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Taher KW, Almofada R, Alomair S, Albassam AA, Alsultan A. Therapeutic Drug Monitoring of Voriconazole in Critically Ill Pediatric Patients: A Single-Center Retrospective Study. Paediatr Drugs 2024; 26:197-203. [PMID: 38228969 DOI: 10.1007/s40272-023-00616-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND AND OBJECTIVE Voriconazole pharmacokinetics are highly variable in pediatric patients, and the optimal dosage has yet to be determined. The purpose of this study was to describe voriconazole pharmacokinetic and pharmacodynamic targets achieved and evaluate the efficacy and safety of voriconazole for critically ill pediatrics. METHODS This is a single-center retrospective study conducted at a pediatric intensive care unit at a tertiary/quaternary hospital. Pediatrics admitted to the pediatric intensive care unit and who received voriconazole for a proven or suspected fungal infection with at least one measured trough concentration were included. The primary outcomes included the percentage of pediatric patients who achieved the pharmacokinetic and pharmacodynamic targets. Secondary outcomes included assessing the correlation between voriconazole trough concentrations and clinical/microbiological outcomes. All statistical analyses were performed using the R statistical software and Microsoft Excel. Multiple logistic regression was used to assess the predictors of both clinical and microbiologic cures. Multiple linear regression was used to determine significant factors associated with trough concentrations. RESULTS A total of 129 voriconazole trough concentrations were measured from 71 participants at steady state after at least three doses of voriconazole. The mean (± standard deviation) of the first and second trough concentrations were 2.9 (4.2) and 2.3 (3.3) mg/L, respectively. Among the first trough concentrations, only 33.8% were within the therapeutic range (1-5 mg/L), 46.5% were below the therapeutic range, and 19.7% were above the therapeutic range. A clinical cure occurred in 78% of patients, while a microbiologic cure occurred in 80% of patients. CONCLUSIONS Voriconazole trough concentrations vary widely in critically ill pediatric patients and only a third of the patients achieved therapeutic concentrations with initial doses.
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Affiliation(s)
- Khalid W Taher
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, MBC 11, P.O. Box 3354, 11211, Riyadh, Saudi Arabia.
| | - Razan Almofada
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, MBC 11, P.O. Box 3354, 11211, Riyadh, Saudi Arabia
| | - Sufyan Alomair
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Department of Pharmacy Practice, College of Clinical Pharmacy, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Ahmed A Albassam
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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2
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Franconi I, Lupetti A. In Vitro Susceptibility Tests in the Context of Antifungal Resistance: Beyond Minimum Inhibitory Concentration in Candida spp. J Fungi (Basel) 2023; 9:1188. [PMID: 38132789 PMCID: PMC10744879 DOI: 10.3390/jof9121188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023] Open
Abstract
Antimicrobial resistance is a matter of rising concern, especially in fungal diseases. Multiple reports all over the world are highlighting a worrisome increase in azole- and echinocandin-resistance among fungal pathogens, especially in Candida species, as reported in the recently published fungal pathogens priority list made by WHO. Despite continuous efforts and advances in infection control, development of new antifungal molecules, and research on molecular mechanisms of antifungal resistance made by the scientific community, trends in invasive fungal diseases and associated antifungal resistance are on the rise, hindering therapeutic options and clinical cures. In this context, in vitro susceptibility testing aimed at evaluating minimum inhibitory concentrations, is still a milestone in the management of fungal diseases. However, such testing is not the only type at a microbiologist's disposal. There are other adjunctive in vitro tests aimed at evaluating fungicidal activity of antifungal molecules and also exploring tolerance to antifungals. This plethora of in vitro tests are still left behind and performed only for research purposes, but their role in the context of invasive fungal diseases associated with antifungal resistance might add resourceful information to the clinical management of patients. The aim of this review was therefore to revise and explore all other in vitro tests that could be potentially implemented in current clinical practice in resistant and difficult-to-treat cases.
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Affiliation(s)
- Iacopo Franconi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy;
- Mycology Unit, Pisa University Hospital, 56126 Pisa, Italy
| | - Antonella Lupetti
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy;
- Mycology Unit, Pisa University Hospital, 56126 Pisa, Italy
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3
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Miyakawa-Tanaka K, Suzuki J, Hirasawa Y, Nakamura S, Takeda K, Narumoto O, Matsui H. Positive correlation between voriconazole trough concentrations and C-reactive protein levels in patients with chronic pulmonary aspergillosis: A retrospective cohort study. J Infect Chemother 2023; 29:683-687. [PMID: 36965708 DOI: 10.1016/j.jiac.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 03/13/2023] [Accepted: 03/17/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Voriconazole (VRCZ) is the first-line treatment for chronic pulmonary aspergillosis (CPA). VRCZ trough concentration monitoring is recommended for adequate therapy because VRCZ concentrations vary widely. However, factors associated with variations in VRCZ concentrations, especially in the same patient at different time points, have not been identified. The objective of this study was to identify factors influencing VRCZ trough concentrations. PATIENTS AND METHODS This single-center retrospective study conducted at our institute between April 2014 and August 2016 included patients with CPA who received VRCZ. Patient trough concentrations were measured more than twice while the patients received the same dose using the same administration route (defined as one series). A step-wise method and multiple regression analysis were used to test the effects of patient characteristics on VRCZ trough concentrations. RESULTS Sixty-nine series in 49 patients were analyzed. VRCZ was administered orally in 59 series, intravenously in 7 series, and by dry syrup in 3 series. The median VRCZ trough concentration and the median variation in VRCZ concentrations were 1.68 and 0.99 μg/ml, respectively. In the simple regression analysis, creatinine, alkaline phosphatase, C-reactive protein (CRP), and creatinine clearance significantly correlated with VRCZ concentrations. Multiple regression analysis demonstrated a significant positive correlation between CRP and VRCZ concentration (P < 0.0001). CONCLUSION In patients with CPA, VRCZ concentration correlated with CRP levels in the same patients receiving the same dose of VRCZ at different time points.
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Affiliation(s)
- Kazuko Miyakawa-Tanaka
- Center for Pulmonary Disease, National Hospital Organization, Tokyo National Hospital, Tokyo, Japan.
| | - Junko Suzuki
- Center for Pulmonary Disease, National Hospital Organization, Tokyo National Hospital, Tokyo, Japan.
| | - Yasutaka Hirasawa
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.
| | - Sumie Nakamura
- Center for Pulmonary Disease, National Hospital Organization, Tokyo National Hospital, Tokyo, Japan.
| | - Keita Takeda
- Center for Pulmonary Disease, National Hospital Organization, Tokyo National Hospital, Tokyo, Japan.
| | - Osamu Narumoto
- Center for Pulmonary Disease, National Hospital Organization, Tokyo National Hospital, Tokyo, Japan.
| | - Hirotoshi Matsui
- Center for Pulmonary Disease, National Hospital Organization, Tokyo National Hospital, Tokyo, Japan.
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4
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Veringa A, Brüggemann RJ, Span LFR, Biemond BJ, de Boer MGJ, van den Heuvel ER, Klein SK, Kraemer D, Minnema MC, Prakken NHJ, Rijnders BJA, Swen JJ, Verweij PE, Wondergem MJ, Ypma PF, Blijlevens N, Kosterink JGW, van der Werf TS, Alffenaar JWC. Therapeutic drug monitoring-guided treatment versus standard dosing of voriconazole for invasive aspergillosis in haematological patients: a multicentre, prospective, cluster randomised, crossover clinical trial. Int J Antimicrob Agents 2023; 61:106711. [PMID: 36642232 DOI: 10.1016/j.ijantimicag.2023.106711] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 11/27/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Voriconazole therapeutic drug monitoring (TDM) is recommended based on retrospective data and limited prospective studies. This study aimed to investigate whether TDM-guided voriconazole treatment is superior to standard treatment for invasive aspergillosis. METHODS A multicentre (n = 10), prospective, cluster randomised, crossover clinical trial was performed in haematological patients aged ≥18 years treated with voriconazole. All patients received standard voriconazole dose at the start of treatment. Blood/serum/plasma was periodically collected after treatment initiation of voriconazole and repeated during treatment in both groups. The TDM group had measured voriconazole concentrations reported back, with dose adjustments made as appropriate, while the non-TDM group had voriconazole concentrations measured only after study completion. The composite primary endpoint included response to treatment and voriconazole treatment discontinuation due to an adverse drug reaction related to voriconazole within 28 days after treatment initiation. RESULTS In total, 189 patients were enrolled in the study. For the composite primary endpoint, 74 patients were included in the non-TDM group and 68 patients in the TDM group. Here, no significant difference was found between both groups (P = 0.678). However, more trough concentrations were found within the generally accepted range of 1-6 mg/L for the TDM group (74.0%) compared with the non-TDM group (64.0%) (P < 0.001). CONCLUSIONS In this trial, TDM-guided dosing of voriconazole did not show improved treatment outcome compared with standard dosing. We believe that these findings should open up the discussion for an approach to voriconazole TDM that includes drug exposure, pathogen susceptibility and host defence. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov registration no. NCT00893555.
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Affiliation(s)
- Anette Veringa
- Department of Clinical Pharmacy, OLVG, Amsterdam, the Netherlands; Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands.
| | - Roger J Brüggemann
- Department of Pharmacy, Centre of Expertise in Mycology Radboudumc/CWZ and Radboud Institute of Health Science, University of Nijmegen, Radboudumc Nijmegen, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Lambert F R Span
- Department of Haematology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Bart J Biemond
- Department of Haematology, Amsterdam University Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Edwin R van den Heuvel
- Department of Mathematics and Computer Science, Eindhoven University of Technology, 5612 AZ, Eindhoven, the Netherlands
| | - Saskia K Klein
- Department of Haematology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands; Department of Haematology, Meander Medical Centre Amersfoort, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Doris Kraemer
- Department of Oncology and Haematology, Oldenburg Clinic, Rahel-Straus-Straße 10, 26133, Oldenburg, Germany
| | - Monique C Minnema
- Department of Haematology, University Medical Centre Utrecht, University Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherland
| | - Niek H J Prakken
- Department of Radiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Bart J A Rijnders
- Department of Internal Medicine and Infectious Diseases, Erasmus University Medical Centre, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology, Radboudumc Nijmegen, the Netherlands; Centre of Expertise in Mycology Radboudumc/CWZ, Radboud University, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Mariëlle J Wondergem
- Department of Haematology, VU University Medical Centre, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - Paula F Ypma
- Department of Haematology, Haga Hospital, Els Borst-Eilersplein 275, 2545 AA, The Hague, the Netherlands
| | - Nicole Blijlevens
- Department of Haematology, Radboudumc Nijmegen, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands; Radboud Institute of Health Sciences, Geert Grooteplein Zuid 21, 6525 EZ, Nijmegen, the Netherlands
| | - Jos G W Kosterink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands; Groningen Research Institute of Pharmacy, Pharmacotherapy, Epidemiology & Economics, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Tjip S van der Werf
- Department of Internal Medicine and Department of Pulmonary Diseases and Tuberculosis Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Jan-Willem C Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands; Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Camperdown NSW 2006, Sydney, Australia; Westmead Hospital, Westmead, Sydney, NSW 2145, Australia
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Gamaletsou MN, Rammaert B, Brause B, Bueno MA, Dadwal SS, Henry MW, Katragkou A, Kontoyiannis DP, McCarthy MW, Miller AO, Moriyama B, Pana ZD, Petraitiene R, Petraitis V, Roilides E, Sarkis JP, Simitsopoulou M, Sipsas NV, Taj-Aldeen SJ, Zeller V, Lortholary O, Walsh TJ. Osteoarticular Mycoses. Clin Microbiol Rev 2022; 35:e0008619. [PMID: 36448782 PMCID: PMC9769674 DOI: 10.1128/cmr.00086-19] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Osteoarticular mycoses are chronic debilitating infections that require extended courses of antifungal therapy and may warrant expert surgical intervention. As there has been no comprehensive review of these diseases, the International Consortium for Osteoarticular Mycoses prepared a definitive treatise for this important class of infections. Among the etiologies of osteoarticular mycoses are Candida spp., Aspergillus spp., Mucorales, dematiaceous fungi, non-Aspergillus hyaline molds, and endemic mycoses, including those caused by Histoplasma capsulatum, Blastomyces dermatitidis, and Coccidioides species. This review analyzes the history, epidemiology, pathogenesis, clinical manifestations, diagnostic approaches, inflammatory biomarkers, diagnostic imaging modalities, treatments, and outcomes of osteomyelitis and septic arthritis caused by these organisms. Candida osteomyelitis and Candida arthritis are associated with greater events of hematogenous dissemination than those of most other osteoarticular mycoses. Traumatic inoculation is more commonly associated with osteoarticular mycoses caused by Aspergillus and non-Aspergillus molds. Synovial fluid cultures are highly sensitive in the detection of Candida and Aspergillus arthritis. Relapsed infection, particularly in Candida arthritis, may develop in relation to an inadequate duration of therapy. Overall mortality reflects survival from disseminated infection and underlying host factors.
