1
|
Cave C, Ramirez R, High R, Ford J, Raulji C, Beck J. Vincristine Side Effects With Concomitant Fluconazole Use During Induction Chemotherapy in Pediatric Acute Lymphoblastic Leukemia. J Pediatr Hematol Oncol 2023; 45:e861-e866. [PMID: 36897660 DOI: 10.1097/mph.0000000000002637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/01/2023] [Indexed: 03/11/2023]
Abstract
As a mainstay of treatment for acute lymphoblastic leukemia (ALL), vincristine's side effect profile is well known. Parallel administration of the antifungal fluconazole has been shown to interfere with the metabolism of vincristine, potentially resulting in increased side effects. We conducted a retrospective chart review to determine whether concomitant administration of vincristine and fluconazole during pediatric ALL induction therapy impacted the frequency of vincristine side effects, namely, hyponatremia and peripheral neuropathy. We also evaluated whether the incidence of opportunistic fungal infections was impacted by fluconazole prophylaxis. Medical charts of all pediatric ALL patients treated with induction chemotherapy at Children's Hospital and Medical Center in Omaha, NE, from 2013 to 2021 were retrospectively reviewed. Fluconazole prophylaxis did not significantly impact the rate of fungal infections. We found no correlation between fluconazole use and increased incidence of hyponatremia or peripheral neuropathy, which supports the safety of fungal prophylaxis with fluconazole during pediatric ALL induction therapy.
Collapse
Affiliation(s)
| | - Reyna Ramirez
- Department of Biology, Summer Undergraduate Research Student, Department of Pediatric Hematology Oncology, University of Nebraska Medical Center
| | - Robin High
- Biostatistics, University of Nebraska Medical Center, Omaha, NE
| | - James Ford
- Medical Department of Pediatric Hematology Oncology, Univeristy of Nebraska Medical Center, Omaha, NE
| | - Chittalsinh Raulji
- Medical Department of Pediatric Hematology Oncology, Univeristy of Nebraska Medical Center, Omaha, NE
| | - Jill Beck
- Medical Department of Pediatric Hematology Oncology, Univeristy of Nebraska Medical Center, Omaha, NE
| |
Collapse
|
2
|
Lin C, Chen G, Huang J, Cheng Y, Xu Y, Zhang A, Xue H, Chen C. Posaconazole aggravates vincristine-related hypertension in children with acute lymphoblastic leukemia: a case report. J Int Med Res 2020; 48:300060520969579. [PMID: 33213238 PMCID: PMC7686620 DOI: 10.1177/0300060520969579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Vincristine-related secondary hypertension is rare. This study reports two
children who were treated with vincristine for acute lymphoblastic leukemia
(ALL) and posaconazole for fungal infections who experienced vincristine-related
secondary hypertension. Blood pressure normalized in both children after halting
the drugs and providing antihypertensive treatment. Thus, posaconazole can
interact with vincristine and induce secondary hypertension in children with
ALL. As an adverse event, this interaction is a rare occurrence.
Collapse
Affiliation(s)
- Chao Lin
- Department of Pediatrics, Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Guohua Chen
- Department of Pediatrics, First People's Hospital of Huizhou, Huizhou, China
| | - Junbin Huang
- Department of Pediatrics, Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Yucai Cheng
- Department of Pediatrics, Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Yahong Xu
- Department of Pediatrics, Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Airun Zhang
- Department of Pediatrics, Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Hongman Xue
- Department of Pediatrics, Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Chun Chen
- Department of Pediatrics, Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| |
Collapse
|
3
|
Pekpak E, İleri T, İnce E, Ertem M, Uysal Z. Toxicity of Vincristine Combined With Posaconazole in Children With Acute Lymphoblastic Leukemia. J Pediatr Hematol Oncol 2018; 40:e309-10. [PMID: 29219892 DOI: 10.1097/MPH.0000000000001022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Vincristine (VCR) is one of the main drugs of acute lymphoblastic leukemia (ALL) treatment. Azole antifungal medications are used for treatment or prophylaxis of invasive fungal infections in acute leukemia. Coadministration of these drugs increases the risk of VCR toxicity. OBSERVATIONS We presented a girl with ALL using posaconazole prophylaxis. She developed VCR toxicity that included tubulopathy, high blood pressure, neuropathic pain, difficulty walking, diffuse muscular weakness, constipation, abdominal pain. CONCLUSIONS There are limited data in children with ALL for posaconazole prophylaxis. We recommend that VCR side effects should be evaluated by careful monitoring of the patients who are on this combination therapy.
