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Poussier L, Mailles A, Tattevin P, Stahl JP, Fillâtre P. Characteristics, management and outcome of Herpes Simplex and Varicella-Zoster virus encephalitis: a multicentre prospective cohort study. Clin Microbiol Infect 2024; 30:917-923. [PMID: 38527616 DOI: 10.1016/j.cmi.2024.03.017] [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: 11/08/2023] [Revised: 03/03/2024] [Accepted: 03/13/2024] [Indexed: 03/27/2024]
Abstract
OBJECTIVE To characterize differences between Herpes Simplex virus encephalitis and Varicella-Zoster virus encephalitis (HSVE and VZVE) and other aetiologies of infectious encephalitis (IE), and to investigate the impact of time-to-aciclovir (ACV) start, ACV dose and duration on outcome. METHODS We compared 132 HSVE, 65 VZVE and 297 other IE enrolled in a prospective cohort (ENCEIF). We estimated associations between time-to-ACV start, dose or duration and outcome through adjusted odds ratio (aOR) using logistic regression analysis. RESULTS Prevalence of immunodepression differed among aetiologies: 15/65 (23%) for VZVE, 13/132 (10%) for HSVE and 30/297 (10%) for other IE (p <0.05), as was presence of seizure at admission: 27/132 (20%) for HSVE, 4/65 (6%) for VZVE and 43/297 (14%) for other IE (p <0.05). Poor outcome at hospital discharge (Glasgow outcome scale ≤3) differed among the three groups: 40/127 (31%) for HSVE, 12/65 (18%) for VZVE and 38/290 (13%) for other IE (p <0.05). Time-to-ACV start was associated with outcome in HSVE (aOR 3.61 [1.25-10.40]), but not in VZVE (aOR 0.84 [0.18-3.85]). Increased ACV dose was not associated with outcome among HSVE (aOR 1.25 [0.44-3.64]) nor VZVE (aOR 1.16 [0.24-5.73]). DISCUSSION HSVE and VZVE are distinct in clinical presentation, outcome and prognostic factors. The impact of early ACV initiation was more apparent for HSVE than for VZVE; however, this could be because of VZVE's smaller sample size and lower outcome rate leading to low statistical power or because of potential distinct IE pathophysiology.
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Affiliation(s)
- Léa Poussier
- Infectious Diseases and Intensive Care Unit, CHU Pontchaillou, Rennes, France; INSERM, CIC 1414, Rennes, France
| | | | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, CHU Pontchaillou, Rennes, France; INSERM, CIC 1414, Rennes, France
| | - Jean-Paul Stahl
- Infectious Diseases Department, University Grenoble Alpes, Grenoble, France
| | - Pierre Fillâtre
- INSERM, CIC 1414, Rennes, France; Intensive Care Unit, Yves Le Foll Hospital, Saint Brieuc, France.
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2
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Takeda S, Ueno S, Zenda R, Muto K, Iseki K, Harada K. Simultaneous analysis of acyclovir and its metabolite using hydrophilic interaction liquid chromatography-tandem mass spectrometry. J Anal Toxicol 2024; 48:204-209. [PMID: 38441245 DOI: 10.1093/jat/bkae019] [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: 01/11/2024] [Revised: 02/21/2024] [Accepted: 02/29/2024] [Indexed: 05/23/2024] Open
Abstract
The antiviral drug acyclovir (ACV) may induce drug-induced neuropsychiatric symptoms as side effects. The detailed pathogenic mechanism remains unclear; however, it is hypothesized that 9-carboxymethoxymethylguanine (CMMG), a metabolite of ACV, is the causative compound. Therefore, the blood concentrations of ACV and CMMG should be analyzed in ACV toxicity studies. However, it is rare to find methods that can sufficiently separate the ACV and CMMG peaks during simultaneous analysis of both compounds. Therefore, we intended to develop a liquid chromatography-tandem mass spectrometry method with improved peak separation of analytes. Samples were deproteinized using methanol/acetonitrile solution (6:4, v/v). Analytes were separated on an InertSustain® Amide column (3 μm, 2.1 mm × 150 mm). The mobile phase consisted of acetonitrile/10 mM ammonium formate (5:95, v/v) (A) and acetonitrile/10 mM ammonium formate (95:5, v/v, pH 5.0) (B) and samples were eluted in the gradient mode. The separation of analytes was satisfactory and the peak shapes were good. Linear regression models weighted 1/x2 were obtained in the range of 0.25-10 μg/mL. The range of quality control (QC) bias was between 3.6% and 19.8%, and the within-run and between-run precisions of QC were within 13.5%. Recovery ranged from 83.6% to 103.7%, but ion suppression was observed. Samples from a patient with ACV encephalopathy were analyzed using this method. The resulting blood ACV and CMMG concentrations were 8.2 and 8.5 μg/mL, respectively. This method, with sufficient separation of ACV and CMMG, proved useful for use in ACV toxicity studies.
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Affiliation(s)
- Saki Takeda
- Department of Forensic Medicine, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima 960-1295, Japan
| | - Satoshi Ueno
- Department of Regional Emergency Medicine, Fukushima Medical University, 1 Hikarigaoka, Fukushima 960-1295, Japan
| | - Rie Zenda
- Department of Emergency and Critical Care Medicine, Fukushima Medical University, School of Medicine, 1 Hikarigaoka, Fukushima 960-1295, Japan
| | - Kazuya Muto
- Department of Emergency and Critical Care Medicine, Fukushima Medical University, School of Medicine, 1 Hikarigaoka, Fukushima 960-1295, Japan
| | - Ken Iseki
- Department of Regional Emergency Medicine, Fukushima Medical University, 1 Hikarigaoka, Fukushima 960-1295, Japan
- Department of Emergency and Critical Care Medicine, Fukushima Medical University, School of Medicine, 1 Hikarigaoka, Fukushima 960-1295, Japan
| | - Kazuki Harada
- Department of Forensic Medicine, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima 960-1295, Japan
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3
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Aboelezz A, Mahmoud SH. Acyclovir dosing in herpes encephalitis: A scoping review. J Am Pharm Assoc (2003) 2024; 64:102040. [PMID: 38364888 DOI: 10.1016/j.japh.2024.02.013] [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: 09/29/2023] [Revised: 02/11/2024] [Accepted: 02/11/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Herpes encephalitis, a rare yet potentially fatal viral infection, is treated exclusively with acyclovir, the sole antiviral medication used for this condition. Acyclovir recommended dose is 10 mg/kg/dose intravenous every 8 hours; however, it is unclear what body weight should be utilized in obese patients. Using the ideal body weight may result in subtherapeutic ineffective concentrations, while utilizing the actual body weight might result in acyclovir induced adverse effects, either nephrotoxicity or neurotoxicity or both. OBJECTIVE The objective of this scoping review is to explore existing evidence regarding acyclovir dosing for obese patients afflicted with herpes encephalitis. METHODS MEDLINE, EMBASE, Scopus, Web of Science, and CINAHL databases were searched on 26 May 2023, with no language restrictions. Two independent reviewers utilized the Covidence software to carry out the screening and selection of the articles. A total of 22 articles were included in the current review. RESULTS The prevalence of acyclovir-associated nephrotoxicity ranged from 13% to 21%, while the prevalence of neurotoxicity was not clearly defined. However, there is lack of evidence regarding what may arise from subtherapeutic concentrations. An approach has been suggested to help clinicians to give the most appropriate acyclovir dose to herpes encephalitis patients. Patients with normal kidney function could receive the normal doses based on actual weight if normal weight and based on adjusted body weight if obese. On the other hand, if the patients are experiencing augmented renal clearance, they could receive up to the maximum recommended doses. CONCLUSION Overall, there is a lack of consistency on which body weight to use to calculate acyclovir dose in obese patients. So it is recommended that further studies compare the concentration of intravenous acyclovir between obese and nonobese patients and relating the resultant concentration with patient outcomes.
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Hafez G, Malyszko J, Golenia A, Klimkowicz-Mrowiec A, Ferreira AC, Arıcı M, Bruchfeld A, Nitsch D, Massy ZA, Pépin M, Capasso G, Mani LY, Liabeuf S. Drugs with a negative impact on cognitive functions (Part 2): drug classes to consider while prescribing in CKD patients. Clin Kidney J 2023; 16:2378-2392. [PMID: 38046029 PMCID: PMC10689198 DOI: 10.1093/ckj/sfad239] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Indexed: 12/05/2023] Open
Abstract
There is growing evidence that chronic kidney disease (CKD) is an independent risk factor for cognitive impairment, especially due to vascular damage, blood-brain barrier disruption and uremic toxins. Given the presence of multiple comorbidities, the medication regimen of CKD patients often becomes very complex. Several medications such as psychotropic agents, drugs with anticholinergic properties, GABAergic drugs, opioids, corticosteroids, antibiotics and others have been linked to negative effects on cognition. These drugs are frequently included in the treatment regimen of CKD patients. The first review of this series described how CKD could represent a risk factor for adverse drug reactions affecting the central nervous system. This second review will describe some of the most common medications associated with cognitive impairment (in the general population and in CKD) and describe their effects.