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Affiliation(s)
- Maria N. Gamaletsou
- Laiko General Hospital of Athens and Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Blandine Rammaert
- Université de Poitiers, Faculté de médecine, CHU de Poitiers, INSERM U1070, Poitiers, France
| | - Barry Brause
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Marimelle A. Bueno
- Far Eastern University-Dr. Nicanor Reyes Medical Foundation, Manilla, Philippines
| | | | - Michael W. Henry
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Aspasia Katragkou
- Nationwide Children’s Hospital, Columbus, Ohio, USA
- The Ohio State University School of Medicine, Columbus, Ohio, USA
| | | | - Matthew W. McCarthy
- Weill Cornell Medicine of Cornell University, New York, New York, USA
- New York Presbyterian Hospital, New York, New York, USA
| | - Andy O. Miller
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | | | - Zoi Dorothea Pana
- Hippokration General Hospital, Aristotle University School of Health Sciences, Thessaloniki, Greece
- Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | - Ruta Petraitiene
- Weill Cornell Medicine of Cornell University, New York, New York, USA
| | | | - Emmanuel Roilides
- Hippokration General Hospital, Aristotle University School of Health Sciences, Thessaloniki, Greece
- Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | | | - Maria Simitsopoulou
- Hippokration General Hospital, Aristotle University School of Health Sciences, Thessaloniki, Greece
- Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | - Nikolaos V. Sipsas
- Laiko General Hospital of Athens and Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Valérie Zeller
- Groupe Hospitalier Diaconesses-Croix Saint-Simon, Paris, France
| | - Olivier Lortholary
- Université de Paris, Faculté de Médecine, APHP, Hôpital Necker-Enfants Malades, Paris, France
- Institut Pasteur, Unité de Mycologie Moléculaire, CNRS UMR 2000, Paris, France
| | - Thomas J. Walsh
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
- Weill Cornell Medicine of Cornell University, New York, New York, USA
- New York Presbyterian Hospital, New York, New York, USA
- Center for Innovative Therapeutics and Diagnostics, Richmond, Virginia, USA
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6
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Takesue Y, Hanai Y, Oda K, Hamada Y, Ueda T, Mayumi T, Matsumoto K, Fujii S, Takahashi Y, Miyazaki Y, Kimura T. Clinical Practice Guideline for the Therapeutic Drug Monitoring of Voriconazole in Non-Asian and Asian Adult Patients: Consensus Review by the Japanese Society of Chemotherapy and the Japanese Society of Therapeutic Drug Monitoring. Clin Ther 2022; 44:1604-1623. [DOI: 10.1016/j.clinthera.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/18/2022] [Accepted: 10/28/2022] [Indexed: 11/23/2022]
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7
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Jiang Z, Wei Y, Huang W, Li B, Zhou S, Liao L, Li T, Liang T, Yu X, Li X, Zhou C, Cao C, Liu T. Population pharmacokinetics of voriconazole and initial dosage optimization in patients with talaromycosis. Front Pharmacol 2022; 13:982981. [PMID: 36225581 PMCID: PMC9549404 DOI: 10.3389/fphar.2022.982981] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/30/2022] [Indexed: 01/08/2023] Open
Abstract
The high variability and unpredictability of the plasma concentration of voriconazole (VRC) pose a major challenge for clinical administration. The aim of this study was to develop a population pharmacokinetics (PPK) model of VRC and identify the factors influencing VRC PPK in patients with talaromycosis. Medical records and VRC medication history of patients with talaromycosis who were treated with VRC as initial therapy were collected. A total of 233 blood samples from 69 patients were included in the study. A PPK model was developed using the nonlinear mixed-effects models (NONMEM). Monte Carlo simulation was applied to optimize the initial dosage regimens with a therapeutic range of 1.0–5.5 mg/L as the target plasma trough concentration. A one-compartment model with first-order absorption and elimination adequately described the data. The typical voriconazole clearance was 4.34 L/h, the volume of distribution was 97.4 L, the absorption rate constant was set at 1.1 h-1, and the bioavailability was 95.1%. Clearance was found to be significantly associated with C-reactive protein (CRP). CYP2C19 polymorphisms had no effect on voriconazole pharmacokinetic parameters. Monte Carlo simulation based on CRP levels showed that a loading dose of 250 mg/12 h and a maintenance dose of 100 mg/12 h are recommended for patients with CRP ≤ 96 mg/L, whereas a loading dose of 200 mg/12 h and a maintenance dose of 75 mg/12 h are recommended for patients with CRP > 96 mg/L. The average probability of target attainment of the optimal dosage regimen in CRP ≤ 96 mg/L and CRP > 96 mg/L groups were 61.3% and 13.6% higher than with empirical medication, and the proportion of Cmin > 5.5 mg/L decreased by 28.9%. In conclusion, the VRC PPK model for talaromycosis patients shows good robustness and predictive performance, which can provide a reference for the clinical individualization of VRC. Adjusting initial dosage regimens based on CRP may promote the rational use of VRC.
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Affiliation(s)
- Zhiwen Jiang
- Department of Dermatology and Venereology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Health Commission Key Lab of Fungi and Mycosis Research and Prevention, Nanning, China
| | - Yinyi Wei
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Weie Huang
- Department of Infectious Diseases, Baise People’s Hospital, Baise, China
| | - Bingkun Li
- Department of Dermatology and Venereology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Health Commission Key Lab of Fungi and Mycosis Research and Prevention, Nanning, China
| | - Siru Zhou
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Liuwei Liao
- Department of Dermatology and Venereology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Health Commission Key Lab of Fungi and Mycosis Research and Prevention, Nanning, China
| | - Tiantian Li
- Guangxi Health Commission Key Lab of Fungi and Mycosis Research and Prevention, Nanning, China
| | - Tianwei Liang
- Department of Dermatology and Venereology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Health Commission Key Lab of Fungi and Mycosis Research and Prevention, Nanning, China
| | - Xiaoshu Yu
- Department of Infectious Diseases, Baise People’s Hospital, Baise, China
| | - Xiuying Li
- Department of Dermatology and Venereology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Health Commission Key Lab of Fungi and Mycosis Research and Prevention, Nanning, China
| | - Changjing Zhou
- Department of Infectious Diseases, Baise People’s Hospital, Baise, China
- *Correspondence: Changjing Zhou, ; Cunwei Cao, ; TaoTao Liu,
| | - Cunwei Cao
- Department of Dermatology and Venereology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Health Commission Key Lab of Fungi and Mycosis Research and Prevention, Nanning, China
- *Correspondence: Changjing Zhou, ; Cunwei Cao, ; TaoTao Liu,
| | - TaoTao Liu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- *Correspondence: Changjing Zhou, ; Cunwei Cao, ; TaoTao Liu,
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8
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Ju C, Lian Q, Chen A, Zhao B, Zhou S, Cai Y, Xie H, Wei L, Li S, He J. Antifungal prophylactic effectiveness and intrapulmonary concentrations of voriconazole versus posaconazole in lung transplant recipients. Med Mycol 2022; 60:6678431. [PMID: 36036471 PMCID: PMC9437723 DOI: 10.1093/mmy/myac041] [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: 02/14/2022] [Revised: 04/22/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
Invasive fungal diseases (IFDs) are one of the leading causes of death in lung transplant recipients. This study aimed to compare the antifungal prophylactic effectiveness, intrapulmonary and plasma levels of voriconazole with posaconazole in lung transplant recipients. This retrospective cohort study analyzed adult recipients who underwent lung transplantation between June 2017 and December 2020. Voriconazole oral tablets or posaconazole oral suspension were used for prophylaxis against posttransplant IFD. Drug concentrations in bronchoalveolar lavage fluid (BALF) and plasma were measured by using liquid chromatography-mass spectrometry. The 182 recipients included 142 in the voriconazole group and 40 in the posaconazole group. The trough plasma levels were comparable between voriconazole and posaconazole (1.65 ± 0.09 vs. 1.69 ± 0.03 μg/ml, p = 0.55). However, the BALF levels were significantly higher for posaconazole than voriconazole (17.47 ± 11.51 vs. 0.56 ± 0.49 μg/ml, p < 0.001). There was no significant difference in the total incidence of breakthrough IFDs between the voriconazole and posaconazole groups (10.6% vs. 7.5%, p = 0.77). The intrapulmonary concentrations of posaconazole were significantly higher than voriconazole. The two agents had comparable antifungal prophylactic effectiveness.
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Affiliation(s)
- Chunrong Ju
- Department of Respiratory and Critical Care Medicine, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qiaoyan Lian
- Department of Organ Transplant, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Ao Chen
- Department of Organ Transplant, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Boxin Zhao
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shouning Zhou
- Department of Pharmacy, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuhang Cai
- Department of Organ Transplant, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Hui Xie
- Department of Pharmacy, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Li Wei
- Department of Pharmacy, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shiyue Li
- Department of Respiratory and Critical Care Medicine, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jianxing He
- Department of Thoracic Surgery, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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9
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Ye Q, Yu X, Chen W, Li M, Gu S, Huang L, Zhan Q, Wang C. Impact of extracorporeal membrane oxygenation on voriconazole plasma concentrations: A retrospective study. Front Pharmacol 2022; 13:972585. [PMID: 36059951 PMCID: PMC9428491 DOI: 10.3389/fphar.2022.972585] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 07/19/2022] [Indexed: 12/03/2022] Open
Abstract
Aims: We aimed to assess the impact of extracorporeal membrane oxygenation (ECMO) on voriconazole exposure. Methods: Adult critically ill patients with or without ECMO support receiving intravenous voriconazole therapy were included in this retrospective study conducted in a tertiary referral intensive care unit. The first therapeutic drug monitoring (TDM) results of voriconazole in ECMO patients and non-ECMO patients were collected, and the prevalence of subtherapeutic concentrations was analyzed. Multivariate analyses were performed to evaluate the effect of ECMO on voriconazole exposure. Results: A total of 132 patients (including 66 patients with ECMO support) were enrolled and their respective first voriconazole trough concentrations (Cmin) were recorded. The median Cmin of the ECMO group and the non-ECMO group was 1.9 (1.4–4.4) and 4.4 (3.2–6.9) mg/L, respectively (p = 0.000), and the proportion of the two groups in subtherapeutic concentrations range (<2 mg/L) was 51.5% and 7.6%, respectively (p = 0.000). Multiple linear regression analysis of voriconazole Cmin identified that the use of ECMO and coadministration of glucocorticoids were associated with significantly reduced concentrations, while increasing SOFA score and increasing daily dose were associated with significantly increased concentrations. The model accounted for 32.2% of the variability of voriconazole Cmin. Furthermore, binary logistic regression demonstrated that the use of ECMO was an independent risk factor (OR = 7.78, p = 0.012) for insufficient voriconazole exposure. Conclusion: Our findings showed that, in addition to the known drug interactions, ECMO is a significant covariable affecting voriconazole exposure. In addition, SOFA score was identified as a factor associated with increased voriconazole concentration.
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Affiliation(s)
- Qinghua Ye
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Xin Yu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Wenqian Chen
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Min Li
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Sichao Gu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Linna Huang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Qingyuan Zhan
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
- *Correspondence: Qingyuan Zhan,
| | - Chen Wang
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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10
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Ashok A, Mangalore RP, Morrissey CO. Azole Therapeutic Drug Monitoring and its Use in the Management of Invasive Fungal Disease. CURRENT FUNGAL INFECTION REPORTS 2022. [DOI: 10.1007/s12281-022-00430-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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11
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Chau MM, Daveson K, Alffenaar JWC, Gwee A, Ho SA, Marriott DJE, Trubiano JA, Zhao J, Roberts JA. Consensus guidelines for optimising antifungal drug delivery and monitoring to avoid toxicity and improve outcomes in patients with haematological malignancy and haemopoietic stem cell transplant recipients, 2021. Intern Med J 2021; 51 Suppl 7:37-66. [PMID: 34937141 DOI: 10.1111/imj.15587] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Antifungal agents can have complex dosing and the potential for drug interaction, both of which can lead to subtherapeutic antifungal drug concentrations and poorer clinical outcomes for patients with haematological malignancy and haemopoietic stem cell transplant recipients. Antifungal agents can also be associated with significant toxicities when drug concentrations are too high. Suboptimal dosing can be minimised by clinical assessment, laboratory monitoring, avoidance of interacting drugs, and dose modification. Therapeutic drug monitoring (TDM) plays an increasingly important role in antifungal therapy, particularly for antifungal agents that have an established exposure-response relationship with either a narrow therapeutic window, large dose-exposure variability, cytochrome P450 gene polymorphism affecting drug metabolism, the presence of antifungal drug interactions or unexpected toxicity, and/or concerns for non-compliance or inadequate absorption of oral antifungals. These guidelines provide recommendations on antifungal drug monitoring and TDM-guided dosing adjustment for selected antifungal agents, and include suggested resources for identifying and analysing antifungal drug interactions. Recommended competencies for optimal interpretation of antifungal TDM and dose recommendations are also provided.
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Affiliation(s)
- Maggie M Chau
- Pharmacy Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Kathryn Daveson
- Department of Infectious Diseases and Microbiology, The Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - Jan-Willem C Alffenaar
- Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Camperdown, New South Wales, Australia.,Pharmacy Department, Westmead Hospital, Westmead, New South Wales, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Camperdown, New South Wales, Australia
| | - Amanda Gwee
- Infectious Diseases Unit, The Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Infectious Diseases Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Su Ann Ho
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Deborah J E Marriott
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Darlinghurst, New South Wales, Australia.,Faculty of Science, University of Technology, Ultimo, New South Wales, Australia.,Faculty of Medicine, The University of New South Wales, Kensington, New South Wales, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Jessie Zhao
- Department of Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason A Roberts
- The University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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12
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García-García I, Dapía I, Montserrat J, Martinez de Soto L, Bueno D, Díaz L, Queiruga J, Rodriguez Mariblanca A, Guerra-García P, Ramirez E, Frías J, Pérez Martínez A, Carcas-Sansuan AJ, Borobia AM. Experience of a Strategy Including CYP2C19 Preemptive Genotyping Followed by Therapeutic Drug Monitoring of Voriconazole in Patients Undergoing Allogenic Hematopoietic Stem Cell Transplantation. Front Pharmacol 2021; 12:717932. [PMID: 34744712 PMCID: PMC8563584 DOI: 10.3389/fphar.2021.717932] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/08/2021] [Indexed: 12/04/2022] Open
Abstract
Many factors have been described to contribute to voriconazole (VCZ) interpatient variability in plasma concentrations, especially CYP2C19 genetic variability. In 2014, Hicks et al. presented data describing the correlation between VCZ plasma concentrations and CYP2C19 diplotypes in immunocompromised pediatric patients and utilized pharmacokinetic modeling to extrapolate a more suitable VCZ dose for each CYP2C19 diplotype. In 2017, in our hospital, a clinical protocol was developed for individualization of VCZ in immunocompromised patients based on preemptive genotyping of CYP2C19 and dosing proposed by Hicks et al., Clinical Pharmacogenetics Implementation Consortium (CPIC) clinical guidelines, and routine therapeutic drug monitoring (TDM). We made a retrospective review of a cohort of 28 immunocompromised pediatric patients receiving VCZ according to our protocol. CYP2C19 gene molecular analysis was preemptively performed using PharmArray®. Plasma trough concentrations were measured by immunoassay analysis until target concentrations (1–5.5 μg/ml) were reached. Sixteen patients (57.14%) achieved VCZ trough target concentrations in the first measure after the initial dose based on PGx. This figure is similar to estimations made by Hicks et al. in their simulation (60%). Subdividing by phenotype, our genotyping and TDM-combined strategy allow us to achieve target concentrations during treatment/prophylaxis in 90% of the CYP2C19 Normal Metabolizers (NM)/Intermediate Metabolizers (IM) and 100% of the Rapid Metabolizers (RM) and Ultrarapid Metabolizers (UM) of our cohort. We recommended modifications of the initial dose in 29% (n = 8) of the patients. In RM ≥12 years old, an increase of the initial dose resulted in 50% of these patients achieving target concentrations in the first measure after initial dose adjustment based only on PGx information. Our experience highlights the need to improve VCZ dose predictions in children and the potential of preemptive genotyping and TDM to this aim. We are conducting a multicenter, randomized clinical trial in patients with risk of aspergillosis in order to evaluate the effectiveness and efficiency of VCZ individualization: VORIGENIPHARM (EudraCT: 2019-000376-41).