Collapse
|
4
|
Smitherman AB, Faircloth CB, Deal A, Troy M, Gold SH. Vincristine toxicity with co-administration of fluconazole during induction therapy for pediatric acute lymphoblastic leukemia. Pediatr Blood Cancer 2017; 64. [PMID: 28333402 DOI: 10.1002/pbc.26525] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 02/15/2017] [Accepted: 02/20/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND Antifungal prophylaxis is recommended for patients with acute lymphoblastic leukemia (ALL) during high-risk periods such as induction; however, increased vincristine toxicities have been reported with the co-administration of triazole antifungals. We sought to determine whether vincristine-associated toxicities are higher among children with ALL concurrently given fluconazole prophylaxis compared to no prophylaxis. PROCEDURE Using a retrospective cohort design, we reviewed records of pediatric patients treated for newly diagnosed ALL from 2003 to 2013. Patients were classified by fluconazole exposure during induction. The development of vincristine-associated toxicity and vincristine dose adjustment were the primary outcomes evaluated. The adjusted risk difference (RD) for vincristine-related toxicity associated with triazole exposure was determined. RESULTS We identified 197 patients meeting inclusion criteria for evaluation, 160 (81%) of whom received fluconazole prophylaxis. Among patients receiving fluconazole, 36/160 (22%) developed vincristine toxicity compared to 7/37 (19%) among those not receiving prophylaxis (RD: 3%, 95% confidence interval [CI] -11 to 18%). Adjusting for patient age and race, no statistically significant increased risk for vincristine-associated toxicity with fluconazole exposure was observed (RD 5%, 95% CI -8 to 17%). An increased risk for vincristine-associated toxicity was independently associated with age 10 years or older (RD 19%, 95% CI 4-34%). CONCLUSION Co-administration of fluconazole during induction therapy for pediatric ALL does not significantly increase the risk for vincristine-associated toxicities; however, patients 10 years or older are at an increased risk for toxicity independent of fluconazole exposure. Prophylaxis with fluconazole during induction therapy for pediatric ALL, if warranted, appears to be a safe clinical practice.
Collapse
Affiliation(s)
- Andrew B Smitherman
- Division of Pediatric Hematology/Oncology, Chapel Hill, North Carolina.,UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | | | - Allison Deal
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Michael Troy
- UNC School of Medicine, Chapel Hill, North Carolina
| | - Stuart H Gold
- Division of Pediatric Hematology/Oncology, Chapel Hill, North Carolina.,UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| |
Collapse
|
5
|
Zhou H, Li L, Zhou Y, Han Y. Syndrome of inappropriate antidiuretic hormone secretion from concomitant use of itraconazole and vindesine. J Clin Pharm Ther 2017; 43:137-140. [PMID: 28782144 DOI: 10.1111/jcpt.12598] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 06/26/2017] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Several studies have reported that itraconazole-induced inhibition of vincristine (VCR) metabolism might result in neurological impairment and syndrome of inappropriate antidiuretic hormone (SIADH). However, there are few reports concerning adverse drug reactions (ADRs) resulting from concomitant use of vindesine (VDS) and itraconazole. Here, we report the first case of adverse drug interactions (ADIs) between itraconazole and VDS in a Chinese child with acute lymphocytic leukaemia (ALL). CASE SUMMARY A 4-year-old boy was diagnosed with standard-risk ALL and was receiving VDS (3 mg/m2 ) for maintenance therapy and itraconazole for IFI recurrence. Severe neurotoxicity, consisting mainly of trismus and SIADH, was noticed after 7 days of VDS administration. After discontinuation of itraconazole and its replacement with caspofungin, the patient recovered from neurological signs and symptoms. The ADIs can be explained by VDS accumulation owing to inherent loss of CYP3A5 (*3/*3) function, and inhibition of CYP3A4 activity by itraconazole. WHAT IS NEW AND CONCLUSION Syndrome of inappropriate antidiuretic hormone from co-administration of itraconazole and VDS has not previously been reported to our knowledge. We suggest that the concomitant use of these drugs should be avoided if possible. The use of alternative antifungal drugs (AFDs) should be considered, and ADRs should be closely monitored when the combination of itraconazole and VDS is unavoidable.