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Affiliation(s)
- Gaye Hafez
- Department of Pharmacology, Faculty of Pharmacy, Altinbas University, Istanbul, Turkey
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | | | - Ana Carina Ferreira
- Nephrology Department, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
- Universidade Nova de Lisboa-Faculdade de Ciências Médicas-Nephology, Lisbon, Portugal
| | - Mustafa Arıcı
- Department of Internal Medicine, Division of Nephrology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Renal Medicine, Karolinska University Hospital and CLINTEC Karolinska Institutet, Stockholm, Sweden
| | - Dorothea Nitsch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Ziad A Massy
- Paris-Saclay University, UVSQ, Inserm, Clinical Epidemiology Team, Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Villejuif, France
- Department of Nephrology, Ambroise Paré University Medical Center, APHP, Paris, France
| | - Marion Pépin
- Department of Nephrology, Ambroise Paré University Medical Center, APHP, Paris, France
- Department of Geriatrics, Ambroise Paré University Medical Center, APHP, Boulogne-Billancourt, France
| | - Giovambattista Capasso
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
- Biogem Research Institute, Ariano Irpino, Italy
| | - Laila-Yasmin Mani
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sophie Liabeuf
- Pharmacoepidemiology Unit, Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France
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Ryan B, Bhashitaa J, Chiew AL, Chan BS. Valacyclovir neurotoxicity and kinetics in a patient with impaired kidney function. Clin Toxicol (Phila) 2023; 61:1062-1063. [PMID: 38189323 DOI: 10.1080/15563650.2023.2288807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/23/2023] [Indexed: 01/09/2024]
Affiliation(s)
- Bradley Ryan
- Clinical Toxicology, Prince of Wales Hospital and Community Health Services Ringgold Standard Institution
| | - Jagarlamudi Bhashitaa
- Clinical Toxicology, Prince of Wales Hospital and Community Health Services Ringgold Standard Institution
| | - Angela L Chiew
- Clinical Toxicology, Prince of Wales Hospital and Community Health Services Ringgold Standard Institution
| | - Betty S Chan
- Clinical Toxicology, Prince of Wales Hospital and Community Health Services Ringgold Standard Institution
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6
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Unita R, Adachi K, Inada A, Shimizu M, Beppu S, Yamazaki H. A decreasing plasma concentration of a toxicologically active metabolite 9-carboxymethoxymethylguanine after dialysis - A potential new clinical biomarker for improving encephalopathy in patients treated with acyclovir. J Infect Chemother 2023; 29:1068-1070. [PMID: 37437659 DOI: 10.1016/j.jiac.2023.07.001] [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: 04/06/2023] [Revised: 06/11/2023] [Accepted: 07/07/2023] [Indexed: 07/14/2023]
Abstract
Although acyclovir is a key drug for the treatment of herpes infections, a consciousness disorder known as "acyclovir encephalopathy" is among its side effects. We encountered a patient with encephalopathy and measured the plasma and cerebrospinal fluid concentrations of acyclovir and its toxicologically active metabolite 9-carboxymethoxymethylguanine (CMMG). Before dialysis, cerebrospinal fluid concentrations of acyclovir and CMMG in this patient with a consciousness disorder were approximately 10% and 1%, respectively, of their plasma concentrations. After 3 days of dialysis, plasma CMMG levels decreased to detectable but below quantitative levels (<0.1 μg/mL), resulting in normal consciousness. These results suggest that decreasing plasma CMMG concentration could be one of clinical biomarkers for improving consciousness in patients with encephalopathy associated with acyclovir.
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Affiliation(s)
- Ryo Unita
- Emergency Department, Kyoto Medical Center, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Koichiro Adachi
- Laboratory of Drug Metabolism and Pharmacokinetics, Showa Pharmaceutical University, 3-3165 Higashi-tamagawa Gakuen, Machida, Tokyo, 194-8543, Japan
| | - Akiyoshi Inada
- Pharmaceutical Department, Kyoto Medical Center, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Makiko Shimizu
- Laboratory of Drug Metabolism and Pharmacokinetics, Showa Pharmaceutical University, 3-3165 Higashi-tamagawa Gakuen, Machida, Tokyo, 194-8543, Japan
| | - Satoru Beppu
- Emergency Department, Kyoto Medical Center, Fushimi-ku, Kyoto, 612-8555, Japan.
| | - Hiroshi Yamazaki
- Laboratory of Drug Metabolism and Pharmacokinetics, Showa Pharmaceutical University, 3-3165 Higashi-tamagawa Gakuen, Machida, Tokyo, 194-8543, Japan.
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7
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Lee H, Martin SO, Lee M, Munjal S. Valacyclovir-Associated Catatonia: A Case Highlighting Its Neuropsychiatric Adverse Effects. J Clin Psychopharmacol 2023; 43:469-471. [PMID: 37683243 DOI: 10.1097/jcp.0000000000001741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Affiliation(s)
- HoLim Lee
- Department of Psychiatry and Behavioral Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC
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8
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Huntjens DW, Dijkstra JA, Verwiel LN, Slijkhuis M, Elbers P, Welkers MRA, Veldkamp AI, Kuijvenhoven MA, de Leeuw DC, Abdullah-Koolmees H, Kuipers MT, Bartelink IH. Optimizing Antiviral Dosing for HSV and CMV Treatment in Immunocompromised Patients. Pharmaceutics 2023; 15:pharmaceutics15010163. [PMID: 36678792 PMCID: PMC9863155 DOI: 10.3390/pharmaceutics15010163] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/27/2022] [Accepted: 12/28/2022] [Indexed: 01/05/2023] Open
Abstract
Herpes simplex virus (HSV) and cytomegalovirus (CMV) are DNA viruses that are common among humans. Severely immunocompromised patients are at increased risk of developing HSV or CMV disease due to a weakened immune system. Antiviral therapy can be challenging because these drugs have a narrow therapeutic window and show significant pharmacokinetic variability. Above that, immunocompromised patients have various comorbidities like impaired renal function and are exposed to polypharmacy. This scoping review discusses the current pharmacokinetic (PK) and pharmacodynamic (PD) knowledge of antiviral drugs for HSV and CMV treatment in immunocompromised patients. HSV and CMV treatment guidelines are discussed, and multiple treatment interventions are proposed: early detection of drug resistance; optimization of dose to target concentration by therapeutic drug monitoring (TDM) of nucleoside analogs; the introduction of new antiviral drugs; alternation between compounds with different toxicity profiles; and combinations of synergistic antiviral drugs. This research will also serve as guidance for future research, which should focus on prospective evaluation of the benefit of each of these interventions in randomized controlled trials.
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Affiliation(s)
- Daan W. Huntjens
- Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Jacob A. Dijkstra
- Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-20-444-3524
| | - Lisanne N. Verwiel
- Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Mirjam Slijkhuis
- Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Paul Elbers
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence (LCCI), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AII), Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Matthijs R. A. Welkers
- Medical Microbiology and Infection Prevention, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Agnes I. Veldkamp
- Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Marianne A. Kuijvenhoven
- Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - David C. de Leeuw
- Hematology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Heshu Abdullah-Koolmees
- Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
- Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Postbus 85500, 3508 GA Utrecht, The Netherlands
- Clinical Pharmacy, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Maria T. Kuipers
- Hematology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Imke H. Bartelink
- Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
- Cancer Center Amsterdam, 1081HV Amsterdam, The Netherlands
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9
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Therapeutic monitoring of serum concentrations of acyclovir and its metabolite 9-(carboxymethoxymethyl) guanine in routine clinical practice. Biomed Pharmacother 2022; 156:113852. [DOI: 10.1016/j.biopha.2022.113852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/23/2022] Open
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Annaji M, Mita N, Rangari S, Aldawsari MF, Alsaqr A, Poudel I, Fasina O, Babu RJ. Enhanced Topical Co-delivery of Acyclovir and Lidocaine Gel Formulation Across Dermatomed Human Skin. AAPS PharmSciTech 2022; 23:305. [DOI: 10.1208/s12249-022-02458-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/03/2022] [Indexed: 11/19/2022] Open
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Wang YC, Juan SH, Li CH, Chou CL, Chen LY, Chien LN, Fang TC. Valacyclovir-associated neurotoxicity among patients on hemodialysis and peritoneal dialysis: A nationwide population-based study. Front Med (Lausanne) 2022; 9:997379. [PMID: 36203771 PMCID: PMC9530346 DOI: 10.3389/fmed.2022.997379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/01/2022] [Indexed: 11/13/2022] Open
Abstract
Whether valacyclovir-associated neurotoxicity (VAN) occurs more frequently in patients with end-stage renal disease (ESRD) on dialysis is unknown. This is the first population-based study to examine the risk of VAN associated with ESRD patients on dialysis. Among 2,284,800 patients diagnosed as having herpes zoster from 2002 to 2016, patients with ESRD on dialysis and individuals with normal renal function were enrolled in this study. Following propensity score matching, we compared the risk of altered mental status between valacyclovir users and non-users in the ESRD and normal renal function cohorts over a 30-day follow-up period. In the ESRD cohort, the incidence of altered mental status was 1.68 and 0.52 per 1,000 person-day in valacyclovir users and non-users, respectively, with an adjusted hazard ratio (HR) of 3.22 (95% confidence interval [CI]: 2.04–4.99, P < 0.001). The incidence of altered mental status of valacyclovir users on hemodialysis (HD) and peritoneal dialysis (PD) was higher than that of non-users. The adjusted HR was 3.20 (95% CI: 1.98–5.15, P < 0.001) for those on HD and 3.44 (95% CI: 1.13–10.49, P = 0.030) for those with PD. However, altered mental status was not observed in patients on HD receiving ≤500 mg of valacyclovir three times per week or in those on PD receiving ≤500 mg of valacyclovir per day. The findings demonstrate that adjusting the valacyclovir dosage and monitoring VAN in patients with HD and PD who have herpes zoster is crucial.