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Affiliation(s)
- Irene García-García
- Clinical Pharmacology Department, IdiPAZ, La Paz University Hospital School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Irene Dapía
- Medical and Molecular Genetics Institute (INGEMM), La Paz University Hospital, Madrid, Spain
| | - Jaime Montserrat
- Clinical Pharmacology Department, IdiPAZ, La Paz University Hospital School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Lucía Martinez de Soto
- Clinical Pharmacology Department, IdiPAZ, La Paz University Hospital School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - David Bueno
- Paediatric Haemato-oncology Department, University Hospital La Paz, Madrid, Spain
| | - Lucía Díaz
- Clinical Pharmacology Department, IdiPAZ, La Paz University Hospital School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Javier Queiruga
- Clinical Pharmacology Department, IdiPAZ, La Paz University Hospital School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Amelia Rodriguez Mariblanca
- Clinical Pharmacology Department, IdiPAZ, La Paz University Hospital School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Pilar Guerra-García
- Paediatric Haemato-oncology Department, University Hospital La Paz, Madrid, Spain
| | - Elena Ramirez
- Clinical Pharmacology Department, IdiPAZ, La Paz University Hospital School of Medicine, Autonomous University of Madrid, Madrid, Spain.,Medical and Molecular Genetics Institute (INGEMM), La Paz University Hospital, Madrid, Spain.,Paediatric Haemato-oncology Department, University Hospital La Paz, Madrid, Spain
| | - Jesus Frías
- Clinical Pharmacology Department, IdiPAZ, La Paz University Hospital School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | | | - Antonio J Carcas-Sansuan
- Clinical Pharmacology Department, IdiPAZ, La Paz University Hospital School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Alberto M Borobia
- Clinical Pharmacology Department, IdiPAZ, La Paz University Hospital School of Medicine, Autonomous University of Madrid, Madrid, Spain
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13
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Yang P, Liu W, Zheng J, Zhang Y, Yang L, He N, Zhai S. Predicting the Outcome of Voriconazole Individualized Medication Using Integrated Pharmacokinetic/Pharmacodynamic Model. Front Pharmacol 2021; 12:711187. [PMID: 34721012 PMCID: PMC8548711 DOI: 10.3389/fphar.2021.711187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
Therapeutic drug monitoring is considered to be an effective tool for the individualized use of voriconazole. However, drug concentration measurement alone doesn’t take into account the susceptibility of the infecting microorganisms to the drug. Linking pharmacodynamic data with the pharmacokinetic profile of individuals is expected to be an effective method to predict the probability of a certain therapeutic outcome. The objective of this study was to individualize voriconazole regimens by integrating individual pharmacokinetic parameters and pathogen susceptibility data through Monte Carlo simulations The individual pharmacokinetic parameters of 35 hospitalized patients who received voriconazole were calculated based on a validated population pharmacokinetic model. The area under the concentration-time curve for free drug/minimal inhibitory concentration (fAUCss/MIC) > 25 was selected as the pharmacokinetic/pharmacodynamic (PK/PD) parameter predicting the efficacy of voriconazole. The cumulative fraction of response (CFR) of the target value was assessed. To verify this conclusion, a logistic regression analysis was used to explore the relationship between actual clinical efficiency and the CFR value. For the 35 patients, the area under the free drug concentration-time curve (fAUCss) was calculated to be 34.90 ± 21.67 mgh/L. According to the dualistic logistic regression analysis, the minimal inhibitory concentration (MIC) value of different kinds of fungi had a great influence on the effectiveness of clinical treatment. It also showed that the actual clinical efficacy and the CFR value of fAUCss/MIC had a high degree of consistency. The results suggest that it is feasible to individualize voriconazole dosing and predict clinical outcomes through the integration of data on pharmacokinetics and antifungal susceptibility.
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Affiliation(s)
- Ping Yang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Wei Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Jiajia Zheng
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, China
| | - Yuanyuan Zhang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Li Yang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Na He
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
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14
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Nagase K, Ishizawa Y, Inoue M, Kokubun M, Yamada S, Kanazawa H. Temperature-responsive spin column for sample preparation using an all-aqueous eluent. Anal Chim Acta 2021; 1179:338806. [PMID: 34535268 DOI: 10.1016/j.aca.2021.338806] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/31/2021] [Accepted: 06/24/2021] [Indexed: 11/21/2022]
Abstract
We present a temperature-responsive spin column using an all-aqueous eluent. The method is intended as a simple sample preparation method for protein removal from serum, which is required for serum drug analysis. As packing materials for the spin column, we prepared two types of silica beads via surface-initiated radical polymerization. The large beads (diameter, 40-63 μm) were grafted with a temperature-responsive cationic copolymer, poly(N-isopropylacrylamide-co-N,N-dimethylaminopropyl acrylamide-co-n-butyl methacrylate) (P(NIPAAm-co-DMAPAAm-co-BMA)), and the small beads (diameter, 5 μm) were grafted with a temperature-responsive hydrophobic copolymer, P(NIPAAm-co-BMA). The beads were packed into the spin column as a double layer: P(NIPAAm-co-BMA) silica beads on the bottom and P(NIPAAm-co-DMAPAAm-co-BMA) silica beads on the top. The sample purification efficacy of the prepared spin column was evaluated on a model sample analyte (the antifungal drug voriconazole mixed with blood serum proteins). At 40 °C, the serum proteins and voriconazole were adsorbed on the prepared spin column via hydrophobic and electrostatic interactions. When the temperature was decreased to 4 °C, the adsorbed voriconazole was eluted from the column with the pure water eluent, while the serum proteins remained in the column. This temperature-responsive spin column realizes sample preparation simply by changing the temperature.
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Affiliation(s)
- Kenichi Nagase
- Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato, Tokyo, 105-8512, Japan.
| | - Yuta Ishizawa
- Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato, Tokyo, 105-8512, Japan
| | - Masakazu Inoue
- Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato, Tokyo, 105-8512, Japan
| | - Matsurika Kokubun
- Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato, Tokyo, 105-8512, Japan
| | - Sota Yamada
- Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato, Tokyo, 105-8512, Japan
| | - Hideko Kanazawa
- Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato, Tokyo, 105-8512, Japan
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15
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Concomitant Treatment with Voriconazole and Flucloxacillin: A Combination to Avoid. Antibiotics (Basel) 2021; 10:antibiotics10091112. [PMID: 34572694 PMCID: PMC8469006 DOI: 10.3390/antibiotics10091112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 01/12/2023] Open
Abstract
Background: Voriconazole is an antifungal drug used as one of the first-line treatments for invasive aspergillosis. This drug is extensively metabolized, predominantly via cytochrome P450 enzymes. An interaction between flucloxacillin and voriconazole, leading to subtherapeutic voriconazole concentrations, has previously been reported. We aimed to demonstrate that flucloxacillin independently influences voriconazole exposure. Methods: Patients from three Belgian hospitals, treated with a combination of voriconazole and flucloxacillin, were included in this retrospective study. Voriconazole concentrations were collected both in a timeframe with and without flucloxacillin co-treatment. Multivariate analyses were performed to study the independent effect of flucloxacillin treatment on voriconazole exposure and the possible influence of the flucloxacillin dose. Results: Thirty-three patients were included in this study and 145 trough concentrations (51 with, and 94 without concomitant flucloxacillin treatment) were analyzed. The median (IQR) voriconazole trough concentration sampled during flucloxacillin co-treatment was 0.5 (0–1.8) mg/L, whereas samples without flucloxacillin co-treatment had a median (IQR) voriconazole trough concentration of 3.5 (1.7–5.1) mg/L (p = 0.002), while receiving similar voriconazole doses. Subtherapeutic concentrations (<1 mg/L) were observed in 69% and 7% of the samples with flucloxacillin co-treatment versus samples without flucloxacillin co-treatment, respectively. Conclusion: This study shows that flucloxacillin co-treatment independently decreases voriconazole exposure. Caution is needed when these two drugs are administered simultaneously.
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16
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Taghvaye-Masoumi H, Hadjibabaie M, Ghadimi M, Zarif-Yeganeh M, Vaezi M, Ghavamzadeh A. Association of Voriconazole Trough Plasma Concentration with Efficacy and Incidence of Hepatotoxicity in Iranian Patients with Hematological Malignancies. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2021; 20:62-71. [PMID: 34400941 PMCID: PMC8170753 DOI: 10.22037/ijpr.2020.112330.13688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
There are conflicting data regarding the association between plasma concentration of voriconazole (VCZ) and both efficacy and safety. This study investigates the association of VCZ trough plasma level with clinical efficacy and hepatotoxicity in the Iranian population suffering hematological malignancies. This cross-sectional study was performed on adult Iranian patients (age ≥ 18 years) with hematological malignancies undergoing treatment with oral or intravenous VCZ for proven or probable invasive aspergillosis. Plasma concentrations of VCZ were measured at two time points on day 4 and 14 during the study period. A total of 60 VCZ trough concentrations of 30 patients were drawn on days 4 and 14 after the initiation of treatment. There was no definite correlation between the mean plasma concentration of VCZ and VCZ dosage (p = 0.134, r = 0.280). In multivariable model, only plasma concentration of VCZ on day 14 was associated with the incidence of hepatotoxicity (p = 0.013; OR = 1.42, 95% CI = 1.07-3.24). Plasma trough concentration neither on day 4 nor on day 14 was related to the treatment response. No significant association was observed between the mean plasma concentration of VCZ and 3-month patients’ survival (p = 0.696). To conclude, VCZ trough concentration may not be a predictor of treatment response or 3-month patients’ survival. However, the wide inter- and intra-patient variability of VCZ plasma concentration coupled with the observed association between VCZ trough level and the incidence of hepatotoxicity would pose the question regarding the potential benefit of VCZ concentration monitoring.
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Affiliation(s)
- Hamidreza Taghvaye-Masoumi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Guilan University of Medical Sciences, Rasht, Iran
| | - Molouk Hadjibabaie
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Ghadimi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Morvarid Zarif-Yeganeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Vaezi
- Hematology-Oncology and Stem Cell Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ardeshir Ghavamzadeh
- Hematology-Oncology and Stem Cell Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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17
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PLASMA VORICONAZOLE CONCENTRATIONS FOLLOWING SINGLE- AND MULTIPLE-DOSE SUBCUTANEOUS INJECTIONS IN WESTERN POND TURTLES ( ACTINEMYS MARMORATA). J Zoo Wildl Med 2021; 52:538-547. [PMID: 34130396 DOI: 10.1638/2020-0161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 11/21/2022] Open
Abstract
A recently characterized fungal pathogen, Emydomyces testavorans, has been associated with ulcerative shell disease and significant morbidity in Western pond turtles. Voriconazole is a second-generation triazole antifungal medication that prevents fungal growth through disruption of ergosterol synthesis, causing abnormalities in the fungal cell membrane. Preliminary reports of minimum inhibitory concentrations (MIC) indicate that voriconazole is effective in vitro against E. testavorans. Ultraperformance liquid chromatography was used to measure voriconazole plasma concentrations in blood samples from healthy Western pond turtles after administration of a single SC injection of 10 mg/kg and after multiple doses (10 mg/kg SC q48h for seven doses). The data were analyzed using a naïve pooled approach. Mean (SE) observed time to maximum concentration was 2 (0.18) h for a single dose and 50 (2.2) h for multiple doses; the multiple-dose trial observed mean (SE) maximum concentration was 12.4 (2.2) µg/ml, and observed mean (SE) trough concentration was 1.7 (0.7) µg/ml. Multifocal skin sloughing following the single-dose trial was observed in one turtle and there was a significant increase in polychromatophilic cells amongst the study turtles after the multiple-dose voriconazole trial. No other adverse effects were observed. When voriconazole was administered at 10 mg/kg SC q48h, observed trough plasma concentrations were consistently higher than reported E. testavorans MIC concentrations. Further study is needed to determine the clinical safety and in vivo efficacy of this dose in Western pond turtles.
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18
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Skaggs CL, Ren GJ, Elgierari ETM, Sturmer LR, Shi RZ, Manicke NE, Kirkpatrick LM. Simultaneous quantitation of five triazole anti-fungal agents by paper spray-mass spectrometry. Clin Chem Lab Med 2021; 58:836-846. [PMID: 31926066 DOI: 10.1515/cclm-2019-0895] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/04/2019] [Indexed: 12/25/2022]
Abstract
Background Invasive fungal disease is a life-threatening condition that can be challenging to treat due to pathogen resistance, drug toxicity, and therapeutic failure secondary to suboptimal drug concentrations. Frequent therapeutic drug monitoring (TDM) is required for some anti-fungal agents to overcome these issues. Unfortunately, TDM at the institutional level is difficult, and samples are often sent to a commercial reference laboratory for analysis. To address this gap, the first paper spray-mass spectrometry assay for the simultaneous quantitation of five triazoles was developed. Methods Calibration curves for fluconazole, posaconazole, itraconazole, hydroxyitraconazole, and voriconazole were created utilizing plasma-based calibrants and four stable isotopic internal standards. No sample preparation was needed. Plasma samples were spotted on a paper substrate in pre-manufactured plastic cartridges, and the dried plasma spots were analyzed directly utilizing paper spray-mass spectrometry (paper spray MS/MS). All experiments were performed on a Thermo Scientific TSQ Vantage triple quadrupole mass spectrometer. Results The calibration curves for the five anti-fungal agents showed good linearity (R2 = 0.98-1.00). The measured assay ranges (lower limit of quantification [LLOQ]-upper limit of quantitation [ULOQ]) for fluconazole, posaconazole, itraconazole, hydroxyitraconazole, and voriconazole were 0.5-50 μg/mL, 0.1-10 μg/mL, 0.1-10 μg/mL, 0.1-10 μg/mL, and 0.1-10 μg/mL, respectively. The inter- and intra-day accuracy and precision were less than 25% over the respective ranges. Conclusions We developed the first rapid paper spray-MS/MS assay for simultaneous quantitation of five triazole anti-fungal agents in plasma. The method may be a powerful tool for near-point-of-care TDM aimed at improving patient care by reducing the turnaround time and for use in clinical research.
