
- Fungus Testing Laboratory, Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Dallas J Smith
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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46
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Liu Y, He Z, Liang H, Han M, Wang J, Liu Q, Guan Y. A high-throughput UPLC-MS/MS method for the determination of eight anti-tumor drugs in plasma. Anal Biochem 2023:115230. [PMID: 37429484 DOI: 10.1016/j.ab.2023.115230] [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: 04/28/2023] [Revised: 06/21/2023] [Accepted: 07/03/2023] [Indexed: 07/12/2023]
Abstract
Rapidly developing UPLC-MS/MS bioassays with high throughput and quality are challenging yet desired in routine clinics. METHODS & RESULTS: A high-throughput UPLC-MS/MS bioassay has been built for simultaneously quantifying gefitinib, ruxolitinib, dasatinib, imatinib, ibrutinib, methotrexate, cyclophosphamide and paclitaxel. After the protein precipitation with methanol, samples were separated on an Acquity BEH C18 column following a gradient elution system with methanol and 2 mM ammonium acetate in water at 40 °C with a run time of 3 min (flow rate 0.4 mL/min). Mass quantification in the positive ion SRM mode was then performed with electrospray ionization. The method of specificity, linearity, accuracy, precision, matrix effects, recovery, stability, dilution integrity and carryover were all validated as per the guideline of the China Food and Drug Administration whose values met the admissible limits. Application of the bioassay to therapeutic drug monitoring revealed important variability in the studied anti-tumour drugs. CONCLUSION: This validated approach was shown to be reliable and effective in clinical management, being a valuable support in therapeutic drug monitoring and subsequent individualized dosing optimization.
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Affiliation(s)
- Yao Liu
- Department of Pharmacy, The Fifth Affiliated Hospital of Sun Yat-sen University, Sun Yat-Sen University, Guangzhou 519000, China; Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, 510006, China.
| | - Zhichao He
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, China
| | - Heng Liang
- School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, 510006, China
| | - Minzhen Han
- The Second Affiliated Hospital of Guizhou Medical University, Kaili, Guizhou, 556000, China
| | - Jinxingyi Wang
- The Second Affiliated Hospital of Guizhou Medical University, Kaili, Guizhou, 556000, China
| | - Qian Liu
- The Second Affiliated Hospital of Guizhou Medical University, Kaili, Guizhou, 556000, China; Guangdong RangerBio Technologies Co., Ltd., Dongguan 523000, China.
| | - Yanping Guan
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, 510006, China.
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Bentley S, Cheong J, Gudka N, Makhecha S, Hadjisymeou-Andreou S, Standing JF. Therapeutic drug monitoring-guided dosing for pediatric cystic fibrosis patients: recent advances and future outlooks. Expert Rev Clin Pharmacol 2023; 16:715-726. [PMID: 37470695 DOI: 10.1080/17512433.2023.2238597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Medicine use in children with cystic fibrosis (CF) is complicated by inconsistent pharmacokinetics at variance with the general population, a lack of research into this and its effects on clinical outcomes. In the absence of established dose regimens, therapeutic drug monitoring (TDM) is a clinically relevant tool to optimize drug exposure and maximize therapeutic effect by the bedside. In clinical practice though, use of this is variable and limited by a lack of expert recommendations. AREAS COVERED We aimed to review the use of TDM in children with CF to summarize recent developments, current recommendations, and opportunities for future directions. We searched PubMed for relevant publications using the broad search terms "cystic fibrosis" in combination with the specific terms "therapeutic drug monitoring (TDM)" and "children." Further searches were undertaken using the name of identified drugs combined with the term "TDM." EXPERT OPINION Further research into the use of Bayesian forecasting and the relationship between exposure and response is required to personalize dosing, with the opportunity for the development of expert recommendations in children with CF. Use of noninvasive methods of TDM has the potential to improve accessibility to TDM in this cohort.
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Affiliation(s)
- Siân Bentley
- Pharmacy Department, Royal Brompton Hospital, London, UK
| | - Jamie Cheong
- Pharmacy Department, Royal Brompton Hospital, London, UK
| | - Nikesh Gudka
- Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | - Joseph F Standing
- Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Infection, Immunity and Inflammation,great Ormond Street Institute of Child Health, University College London, London, UK
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48
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Phoophiboon V, Brown P, Burns KEA. Systemic lupus erythematosus associated with development of macrophage activation syndrome and disseminated aspergillosis. Can J Anaesth 2023; 70:1255-1260. [PMID: 37349668 DOI: 10.1007/s12630-023-02506-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 01/05/2023] [Accepted: 01/14/2023] [Indexed: 06/24/2023] Open
Abstract
PURPOSE Macrophage activation syndrome (MAS) is a rare illness, especially in critically ill adults. The diagnosis of MAS is challenging, requiring the expertise of multiple specialists, and treatments for MAS can be associated with catastrophic complications. CLINICAL FEATURES We describe the case of a 31-yr-old Vietnamese student who was diagnosed with cutaneous systemic lupus erythematosus (SLE) in November 2020 and was initiated on treatment with low-dose corticosteroids and hydroxychloroquine as an outpatient. Ten days later, she presented to hospital with decreased consciousness, fever, periorbital swelling, and hypotension necessitating intubation. Computed tomography angiography (CTA) and lumbar puncture did not show a stroke or central nervous system infection. Serology and clinical presentation were consistent with MAS. She was initially treated with 4.5 g pulse methylprednisolone and subsequently with the interleukin-1 receptor antagonist, anakinra, and maintenance corticosteroids because of persistently elevated inflammatory markers. Her intensive care unit stay was complicated by aspiration, airway obstruction due to fungal tracheobronchitis necessitating extracorporeal membrane oxygenation (ECMO), and ring-enhancing cerebral lesions, and, ultimately, massive hemoptysis resulting in death. CONCLUSIONS Four features of this case merit discussion, including the: 1) infrequent association of SLE with MAS; 2) short interval between SLE diagnosis and critical illness; 3) manifestation of fungal tracheobronchitis with airway obstruction; and 4) lack of response to antifungal treatment while receiving ECMO.
