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Díaz-Tomé V, García-Otero X, Varela-Fernández R, Martín-Pastor M, Conde-Penedo A, Aguiar P, González-Barcia M, Fernández-Ferreiro A, Otero-Espinar FJ. In situ forming and mucoadhesive ophthalmic voriconazole/HPβCD hydrogels for the treatment of fungal keratitis. Int J Pharm 2021; 597:120318. [PMID: 33540021 DOI: 10.1016/j.ijpharm.2021.120318] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 11/18/2022]
Abstract
Fungal keratitis is a severe infectious corneal disease. At present, no voriconazole ophthalmic formulations are approved by the FDA or EMA. This lack of therapeutic options leads to the reformulation of intravenous voriconazole preparations (VFEND®) by the hospital pharmacy departments to prepare the appropriate ophthalmic formulations (pharmacy compounding). However, the limited residence time of these formulations leads to an intensive treatment posology that may increase the occurrence of side effects. In the present study, two different hydrogels were developed and characterized in order to improve the voriconazole's ophthalmic solubility, permanence, and security. Voriconazole-cyclodextrin (HPβCD or HPɣCD) inclusion complexes in aqueous solutions were characterized by NMR and molecular modeling. Complexes were formed by encapsulation of voriconazole into the cyclodextrin's internal cavity which considerably increases its water solubility. Ocular safety was proven by ocular irritation studies. Permeability studies suggest both hydrogels have good corneal permeability. Furthermore, in vivo ocular permanence study by PET/CT showed a longer permanence time on the ocular surface (t1/2 = 58.91 ± 13.4 min and 96.28 ± 49.11 min for VZHAH and VZISH 0.65 respectively) compared to the voriconazole control formulation (VFEND® t1/2 = 32.27 ± 15.56 min). Results suggest these formulations are a good alternative for the treatment of fungal keratitis.
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Affiliation(s)
- Victoria Díaz-Tomé
- Department of Pharmacology, Pharmacy and Pharmaceutical Technology and Industrial Pharmacy Institute, Faculty of Pharmacy, University of Santiago de Compostela (USC), Santiago de Compostela. Spain; Clinical Pharmacology Group, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Xurxo García-Otero
- Department of Pharmacology, Pharmacy and Pharmaceutical Technology and Industrial Pharmacy Institute, Faculty of Pharmacy, University of Santiago de Compostela (USC), Santiago de Compostela. Spain; Molecular Imaging Group, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Rubén Varela-Fernández
- Department of Pharmacology, Pharmacy and Pharmaceutical Technology and Industrial Pharmacy Institute, Faculty of Pharmacy, University of Santiago de Compostela (USC), Santiago de Compostela. Spain; Clinical Neurosciences Group, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Manuel Martín-Pastor
- Nuclear Magnetic Resonance Unit, Research Infrastructures Area, Universidade de Santiago de Compostela, Campus Vida, Santiago de Compostela, Spain
| | - Andrea Conde-Penedo
- Department of Pharmacology, Pharmacy and Pharmaceutical Technology and Industrial Pharmacy Institute, Faculty of Pharmacy, University of Santiago de Compostela (USC), Santiago de Compostela. Spain
| | - Pablo Aguiar
- Molecular Imaging Group, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Miguel González-Barcia
- Pharmacy Department. University Clinical Hospital Santiago de Compostela (SERGAS), Santiago de Compostela, Spain; Clinical Pharmacology Group, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Anxo Fernández-Ferreiro
- Pharmacy Department. University Clinical Hospital Santiago de Compostela (SERGAS), Santiago de Compostela, Spain; Clinical Pharmacology Group, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.
| | - Francisco J Otero-Espinar
- Department of Pharmacology, Pharmacy and Pharmaceutical Technology and Industrial Pharmacy Institute, Faculty of Pharmacy, University of Santiago de Compostela (USC), Santiago de Compostela. Spain; Paraquasil Group, University Clinical Hospital, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.
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Bourcier T, Sauer A, Dory A, Denis J, Sabou M. [Fungal keratitis]. J Fr Ophtalmol 2017; 40:882-888. [PMID: 29150029 DOI: 10.1016/j.jfo.2017.05.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 05/02/2017] [Indexed: 11/19/2022]
Abstract
Fungal keratitis, or keratomycoses, are corneal infections which must be considered in cases of corneal trauma, prior corneal surgery, chronic ocular surface disease, topical corticosteroids or contact lens wear. Filamentous fungi or yeasts may be involved. Presenting clinical features such as corneal infiltrates with feathery edges and/or raised surface, intact epithelium with deep stromal involvement, satellite lesions, endothelial plaques, lack of improvement with antibiotics and worsening with steroids are suggestive of fungal keratitis. Corneal scraping for laboratory examination is mandatory. Medical management with antifungal eye drops and systemic agents should be started as soon as possible. Surgical interventions are required in a significant number of cases to control the infection. The prognosis of fungal keratitis is worse than that of bacterial keratitis.