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Affiliation(s)
- Yi-Chun Wang
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Shu-Hui Juan
- Department of Physiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ching-Hao Li
- Department of Physiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chu-Lin Chou
- TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Hsin Kuo Min Hospital, Taipei Medical University, Taoyuan City, Taiwan
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Li-Ying Chen
- Health Data Analytics and Statistics Center, Office of Data Science, Taipei Medical University, Taipei, Taiwan
| | - Li-Nien Chien
- Institute of Health and Welfare Policy, College of Medicince, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan
- Li-Nien Chien,
| | - Te-Chao Fang
- TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
- *Correspondence: Te-Chao Fang,
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12
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Tai T, Yamaguchi K, Kurokawa N, Shinmura W, Matsubara A, Watanabe M, Motoki T, Tanaka H, Houchi H, Kosaka S. [A Pharmacist's Query Avoiding Exacerbation of Adverse Effects in a Patient with Acyclovir Encephalopathy: A Case Report]. YAKUGAKU ZASSHI 2022; 142:771-774. [PMID: 35781507 DOI: 10.1248/yakushi.21-00237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We report a haemodialysis patient with end-stage renal failure whom a pharmacist aided in the management of acyclovir (ACV) encephalopathy, which may have been related to valacyclovir hydrochloride (VACV) administered without sufficient dose reduction. The patient 78 years was admitted with a tentative diagnosis of varicella zoster viral meningitis. A pharmacist suspected ACV encephalopathy related to excessive VACV administration and raised a query with the attending physician. According to the pharmacist's proposal, ACV administration was discontinued and continuous hemodiafiltration (CHDF) was performed. On day 5 of hospitalisation, the consciousness disorder was improved. In this report, we showed the detailed CHDF conditions of the present case, and the contribution of a pharmacist to treating and avoiding ACV encephalopathy was discussed.
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Affiliation(s)
- Tatsuya Tai
- Department of Pharmacy, Kagawa University Hospital
| | | | | | | | | | | | | | | | - Hitoshi Houchi
- Kagawa School of Pharmaceutical Sciences, Tokushima Bunri University
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13
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Maillard M, Gong L, Nishii R, Yang JJ, Whirl-Carrillo M, Klein TE. PharmGKB summary: acyclovir/ganciclovir pathway. Pharmacogenet Genomics 2022; 32:201-208. [PMID: 35665708 PMCID: PMC9179945 DOI: 10.1097/fpc.0000000000000474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Maud Maillard
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Li Gong
- Departments of Biomedical Data Science
| | - Rina Nishii
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jun J Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Teri E Klein
- Departments of Biomedical Data Science
- Medicine (BMIR), Stanford University, Stanford, California, USA
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Wei Y, Yao L, Wu Y, Liu X, Feng J, Ding J, Li K, He Q. Ultrasensitive electrochemical detection for nanomolarity Acyclovir at ferrous molybdate nanorods and graphene oxide composited glassy carbon electrode. Colloids Surf A Physicochem Eng Asp 2022. [DOI: 10.1016/j.colsurfa.2022.128601] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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15
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Ärlemalm A, Helldén A, Karlsson L, Carlsson B. Rapid determination of acyclovir, its main metabolite 9-carboxymethoxymethylguanine, ganciclovir and penciclovir in human serum by LC-MS/MS. Biomed Chromatogr 2022; 36:e5315. [PMID: 34981553 PMCID: PMC9285573 DOI: 10.1002/bmc.5315] [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: 11/11/2021] [Revised: 12/08/2021] [Accepted: 12/13/2021] [Indexed: 12/02/2022]
Abstract
A novel MS‐based analytical method for simultaneous analysis of the antiviral drugs acyclovir, its metabolite 9‐carboxymethoxymethylguanine, ganciclovir, and penciclovir in human serum is described. These antiviral drugs are active against herpes virus infections. Acyclovir and penciclovir are regarded as safe and effective medicines with mild side effects such as headache and gastrointestinal discomfort, and ganciclovir is regarded as more toxic and is known to cause, for example, bone marrow suppression. Acyclovir’s main metabolite 9‐carboxymethoxymethylguanine is a presumptive neurotoxin and should be monitored in patients with impaired renal function or in cases with neurotoxic symptoms. A sample was prepared using protein precipitation with 1% formic acid in methanol containing isotopically labeled internal standard. Chromatographic separation on a biphenyl column and mass spectrometric detection were performed in multiple reaction monitoring (MRM) mode on a Xevo TQ‐S micro with ESI in positive ion mode, within 3 min. Inter‐day assay accuracies for the quality controls varied between 95 and 104% and intra‐day assay between 93 and 105%. Inter‐day and intra‐day assay imprecision for the quality controls ranged between 1.4 and 4.2% and 1.7 and 6.5% respectively. The lower limit of quantification for all four substances was 0.156 μmol/L. It is an accurate and reproducible method for therapeutic drug monitoring.
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Affiliation(s)
- Andreas Ärlemalm
- Department of Clinical Pharmacology and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Anders Helldén
- Department of Clinical Pharmacology and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Louise Karlsson
- Department of Clinical Pharmacology and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Björn Carlsson
- Department of Clinical Pharmacology and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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16
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Nakajima K, Momo K, Nimura S, Kaizaki-Mitsumoto A, Kanazawa N, Inaba T, Saito T, Wada Y, Honda H, Numazawa S, Sasaki T. Severe acyclovir-induced encephalopathy in an elderly patient with herpes zoster. Eur J Clin Pharmacol 2021; 78:527-529. [PMID: 34714374 DOI: 10.1007/s00228-021-03243-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 10/21/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Kota Nakajima
- Department of Pharmacy, Showa University Hospital, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8666, Japan.,Department of Toxicology, School of Pharmacy, Showa University, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Kenji Momo
- Department of Pharmacy, Showa University Hospital, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8666, Japan. .,Department of Hospital Pharmaceutics, School of Pharmacy, Showa University, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8555, Japan.
| | - Satomi Nimura
- Department of Pharmacy, Showa University Hospital, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8666, Japan.,Department of Hospital Pharmaceutics, School of Pharmacy, Showa University, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Asuka Kaizaki-Mitsumoto
- Department of Toxicology, School of Pharmacy, Showa University, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Nobuhiro Kanazawa
- Department of Medicine, Division of Nephrology, Showa University School of Medicine, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Taro Inaba
- Department of Medicine, Division of Nephrology, Showa University School of Medicine, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Tomohiro Saito
- Department of Medicine, Division of Nephrology, Showa University School of Medicine, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Yukihiro Wada
- Department of Medicine, Division of Nephrology, Showa University School of Medicine, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Hirokazu Honda
- Department of Medicine, Division of Nephrology, Showa University School of Medicine, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Satoshi Numazawa
- Department of Toxicology, School of Pharmacy, Showa University, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8555, Japan
| | - Tadanori Sasaki
- Department of Pharmacy, Showa University Hospital, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8666, Japan
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17
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Jose N, Jayaprakash V, Deiva A, Jayakumar M. An Unusual Neurological Syndrome in a Haemodialysis Patient. Indian J Nephrol 2021; 31:293-295. [PMID: 34376947 PMCID: PMC8330665 DOI: 10.4103/ijn.ijn_11_20] [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: 01/09/2020] [Revised: 04/02/2020] [Accepted: 04/14/2020] [Indexed: 11/17/2022] Open
Abstract
Advanced age and immunosuppressed states allow for complications of herpes zoster such as encephalitis. In this case report, we describe a patient with encephalopathy two days after initiation of antiviral therapy. After the necessary imaging and cerebrospinal fluid (CSF) analysis, it became evident that the neurological syndrome was due to acyclovir. Despite currently practised renal dose modification, the patient developed acyclovir-induced neurotoxicity and required intensification of his dialysis schedule to eliminate the drug. Acyclovir-induced neurotoxicity is a rare clinical presentation and presents a clinical dilemma to the physician who has to distinguish this entity from herpes zoster encephalitis and posterior circulation stroke.