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Affiliation(s)
- Christine L Skaggs
- Department of Chemistry and Chemical Biology, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
| | - Greta J Ren
- Department of Chemistry and Chemical Biology, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
| | | | - Lillian R Sturmer
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Run Z Shi
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Nicholas E Manicke
- Department of Chemistry and Chemical Biology, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA.,Forensic and Investigative Sciences, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
| | - Lindsey M Kirkpatrick
- Department of Pediatrics, Division of Pediatric Infectious Diseases, J.W. Riley Hospital for Children, Indiana University School of Medicine, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA
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Combined Impact of Inflammation and Pharmacogenomic Variants on Voriconazole Trough Concentrations: A Meta-Analysis of Individual Data. J Clin Med 2021; 10:jcm10102089. [PMID: 34068031 PMCID: PMC8152514 DOI: 10.3390/jcm10102089] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/11/2021] [Accepted: 05/11/2021] [Indexed: 01/23/2023] Open
Abstract
Few studies have simultaneously investigated the impact of inflammation and genetic polymorphisms of cytochromes P450 2C19 and 3A4 on voriconazole trough concentrations. We aimed to define the respective impact of inflammation and genetic polymorphisms on voriconazole exposure by performing individual data meta-analyses. A systematic literature review was conducted using PubMed to identify studies focusing on voriconazole therapeutic drug monitoring with data of both inflammation (assessed by C-reactive protein level) and the pharmacogenomics of cytochromes P450. Individual patient data were collected and analyzed in a mixed-effect model. In total, 203 patients and 754 voriconazole trough concentrations from six studies were included. Voriconazole trough concentrations were independently influenced by age, dose, C-reactive protein level, and both cytochrome P450 2C19 and 3A4 genotype, considered individually or through a combined genetic score. An increase in the C-reactive protein of 10, 50, or 100 mg/L was associated with an increased voriconazole trough concentration of 6, 35, or 82%, respectively. The inhibitory effect of inflammation appeared to be less important for patients with loss-of-function polymorphisms for cytochrome P450 2C19. Voriconazole exposure is influenced by age, inflammatory status, and the genotypes of both cytochromes P450 2C19 and 3A4, suggesting that all these determinants need to be considered in approaches of personalization of voriconazole treatment.
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Blanco-Dorado S, Belles Medall MD, Pascual-Marmaneu O, Campos-Toimil M, Otero-Espinar FJ, Rodríguez-Riego R, Rodríguez-Jato T, Zarra-Ferro I, Lamas MJ, Fernández-Ferreiro A. Therapeutic drug monitoring of voriconazole: validation of a high performance liquid chromatography method and comparison with an ARK immunoassay. Eur J Hosp Pharm 2021. [DOI: 10.1136/ejhpharm-2019-002155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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21
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Determination of Voriconazole Plasma Concentration by HPLC Technique and Evaluating Its Association with Clinical Outcome and Adverse Effects in Patients with Invasive Aspergillosis. ACTA ACUST UNITED AC 2021; 2021:5497427. [PMID: 33953804 PMCID: PMC8057903 DOI: 10.1155/2021/5497427] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 02/22/2021] [Accepted: 04/01/2021] [Indexed: 11/17/2022]
Abstract
Purpose Invasive aspergillosis is a prevalent fungal disease, especially in Asian countries with a high mortality rate. Voriconazole (VRZ) is the first choice for invasive aspergillosis treatment. Plasma concentration of this drug is unpredictable and varies among individuals. This variability is influenced by many factors leading to clinical implication. Therapeutic drug monitoring (TDM) may have a crucial role in the patients' treatment process. The HPLC method provides sufficient specificity and sensitivity for plasma VRZ concentration determination for TDM purposes of this drug. Methods Patients who initiated oral or intravenous VRZ for invasive aspergillosis were enrolled in this study. Demographic characteristics and clinical data, outcome, and adverse effects were documented. For each patient, the plasma sample was collected under steady-state condition and analyzed using a validated HPLC method. Results A total of 22 measurements were performed. Fifty percent of patients were out of the therapeutic range. From them, 27.27% and 22.73% were in subtherapeutic and supratherapeutic ranges (<1 μg/mL and >5.5 μg/mL), respectively. There was a significant correlation between VRZ plasma concentration and treatment outcomes (P=0.022). Treatment failure was five times higher than treatment success in those in the subtherapeutic range. Adverse effects were observed more frequently in patients with supratherapeutic concentrations compared to those with non-supratherapeutic levels. Furthermore, the mortality rate in patients experiencing treatment failure was 2.17 times higher than those with treatment success. Conclusions TDM of VRZ plays an important role in better evaluation of efficacy and toxicity during treatment. Therefore, determination of the drug level may be of clinical significance.
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L Kandaurava S, S Baslyk K, A Migas A, V Hill A, I Bydanov O, A Mishkova V, V Aleinikova O. Comparative study of prophylaxis with high and low doses of voriconazole in children with malignancy. Curr Med Mycol 2021; 6:27-34. [PMID: 34195457 PMCID: PMC8226053 DOI: 10.18502/cmm.6.4.5331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background and Purpose: Children with acute myeloid leukemia and relapses of leukemia are at high risk of developing fungal infections and need antifungal prophylaxis. This study aimed to compare the efficacy and toxicity of two different dosage regimens of voriconazole (VRC) during prophylactic administration in children with malignancy and neutropenia. Materials and Methods: This prospective study was conducted at the Belarusian Research Center for Pediatric Oncology, Hematology, and Immunology from May 2017 to December 2019.
The present study included 21 Caucasian patients with malignant hematological diseases (20 patients with acute myeloid leukemia and relapses of leukemia
and 1 patient with Non-Hodgkin's lymphoma) aged 2-18 years. All patients were randomly divided into two groups that received different dosage regimens
of VRCZ prophylaxis. Patients in the “high-dose” group received VRCZ at a dose of 9 mg/kg twice a day PO, or 8 mg/kg twice a day IV without a loading dose
(children of 2-11 and adolescents and of 12-14 years old with <50 kg weight body), or a dose of 4 mg/kg twice a day PO or IV (adolescents
of 12-14 years old with ≥50 kg body weight and all adolescents over 14 years old). Patients in the “low-dose” group received VRCZ at a dose of
4 mg/kg twice a day, PO or IV, without a loading dose (children of 2-11 and adolescents of 12-14 years old with <50 kg body weight),
or at a dose of 3 mg/kg twice a day, PO or IV (adolescents of 12-14 years old with ≥ 50 kg body weight and all adolescents over 14 years old).
When neutropenia recurred (after the next chemotherapy block), the patients were re-randomized and prophylaxis was resumed in the absence
of fungal infection. Therefore, some patients (n=12, 57%) entered the study several times (maximum four times, after each chemotherapy block).
In total, 21 patients experienced 40 episodes of VRCZ prophylaxis. Results: In the high-dose group (n=20 episodes of prophylaxis), invasive fungal infections (IFI) signs were recorded in one (5%) case.
In the low-dose group (n=20 episodes), IFI signs were observed in six (30%) cases (P=0.0375). The residual serum concentration was significantly
higher in patients who received high doses of VRCZ (P<0.0001). Most patients with IFI (n=6, 86%) had a mean value (i.e., <0.74 μg/ml)
of the residual serum concentration of the medication. Median of the first signs of fungal infection was 22 days from the start of prophylaxis.
The dosage was the only highly significant factor that affected the metabolism of VRCZ. Conclusion: The likelihood of IFI was significantly lower in children who prophylactically received VRCZ in high doses (P=0.0375) and had ≥
0.74 μg/ml residual serum concentration of the medication (P=0.0258). Residual serum concentration of VRCZ reached a plateau by day sixth
of the treatment. In children, the dosage was the only highly significant factor affecting the metabolism of VRCZ.
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Affiliation(s)
- Sviatlana L Kandaurava
- Infection Control Department, Belarusian Research Center for Pediatric Oncology, Hematology, and Immunology, Minsk, Belarus
| | - Kseniya S Baslyk
- Laboratory of Genetic Biotechnology, Scientific Department, Belarusian Research Center for Pediatric Oncology, Hematology, and Immunology, Minsk, Belarus
| | - Alexandr A Migas
- Laboratory of Genetic Biotechnology, Scientific Department, Belarusian Research Center for Pediatric Oncology, Hematology, and Immunology, Minsk, Belarus
| | - Anna V Hill
- Group of Molecular Biology and Transplant Processing, Belarusian Research Center for Pediatric Oncology, Hematology, and Immunology, Minsk, Belarus
| | - Oleg I Bydanov
- Automated Control Systems Department, Belarusian Research Center for Pediatric Oncology, Hematology, and Immunology, Minsk, Belarus
| | - Volha A Mishkova
- Laboratory of Molecular and Genetic Research, Scientific Department, Belarusian Research Center for Pediatric Oncology, Hematology, and Immunology, Minsk, Belarus
| | - Olga V Aleinikova
- Laboratory of Cellular Biotechnology and Cytotherapy, Scientific Department, Belarusian Research Center for Pediatric Oncology, Hematology, and Immunology, Minsk, Belarus
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Li H, Zhang D, Cheng X, Sultan MFA, Xiong L, Ma Y, Wang M, Feng W. Application of the Westgard Multi-rule Theory to Internal Quality Control Evaluation of Voriconazole for Therapeutic Drug Monitoring. CURR PHARM ANAL 2021. [DOI: 10.2174/1573412916999200818104337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
There is no worldwide recognized reference internal quality control method
for Therapeutic Drug Monitoring (TDM) of voriconazole (VCZ) by Liquid Chromatography (LC). In
this study, we aimed to develop an internal quality control method for TDM of VCZ, evaluate it by the
Westgard multi-rule theory, and guarantee the analytical quality of the assays.
Methods:
The plasma concentration of VCZ was detected by two-dimensional liquid chromatography
with ultraviolet detection (2D-LC-UV) method. The internal quality control results accompanying with
TDM of VCZ in our laboratory from July 2019 to January 2020 were collected and retrospectively
studied. The Levey-Jennings quality chart and Z-score quality chart were drawn and Westgard multirules
of 12s/13s/22s/R4s/41s/10x were applied to assess the suitable quality control method for TDM of
VCZ.
Results:
The 2D-LC-UV method was well suited to monitor the plasma concentration of VCZ and increase
the real-time capability of TDM for VCZ. Combined with Westgard multi-rules, the quality control
charts of Levery-Jennings and Z-score both can timely discover and judge the systematic errors
and random errors for the internal quality control results. 86 batches of quality control products were
assessed and 7 times warnings and 6 times out of control were detected.
Conclusion:
The Westgard multi-rules, with high efficacy in determining detection errors, has important
application value in the internal quality control for TDM of VCZ. The developed quality control
method can improve the accuracy and reliability for VCZ measurement by the 2D-LC-UV method
and further promote the clinical rational use of the drug.
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Affiliation(s)
- Houli Li
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Di Zhang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiaoliang Cheng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | | | - Lilong Xiong
- School of Chemistry, Xi’an Jiaotong University, Xi’an, China
| | - Ying Ma
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Maoyi Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Weiyi Feng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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24
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Li X, Li W, Li M, Zhang Z, Liu S, Chen Z. Correlation between enzyme multiplied immunoassay technique and high-performance liquid chromatography in the quantification of voriconazole in a paediatric population. Scand J Clin Lab Invest 2021; 81:121-126. [PMID: 33426972 DOI: 10.1080/00365513.2020.1868048] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The enzyme multiplied immunoassay technique (EMIT) is a new method for determining the plasma concentration of voriconazole (VRZ). This study aimed to investigate the correlation between EMIT and high-performance liquid chromatography/ultraviolet rays (HPLC/UV) in determining the plasma VRZ trough concentration in children, in China. A total of 419 blood samples were collected, and plasma VRZ concentrations were detected by the EMIT and HPLC methods. The results of 304 samples were analysed after excluding samples that were undetectable or beyond the quantification limit. A test result value of 0 was defined as undetectable, while concentrations outside the detection range (0.2 - 20.0 μg/ml for HPLC and 0.5 - 16.0 µg/ml for EMIT) were defined as beyond the quantification limit. Results from both methods were compared using the Passing Bablok regression, Bland-Altman plot analysis, and paired Wilcoxon test. The plasma VRZ concentrations determined by EMIT and HPLC showed a strong linear correlation through the linear regression equation YEMIT = 1.310 × HPLC +0.149 (R2 = 0.9082). The Bland-Altman plot analysis showed poor level consistency as measured by the two methods. The paired Wilcoxon-test showed a significant difference between the two methods (p < .0001). Compared to EMIT, HPLC accurately detected plasma VRZ concentration, making it suitable for VRZ therapeutic drug monitoring. The numerical values of the EMIT-measured levels were higher than those of HPLC, which may be related to VRZ metabolites interference and co-administrated drugs.