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Affiliation(s)
- T Bourcier
- Service d'ophtalmologie, Nouvel hôpital civil, EA7290, FMTS, hôpitaux universitaires, université de Strasbourg, 1, place de l'Hôpital, BP 426, 67091 Strasbourg cedex, France.
| | - A Sauer
- Service d'ophtalmologie, Nouvel hôpital civil, EA7290, FMTS, hôpitaux universitaires, université de Strasbourg, 1, place de l'Hôpital, BP 426, 67091 Strasbourg cedex, France
| | - A Dory
- Service de pharmacie, Nouvel hôpital civil, FMTS, hôpitaux universitaires, université de Strasbourg, BP 426, 67091 Strasbourg, France
| | - J Denis
- Service de parasitologie - mycologie, plateau technique de microbiologie, Nouvel hôpital civil, FMTS, hôpitaux universitaires, université de Strasbourg, BP 426, 67091 Strasbourg, France
| | - M Sabou
- Service de parasitologie - mycologie, plateau technique de microbiologie, Nouvel hôpital civil, FMTS, hôpitaux universitaires, université de Strasbourg, BP 426, 67091 Strasbourg, France
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Prajna NV, Krishnan T, Rajaraman R, Patel S, Srinivasan M, Das M, Ray KJ, O'Brien KS, Oldenburg CE, McLeod SD, Zegans ME, Porco TC, Acharya NR, Lietman TM, Rose-Nussbaumer J. Effect of Oral Voriconazole on Fungal Keratitis in the Mycotic Ulcer Treatment Trial II (MUTT II): A Randomized Clinical Trial. JAMA Ophthalmol 2017; 134:1365-1372. [PMID: 27787540 DOI: 10.1001/jamaophthalmol.2016.4096] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective To compare oral voriconazole with placebo in addition to topical antifungals in the treatment of filamentous fungal keratitis. Design, Setting, and Participants The Mycotic Ulcer Treatment Trial II (MUTT II), a multicenter, double-masked, placebo-controlled, randomized clinical trial, was conducted in India and Nepal, with 2133 individuals screened for inclusion. Patients with smear-positive filamentous fungal ulcers and visual acuity of 20/400 (logMAR 1.3) or worse were randomized to receive oral voriconazole vs oral placebo; all participants received topical antifungal eyedrops. The study was conducted from May 24, 2010, to November 23, 2015. All trial end points were analyzed on an intent-to-treat basis. Interventions Study participants were randomized to receive oral voriconazole vs oral placebo; a voriconazole loading dose of 400 mg was administered twice daily for 24 hours, followed by a maintenance dose of 200 mg twice daily for 20 days, with dosing altered to weight based during the trial. All participants received topical voriconazole, 1%, and natamycin, 5%. Main Outcomes and Measures The primary outcome of the trial was rate of corneal perforation or the need for therapeutic penetrating keratoplasty (TPK) within 3 months. Secondary outcomes included microbiologic cure at 6 days, rate of re-epithelialization, best-corrected visual acuity and infiltrate and/or scar size at 3 weeks and 3 months, and complication rates associated with voriconazole use. Results A total of 2133 patients in India and Nepal with smear-positive ulcers were screened; of the 787 who were eligible, 240 (30.5%) were enrolled. Of the 119 patients (49.6%) in the oral voriconazole treatment group, 65 were male (54.6%), and the median age was 54 years (interquartile range, 42-62 years). Overall, no difference in the rate of corneal perforation or the need for TPK was determined for oral voriconazole vs placebo (hazard ratio, 0.82; 95% CI, 0.57-1.18; P = .29). In prespecified subgroup analyses comparing treatment effects among organism subgroups, there was some suggestion that Fusarium species might have a decreased rate of perforation or TPK in the oral voriconazole-treated arm; however, this was not a statistically significant finding after Holms-Šidák correction for multiple comparisons (effect coefficient, 0.49; 95% CI, 0.26-0.92; P = .03). Patients receiving oral voriconazole experienced a total of 58 adverse events (48.7%) compared with 28 adverse events (23.1%) in the placebo group (P < .001 after Holms-Šidák correction for multiple comparisons). Conclusions and Relevance There appears to be no benefit to adding oral voriconazole to topical antifungal agents in the treatment of severe filamentous fungal ulcers. All patients in this study were enrolled in India and Nepal; therefore, it is possible that organisms in this region may exhibit characteristics different from those in other regions of the world. Trial Registration clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
- N Venkatesh Prajna
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Tiruvengada Krishnan
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | | | - Muthiah Srinivasan
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Manoranjan Das
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | | | - Stephen D McLeod
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco
| | | | - Travis C Porco
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco.,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco.,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco
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McGhee CN, Kim BZ. Fungal keratitis: dealing with a diverse kingdom of ocular assailants. Clin Exp Ophthalmol 2016; 44:755-756. [PMID: 28001007 DOI: 10.1111/ceo.12848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Charles Nj McGhee
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Bia Z Kim
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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