Collapse
Affiliation(s)
- H Zhou
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - L Li
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Y Zhou
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Y Han
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
6
|
Xu XH, Zhang L, Cao XX, Li J, Zhang W, Zhu TN, Cai HC, Chen M, Han X, Yang C, Han B, Zhang Y, Zhuang JL, Zhou DB, Duan MH. Evaluation of the implementation rate of primary antifungal prophylaxis and the prognosis of invasive fungal disease in acute leukemia patients in China. J Infect Chemother 2017; 23:360-7. [PMID: 28341518 DOI: 10.1016/j.jiac.2017.02.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 02/11/2017] [Accepted: 02/26/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Invasive fungal disease (IFD) is a major complication of acute leukemia, thus primary antifungal prophylaxis (PAP) is recommended by guidelines. Nevertheless, guidelines might not be commonly followed in developing countries due to economic factors. The primary objectives were to evaluate the implementation rate of PAP in acute leukemia patients in China and to compare the prognosis of IFD with and without PAP. The secondary objectives were to investigate the safety of PAP, clinical characteristics of IFDs and risk factors of breakthrough. METHODS This was a retrospective observational single-center study, including non-M3 acute myeloid leukemia (AML) and acute lymphocytic leukemia (ALL) patients receiving uniform induction or salvage chemotherapy between 2012 and 2016. RESULTS There were 29.4% of patients without PAP among a total of 248 cases. The incidence of breakthrough proven/probable/possible IFDs was 24.7%, 6.5%, 5.5%, 5.4% and 5.3% in control (no prophylaxis), fluconazole, itraconazole, voriconazole and posaconazole group respectively (P = 0.007), while the percentage of patients requiring empirical or pre-emptive therapy was 54.8%, 45.7%, 23.3%, 18.9%, 10.5% respectively (P < 0.001). PAP could also significantly improve IFD-free survival (P < 0.001) and reduce 90-day overall mortality in patients on AML salvage regimen (P = 0.021). There were no statistical differences in PAP-related adverse events. Past history of IFD (OR 9.5, P = 0.006) was confirmed to be independent risk factors. CONCLUSIONS There are a considerable number of acute leukemia patients without PAP in China, who have higher IFD incidence, increased empiric/pre-emptive antifungal drug use and worse IFD-free survival.
Collapse
|
7
|
|
8
|
Hamdy DA, El-Geed H, El-Salem S, Zaidan M. Posaconazole-vincristine coadministration triggers seizure in a young female adult: a case report. Case Rep Hematol 2012; 2012:343742. [PMID: 22937325 DOI: 10.1155/2012/343742] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 01/10/2012] [Indexed: 12/01/2022] Open
Abstract
Coadministration of azoles and vincristine has been shown to increase vincristine neurotoxic effects due to the inhibition of cytochrome P450 (CYP) isoform 3A4, for which vincristine is a substrate. Despite the absence of any casual relationship between seizure and coadministration of azoles, few case reports of vincristine-induced seizure have been documented after coadministration of fluconazole or posaconazole in children. In this paper we are reporting the first young female adult who experienced generalized seizure after coadministration of posaconazole and vincristine. The 19-year-old female was diagnosed with acute lymphoblastic leukemia. She started induction phase of Berlin Frankfurt Muenster protocol along with posaconazole 200 mg three times daily as prophylactic antifungal therapy. Five days after the third vincristine dose, she developed generalized seizure accompanied by high blood pressure and SIADH. Her neurological exam/CT scan did not show any abnormality. In conclusion, this study reports a novel finding in the sense that all previous case reports pertaining to posaconazole-vincristine-induced seizure in literature involved children. Physicians should be made aware of this rare possible outcome to closely monitor their patients and take appropriate measures to prevent such possible adverse effect.