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Affiliation(s)
- Vorakamol Phoophiboon
- Interdepartmental Division of Critical Care Medicine, Temerty School of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Paula Brown
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
| | - Karen E A Burns
- Division of Critical Care Medicine, Unity Health Toronto - St. Michael's Hospital, Li Ka Shing Knowledge Institute, 30 Bond Street, Office 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
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McCann S, Sinha J, Wilson WS, McKinzie CJ, Garner LM, Gonzalez D. Population Pharmacokinetics of Posaconazole in Immune-Compromised Children and Assessment of Target Attainment in Invasive Fungal Disease. Clin Pharmacokinet 2023; 62:997-1009. [PMID: 37179512 PMCID: PMC10338595 DOI: 10.1007/s40262-023-01254-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND AND OBJECTIVE Posaconazole (PSZ) is a triazole antifungal for the management of invasive fungal disease (IFD) in adults and children. Although PSZ is available as an intravenous (IV) solution, oral suspension (OS) and delayed-release tablets (DRTs), OS is the preferred formulation for pediatric use because of potential safety concerns associated with an excipient in the IV formulation and difficulty in swallowing intact tablets by children. However, poor biopharmaceutical characteristics of the OS formulation leads to an unpredictable dose-exposure profile of PSZ in children, potentially risking therapeutic failure. The goal of this study was to characterize the population pharmacokinetics (PK) of PSZ in immunocompromised children and assess therapeutic target attainment. METHODS Serum concentrations of PSZ were collected retrospectively from records of hospitalized patients. A population PK analysis was performed in a nonlinear mixed-effects modeling framework with NONMEM (v7.4). The PK parameters were scaled to body weight, then potential covariate effects were assessed. The final PK model was used to evaluate recommended dosing schemes through simulation of target attainment (as a percentage of the population having steady-state trough concentrations above the recommended target) using Simulx (v2021R1). RESULTS Repeated measurement data of 202 serum concentrations of total PSZ were acquired from 47 immunocompromised patients between 1 and 21 years of age receiving PSZ either intravenously or orally, or both. A one-compartment PK model with first-order absorption and linear elimination best fit the data. The estimated absolute bioavailability (95% confidence interval) for suspension (Fs) was 16% (8-27%), which was significantly lower than the reported tablet bioavailability (Ft) [67%]. Fs was reduced by 62% and 75% upon concomitant administration with pantoprazole (PAN) and omeprazole (OME), respectively. Famotidine resulted in a reduction of Fs by only 22%. Both fixed dosing and weight-based adaptive dosing provided adequate target attainment when PAN or OME were not coadministered with the suspension. CONCLUSIONS The results of this study revealed that both fixed and weight-based adaptive dosing schemes can be appropriate for target attainment across all PSZ formulations, including suspension. Additionally, covariate analysis suggests that concomitant proton pump inhibitors should be contraindicated during PSZ suspension dosing.
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Affiliation(s)
- Sean McCann
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA
| | - Jaydeep Sinha
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA
- Department of Pediatrics, UNC School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William S Wilson
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Cameron J McKinzie
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Lauren M Garner
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA.
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Gorham J, Taccone FS, Hites M. Therapeutic Drug Monitoring of Antimicrobials in Critically Ill Obese Patients. Antibiotics (Basel) 2023; 12:1099. [PMID: 37508195 PMCID: PMC10376599 DOI: 10.3390/antibiotics12071099] [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: 05/10/2023] [Revised: 06/14/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
Obesity is a significant global public health concern that is associated with an elevated risk of comorbidities as well as severe postoperative and nosocomial infections. The treatment of infections in critically ill obese patients can be challenging because obesity affects the pharmacokinetics and pharmacodynamics of antibiotics, leading to an increased risk of antibiotic therapy failure and toxicity due to inappropriate dosages. Precision dosing of antibiotics using therapeutic drug monitoring may help to improve the management of this patient population. This narrative review outlines the pharmacokinetic and pharmacodynamic changes that result from obesity and provides a comprehensive critical review of the current available data on dosage adjustment of antibiotics in critically ill obese patients.
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Affiliation(s)
- Julie Gorham
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (H.U.B), 1070 Brussels, Belgium
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (H.U.B), 1070 Brussels, Belgium
| | - Maya Hites
- Clinic of Infectious Diseases, Hôpital Universitaire de Bruxelles (H.U.B), 1070 Brussels, Belgium
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