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Affiliation(s)
- Xuejuan Li
- Department of Pharmacy, Shenzhen Children Hospital, Shenzhen, China
| | - Wei Li
- Department of Pharmacy, The Third People's Hospital of Shenzhen, Shenzhen, China
| | - Meng Li
- Department of Pharmacy, Shenzhen Children Hospital, Shenzhen, China
| | - Zhou Zhang
- Department of Pharmacy, Shenzhen Children Hospital, Shenzhen, China
| | - Sixi Liu
- Department of Haematology, Shenzhen Children Hospital, Shenzhen, China
| | - Zebin Chen
- Department of Pharmacy, Shenzhen Children Hospital, Shenzhen, China
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Gautier-Veyret E, Thiebaut-Bertrand A, Roustit M, Bolcato L, Depeisses J, Schacherer M, Schummer G, Fonrose X, Stanke-Labesque F. Optimization of voriconazole therapy for treatment of invasive aspergillosis: Pharmacogenomics and inflammatory status need to be evaluated. Br J Clin Pharmacol 2020; 87:2534-2541. [PMID: 33217017 DOI: 10.1111/bcp.14661] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/04/2020] [Accepted: 11/11/2020] [Indexed: 12/13/2022] Open
Abstract
AIMS Cytochrome 2C19 genotype-directed dosing of voriconazole (VRC) reduces the incidence of insufficient VRC trough concentrations (Cmin ) but does not account for CYP3A polymorphisms, also involved in VRC metabolism. This prospective observational study aimed to evaluate the utility of a genetic score combining CYP2C19 and CYP3A genotypes to predict insufficient initial VRC Cmin (<1 mg/L). METHODS The genetic score was determined in hematological patients treated with VRC. The higher the genetic score, the faster the metabolism of the patient. The impact of the genetic score was evaluated considering initial VRC Cmin and all VRC Cmin (n = 159) determined during longitudinal therapeutic drug monitoring. RESULTS Forty-three patients were included, of whom 41 received VRC for curative indication. Thirty-six patients had a genetic score ≥2, of whom 11 had an initial insufficient VRC Cmin . A genetic score ≥2 had a positive predictive value of 0.31 for having an initial insufficient VRC Cmin and initial VRC Cmin was not associated with the genetic score. The lack of association between the genetic score and VRC Cmin may be related to the inflammatory status of the patients (C-reactive protein [CRP] levels: median [Q1-Q3]: 43.0 [11.0-110.0] mg/L), as multivariate analysis performed on all VRC Cmin identified CRP as an independent determinant of the VRC Cmin adjusted for dose (P < .0001). CONCLUSION The combined genetic score did not predict low VRC exposure in patients with inflammation, which is frequent in patients with invasive fungal infections. Strategies for the individualization of VRC dose should integrate the inflammatory status of patients in addition to pharmacogenetic variants.
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Affiliation(s)
- Elodie Gautier-Veyret
- Inserm, CHU Grenoble Alpes, HP2, Universitaire Grenoble Alpes, Grenoble, 38000, France
| | | | - Matthieu Roustit
- Inserm, CHU Grenoble Alpes, HP2, Universitaire Grenoble Alpes, Grenoble, 38000, France
| | - Léa Bolcato
- Laboratoire de Pharmacologie, Pharmacogénétique et Toxicologie, CHU Grenoble Alpes, France
| | | | | | - Gabriel Schummer
- Univ. Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, Grenoble, France
| | - Xavier Fonrose
- Laboratoire de Pharmacologie, Pharmacogénétique et Toxicologie, CHU Grenoble Alpes, France
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Population Pharmacokinetics of Voriconazole in Patients With Invasive Aspergillosis: Serum Albumin Level as a Novel Marker for Clearance and Dosage Optimization. Ther Drug Monit 2020; 42:872-879. [PMID: 32947557 DOI: 10.1097/ftd.0000000000000799] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Voriconazole (VRCZ) is an antifungal triazole recommended as an effective first-line agent for treating invasive aspergillosis. OBJECTIVES To develop a population pharmacokinetic model of VRCZ and trough concentration-based dosing simulation for dynamic patient conditions. METHODS The authors combined plasma VRCZ data from intensive sampling, and retrospective trough concentration monitoring for analysis. Nonlinear mixed-effects modeling with subsequent model validation was performed. The recommended dosage regimens were simulated based on the developed model. RESULTS The study participants included 106 patients taking oral VRCZ. A linear one-compartment model with first-order elimination and absorption best described the observed data. The CYP2C19 phenotypes did not influence the pharmacokinetic parameters. Serum albumin (SA) levels and gamma-glutamyl transferase significantly correlated with the VRCZ clearance rate, whereas the actual body weight influenced the volume. A visual predictive check showed good consistency with the observed data, whereas SA levels across the treatment course correlated with linear clearance, irrespective of the CYP2C19 phenotype. Patients with SA levels ≤30 g/L had lower linear clearance than that in patients with SA levels >30 g/L. Dosing simulation based on the developed model indicated that patients with SA levels of ≤30 g/L required a lower daily maintenance dose to attain the therapeutic trough level. CONCLUSIONS SA level was identified as a novel marker associated with VRCZ clearance. This marker may be a practical choice for physicians to perform therapeutic drug monitoring and optimize VRCZ dosage.
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Machida M, Nakamura I, Sato A, Nakamura S, Miyazaki Y, Watanabe H. Hypertrophic pachymeningitis caused by Schizophyllum sp.: a novel case report. Infection 2020; 49:775-779. [PMID: 33156492 DOI: 10.1007/s15010-020-01544-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/23/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The pathogenic fungus Schizophyllum sp. can cause allergic fungal rhinosinusitis and allergic bronchopulmonary mycosis in humans. Sinus and lung infections due to Schizophyllum sp. have been reported globally; however, no case of hypertrophic pachymeningitis due to this pathogen has been reported yet. Herein, we describe for the first time, a case of hypertrophic pachymeningitis due to Schizophyllum sp. CASE PRESENTATION A 69-year-old woman visited the hospital with chief complaints of headache, right trigeminal neuralgia (third branch), ataxic gait, and deafness in the right ear. Magnetic resonance imaging revealed a tumor in the right sphenoidal sinus and thickening of the dura mater surrounding the right porus acusticus internus. Endoscopic sinus surgery and neuroendoscopic biopsy were performed to remove sinus lesions and intracranial lesions, respectively. Both pathological specimens showed findings indicative of filamentous fungi on Grocott's staining. DNA sequencing with the sinus specimen revealed Schizophyllum sp. as the causative pathogen, consistent with the diagnosis of fungal sinusitis and hypertrophic pachymeningitis. Intravenous liposomal amphotericin B was started, but owing to lack of improvement, the treatment was switched to intravenous voriconazole. We observed improvements in both radiological findings and symptoms. However, the symptoms exacerbated again when the trough level of voriconazole decreased. Upon increasing the voriconazole dose, a higher trough level was obtained and the symptoms improved. CONCLUSION Our study suggests that when symptoms of central nervous system infection due to Schizophyllum sp. do not improve with liposomal amphotericin B, voriconazole can be administered at high trough levels to improve the symptoms.
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Affiliation(s)
- Masaki Machida
- Tokyo Medical University Hospital, Department of Infection Prevention and Control, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.,Tokyo Medical University, Department of Preventive Medicine and Public Health, 6-1-1 Shinjuku, Shinjuku-ku, Tokyo, 160-8402, Japan
| | - Itaru Nakamura
- Tokyo Medical University Hospital, Department of Infection Prevention and Control, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Akihiro Sato
- KARADA Internal Medicine Clinic, 1-2-8-10 Nishigotanda, Shinagawa-ku, Tokyo, 141-0031, Japan
| | - Shigeki Nakamura
- Tokyo Medical University, Department of Microbiology, 6-1-1 Shinjuku, Shinjuku-ku, Tokyo, 160-8402, Japan
| | - Yoshitsugu Miyazaki
- National Institute of Infectious Diseases, Department of Chemotherapy and Mycoses, 1-23-1Shinjuku-ku, Toyama, 162-8640, Japan
| | - Hidehiro Watanabe
- Tokyo Medical University Hospital, Department of Infection Prevention and Control, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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Amanati A, Badiee P, Lotfi M, Monabati A, Faghihi MA, Yavarian M, Hatami Mazinani N. Generalized exfoliative skin rash as an early predictor of supratherapeutic voriconazole trough levels in a leukemic child: A case report. Curr Med Mycol 2020; 6:73-78. [PMID: 33834148 PMCID: PMC8018824 DOI: 10.18502/cmm.6.3.4500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background and Purpose: Skin rashes, mostly seen in children and adolescents, are considered among the most common side effects of azole antifungals. Although therapeutic concentrations of voriconazole (VCZ) have been documented for infected skin, there is no evidence specifying whether specific dermatologic side effects could predict high VCZ serum concentration, especially in high-risk leukemic children. Case report: Herein, we report a unique skin side effect of VCZ in a 5-year-old boy with T-cell acute lymphoblastic leukemia (ALL) referred to Amir Medical Oncology Center in Shiraz, Iran. The patient experienced erythroderma and macular rashes shortly after VCZ consumption, leading to generalized exfoliative skin rashes. Concurrent to these skin manifestations, VCZ serum concentration reached the supratherapeutic levels despite the recommended VCZ doses. As a result, VCZ was withheld, and the patient was treated with caspofungin. The lesions were resolved gradually within 2 weeks, and the patient successfully completed his treatment course with caspofungin. Conclusion: The unique case presented in this study emphasizes the need for a high index of suspicion for VCZ toxicity in any patient with atypical dermatologic manifestations, especially generalized exfoliative skin rashes. Based on this report, VCZ supratherapeutic concentration could be predicted early in the course of treatment. Additional therapeutic dose monitoring should be considered to establish a confirmatory diagnosis. It is required to further investigate the toxic effect of high VCZ concentration on the skin epithelium.
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Affiliation(s)
- Ali Amanati
- Professor Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parisa Badiee
- Professor Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrzad Lotfi
- Medical Imaging Research Center, Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ahmad Monabati
- Department of Hematopathology, Molecular Pathology and Cytogenetics, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Ali Faghihi
- Center for Therapeutic Innovation, Department of Psychiatry and Behavioral Sciences, University of Miami, Miami, USA.,Persian Bayan Gene Research and Training Center, Shiraz, Iran
| | - Majid Yavarian
- Persian Bayan Gene Research and Training Center, Shiraz, Iran.,Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nazafarin Hatami Mazinani
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
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Blanco-Dorado S, Maroñas O, Latorre-Pellicer A, Rodríguez Jato MT, López-Vizcaíno A, Gómez Márquez A, Bardán García B, Belles Medall D, Barbeito Castiñeiras G, Pérez Del Molino Bernal ML, Campos-Toimil M, Otero Espinar F, Blanco Hortas A, Durán Piñeiro G, Zarra Ferro I, Carracedo Á, Lamas MJ, Fernández-Ferreiro A. Impact of CYP2C19 Genotype and Drug Interactions on Voriconazole Plasma Concentrations: A Spain Pharmacogenetic-Pharmacokinetic Prospective Multicenter Study. Pharmacotherapy 2020; 40:17-25. [PMID: 31782536 DOI: 10.1002/phar.2351] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Voriconazole, a first-line agent for the treatment of invasive fungal infections, is mainly metabolized by cytochrome P450 (CYP) 2C19. A significant portion of patients fail to achieve therapeutic voriconazole trough concentrations, with a consequently increased risk of therapeutic failure. OBJECTIVE To show the association between subtherapeutic voriconazole concentrations and factors affecting voriconazole pharmacokinetics: CYP2C19 genotype and drug-drug interactions. METHODS Adults receiving voriconazole for antifungal treatment or prophylaxis were included in a multicenter prospective study conducted in Spain. The prevalence of subtherapeutic voriconazole troughs was analyzed in the rapid metabolizer and ultra-rapid metabolizer patients (RMs and UMs, respectively), and compared with the rest of the patients. The relationship between voriconazole concentration, CYP2C19 phenotype, adverse events (AEs), and drug-drug interactions was also assessed. RESULTS In this study 78 patients were included with a wide variability in voriconazole plasma levels with only 44.8% of patients attaining trough concentrations within the therapeutic range of 1 and 5.5 µg/ml. The allele frequency of *17 variant was found to be 29.5%. Compared with patients with other phenotypes, RMs and UMs had a lower voriconazole plasma concentration (RM/UM: 1.85 ± 0.24 µg/ml vs other phenotypes: 2.36 ± 0.26 µg/ml). Adverse events were more common in patients with higher voriconazole concentrations (p<0.05). No association between voriconazole trough concentration and other factors (age, weight, route of administration, and concomitant administration of enzyme inducer, enzyme inhibitor, glucocorticoids, or proton pump inhibitors) was found. CONCLUSION These results suggest the potential clinical utility of using CYP2C19 genotype-guided voriconazole dosing to achieve concentrations in the therapeutic range in the early course of therapy. Larger studies are needed to confirm the impact of pharmacogenetics on voriconazole pharmacokinetics.