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Affiliation(s)
- Nisha Jose
- Department of Nephrology, SRIHER, Porur, Tamil Nadu, India
| | - V Jayaprakash
- Department of Nephrology, SRMIST, Kattankulathur, Tamil Nadu, India
| | - A Deiva
- Department of Nephrology, SRIHER, Porur, Tamil Nadu, India
| | - M Jayakumar
- Department of Nephrology, SRIHER, Porur, Tamil Nadu, India
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18
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Nishii R, Mizuno T, Rehling D, Smith C, Clark BL, Zhao X, Brown SA, Smart B, Moriyama T, Yamada Y, Ichinohe T, Onizuka M, Atsuta Y, Yang L, Yang W, Thomas PG, Stenmark P, Kato M, Yang JJ. NUDT15 polymorphism influences the metabolism and therapeutic effects of acyclovir and ganciclovir. Nat Commun 2021; 12:4181. [PMID: 34234136 PMCID: PMC8263746 DOI: 10.1038/s41467-021-24509-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 06/14/2021] [Indexed: 02/05/2023] Open
Abstract
Nucleobase and nucleoside analogs (NNA) are widely used as anti-viral and anti-cancer agents, and NNA phosphorylation is essential for the activity of this class of drugs. Recently, diphosphatase NUDT15 was linked to thiopurine metabolism with NUDT15 polymorphism associated with drug toxicity in patients. Profiling NNA drugs, we identify acyclovir (ACV) and ganciclovir (GCV) as two new NNAs metabolized by NUDT15. NUDT15 hydrolyzes ACV and GCV triphosphate metabolites, reducing their effects against cytomegalovirus (CMV) in vitro. Loss of NUDT15 potentiates cytotoxicity of ACV and GCV in host cells. In hematopoietic stem cell transplant patients, the risk of CMV viremia following ACV prophylaxis is associated with NUDT15 genotype (P = 0.015). Donor NUDT15 deficiency is linked to graft failure in patients receiving CMV-seropositive stem cells (P = 0.047). In conclusion, NUDT15 is an important metabolizing enzyme for ACV and GCV, and NUDT15 variation contributes to inter-patient variability in their therapeutic effects.
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Affiliation(s)
- Rina Nishii
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Takanori Mizuno
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Daniel Rehling
- Department of Biochemistry and Biophysics, Arrhenius Laboratories for Natural Sciences, Stockholm University, Stockholm, Sweden
| | - Colton Smith
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Brandi L Clark
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Xujie Zhao
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Scott A Brown
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Brandon Smart
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Takaya Moriyama
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yuji Yamada
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Tatsuo Ichinohe
- Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | | | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Aichi, Japan
| | - Lei Yang
- Department of Chemical Biology & Therapeutics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Wenjian Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Paul G Thomas
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Pål Stenmark
- Department of Biochemistry and Biophysics, Arrhenius Laboratories for Natural Sciences, Stockholm University, Stockholm, Sweden. .,Department of Experimental Medical Science, Lund University, Lund, Sweden.
| | - Motohiro Kato
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan.
| | - Jun J Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA. .,Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA. .,Hematological Malignancies Program, Comprehensive Cancer Center, St. Jude Children's Research Hospital, Memphis, TN, USA.
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19
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Urinovska R, Kacirova I, Sagan J. Determination of acyclovir and its metabolite 9-carboxymethoxymethylguanide in human serum by ultra-high-performance liquid chromatography-tandem mass spectrometry. J Sep Sci 2021; 44:3080-3088. [PMID: 34165890 DOI: 10.1002/jssc.202100241] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 06/16/2021] [Accepted: 06/19/2021] [Indexed: 11/08/2022]
Abstract
A simple and rapid ultra-high-performance liquid chromatography coupled with mass spectrometry method was developed for acyclovir and its metabolite 9-carboxymethoxymethylguanine in human serum. After precipitation of serum samples with 0.1% formic acid in acetonitrile/methanol (40:60, v/v), components were separated on a Luna Omega C18 column (1.6 μm; 2.1 × 150 mm) at 40°C. Mobile phase A (2 mmol/L ammonium acetate, 0.1% formic acid in 5% acetonitrile, v/v/v) and mobile phase B (2 mmol/L ammonium acetate, 0.1% formic acid in 95% acetonitrile, v/v/v) were used for gradient elution. A linear calibration curve was obtained over the range of 0.05-50 mg/L, and the correlation coefficients were better than 0.999. The limit of quantitation was 0.05 mg/L for both analytes. The intra- and interday accuracy and precision at three concentration levels ranged between 1.6 and 13.3%, and recoveries were achieved with a range between 92.2 and 114.2%. This method was developed and validated for the therapeutic monitoring of acyclovir in patients.
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Affiliation(s)
- Romana Urinovska
- Departments of Clinical Pharmacology and Laboratory Medicine, University Hospital Ostrava, Ostrava, Czech Republic.,Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Ivana Kacirova
- Departments of Clinical Pharmacology and Laboratory Medicine, University Hospital Ostrava, Ostrava, Czech Republic.,Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Jiri Sagan
- Clinic of Infectious Medicine, University Hospital Ostrava, Ostrava, Czech Republic.,Clinic of Infectious Medicine, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
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20
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Brandariz-Nuñez D, Correas-Sanahuja M, Maya-Gallego S, Martín Herranz I. Neurotoxicity associated with acyclovir and valacyclovir: A systematic review of cases. J Clin Pharm Ther 2021; 46:918-926. [PMID: 34146428 DOI: 10.1111/jcpt.13464] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/15/2021] [Accepted: 05/24/2021] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Acyclovir and valacyclovir are commonly used antivirals with good general tolerance. Despite their good safety profile, they can cause systemic adverse effects, such as neurotoxicity, which are less frequent and known. The objective of this review was to collect all the reported cases of neurotoxicity associated with acyclovir and valaciclovir published in the literature and characterize their clinical course and interventions. METHODS A systematic review of cases was carried out following the guidelines established by "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA). The research was carried out using the PubMed-Medline and Embase databases, between July 1984 and March 2021. RESULTS AND DISCUSSION A total of 119 cases with neurotoxicity mainly related to acyclovir (n = 88; 73.9%), followed by valaciclovir (n = 35; 29.4%) were analysed. 49.6% (n = 59) were men with a mean age of 59.5 years ± 21.1 (0.5-88). In 83.3% of the cases, renal impairment was documented and 57.1% (n = 68) with end-stage renal disease. The administered dose was higher than the renal adjustment recommendations in 59.7% of the cases. The global mean of onset of symptoms was 3.1 days ± 4.3 (0.2-28) after the start of antivirals. The mean recovery time was 9.8 days ± 21.7 (0.2-180). 74.4% of the patients had a recovery of ≤7 days, 15.9% between 8 and 15 days and 9.8% > 15 days. WHAT IS NEW AND CONCLUSION The neurotoxicity induced by acyclovir and its derivative valacyclovir is a poorly known and rare adverse effect that can occur mainly in patients with advanced age and impaired renal function. The most characteristic symptoms are confusion, altered level of consciousness, hallucinations, agitation and dysarthria. The basis of treatment is the discontinuation of the antiviral, and in some cases, it may require additional clearance by dialysis.
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Affiliation(s)
| | | | - Sara Maya-Gallego
- Pediatric Infectious Disease Service, San Joan de Deu Hospital, Barcelona, Spain
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21
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von Hofsten J, Studahl M. Comment on "Acute Retinal Necrosis: Is the Current Valacyclovir Regimen Adequate?". Ocul Immunol Inflamm 2021; 30:1289. [PMID: 33512259 DOI: 10.1080/09273948.2020.1860234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Joanna von Hofsten
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Ophthalmology, Halland Hospital Halmstad, Halmstad, Sweden
| | - Marie Studahl
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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22
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Lindström J, Helldén A, Lycke J, Grahn A, Studahl M. An unexpectedly high occurrence of aciclovir-induced neuropsychiatric symptoms in patients treated for herpesvirus CNS infection: a prospective observational study. J Antimicrob Chemother 2020; 74:3565-3572. [PMID: 31504577 PMCID: PMC6857197 DOI: 10.1093/jac/dkz357] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/13/2019] [Accepted: 07/16/2019] [Indexed: 01/28/2023] Open
Abstract
Background Aciclovir is effective in herpesvirus infections of the CNS. Aciclovir-induced neuropsychiatric symptoms (AINS) have been reported and are associated with high CSF concentrations of aciclovir metabolite 9-carboxymethoxymethylguanine (CMMG). Risk factors except for renal failure have not been explored, and disruption of the blood–brain barrier (BBB) in acute CNS infection may be of interest. Objectives To investigate the impact of risk factors on aciclovir and CMMG concentrations, and to relate the results to AINS. Methods We investigated 21 consecutively included, consenting patients treated with aciclovir or valaciclovir for herpesvirus CNS infection. Regression models were constructed to study the impact of risk factors including BBB disruption, as measured with CSF:serum albumin ratio, on CSF aciclovir and CMMG concentrations. Medical records were assessed retrospectively to identify patients with AINS. Results Increased CSF:serum albumin ratio, as well as decreased renal function and high aciclovir doses, was associated with increased aciclovir and CMMG concentrations in the CSF. We identified five patients with new neuropsychiatric symptoms; four of those were considered to have AINS and had increased CSF CMMG concentrations. Only one patient without suspicion of AINS had an increased CSF CMMG concentration. Conclusions In patients with herpesvirus CNS infections, BBB disruption is associated with increasing aciclovir and CMMG CSF concentrations. We also found an unexpectedly high number of patients with AINS. Evaluation of CSF:serum albumin ratios, renal function and CSF concentrations of aciclovir and CMMG may all contribute to the optimization of aciclovir dosing and avoidance of AINS.