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Affiliation(s)
- Sara Blanco-Dorado
- Pharmacy Department, University Clinical Hospital Santiago de Compostela (CHUS), Santiago de Compostela, Spain.,Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), University Clinical Hospital, Santiago de Compostela, Spain.,Department of Pharmacology, Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - Olalla Maroñas
- Genomic Medicine Group, Centro Nacional de Genotipado (CEGEN-PRB3), CIBERER, CIMUS, University of Santiago de Compostela (USC), Santiago de Compostela, Spain.,Galician Foundation of Genomic Medicine, Health Research Institute of Santiago de Compostela (IDIS), SERGAS, Santiago de Compostela, Spain
| | - Ana Latorre-Pellicer
- Genomic Medicine Group, Centro Nacional de Genotipado (CEGEN-PRB3), CIBERER, CIMUS, University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - María Teresa Rodríguez Jato
- Pharmacy Department, University Clinical Hospital Santiago de Compostela (CHUS), Santiago de Compostela, Spain
| | - Ana López-Vizcaíno
- Pharmacy Department, University Hospital Lucus Augusti (HULA), Lugo, Spain
| | | | | | | | - Gema Barbeito Castiñeiras
- Microbiology Department, University Clinical Hospital Santiago de Compostela (CHUS), Santiago de Compostela, Spain
| | | | - Manuel Campos-Toimil
- Department of Pharmacology, Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - Francisco Otero Espinar
- Department of Pharmacology, Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - Andrés Blanco Hortas
- Epidemiology Unit, Fundación Instituto de Investigación Sanitaria de Santiago de Compostela (FIDIS), University Hospital Lucus Augusti (HULA), Lugo, Spain
| | - Goretti Durán Piñeiro
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), University Clinical Hospital, Santiago de Compostela, Spain
| | - Irene Zarra Ferro
- Pharmacy Department, University Clinical Hospital Santiago de Compostela (CHUS), Santiago de Compostela, Spain.,Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), University Clinical Hospital, Santiago de Compostela, Spain
| | - Ángel Carracedo
- Genomic Medicine Group, Centro Nacional de Genotipado (CEGEN-PRB3), CIBERER, CIMUS, University of Santiago de Compostela (USC), Santiago de Compostela, Spain.,Galician Foundation of Genomic Medicine, Health Research Institute of Santiago de Compostela (IDIS), SERGAS, Santiago de Compostela, Spain
| | - María Jesús Lamas
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), University Clinical Hospital, Santiago de Compostela, Spain
| | - Anxo Fernández-Ferreiro
- Pharmacy Department, University Clinical Hospital Santiago de Compostela (CHUS), Santiago de Compostela, Spain.,Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), University Clinical Hospital, Santiago de Compostela, Spain.,Department of Pharmacology, Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Santiago de Compostela (USC), Santiago de Compostela, Spain
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Tanaka R, Fujioka T, Suzuki Y, Iwao M, Itoh H. A Prospective Study on the Usefulness of Initial Voriconazole Dose Adjustment Based on CYP2C19 Gene Polymorphism Analysis. Chemotherapy 2020; 65:59-64. [PMID: 32877905 DOI: 10.1159/000509970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/27/2020] [Indexed: 11/19/2022]
Abstract
Genetic polymorphism exists for CYP2C19, a dominant metabolic enzyme of voriconazole (VRCZ), and VRCZ pharmacokinetics has been shown to fluctuate according to the CYP2C19 phenotype. Although dosages for different phenotypes have been recommended in various retrospective studies, few reports have adjusted the initial VRCZ dose based on CYP2C19 phenotype determined prior to administration. In this study, we prospectively evaluated the usefulness of CYP2C19 polymorphism analysis in adjusting the initial VRCZ maintenance dose. The study enrolled 19 patients who underwent analysis of CYP2C19 polymorphism prior to VRCZ administration. Subjects were classified into 3 phenotype subgroups: extensive metabolizer (EM), intermediate metabolizer (IM), and poor metabolizer (PM). The initial VRCZ maintenance doses given twice daily were proposed as follows: approximately 8, 6, and 4 mg/kg/day for EM, IM and PM, respectively, according to previous reports. In EM, the initial maintenance dose was 8.0 ± 0.5 mg/kg/day, and trough level was 6.6 ± 2.4 μg/mL. By contrast, the initial maintenance doses in IM and PM were 5.5 ± 0.7 and 4.1 ± 0.3 mg/kg/day, and the initial trough concentrations were 2.9 ± 1.2 and 2.6 ± 0.4 μg/mL, respectively. The attainment rate of target trough concentration of 1-6 μg/mL was 50% in EM, and was 100% in IM and PM. Determining the initial dose of VRCZ only by phenotype based on CYP2C19 gene polymorphism was found to be challenging. However, decreasing the initial maintenance dose in IM and PM may be important for adjusting the initial trough level to target range.
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Affiliation(s)
- Ryota Tanaka
- Department of Clinical Pharmacy, Oita University Hospital, Oita, Japan,
| | - Takashi Fujioka
- Department of Clinical Pharmacy, Oita University Hospital, Oita, Japan
| | - Yosuke Suzuki
- Department of Clinical Pharmacy, Oita University Hospital, Oita, Japan
| | - Motoshi Iwao
- Department of Clinical Pharmacy, Oita University Hospital, Oita, Japan
| | - Hiroki Itoh
- Department of Clinical Pharmacy, Oita University Hospital, Oita, Japan
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Isavuconazole Treatment of Cerebral and Pulmonary Aspergillosis in a Pediatric Patient With Acute Lymphoblastic Leukemia: Case Report and Review of Literature. J Pediatr Hematol Oncol 2020; 42:e469-e471. [PMID: 31094909 DOI: 10.1097/mph.0000000000001508] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Invasive aspergillosis in hematologic pediatric patients is an opportunistic infection that is difficult to treat, with a high mortality rate when localized in the central nervous system. We are describing a 3-year-old girl who was affected by acute lymphoblastic leukemia who developed cerebral and pulmonary aspergillosis during induction chemotherapy. The patient failed first-line voriconazole treatment because of being a CYP2C19 ultrarapid metabolizer and received effective isavuconazole therapy with no notable side effects.
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Abdul-Aziz MH, Alffenaar JWC, Bassetti M, Bracht H, Dimopoulos G, Marriott D, Neely MN, Paiva JA, Pea F, Sjovall F, Timsit JF, Udy AA, Wicha SG, Zeitlinger M, De Waele JJ, Roberts JA. Antimicrobial therapeutic drug monitoring in critically ill adult patients: a Position Paper .. Intensive Care Med 2020; 46:1127-1153. [PMID: 32383061 PMCID: PMC7223855 DOI: 10.1007/s00134-020-06050-1] [Citation(s) in RCA: 463] [Impact Index Per Article: 115.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/10/2020] [Indexed: 12/12/2022]
Abstract
Purpose This Position Paper aims to review and discuss the available data on therapeutic drug monitoring (TDM) of antibacterials, antifungals and antivirals in critically ill adult patients in the intensive care unit (ICU). This Position Paper also provides a practical guide on how TDM can be applied in routine clinical practice to improve therapeutic outcomes in critically ill adult patients.
Methods Literature review and analysis were performed by Panel Members nominated by the endorsing organisations, European Society of Intensive Care Medicine (ESICM), Pharmacokinetic/Pharmacodynamic and Critically Ill Patient Study Groups of European Society of Clinical Microbiology and Infectious Diseases (ESCMID), International Association for Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT) and International Society of Antimicrobial Chemotherapy (ISAC). Panel members made recommendations for whether TDM should be applied clinically for different antimicrobials/classes. Results TDM-guided dosing has been shown to be clinically beneficial for aminoglycosides, voriconazole and ribavirin. For most common antibiotics and antifungals in the ICU, a clear therapeutic range has been established, and for these agents, routine TDM in critically ill patients appears meritorious. For the antivirals, research is needed to identify therapeutic targets and determine whether antiviral TDM is indeed meritorious in this patient population. The Panel Members recommend routine TDM to be performed for aminoglycosides, beta-lactam antibiotics, linezolid, teicoplanin, vancomycin and voriconazole in critically ill patients. Conclusion Although TDM should be the standard of care for most antimicrobials in every ICU, important barriers need to be addressed before routine TDM can be widely employed worldwide. Electronic supplementary material The online version of this article (10.1007/s00134-020-06050-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia
| | - Jan-Willem C Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Westmead Hospital, Westmead, NSW, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa, Genoa and Hospital Policlinico San Martino - IRCCS, Genoa, Italy
| | - Hendrik Bracht
- Department of Anaesthesiology, University Ulm, Ulm, Germany
| | - George Dimopoulos
- Department of Critical Care, University Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
| | - Deborah Marriott
- Department of Microbiology and Infectious Diseases, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Michael N Neely
- Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Division of Infectious Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jose-Artur Paiva
- Department of Medicine, Faculty of Medicine of Porto, Porto, Portugal.,Department of Emergency and Intensive Care Medicine, Centro Hospitalar Universitario de São João, Porto, Portugal
| | - Federico Pea
- Institute of Clinical Pharmacology, SM Misericordia University Hospital, ASUFC, Udine, Italy
| | - Fredrik Sjovall
- Department of Perioperative Medicine, Skåne University Hospital, Malmö, Sweden
| | - Jean F Timsit
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, Paris, France.,Infection, Antimicrobials, Modelling, Evolution (IAME), Paris Diderot University, Paris, France
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia. .,Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia. .,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia. .,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
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The First Case Report of Septic Arthritis and Osteomyelitis of the Knee Caused by Candida viswanathii. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2020. [DOI: 10.1097/ipc.0000000000000813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Therapeutic Drug Monitoring of Antifungal Drugs: Another Tool to Improve Patient Outcome? Infect Dis Ther 2020; 9:137-149. [PMID: 32026399 PMCID: PMC7054538 DOI: 10.1007/s40121-020-00280-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Indexed: 01/28/2023] Open
Abstract
Introduction This study aimed to examine the relationship among adequate dose, serum concentration and clinical outcome in a non-selected group of hospitalized patients receiving antifungals. Methods Prospective cross-sectional study performed between March 2015 and June 2015. Dosage of antifungals was considered adequate according to the IDSA guidelines, whereas trough serum concentrations (determined with HPLC) were considered adequate as follows: fluconazole > 11 µg/ml, echinocandins > 1 µg/ml, voriconazole 1–5.5 µg/ml and posaconazole > 0.7 µg/ml. Results During the study period, 84 patients (65.4% male, 59.6 years) received antifungals for prophylaxis (40.4%), targeted (31.0%) and empirical therapy (28.6%). The most frequent drug was micafungin (28/84; 33.3%) followed by fluconazole (23/84; 27.4%), voriconazole (15/84; 17.9%), anidulafungin (8/84; 9.5%), posaconazole (7/84; 8.3%) and caspofungin (3/84; 3.6%). Considerable interindividual variability was observed for all antifungals with a large proportion of the patients (64.3%) not attaining adequate trough serum concentrations, despite receiving an adequate antifungal dose. Attaining the on-target serum antifungal level was significantly associated with a favorable clinical outcome (OR = 0.02; 95% CI 0.01–0.64; p = 0.03), whereas the administration of an adequate antifungal dosage was not. Conclusions With the standard antifungal dosage, a considerable proportion of patients have low drug concentrations, which are associated with poor clinical outcome.
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Zhou PY, Lim TP, Tang SLS, Liew Y, Chua SGN, Lim LLC, Lee HLW, Tan SX, Lai OF, Tan TT, Wong GC, Kwa LHA. The utility of voriconazole therapeutic drug monitoring in a multi-racial cohort in Southeast Asia. J Glob Antimicrob Resist 2019; 21:427-433. [PMID: 31846723 DOI: 10.1016/j.jgar.2019.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/04/2019] [Accepted: 12/09/2019] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Voriconazole serum concentration, which is affected by several factors, is associated with treatment response and toxicity. There is paucity of data on voriconazole therapeutic drug monitoring (TDM) among Southeast Asians, who exhibit a higher prevalence of CYP2C19-poor metabolisers compared with Caucasians and East Asians. Hence, there are concerns for higher risk of voriconazole accumulation and toxicity. We aim to determine the utility of voriconazole TDM through establishing: (1) proportion of patients achieving therapeutic troughs without dose adjustments; (2) characterisation of patients with sub-therapeutic, therapeutic and supra-therapeutic levels; (3) appropriate dose titrations/dose required for therapeutic troughs; (4) correlation between troughs and adverse events, treatment response/fungal breakthrough. PATIENTS AND METHODS A single-centre retrospective analysis of data from adults (≥21 years old) with ≥1 voriconazole trough measured at Singapore General Hospital from 2015 to 2017 was performed. RESULTS Thirty-two patients (45.7%) among 70 patients achieved therapeutic troughs (defined as 2.0-5.5 mg/L) without dose adjustments. Eleven patients (15.7%) experienced hepatotoxicity (troughs 0.5 to >7.5 mg/L). Neurotoxicity occurred in three patients (4.3%) (troughs ≥6.7 mg/L) and all patients had symptom resolution upon dose reduction. Treatment failure of invasive fungal infection appeared less in patients with therapeutic troughs compared with sub-therapeutic troughs (11.4% vs. 14.2%). Two patients experienced treatment failure despite supra-therapeutic voriconazole troughs. CONCLUSIONS TDM should be implemented due to significant unpredictability in dose exposure. TDM can reduce unnecessary switches to alternatives due to intolerability and rule in the possibility of resistant organisms in the event of treatment failure despite therapeutic troughs, alerting clinicians to switch to alternatives promptly.
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Affiliation(s)
- Peijun Yvonne Zhou
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | - Tze Peng Lim
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | - Si Lin Sarah Tang
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | - Yixin Liew
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | | | - Li Ling Cheryl Lim
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | | | - Si Xuan Tan
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | - Oi Fah Lai
- Department of Clinical Translational Research, Singapore General Hospital, Singapore, Singapore
| | - Thuan Tong Tan
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore
| | - Gee Chuan Wong
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Lay Hoon Andrea Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore; Emerging Infectious Diseases, Duke-NUS Medical School, Singapore, Singapore; Singhealth Duke-NUS Medicine Academic Clinical Programme, Singapore, Singapore.
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36
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Yamada T, Mino Y, Naito T, Kawakami J. Impact of flavin-containing monooxygenase 3 and CYP2C19 genotypes on plasma disposition and adverse effects of voriconazole administered orally in immunocompromised patients. J Infect Chemother 2019; 25:1019-1025. [DOI: 10.1016/j.jiac.2019.05.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 05/27/2019] [Accepted: 05/29/2019] [Indexed: 11/29/2022]
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A phase I dose finding study of intravenous voriconazole in pediatric patients undergoing hematopoietic cell transplantation. Bone Marrow Transplant 2019; 55:955-964. [PMID: 31768008 DOI: 10.1038/s41409-019-0757-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/06/2019] [Accepted: 11/13/2019] [Indexed: 11/08/2022]
Abstract
To optimize voriconazole dosing in pediatric hematopoietic cell transplantation (HCT), we conducted a phase I study with a modified 3 + 3 dose-escalation followed by an expansion cohort at the maximum tolerated, minimum efficacious dose (MTD/MED). Patients ≤21 years who required voriconazole for prevention or treatment of an invasive fungal infection were assigned to three age groups. Of the 59 evaluable patients, 13 were <2 years, 23 were 2-11, and 23 were 12-21. Therapeutic serum voriconazole troughs (1.5-5 µg/mL) drawn at 7 days after initiation determined efficacy. The MTD/MED was 12 mg/kg/dose q12 h × 2 loading doses, then 10 mg/kg/dose q12 h in patients <2, and was 10 mg/kg/dose q12 h in patients 2-11. The 12-21 age group had no dose-limiting toxicity at 8 mg/kg/dose q12 h; however, the MED was not reached. Drug-related AEs ≥grade 3 included increased bilirubin, transaminases, and creatinine, all occurring in <10%. There was no significant association between supra-therapeutic troughs and AEs. Five of 17 patients who had supra-therapeutic troughs (29%) had an AE, compared to 8 of 42 who did not (19%, p = 0.38). Observational population pharmacokinetic analysis demonstrated that inter-individual variability on voriconazole clearance was >100% CV, and clearance increased with age.