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Affiliation(s)
- Johan Lindström
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Infectious Diseases, Gothenburg, Sweden
| | - Anders Helldén
- Department of Medical and Health Sciences, Division of Drug Research/Pharmacology, Linköping University Hospital, Linköping, Sweden
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anna Grahn
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Infectious Diseases, Gothenburg, Sweden
| | - Marie Studahl
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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23
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24
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Marks D, De La Paz A, Walston BJ. Acyclovir-induced neurotoxicity in an immunocompromised patient. SAGE Open Med Case Rep 2020; 8:2050313X20946518. [PMID: 32850129 PMCID: PMC7425261 DOI: 10.1177/2050313x20946518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 07/13/2020] [Indexed: 11/25/2022] Open
Abstract
This is a case report of a 75-year-old immunocompromised male who developed encephalopathy while undergoing treatment for disseminated herpes zoster with peripheral nerve involvement. While his initial presentation involved primarily profound lower extremity weakness, he developed progressive confusion to the point of obtundation only after initiation of standard therapy with intravenous acyclovir. The evaluation of his altered mental status was largely unremarkable. It was only after his acyclovir was discontinued that his symptoms resolved and he returned to his baseline mental status. His presentation was most consistent with acyclovir-induced neurotoxicity, which can present in patients with renal impairment and those who are immunocompromised.
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Affiliation(s)
- Daniel Marks
- School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrew De La Paz
- Internal Medicine Residency Program, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bobbi Jo Walston
- Infectious Diseases, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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25
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Kawabe Matsukawa M, Suzuki Y, Ikuma D, Suwabe T, Uesaka Y, Sugimoto I. [Acyclovir encephalopathy in a peritoneal dialysis patient despite adjusting the dose of oral acyclovir: a case report]. Rinsho Shinkeigaku 2019; 59:834-839. [PMID: 31761838 DOI: 10.5692/clinicalneurol.cn-001355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
We report a case of acyclovir encephalopathy in a 77-year-old man who was introduced to peritoneal dialysis three years earlier. He developed herpes zoster and was treated with acyclovir (ACV) at 800 mg daily per oral. Two days later, he developed consciousness disturbance, hallucinations and asterixis. Acyclovir was stopped and continuous ambulatory peritoneal dialysis (CAPD) was switched to hemodialysis, which resulted in the resolution of his symptoms. Because the optimal dose of ACV varies among individuals depending on the bioavailability of ACV and metabolic enzyme activity, ACV encephalopathy can occur even when the acyclovir dose is modified according to the renal function of the affected patient. Because CAPD provides a poorer ACV clearance than hemodialysis, CAPD patients tend to have a higher risk of developing ACV encephalopathy and to recover more slowly. If CAPD patients develop ACV encephalopathy, a temporary change in the type of dialysis to hemodialysis should be considered.
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Affiliation(s)
| | - Yuya Suzuki
- Department of Neurology, Toranomon Hospital Kajigaya
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26
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Zamora LD, Collante MTM, Navarra SV. Risk factors for herpes zoster infection among Filipinos with systemic lupus erythematosus. Int J Rheum Dis 2019; 23:197-202. [DOI: 10.1111/1756-185x.13725] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 09/23/2019] [Accepted: 09/30/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Leonid D. Zamora
- Section of Rheumatology University of Santo Tomas Manila Philippines
| | | | - Sandra V. Navarra
- Section of Rheumatology University of Santo Tomas Manila Philippines
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27
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Choi SJ, Ryu E, Lee S, Huh S, Shin YS, Kang BW, Kim JG, Cho H, Kang H. Adenosine Induces EBV Lytic Reactivation through ADORA1 in EBV-Associated Gastric Carcinoma. Int J Mol Sci 2019; 20:ijms20061286. [PMID: 30875759 PMCID: PMC6471230 DOI: 10.3390/ijms20061286] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 02/28/2019] [Accepted: 03/03/2019] [Indexed: 02/07/2023] Open
Abstract
Cordyceps species are known to contain numerous bioactive compounds, including cordycepin. Extracts of Cordyceps militaris (CME) are used in diverse medicinal purposes because of their bioactive components. Cordycepin, one of the active components of CME, exhibits anti-proliferative, pro-apoptotic, and anti-inflammatory effects. Cordycepin structurally differs from adenosine in that its ribose lacks an oxygen atom at the 3′ position. We previously reported that cordycepin suppresses Epstein–Barr virus (EBV) gene expression and lytic replication in EBV-associated gastric carcinoma (EBVaGC). However, other studies reported that cordycepin induces EBV gene expression and lytic reactivation. Thus, it was reasonable to clarify the bioactive effects of CME bioactive compounds on the EBV life cycle. We first confirmed that CME preferentially induces EBV gene expression and lytic reactivation; second, we determined that adenosine in CME induces EBV gene expression and lytic reactivation; third, we discovered that the adenosine A1 receptor (ADORA1) is required for adenosine to initiate signaling for upregulating BZLF1, which encodes for a key EBV regulator (Zta) of the EBV lytic cycle; finally, we showed that BZLF1 upregulation by adenosine leads to delayed tumor development in the EBVaGC xenograft mouse model. Taken together, these results suggest that adenosine is an EBV lytic cycle inducer that inhibits EBVaGC development.
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Affiliation(s)
- Su Jin Choi
- College of Pharmacy and Cancer Research Institute and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu 41566, Korea.
| | - Eunhyun Ryu
- College of Pharmacy and Cancer Research Institute and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu 41566, Korea.
| | - Seulki Lee
- College of Pharmacy and Innovative Drug Center, Duksung Women's University, Seoul 01369, Korea.
| | - Sora Huh
- College of Pharmacy and Cancer Research Institute and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu 41566, Korea.
| | - Yu Su Shin
- Department of Medical Crop Research, National Institute of Horticultural and Herbal Science, Rural Development Administration, Eumseong 27709, Korea.
| | - Byung Woog Kang
- Department of Oncology/Hematology and Cancer Research Institute and School of Medicine, Kyungpook National University Hospital and Kyungpook National University, Daegu 41404, Korea.
| | - Jong Gwang Kim
- Department of Oncology/Hematology and Cancer Research Institute and School of Medicine, Kyungpook National University Hospital and Kyungpook National University, Daegu 41404, Korea.
| | - Hyosun Cho
- College of Pharmacy and Innovative Drug Center, Duksung Women's University, Seoul 01369, Korea.
| | - Hyojeung Kang
- College of Pharmacy and Cancer Research Institute and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu 41566, Korea.
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28
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Umoru GO, Shah PJ, Tariq F. A Case Report of Neurotoxicity After Prolonged Doses of Acyclovir in a Patient With Renal Dysfunction. J Pharm Pract 2019; 33:217-221. [PMID: 30669921 DOI: 10.1177/0897190018825033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Renal dysfunction is a significant risk factor for acyclovir-induced neurotoxicity and altered mentation and myoclonic movements are the most common clinical symptoms observed. In majority of reported cases, neurological sequelae associated with acyclovir-induced neurotoxicity often mimic viral infections of the central nervous system and makes diagnosis of the former challenging. Although plasma concentrations of the drug may not always correlate with neurotoxic symptoms, obtaining serum levels of acyclovir may be helpful in confirming drug-induced neurotoxicity. Hemodialysis has been shown to significantly improve altered mentation in patients with suspected or confirmed acyclovir-induced neurotoxicity. Here, we report a definite case of acyclovir-induced neurotoxicity in a patient with end-stage renal disease. Clinical improvements in neurologic symptoms were observed following discontinuation of the drug and hemodialysis.
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Affiliation(s)
| | - Punit J Shah
- Houston Methodist Sugarland Hospital, Sugar Land, TX, USA
| | - Farheen Tariq
- Houston Methodist Sugarland Hospital, Sugar Land, TX, USA
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Sadjadi SA, Regmi S, Chau T. Acyclovir Neurotoxicity in a Peritoneal Dialysis Patient: Report of a Case and Review of the Pharmacokinetics of Acyclovir. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:1459-1462. [PMID: 30531673 PMCID: PMC6298245 DOI: 10.12659/ajcr.911520] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The elderly population in the United States and the world is rapidly increasing. With aging, immunity and kidney function decrease, thus predisposing people to viral illnesses for which there is no effective prophylaxis. Herpes zoster afflicts the elderly and other immunocompromised patients, like those with end-stage renal disease, transplant recipients, and cancer patients, causing significant morbidity and sometimes mortality. Treating herpes zoster becomes problematic when the regular pharmacokinetics of the antiviral drugs are disturbed. CASE REPORT An 83-year-old African American man with end-stage kidney disease (ESRD) and on chronic peritoneal dialysis (PD) developed herpes zoster, for which he received the manufacturer-recommended intravenous dose of acyclovir. Shortly after taking the medication, he developed confusion, disorientation, and visual hallucinations. He was switched from PD to hemodialysis (HD), with successful recovery. Examination of the cerebrospinal fluid for meningitis and imaging studies of the head were negative. Serum levels of acyclovir were elevated. CONCLUSIONS Even when the acyclovir dose is properly adjusted for kidney function based on the current manufacturer's recommendations, it can cause neurotoxicity. Here, we discuss the pharmacokinetics of acyclovir and make some recommendations with regard to dose adjustment in patients with ESRD.
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Affiliation(s)
- Seyed-Ali Sadjadi
- Nephrology Section, Jerry L Pettis Veterans Memorial Medical Center, Loma Linda, CA, USA
| | - Surakshya Regmi
- Nephrology Section, Jerry L Pettis Veterans Memorial Medical Center, Loma Linda, CA, USA
| | - Tony Chau
- Pharmacy Section, Jerry L Pettis Veterans Memorial Medical Center, Loma Linda, CA, USA
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Abstract
Acyclovir (ACV) is an effective antiviral agent for treating lytic Herpes Simplex virus, type 1 (HSV-1) infections, and it has dramatically reduced the mortality rate of herpes simplex encephalitis. However, HSV-1 resistance to ACV and its derivatives is being increasingly documented, particularly among immunocompromised individuals. The burgeoning drug resistance compels the search for a new generation of more efficacious anti-herpetic drugs. We have previously shown that trans-dihydrolycoricidine (R430), a lycorane-type alkaloid derivative, effectively inhibits HSV-1 infections in cultured cells. We now report that R430 also inhibits ACV-resistant HSV-1 strains, accompanied by global inhibition of viral gene transcription and enrichment of H3K27me3 methylation on viral gene promoters. Furthermore, we demonstrate that R430 prevents HSV-1 reactivation from latency in an ex vivo rodent model. Finally, among a panel of DNA viruses and RNA viruses, R430 inhibited Zika virus with high therapeutic index. Its therapeutic index is comparable to standard antiviral drugs, though it has greater toxicity in non-neuronal cells than in neuronal cells. Synthesis of additional derivatives could enable more efficacious antivirals and the identification of active pharmacophores.
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Murakami T, Akimoto T, Okada M, Hishida E, Sugase T, Miki A, Kohara M, Yoshizawa H, Masuda T, Kobayashi T, Saito O, Muto S, Nagata D. Valacyclovir Neurotoxicity and Nephrotoxicity in an Elderly Patient Complicated by Hyponatremia. Drug Target Insights 2018; 12:1177392818782899. [PMID: 30013310 PMCID: PMC6043912 DOI: 10.1177/1177392818782899] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 05/16/2018] [Indexed: 11/17/2022] Open
Abstract
A 66-year-old women with no history of renal disease was admitted due to a coma and acute kidney injury with a serum creatinine level of 7.44 mg/dL which were ascribed to valacyclovir neurotoxicity and nephrotoxicity, respectively. She had received valacyclovir at a standard dosage for the treatment of herpes zoster and was finally discharged, having fully returned to her normal baseline mental status with a recovered serum creatinine level of 0.68 mg/dL. We feel that awareness of this pathology remains a challenge for physicians and therefore strongly recommend the further accumulation of experiences similar to our own. Our experience underscores the pitfalls of administering valacyclovir to elderly patients who barely appear to have a favorable renal function. Several concerns regarding the therapeutic management, including blood purification strategies, that emerged in this case are also discussed.
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Affiliation(s)
- Takuya Murakami
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Mari Okada
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Erika Hishida
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Taro Sugase
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Atsushi Miki
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Marina Kohara
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Hiromichi Yoshizawa
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Takahiro Masuda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Takahisa Kobayashi
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Osamu Saito
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Shigeaki Muto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
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Fracaso renal agudo y neurotoxicidad severa tras sobredosis accidental por valaciclovir en población geriátrica: a propósito de un caso. Nefrologia 2018. [DOI: 10.1016/j.nefro.2017.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Gallacher PJ, Phelan PJ. Effective Clearance of Aciclovir Using Hemodiafiltration in a Patient With Neurotoxicity. Artif Organs 2017; 41:496-497. [DOI: 10.1111/aor.12774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/29/2016] [Accepted: 05/05/2016] [Indexed: 11/27/2022]
Affiliation(s)
- P. J. Gallacher
- Department of Renal Medicine; New Royal Infirmary of Edinburgh; 51 Little France Crescent Edinburgh EH16 4SA UK
| | - P. J. Phelan
- Department of Renal Medicine; New Royal Infirmary of Edinburgh; 51 Little France Crescent Edinburgh EH16 4SA UK
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Ericson JE, Gostelow M, Autmizguine J, Hornik CP, Clark RH, Benjamin DK, Smith PB. Safety of High-dose Acyclovir in Infants With Suspected and Confirmed Neonatal Herpes Simplex Virus Infections. Pediatr Infect Dis J 2017; 36:369-373. [PMID: 27977557 PMCID: PMC5348260 DOI: 10.1097/inf.0000000000001451] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Acyclovir is used to treat herpes simplex virus disease in infants. Treatment with high-dose acyclovir, 60 mg/kg/d, is recommended; however, the safety of this dosage has not been assessed in the past 15 years, and this dosage is not currently approved for infants by the US Food and Drug Administration. METHODS We included infants with neonatal herpes simplex virus disease treated with ≥14 days of intravenous acyclovir starting in the first 120 days of life admitted to 1 of 42 neonatal intensive care units managed by the Pediatrix Medical Group between 2002 and 2012. We determined the frequency and proportion of infants with clinical and laboratory adverse events (AEs) as well as the number and proportion of infant days with laboratory AEs occurring during acyclovir exposure. RESULTS We identified 89 infants during the study period with 1658 days of acyclovir exposure. Almost all received high-dose acyclovir therapy (79/89, 89%). The most common clinical AEs were hypotension and seizure, both occurring in 9% of infants. Thrombocytopenia was the most common laboratory AE occurring in 25% of infants and on 9% of infant-days. Elevated creatinine occurred in 2% of infants and 0.2% of infant-days and no infants developed renal failure requiring dialysis. Overall, 45% of infants had ≥1 AE. CONCLUSIONS In this cohort of infants treated during the high-dose acyclovir era, AEs were common but usually not severe. Many of the AEs reported in this cohort may be related to the underlying infection rather than due to acyclovir exposure.
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Affiliation(s)
- Jessica E. Ericson
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA
| | | | - Julie Autmizguine
- Department of Pediatrics, CHU Sainte Justine, University of Montreal, Montreal, Quebec
- Department of Pharmacology, University of Montreal, Montreal, Quebec
| | - Christoph P. Hornik
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Reese H. Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - P. Brian Smith
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
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Watson WA, Rhodes NJ, Echenique IA, Angarone MP, Scheetz MH. Resolution of acyclovir-associated neurotoxicity with the aid of improved clearance estimates using a Bayesian approach: A case report and review of the literature. J Clin Pharm Ther 2017; 42:350-355. [PMID: 28370067 DOI: 10.1111/jcpt.12520] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 02/19/2017] [Indexed: 12/31/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Neurotoxicity is a side effect of acyclovir. We report the first case, to our knowledge, whereby Bayesian-informed clearance estimates supported a therapeutic intervention for acyclovir-associated neurotoxicity. CASE SUMMARY A 62-year-old male with the diagnosis of disseminated zoster was being treated with intravenous (IV) acyclovir when he developed symptoms of acute neurotoxicity. Acyclovir had been dose-adjusted for renal dysfunction according to traditional creatinine clearance estimates; however, as the patient was also on vancomycin, Bayesian estimates of vancomycin clearances were performed, which revealed a 2-fold lower creatinine clearance. In response to the Bayesian estimates, acyclovir was discontinued, and improvements in mentation were noted within 24 hours. WHAT IS NEW AND CONCLUSION Alternate approaches to estimate renal function beyond Cockcroft-Gault, such as a Bayesian approach used in our patient, should be considered when population estimates are likely to be inaccurate and potentially dangerous to the patient.
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Affiliation(s)
- W A Watson
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | - N J Rhodes
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA.,Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, Downers Grove, FL, USA
| | - I A Echenique
- Department of Infectious Disease, Cleveland Clinic Florida, Weston, FL, USA
| | - M P Angarone
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - M H Scheetz
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA.,Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, Downers Grove, FL, USA
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D'Aiuto L, Williamson K, Dimitrion P, McNulty J, Brown CE, Dokuburra CB, Nielsen AJ, Lin WJ, Piazza P, Schurdak ME, Wood J, Yolken RH, Kinchington PR, Bloom DC, Nimgaonkar VL. Comparison of three cell-based drug screening platforms for HSV-1 infection. Antiviral Res 2017; 142:136-140. [PMID: 28342892 DOI: 10.1016/j.antiviral.2017.03.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 03/21/2017] [Indexed: 02/07/2023]
Abstract
Acyclovir (ACV) and its derivatives have been highly effective for treating recurrent, lytic infections with Herpes Simplex Virus, type 1 (HSV-1), but searches for additional antiviral drugs are motivated by recent reports of resistance to ACV, particularly among immunocompromised patients. In addition, the relative neurotoxicity of ACV and its inability to prevent neurological sequelae among HSV-1 encephalitis survivors compel searches for new drugs to treat HSV-1 infections of the central nervous system (CNS). Primary drug screens for neurotropic viruses like HSV-1 typically utilize non-neuronal cell lines, but they may miss drugs that have neuron specific antiviral effects. Therefore, we compared the effects of a panel of conventional and novel anti-herpetic compounds in monkey epithelial (Vero) cells, human induced pluripotent stem cells (hiPSCs)-derived neural progenitor cells (NPCs) and hiPSC-derived neurons (N = 73 drugs). While the profiles of activity for the majority of the drugs were similar in all three tissues, Vero cells were less likely than NPCs to identify drugs with substantial inhibitory activity in hiPSC-derived neurons. We discuss the relative merits of each cell type for antiviral drug screens against neuronal infections with HSV-1.