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38
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Hicks JK, Quilitz RE, Komrokji RS, Kubal TE, Lancet JE, Pasikhova Y, Qin D, So W, Caceres G, Kelly K, Salchert YS, Shahbazian K, Abbas-Aghababazadeh F, Fridley BL, Velez AP, McLeod HL, Greene JN. Prospective CYP2C19-Guided Voriconazole Prophylaxis in Patients With Neutropenic Acute Myeloid Leukemia Reduces the Incidence of Subtherapeutic Antifungal Plasma Concentrations. Clin Pharmacol Ther 2019; 107:563-570. [PMID: 31549389 DOI: 10.1002/cpt.1641] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 09/14/2019] [Indexed: 11/11/2022]
Abstract
A risk mitigation strategy was implemented to determine if a higher prophylactic voriconazole dosage in patients with CYP2C19 rapid metabolizer neutropenic acute myeloid leukemia (AML) reduces the incidence of subtherapeutic trough concentrations. Patients with AML (n = 263) were preemptively genotyped for CYP2C19*2, *3, and *17 alleles as part of a single-center prospective, interventional, quality improvement study. CYP2C19 rapid metabolizers (CYP2C19*1/*17) were recommended to receive interventional voriconazole 300 mg twice daily, ultrarapid metabolizers (CYP2C19*17/*17) were recommended to avoid voriconazole, and all others received the standard prophylactic dosage of 200 mg twice daily. In this real-world setting, 202 patients (76.8%) were prescribed prophylactic voriconazole, and of these patients 176 (87.1%) received CYP2C19-guided prophylactic dosing. Voriconazole trough concentrations were obtained for 41 of the 58 (70.7%) CYP2C19 rapid metabolizers prescribed prophylactic voriconazole. Interventional voriconazole resulted in higher plasma trough concentrations (median 2.7 μg/mL) compared with the standard prophylactic dosage (median 0.6 μg/mL; P = 0.001). Subtherapeutic concentrations were avoided in 83.8% of CYP2C19 rapid metabolizers receiving interventional dosage compared to 46.2% receiving standard dosage (P = 0.02). CYP2C19 genotyping to preemptively guide prophylactic voriconazole dosing is feasible and may be a potential strategy for reducing the risk of subtherapeutic trough concentrations that potentiate breakthrough fungal infections.
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Affiliation(s)
- J Kevin Hicks
- Department of Individualized Cancer Management, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Rod E Quilitz
- Department of Pharmacy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Rami S Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Timothy E Kubal
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Jeffrey E Lancet
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Yanina Pasikhova
- Department of Pharmacy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Dahui Qin
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Wonhee So
- Department of Pharmacy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Gisela Caceres
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Kerry Kelly
- Department of Clinical Informatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Yasmina S Salchert
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Kevin Shahbazian
- Department of Individualized Cancer Management, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Farnoosh Abbas-Aghababazadeh
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Brooke L Fridley
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Ana P Velez
- Department of Infectious Disease, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Howard L McLeod
- Department of Individualized Cancer Management, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - John N Greene
- Department of Infectious Disease, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
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Patel JN, Hamadeh IS, Robinson M, Shahid Z, Symanowski J, Steuerwald N, Hamilton A, Reese ES, Plesca DC, Arnall J, Taylor M, Trivedi J, Grunwald MR, Gerber J, Ghosh N, Avalos B, Copelan E. Evaluation of CYP2C19 Genotype-Guided Voriconazole Prophylaxis After Allogeneic Hematopoietic Cell Transplant. Clin Pharmacol Ther 2019; 107:571-579. [PMID: 31549386 DOI: 10.1002/cpt.1642] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 07/22/2019] [Indexed: 01/09/2023]
Abstract
There is a high risk of voriconazole failure in those with subtherapeutic drug concentrations, which is more common in CYP2C19 (cytochrome P450 2C19) rapid/ultrarapid metabolizers (RMs/UMs). We evaluated CYP2C19 genotype-guided voriconazole dosing on drug concentrations and clinical outcomes in adult allogeneic hematopoietic cell transplant recipients. Poor (PMs), intermediate (IMs), and normal metabolizers (NMs) received voriconazole 200 mg twice daily; RMs/UMs received 300 mg twice daily. Steady-state trough concentrations were obtained after 5 days, targeting 1.0-5.5 mg/L. Of 89 evaluable patients, 29% had subtherapeutic concentrations compared with 50% in historical controls (P < 0.001). Zero, 26%, 50%, and 16% of PMs, IMs, NMs, and RMs/UMs were subtherapeutic. Voriconazole success rate was 78% compared with 54% in historical controls (P < 0.001). No patients experienced an invasive fungal infection (IFI). Genotype-guided dosing resulted in $4,700 estimated per patient savings as compared with simulated controls. CYP2C19 genotype-guided voriconazole dosing reduced subtherapeutic drug concentrations and effectively prevented IFIs.
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Affiliation(s)
- Jai N Patel
- Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Issam S Hamadeh
- Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Myra Robinson
- Department of Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Zainab Shahid
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - James Symanowski
- Department of Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Nury Steuerwald
- Molecular Biology Core Laboratory, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Alicia Hamilton
- Molecular Biology Core Laboratory, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Emily S Reese
- Translational Research, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Dragos C Plesca
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Justin Arnall
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Margaret Taylor
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Jigar Trivedi
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Jonathan Gerber
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Health Care, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Nilanjan Ghosh
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Belinda Avalos
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Edward Copelan
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
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Nield B, Larsen SR, van Hal SJ. Clinical experience with new formulation SUBA®-itraconazole for prophylaxis in patients undergoing stem cell transplantation or treatment for haematological malignancies. J Antimicrob Chemother 2019; 74:3049-3055. [DOI: 10.1093/jac/dkz303] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/01/2019] [Accepted: 06/14/2019] [Indexed: 01/09/2023] Open
Abstract
AbstractBackgroundSUper BioAvailability-itraconazole (SUBA®-itraconazole) was introduced into Australia in April 2014 as a substitute for standard itraconazole on the basis of improved bioavailability, tolerance and interpatient variability. Shortly after its introduction, our centre converted to the novel formulation for mould prophylaxis in patients undergoing allogeneic HSCT, autologous HSCT or treatment for haematological malignancies with an intermediate/high risk of invasive fungal infection (IFI).MethodsA single-institution, investigator-initiated retrospective cohort study was conducted between June 2016 and April 2018 to assess therapeutic drug concentrations, safety and tolerability of a standard prophylactic dose of SUBA®-itraconazole.ResultsA total of 74 patients were assessed across 98 admissions with 178 measured itraconazole trough concentrations. The median duration of prophylaxis was 15.5 (1–59) days. No significant correlation was identified between trough concentrations and patient demographics including gender and weight. Drug concentrations were reduced by gastric acid suppression and diarrhoea. Therapeutic itraconazole trough concentrations (≥0.5 mg/L) were achieved at a median of 7 (95% CI = 6–8) days, with 87% of patients achieving therapeutic concentrations at day 14 (expected steady-state). One (1%) proven/probable IFI and 5 (5%) possible breakthrough IFIs were identified. Although adverse events were experienced by 42% of the cohort, only a single event was directly attributable to SUBA®-itraconazole, resulting in change of prophylactic agent.ConclusionsSUBA®-itraconazole achieved rapid therapeutic trough concentrations, was associated with low rates of IFI and was well tolerated in the study population. This formulation should be considered a realistic and safe first-line agent for the prevention of IFIs in those undergoing HSCT and intermediate/high-risk therapy for haematological malignancies.
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Affiliation(s)
- Blake Nield
- Department of Microbiology and Infectious Disease, Royal Prince Alfred Hospital, Sydney, Australia
| | - Stephen R Larsen
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Sebastiaan J van Hal
- Department of Microbiology and Infectious Disease, Royal Prince Alfred Hospital, Sydney, Australia
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Ruiz J, Gordon M, Villarreal E, Peruccioni M, Marqués MR, Poveda-Andrés JL, Castellanos-Ortega Á, Ramirez P. Impact of voriconazole plasma concentrations on treatment response in critically ill patients. J Clin Pharm Ther 2019; 44:572-578. [PMID: 30851209 DOI: 10.1111/jcpt.12817] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/13/2019] [Accepted: 01/18/2019] [Indexed: 12/21/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Several authors have demonstrated the relationship between voriconazole concentrations and the risk of therapeutic failure and adverse events However, the information about voriconazole concentrations in the critically ill patient is scarce. The aim of this study was to analyse the plasma concentrations and pharmacokinetic behaviour of voriconazole in critically ill patients and their association with the treatment response and development of toxicity. METHODS A prospective, observational study was conducted. Patients admitted to an intensive care unit and on treatment with intravenous voriconazole were included. Plasma concentrations were measured between days 4 and 7 from the start of the treatment. The pharmacokinetic analysis was performed using the NONMEM® software. A regression model was used to evaluate the variables associated with the values outside the therapeutic range, as well as the relationship between the plasma concentrations and the treatment response and the development of hepatotoxicity. RESULTS AND DISCUSSION A total of 33 patients were included. Plasma concentrations outside the therapeutic range (1-5.5 mg/L) were observed in 15 patients, being above the established range in 9 (27.3%) cases, and below it in 6 (18.2%) cases. The presence of a bilirubin value of >1.5 mg/dL and a C-reactive protein >100 mg/dL was associated with supra-therapeutic concentrations. Voriconazole concentrations greater than 5.5 mg/dL were associated with the development of hepatotoxicity. WHAT IS NEW AND CONCLUSIONS There is a wide variation in voriconazole concentrations in critically ill patients, being associated with a high frequency of adverse events. Close monitoring of these values is required in order to decrease the risk of therapeutic failure and toxicity.
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Affiliation(s)
- Jesus Ruiz
- Intensive Care Unit, IIS La Fe. Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Mónica Gordon
- Intensive Care Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Esther Villarreal
- Intensive Care Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Marcela Peruccioni
- Intensive Care Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | | | | | - Paula Ramirez
- Intensive Care Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Kirbs C, Kluwe F, Drescher F, Lackner E, Matzneller P, Weiss J, Zeitlinger M, Kloft C. High voriconazole target-site exposure after approved sequence dosing due to nonlinear pharmacokinetics assessed by long-term microdialysis. Eur J Pharm Sci 2019; 131:218-229. [PMID: 30731238 DOI: 10.1016/j.ejps.2019.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 12/20/2018] [Accepted: 02/03/2019] [Indexed: 01/18/2023]
Abstract
Voriconazole, a broad-spectrum antifungal drug used to prevent and treat invasive fungal infections, shows complex pharmacokinetics and is primarily metabolised by various CYP enzymes. An adequate unbound antibiotic concentration-time profile at the target-site of an infection is crucial for effective prophylaxis or therapy success. Therefore, the aim was to evaluate the pharmacokinetics of voriconazole after the approved sequence dosing in healthy volunteers in interstitial space fluid, assessed by microdialysis, and in plasma. Moreover, potential pharmacogenetic influences of CYP2C19 polymorphisms on pharmacokinetics were investigated. The prospective, open-labelled, uncontrolled long-term microdialysis study included 9 healthy male individuals receiving the approved sequence dosing regimen for voriconazole. Unbound voriconazole concentrations were sampled over 84 h in interstitial space fluid of subcutaneous adipose tissue and in plasma and subsequently quantified via high-performance liquid chromatography. For pharmacokinetic data analysis, non-compartmental analysis was used. High interindividual variability in voriconazole concentration-time profiles was detected although dosing was adapted to body weight for the first intravenous administrations. Due to nonlinear pharmacokinetics, target-site exposure of voriconazole in healthy volunteers was found to be highly comparable to plasma exposure, particularly after multiple dosing. Regarding the CYP2C19 genotype-predicted phenotype, the individuals revealed a broad spectrum, ranging from poor to rapid metaboliser status. A strong relation between CYP2C19 genotype-predicted phenotype and voriconazole clearance was identified.
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Affiliation(s)
- Claudia Kirbs
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany; Department of Clinical Pharmacy, Institute of Pharmacy, Martin-Luther-Universitaet Halle-Wittenberg, Wolfgang-Langenbeck-Straße 4, 06120 Halle (Saale), Germany.
| | - Franziska Kluwe
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany; Graduate Research Training Program PharMetrX, Germany.
| | - Franziska Drescher
- Department of Clinical Pharmacy, Institute of Pharmacy, Martin-Luther-Universitaet Halle-Wittenberg, Wolfgang-Langenbeck-Straße 4, 06120 Halle (Saale), Germany
| | - Edith Lackner
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Peter Matzneller
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Johanna Weiss
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany.
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany; Department of Clinical Pharmacy, Institute of Pharmacy, Martin-Luther-Universitaet Halle-Wittenberg, Wolfgang-Langenbeck-Straße 4, 06120 Halle (Saale), Germany.