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Affiliation(s)
- Leonardo D'Aiuto
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Kelly Williamson
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Peter Dimitrion
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Chemistry and Departments of Biological Sciences, University of Pittsburgh, PA, USA
| | - James McNulty
- Department of Chemistry and Chemical-Biology, McMaster University, Canada
| | - Carla E Brown
- Department of Chemistry and Chemical-Biology, McMaster University, Canada
| | | | | | - Wen Jing Lin
- Department of Chemistry and Chemical-Biology, McMaster University, Canada
| | - Paolo Piazza
- Department of Infectious Diseases and Microbiology, University of Pittsburgh, USA
| | - Mark E Schurdak
- Drug Discovery Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joel Wood
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert H Yolken
- Division of Neurovirology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul R Kinchington
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Molecular Genetics & Biochemistry, University of Pittsburgh, Pittsburgh, PA, USA
| | - David C Bloom
- Department of Molecular Genetics & Microbiology, University of Florida College of Medicine, USA
| | - Vishwajit L Nimgaonkar
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, USA
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Abstract
Neurotoxicity can develop as a side effect of intravenous acyclovir use in patients with renal impairment. It is underreported in clinical practice and often confused with worsening herpes encephalitis. We present a 69-year-old woman with end-stage renal disease on hemodialysis with acyclovir neurotoxicity treated with daily extended hemodialysis sessions. Daily hemodialysis for extended period may shorten the neurotoxicity period and can help with faster return to normal mentation. A high index of suspicion is warranted to diagnose acyclovir-induced neurotoxicity.
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Gorlitsky BR, Herion JT. Sticking to the script: A curious case of confusion in an ESRD patient. Hemodial Int 2017; 21:E58-E62. [PMID: 28067468 DOI: 10.1111/hdi.12534] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A 60-year-old male Dialysis patient presented with altered mental status and Hypertensive Urgency. He had a significant lesion noted on his glans penis. He was treated for infection and hypertension with expectant management, without significant improvement in his mental acuity. Laboratory and radiologic workup were unrevealing for the etiology. Upon detailed review it was noted he had recently been given Acyclovir for a presumed Herpes Simplex Virus infection. He had been prescribed what is considered correct dosing for an ESRD patient. An Acyclovir level was obtained and urgent Dialysis was undertaken, presuming Acyclovir neurotoxicity may be the culprit. Initially no improvement was noted and a 2nd level and hemodialysis were undertaken. This case and review of the literature will highlight key aspects of acyclovir neurotoxicity in ESRD patients, including how to diagnose and treat, which laboratory tests to obtain and what one can expect from various dialysis modalities. We will also reveal how to dose Acyclovir to avoid toxicity and other key elements of the drug.
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Affiliation(s)
- Barry R Gorlitsky
- The Edward Via College of Osteopathic Medicine Internal Medicine, Nephrology
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Abstract
We present the case of a 52-year-old man with hypertension, diastolic congestive heart failure, end-stage renal disease on hemodialysis 3 times a week and a remote history of a hemorrhagic stroke who presented to the emergency department with a vesicular rash on his left arm. The rash was observed to be in a dermatomal distribution, and a diagnosis of herpes zoster was made. The patient was discharged home on valacyclovir 1 g 3 times a day for a duration of 7 days. The patient took 2 doses of valacyclovir before presenting to the hospital again with irritability and hallucinations. Over the next several days, the patient's neurologic status declined and he became disoriented and increasingly somnolent. Because of a concern for varicella zoster virus (VZV) or herpes simplex virus (HSV) meningoencephalitis, acyclovir was initiated intravenously at 600 mg (10 mg/kg) for every 12 hours. Computed tomography and magnetic resonance imaging of the brain failed to reveal an acute process. Electroencephalogram was interpreted as seizure activity versus metabolic encephalopathy. Lumbar puncture was not suggestive for meningitis, subarachnoid hemorrhage, or HSV/VZV infection. The patient subsequently had a witnessed seizure during dialysis and was felt to have status epilepticus due to acyclovir and valacyclovir neurotoxicity. The patient underwent daily hemodialysis for removal of the drug and eventually made a full neurologic recovery. Our case highlights that acyclovir neurotoxicity can result in status epilepticus, hallucinations, and altered consciousness. Differentiating acyclovir neurotoxicity from HSV or VZV meningoencephalitis is of crucial importance because the symptoms are similar but the management is vastly different.
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40
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Peredo I, Helldén A, Wolmer-Solberg N, Pohanka A, Stragliotto G, Rahbar A, Ståhle L, Bellander BM, Söderberg-Nauclér C. Ganciclovir concentrations in the cerebral extracellular space after valganciclovir treatment; a case study. BMJ Case Rep 2015; 2015:bcr-2014-207694. [PMID: 26670887 DOI: 10.1136/bcr-2014-207694] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Nearly all glioblastomas (GBMs), brain tumours with very poor prognosis, are infected with human cytomegalovirus (CMV). The anti-CMV drug valganciclovir (VGCV) has shown promise as a treatment option for patients with GBM, but its penetration into the central nervous system (CNS) is unknown. Here we describe a patient with GMB receiving VGCV in whom an intracerebral microdialysis catheter was implanted and ganciclovir (GCV) concentrations in brain extracellular fluid (BECF) and serum were monitored. GCV was rapidly absorbed. Cmax values (at 3 h) in serum and BECF were 19.6 and 10.2 µmol/L, T½ values were 3.2 and 4.5 h, and plasma and BECF AUC0-∞ values were 90.7 and 75.9 µmol h/L, respectively. Thus, VGCV treatment results in significant intracerebral levels of GCV that may be sufficient for therapeutic effects. Further studies of this drug in patients with GBM are warranted.
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Affiliation(s)
- Inti Peredo
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden Department of Medicine, Unit for Microbial Pathogenesis, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Helldén
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Nina Wolmer-Solberg
- Department of Medicine, Unit for Microbial Pathogenesis, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Anton Pohanka
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Giuseppe Stragliotto
- Department of Medicine, Unit for Microbial Pathogenesis, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Afsar Rahbar
- Department of Medicine, Unit for Microbial Pathogenesis, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Ståhle
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | - Cecilia Söderberg-Nauclér
- Department of Medicine, Unit for Microbial Pathogenesis, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Helldén A, Al-Aieshy F, Bastholm-Rahmner P, Bergman U, Gustafsson LL, Höök H, Sjöviker S, Söderström A, Odar-Cederlöf I. Development of a computerised decisions support system for renal risk drugs targeting primary healthcare. BMJ Open 2015; 5:e006775. [PMID: 26150141 PMCID: PMC4499680 DOI: 10.1136/bmjopen-2014-006775] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To assess general practitioners (GPs) experience from the implementation and use of a renal computerised decision support system (CDSS) for drug dosing, developed for primary healthcare, integrated into the patient's electronic health record (EHR), and building on estimation of the patient's creatinine clearance (ClCG). DESIGN Qualitative research design by a questionnaire and a focus group discussion. SETTING AND PARTICIPANTS Eight GPs at two primary healthcare centres (PHCs). INTERVENTIONS The GP at PHC 1, and the project group, developed and tested the technical solution of the CDSS. Proof-of-concept was tested by seven GPs at PHC 2. They also participated in a group discussion and answered a questionnaire. A web window in the EHR gave drug and dosage in relation to ClCG. Each advice was according to three principles: If? Why? Because. OUTCOME MEASURES (1) The GPs' experience of 'easiness to use' and 'perceived usefulness' at PHC 2, based on loggings of use, answers from a questionnaire using a 5-point Likert scale, and answers from a focus group discussion. (2) The number of patients aged 65 years and older with an estimation of ClCG before and after the implementation of the CDSS. RESULTS The GPs found the CDSS fast, simple and easy to use. They appreciated the automatic presentation of the CICG status on opening the medication list, and the ability to actively look up specific drug recommendations in two steps. The CDSS scored high on the Likert scale. All GPs wanted to continue the use of the CDSS and to recommend it to others. The number of patients with an estimated ClCG increased 1.6-fold. CONCLUSIONS Acceptance of the simple graphical interface of this push and pull renal CDSS was high among the primary care physicians evaluating this proof of concept. The graphical model should be useful for further development of renal decision support systems.
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Affiliation(s)
- Anders Helldén
- Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Fadiea Al-Aieshy
- Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Pia Bastholm-Rahmner
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Healthcare Development, Public Healthcare Administration, Stockholm County Council, Stockholm, Sweden
| | - Ulf Bergman
- Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lars L Gustafsson
- Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hans Höök
- Department of Healthcare Development, Public Healthcare Administration, Stockholm County Council, Stockholm, Sweden
| | - Susanne Sjöviker
- Department of Healthcare Development, Public Healthcare Administration, Stockholm County Council, Stockholm, Sweden
| | | | - Ingegerd Odar-Cederlöf
- Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
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Abstract
Valacyclovir is an oral antiviral agent being used more frequently than acyclovir because of the ease of administration and efficacy. Serious neuropsychiatric side effects have been demonstrated with the use of valacyclovir in renal failure patients. We report a case of valacyclovir neurotoxicity to emphasis the importance of dose adjustment in patients with chronic kidney disease and on dialysis.
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43
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Death Delusions and Myoclonus: Acyclovir Toxicity. Am J Med 2015; 128:692-4. [PMID: 25784625 DOI: 10.1016/j.amjmed.2015.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 03/04/2015] [Accepted: 03/04/2015] [Indexed: 01/02/2023]
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44
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Steinberg I, Kimberlin DW. Acyclovir Dosing and Acute Kidney Injury: Deviations and Direction. J Pediatr 2015; 166:1341-4. [PMID: 25890674 DOI: 10.1016/j.jpeds.2015.03.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 03/30/2015] [Indexed: 12/25/2022]
Affiliation(s)
- Irving Steinberg
- Division of Pediatric Pharmacotherapy, Department of Pediatrics, LAC+USC Medical Center, University of Southern California, Keck School of Medicine and School of Pharmacy, Los Angeles, California
| | - David W Kimberlin
- Division of Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama.
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45
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Berry L, Venkatesan P. Aciclovir-induced neurotoxicity: Utility of CSF and serum CMMG levels in diagnosis. J Clin Virol 2014; 61:608-10. [PMID: 25440915 DOI: 10.1016/j.jcv.2014.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 08/30/2014] [Accepted: 09/03/2014] [Indexed: 11/26/2022]
Abstract
Aciclovir is an anti-viral frequently used for herpes virus infections. Neurotoxicity and nephrotoxicity are uncommon but serious side effects of aciclovir treatment. This case illustrates how aciclovir induced neurotoxicity can present and how it can be diagnosed using quantitative assays of aciclovir and its metabolite in the CSF and serum.
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Affiliation(s)
- L Berry
- Department of Infectious Diseases, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, United Kingdom(1).
| | - P Venkatesan
- Department of Infectious Diseases, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, United Kingdom(1)
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46
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Elinder CG, Bárány P, Heimbürger O. The Use of Estimated Glomerular Filtration Rate for Dose Adjustment of Medications in the Elderly. Drugs Aging 2014; 31:493-9. [DOI: 10.1007/s40266-014-0187-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Potluri K, Holt D, Hou S. Neurologic complications in renal transplantation. HANDBOOK OF CLINICAL NEUROLOGY 2014; 121:1245-1255. [PMID: 24365416 DOI: 10.1016/b978-0-7020-4088-7.00084-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Neurologic complications following kidney transplant are more common than in the general population with the reported incidence around 10-21%. Need for multiple drugs, decreased cellular immunity, accelerated atherosclerotic disease, and frequency of metabolic abnormalities are the most common predisposing factors for neurologic abnormalities. Neurologic side-effects of calcineurin inhibitors range from mild tremors to paraplegia or posterior reversible encephalopathy syndrome (PRES) and are generally reversible by lowering the dose or complete discontinuation of the drug when possible. Clinical presentation of central nervous system infection in transplant recipients can be different from the normal population as the anti-inflammatory effects of immunosuppressive therapy may obscure signs of meningeal inflammation and changes in the level of consciousness may be subtle. Bacterial infections remain the most common infections but unusual pathogens figure prominently in the differential diagnosis. The most frequent malignancies of the brain are lymphomas and metastatic tumors which are for the most part, de novo malignancies from immunosuppression. Decreasing immunosuppression is almost always a part of treating malignancy. The prevalence of stroke is reported to be around 8% with age>40 years, diabetic nephropathy as the underlying cause of end-stage kidney disease, and peripheral vascular disease being the strongest predictors.
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Affiliation(s)
- Kavitha Potluri
- Department of Medicine, Division of Nephrology and Hypertension, Loyola University Medical Center, Maywood, IL, USA.
| | - David Holt
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Susan Hou
- Department of Medicine, Division of Nephrology and Hypertension, Loyola University Medical Center, Maywood, IL, USA
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Differential Diagnosis of Central Nervous System Involvement in a Patient Treated With Acyclovir. Ther Drug Monit 2013; 35:417-9. [DOI: 10.1097/ftd.0b013e31828faa35] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pugi A, Bonaiuti R, Maggini V, Moschini M, Tuccori M, Leone R, Rossi M, Motola D, Piccinni C, Ferrazin F, Sottosanti L, Mugelli A, Vannacci A, Lapi F. Safety profile of antiviral medications: A pharmacovigilance study using the Italian spontaneous-reporting database. Am J Health Syst Pharm 2013; 70:1039-46. [DOI: 10.2146/ajhp120665] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Alessandra Pugi
- Department of Neuroscience, Psychology, Drug Research and Child Health, Interuniversity Center of Molecular Medicine and Applied Biophysics (CIMMBA), University of Florence, and Pharmacovigilance Center of Tuscan County (PCTC), Florence, Italy
| | - Roberto Bonaiuti
- Department of Neuroscience, Psychology, Drug Research and Child Health, Interuniversity Center of Molecular Medicine and Applied Biophysics (CIMMBA), University of Florence, and Pharmacovigilance Center of Tuscan County (PCTC), Florence, Italy
| | - Valentina Maggini
- Department of Neuroscience, Psychology, Drug Research and Child Health, Interuniversity Center of Molecular Medicine and Applied Biophysics (CIMMBA), University of Florence, and Pharmacovigilance Center of Tuscan County (PCTC), Florence, Italy
| | - Martina Moschini
- Department of Neuroscience, Psychology, Drug Research and Child Health, Interuniversity Center of Molecular Medicine and Applied Biophysics (CIMMBA), University of Florence, and Pharmacovigilance Center of Tuscan County (PCTC), Florence, Italy
| | - Marco Tuccori
- PCTC, and Interdepartmental Center for Research in Clinical Pharmacology and Experimental Therapeutics, University of Pisa, Pisa, Italy
| | - Roberto Leone
- Clinical Pharmacology Unit, University of Verona, Verona, Italy
| | - Marco Rossi
- PCTC, and University Hospital of Siena, Siena, Italy
| | - Domenico Motola
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Carlo Piccinni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fernanda Ferrazin
- National Pharmacovigilance Office, Pharmacovigilance Unit, Italian Medicines Agency, Rome
| | - Laura Sottosanti
- National Pharmacovigilance Office, Pharmacovigilance Unit, Italian Medicines Agency, Rome
| | - Alessandro Mugelli
- Department of Neuroscience, Psychology, Drug Research and Child Health, CIMMBA, and PCTC
| | - Alfredo Vannacci
- Department of Neuroscience, Psychology, Drug Research and Child Health, CIMMBA, and PCTC
| | - Francesco Lapi
- Department of Neuroscience, Psychology, Drug Research and Child Health, CIMMBA, PCTC, and the Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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Helldén A, Odar-Cederlöf I, Nilsson G, Sjöviker S, Söderström A, von Euler M, Öhlén G, Bergman U. Renal function estimations and dose recommendations for dabigatran, gabapentin and valaciclovir: a data simulation study focused on the elderly. BMJ Open 2013; 3:bmjopen-2013-002686. [PMID: 23585393 PMCID: PMC3641460 DOI: 10.1136/bmjopen-2013-002686] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES The thrombin inhibitor dabigatran is mainly excreted by the kidneys. We investigated whether the recommended method for estimation of renal function used in the clinical trials, the Cockcroft-Gault (CGold) equation and the estimated glomerular filtration rate (eGFR) modification of diet in renal disease equation 4 (MDRD4), differ in elderly participants, resulting in erroneously higher dose recommendations of dabigatran, which might explain the serious, even fatal, bleeding reported. The renally excreted drugs gabapentin and valaciclovir were also included for comparison. DESIGN A retrospective data simulation study. PARTICIPANTS Participants 65 years and older included in six different studies. MAIN OUTCOME MEASURE Estimated renal function by CG based on uncompensated ('old Jaffe' method) creatinine (CGold) or by MDRD4 based on standardised compensated P-creatinine traceable to isotope-dilution mass spectrometry, and the resulting doses. RESULTS 790 participants (432 females), mean age (±SD) 77.6±5.7 years. Mean estimated creatinine clearance (eCrCl) by the CGold equation was 44.2±14.8 ml/min, versus eGFR 59.6±20.7 ml/min/1.73 m(2) with MDRD4 (p<0.001), absolute median difference 13.5, 95% CI 12.9 to 14.2. MDRD4 gave a significantly higher mean dose (valaciclovir +21%, dabigatran +25% and gabapentin +37%) of all drugs (p<0.001). With MDRD4 58% of the women would be recommended a full dose of dabigatran compared with 18% if CGold is used. CONCLUSIONS MDRD4 would result in higher recommended doses of the three studied drugs to elderly participants compared with CG, particularly in women, and thus increased the risk of dose and concentration-dependent adverse reactions. It is important to know which method of estimation of renal function the Summary of Products Characteristics was based on, and use only that one when prescribing renally excreted drugs with narrow safety window. Doses based on recently developed methods for estimation of renal function may be associated with considerable risk of overtreatment in the elderly.
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Affiliation(s)
- Anders Helldén
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ingegerd Odar-Cederlöf
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Göran Nilsson
- Centre of Clinical Research, Uppsala University, Västerås, Sweden
| | - Susanne Sjöviker
- Department of Drug Management and Informatics, Centre for Health Care Improvement, Stockholm County Council, Stockholm, Sweden at the time of the study
| | - Anders Söderström
- Farsta home care center at the time of the study, presently at Vendelsö home care center, Stockholm, Sweden
| | - Mia von Euler
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Karolinska Institutet Stroke Research Network at Södersjukhuset, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet
| | - Gunnar Öhlén
- Quality and Patient Safety, Karolinska University Hospital, Stockholm, Sweden, Karolinska University Hospital, Stockholm, Sweden
| | - Ulf Bergman
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Division of Clinical Pharmacology, a partner in European Network of Centres for Pharmacoepidemiology and Pharmacovigilance (ENCePP), coordinated by the European Medicines Agency (EMA), Karolinska University Hospital, Stockholm, Sweden
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