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Validation of a Reversed-Phase Ultra-High-Performance Liquid Chromatographic Method With Photodiode Array Detection for the Determination of Voriconazole in Human Serum and Its Application to Therapeutic Drug Monitoring. Ther Drug Monit 2018; 40:276-283. [PMID: 29432386 DOI: 10.1097/ftd.0000000000000491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Voriconazole is a broad-spectrum triazole antifungal agent. It is widely used in the treatment of invasive fungal infections in immunocompromised patients. Because the pharmacokinetics of voriconazole demonstrates considerable variability, monitoring its serum levels plays an important role in optimizing therapies against many clinically relevant fungal pathogens. The aim of this study was to validate a simple and rapid U-HPLC-PDA method with minimal sample preparation for routine therapeutic drug monitoring (TDM) of voriconazole. METHODS After protein precipitation with the internal standard solution (posaconazole 5.0 mg/L in acetonitrile), chromatographic separation was performed in 4 minutes using water and acetonitrile as mobile phases and an Acquity UPLC BEH HSS C18 column (2.1 × 100 mm, 1.7 µm). The temperature was set at 45°C and the flow rate was 0.4 mL/min. Photodiode array detection at 256 nm was used as detection system. The method was validated according international guidelines for linearity, accuracy, precision, selectivity, lower limit of quantitation, carry over, and stability under different conditions. RESULTS All performance parameters were within acceptance criteria, demonstrating that the validated method is fit for purpose. After assay validation, 115 serum samples collected from 41 patients were analyzed to report the experience of the laboratory in TDM of voriconazole. Results showed a large variability in voriconazole trough levels, suggesting that this drug should be frequently measured in patients under treatment to enhance therapies efficacy and improve safety. CONCLUSIONS In this study, a reproducible U-HPLC-PDA assay with a short analysis time, requiring only a small amount of serum, good accuracy and reproducibility was validated, which is suitable for routine TDM of voriconazole in serum.
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Mangal N, Hamadeh I, Arwood MJ, Cavallari LH, Samant TS, Klinker KP, Bulitta J, Schmidt S. Optimization of Voriconazole Therapy for the Treatment of Invasive Fungal Infections in Adults. Clin Pharmacol Ther 2018; 104:957-965. [PMID: 29315506 PMCID: PMC6037619 DOI: 10.1002/cpt.1012] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 11/10/2022]
Abstract
Therapeutic concentrations of voriconazole in invasive fungal infections (IFIs) are ensured using a drug monitoring approach, which relies on attainment of steady-state pharmacokinetics. For voriconazole, time to reach steady state can vary from 5-7 days, not optimal for critically ill patients. We developed a population pharmacokinetic/pharmacodynamic model-based approach to predict doses that can maximize the net benefit (probability of efficacy-probability of adverse events) and ensure therapeutic concentrations, early on during treatment. The label-recommended 200 mg voriconazole dose resulted in attainment of targeted concentrations in ≥80% patients in the case of Candida spp. infections, as compared to only 40-50% patients, with net benefit ranging from 5.8-61.8%, in the case of Aspergillus spp. infections. Voriconazole doses of 300-600 mg were found to maximize the net benefit up to 51-66.7%, depending on the clinical phenotype (due to CYP2C19 status and pantoprazole use) of the patient and type of Aspergillus infection.
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Affiliation(s)
- Naveen Mangal
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL
| | - Issam Hamadeh
- Levine Cancer Institute, Department of Cancer Pharmacology, Charlotte, NC
| | - Meghan J. Arwood
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL
| | | | - Kenneth P. Klinker
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL
| | - Jurgen Bulitta
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL
| | - Stephan Schmidt
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL
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Patel JN, Wiebe LA, Dunnenberger HM, McLeod HL. Value of Supportive Care Pharmacogenomics in Oncology Practice. Oncologist 2018; 23:956-964. [PMID: 29622698 PMCID: PMC6156181 DOI: 10.1634/theoncologist.2017-0599] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 02/21/2018] [Indexed: 12/14/2022] Open
Abstract
Genomic medicine provides opportunities to personalize cancer therapy for an individual patient. Although novel targeted therapies prolong survival, most patients with cancer continue to suffer from burdensome symptoms including pain, depression, neuropathy, nausea and vomiting, and infections, which significantly impair quality of life. Suboptimal management of these symptoms can negatively affect response to cancer treatment and overall prognosis. The effect of genetic variation on drug response-otherwise known as pharmacogenomics-is well documented and directly influences an individual patient's response to antiemetics, opioids, neuromodulators, antidepressants, antifungals, and more. The growing body of pharmacogenomic data can now guide clinicians to select the safest and most effective supportive medications for an individual patient with cancer from the very first prescription. This review outlines a theoretical patient case and the implications of using pharmacogenetic test results to personalize supportive care throughout the cancer care continuum. IMPLICATIONS FOR PRACTICE Integration of palliative medicine into the cancer care continuum has resulted in increased quality of life and survival for patients with many cancer types. However, suboptimal management of symptoms such as pain, neuropathy, depression, and nausea and vomiting continues to place a heavy burden on patients with cancer. As demonstrated in this theoretical case, pharmacogenomics can have a major effect on clinical response to medications used to treat these conditions. Recognizing the value of supportive care pharmacogenomics in oncology and application into routine practice offers an objective choice for the safest and most effective treatment compared with the traditional trial and error method.
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Affiliation(s)
- Jai N Patel
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina, USA
| | - Lauren A Wiebe
- NorthShore University Health System, Evanston, Illinois, USA
| | | | - Howard L McLeod
- The DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, Florida, USA
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Perreault S, McManus D, Anderson A, Lin T, Ruggero M, Topal JE. Evaluating a voriconazole dose modification guideline to optimize dosing in patients with hematologic malignancies. J Oncol Pharm Pract 2018; 25:1305-1311. [PMID: 29996736 DOI: 10.1177/1078155218786028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Voriconazole is an azole antifungal utilized for prophylaxis and treatment of invasive fungal infections in hematologic patients. Previous studies have revealed decreased efficacy and increased toxicity with subtherapeutic <1 mcg/mL and supratherapeutic > 4 mcg/mL levels. A voriconazole dose modification guideline was introduced in July 2014 based on a retrospective analysis. OBJECTIVE The primary objective was to evaluate the voriconazole dose modification guideline. Secondary objectives were to identify patient-specific characteristics that contribute to inadequate levels, adverse effects, and breakthrough invasive fungal infections. METHODS This prospective study included 128 patients with 250 admissions who received voriconazole from July 2014 to February 2016. Eligible adult patients receiving voriconazole for prophylaxis or treatment with at least one trough level, drawn appropriately, were included. Demographics, adverse effects, and breakthrough invasive fungal infections were documented. RESULTS Voriconazole use was categorized as: new start, new start with loading dose, or continuation of home therapy. The median initial levels were 1.5, 3.5, and 1.7 mcg/mL with 62% (73/119), 55% (6/11), and 60% (72/120) within the therapeutic range, respectively. Using the voriconazole dose modification guideline, 80% were within goal by the second dose adjustment. Age ≤ 30 and BMI ≤ 25 kg/m2 had higher rates of subtherapeutic levels in the new start cohorts (p = 0.024 and p = 0.009). Approximately 7.6% of patients experienced an adverse effect with neurologic/psychological being the most common. A total of 8.5% of patients had a possible, probable or proven breakthrough invasive fungal infections while on voriconazole. CONCLUSION Using the voriconazole dose modification guideline, the number of patients that reached therapeutic range improved from 36% to 80% by the second dose adjustment (p = 0.007). This voriconazole dose modification guideline can be utilized to help dose and adjust voriconazole in order to achieve therapeutic levels.
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Affiliation(s)
- Sarah Perreault
- 1 Department of Pharmacy Services, Yale-New Haven Hospital, New Haven, CT, USA
| | - Dayna McManus
- 1 Department of Pharmacy Services, Yale-New Haven Hospital, New Haven, CT, USA
| | - Anthony Anderson
- 2 Department of Pharmacy Services, University of Miami, Miami, FL, USA
| | - Tiffany Lin
- 3 Department of Pharmacy Services, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael Ruggero
- 4 Department of Pharmacy Services, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey E Topal
- 5 Department of Internal Medicine, Section of Infectious Disease, Yale-New Haven Hospital, New Haven, CT, USA
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Walldorf JA, Kishk OA, Campbell JD, Lardieri AB. Voriconazole: Poor Oral Bioavailability and Possible Renal Toxicity in an Infant With Invasive Aspergillosis. J Pediatr Pharmacol Ther 2018; 23:54-58. [DOI: 10.5863/1551-6776-23.1.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Voriconazole is the recommended agent of choice for treatment of invasive aspergillosis; however, achieving therapeutic serum concentrations while avoiding toxicity, both with intravenous and oral formulations, is challenging in infants. We report the case of an infant with confirmed invasive aspergillosis who developed renal toxicity possibly associated with IV voriconazole. Renal function improved upon withdrawal of the IV agent and switch to the oral formulation. The infant subsequently required large oral weight-based dosing to achieve therapeutic voriconazole serum concentrations. This case illustrates a rare side effect associated with voriconazole as well as the issues surrounding the pharmacokinetic profile of voriconazole in a pediatric patient.
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Abstract
BACKGROUND Routine therapeutic drug monitoring of voriconazole seems to be beneficial. This study investigated the therapeutic drug monitoring practices in intensive care to derive possible recommendations for improvement. METHODS A retrospective chart review was performed for patients aged ≥18 years who started treatment with voriconazole, which lasted for at least 3 days while being admitted to an intensive care unit to assess possible differences between the patients with and without voriconazole trough concentrations measured. RESULTS In 64 (76%) of the 84 patients, voriconazole trough concentrations were measured. The groups differed significantly with respect to the duration of voriconazole treatment and intensive care unit admission. Time of sampling was very early and therefore inappropriate for 49% of the first measured voriconazole trough concentrations and in 48% of the subsequent measured concentrations. Of the 349 trough concentrations measured, 129 (37%) were outside the therapeutic window. In 11% of these cases, no recommendation was provided without identifiable reason. In addition, 27% of recommended dose adjustments were not implemented, probably because the advice was not suited for the specific clinical situation. CONCLUSIONS The performance of voriconazole therapeutic drug monitoring can still be improved although voriconazole concentrations were monitored in most patients. A multidisciplinary approach-for instance by means of antifungal stewardship-will probably be able to overcome problems encountered such as timing of sampling, incompleteness of data in clinical context, and lack of implementation of recommendations.
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Hashemizadeh Z, Badiee P, Malekhoseini SA, Raeisi Shahraki H, Geramizadeh B, Montaseri H. Observational Study of Associations between Voriconazole Therapeutic Drug Monitoring, Toxicity, and Outcome in Liver Transplant Patients. Antimicrob Agents Chemother 2017; 61:e01211-17. [PMID: 28923870 PMCID: PMC5700347 DOI: 10.1128/aac.01211-17] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 09/11/2017] [Indexed: 01/10/2023] Open
Abstract
The aim of this study was to investigate the variability of the voriconazole plasma level and its relationships with clinical outcomes and adverse events among liver transplant recipients to optimize the efficacy and safety of their treatment. Liver transplant recipients treated with voriconazole were included, and voriconazole trough levels were quantified by a validated high-performance liquid chromatography method. Cytochrome P450 genotypes for CYP2C19 were evaluated in allograft liver tissues. A total of 832 voriconazole trough levels from 104 patients were measured. Proven, probable, and possible invasive fungal infections were reported for 8/104 (7.7%), 42/104 (40.4%), and 54/104 (51.9%) patients, respectively. Receiver operating characteristic (ROC) curve analysis indicated that trough concentrations of ≥1.3 μg/ml minimized the incidence of treatment failure (95% confidence interval [CI], 0.68 to 0.91 μg/ml) (P < 0.001) and that those of <5.3 μg/ml minimized the incidence of any adverse events (95% CI, 0.83 to 0.97 μg/ml) (P < 0.001). Voriconazole trough levels were significantly higher for heterozygous extensive metabolizers, poor metabolizers, and individuals receiving coadministration with proton pump inhibitors. For ultrarapid metabolizers, oral administration of voriconazole, and concomitant use of glucocorticoids, voriconazole blood concentrations were significantly reduced. Furthermore, there was no statistically significant association of patient age, weight, or gender or coadministration of tacrolimus and cyclosporine with the voriconazole trough level. In conclusion, the results of our analysis indicate large inter- and intraindividual variabilities of voriconazole concentrations in liver transplant recipients. Voriconazole trough concentrations of ≥1.3 μg/ml and <5.3 μg/ml are optimal for treatment and for minimization of adverse events. Optimization of drug efficacy and safety requires the use of rational doses for voriconazole therapy.
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Affiliation(s)
- Zahra Hashemizadeh
- Professor Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parisa Badiee
- Professor Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Ali Malekhoseini
- Department of Organ Transplantation, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hadi Raeisi Shahraki
- Department of Biostatistics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Bita Geramizadeh
- Department of Pathology, Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hashem Montaseri
- Department of Pharmaceutics, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
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Impact of the CYP2C19 genotype on voriconazole exposure in adults with invasive fungal infections. Pharmacogenet Genomics 2017; 27:190-196. [PMID: 28306618 DOI: 10.1097/fpc.0000000000000277] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Voriconazole, a first-line agent for the treatment of invasive fungal infections (IFIs), is metabolized by CYP2C19. A significant proportion of patients fail to achieve therapeutic trough concentrations with standard weight-based voriconazole dosing, placing them at increased risk for treatment failure, which can be life threatening. We sought to test the association between the CYP2C19 genotype and subtherapeutic voriconazole concentrations in adults with IFIs. PATIENT AND METHODS Adults receiving weight-based voriconazole dosing for the treatment of IFIs were genotyped for the CYP2C19*2, *3, and *17 polymorphisms, and CYP2C19 metabolizer phenotypes were inferred. Steady-state voriconazole trough plasma concentrations and the prevalence of subtherapeutic troughs (<2 mg/l) were compared between patients with the CYP2C19*17/*17 (ultrarapid metabolizer, UM) or *1/*17 (rapid metabolizer, RM) genotype versus those with other genotypes. Logistic regression, adjusting for clinical factors, was performed to estimate the odds of subtherapeutic concentrations. RESULTS Of 70 patients included (mean age 52.5±18 years), 39% were RMs or UMs. Compared with patients with the other phenotypes, RMs/UMs had a lower steady-state trough concentration (4.26±2.2 vs. 2.86±2.3, P=0.0093) and a higher prevalence of subtherapeutic troughs (16 vs. 52%, P=0.0028), with an odds ratio of 5.6 (95% confidence interval: 1.64-19.24, P=0.0044). CONCLUSION Our findings indicate that adults with the CYP2C19 RM or UM phenotype are more likely to have subtherapeutic concentrations with weight-based voriconazole dosing. These results corroborate previous findings in children and support the potential clinical utility of CYP2C19 genotype-guided voriconazole dosing to avoid underexposure in RMs and UMs.
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