Collapse
|
9
|
Moriyama B, Henning SA, Leung J, Falade-Nwulia O, Jarosinski P, Penzak SR, Walsh TJ. Adverse interactions between antifungal azoles and vincristine: review and analysis of cases. Mycoses 2011; 55:290-7. [PMID: 22126626 DOI: 10.1111/j.1439-0507.2011.02158.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Triazole and imidazole antifungal agents inhibit metabolism of vincristine, leading to excess vinca alkaloid exposure and severe neurotoxicity. Recent reports of debilitating interactions between vincristine and itraconazole, as well as posaconazole, voriconazole and ketoconazole underscore the need to improve medical awareness of this adverse combination. We, therefore, undertook a comprehensive analysis of reports of adverse drug interactions (ADIs) with the combination of vincristine and azole antifungal agents, established a new classification, and provided a detailed summary of these toxicities. In patients who had sufficient data for analysis, 47 individuals were identified who had an ADI with the combination of vincristine and antifungal azoles. Median age was 8 years (1.3-68 years) with 33(70%) having a diagnosis of acute lymphoblastic leukaemia. Median time to ADI with vincristine was 9.5 days with itraconazole, 13.5 days posaconazole and 30 days voriconazole. The median number of vincristine doses preceding the ADI was 2 doses with itraconazole, 3 doses posaconazole and 2 doses voriconazole. The most common severe ADIs included gastrointestinal toxicity, peripheral neuropathy, hyponatremia/SIADH, autonomic neuropathy and seizures. Recovery from these ADIs occurred in 80.6% of patients. We recommend using alternative antifungal agents if possible in patients receiving vincristine to avoid this serious and potentially life-threatening drug interaction.
Collapse
Affiliation(s)
- Brad Moriyama
- NIH Clinical Center Pharmacy Department, Bethesda, MD, USA
| | | | | | | | | | | | | |
Collapse
|
10
|
Pana ZD, Roilides E. Risk of azole-enhanced vincristine neurotoxicity in pediatric patients with hematological malignancies: old problem - new dilemma. Pediatr Blood Cancer 2011; 57:30-5. [PMID: 21265011 DOI: 10.1002/pbc.22972] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Accepted: 11/17/2010] [Indexed: 01/13/2023]
Abstract
One of the most well-known drug interactions in pediatric oncology concerns the co-administration of itraconazole, an antifungal triazole, and vincristine, an antileukemic agent, which seems to enhance the risk of neurotoxicity of the latter, mediated through the cytochrome CYP450 enzyme system. The aim of this article is to review the metabolism of these two drugs, to analyze the published cases with severe triazole-enhanced vincristine neurotoxicity, to discuss the pathophysiological mechanisms of this adverse effect, and to contribute in understanding the differences in triazole-vincristine interaction severity.
Collapse
Affiliation(s)
- Zoe Dorothea Pana
- 2nd Department of Pediatrics, Unit of Pediatric Hematology Oncology, AHEPA Hospital, Thessaloniki, Greece.
| | | |
Collapse
|
11
|
Karadi RL, Gow D, Kellett M, Denning DW, O'Driscoll RB. Itraconazole associated quadriparesis and edema: a case report. J Med Case Rep 2011; 5:140. [PMID: 21477327 PMCID: PMC3080323 DOI: 10.1186/1752-1947-5-140] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2010] [Accepted: 04/09/2011] [Indexed: 11/18/2022] Open
Abstract
Introduction Itraconazole is an anti-fungal agent widely used to treat various forms of mycosis. It is particularly useful in allergic bronchopulmonary aspergillosis and severe asthma with fungal sensitization. Side effects are uncommon and usually mild. Mild neuropathy is noted to occur very rarely. We present an unusual and, to the best of our knowledge, as yet unreported case of severe neuropathy and peripheral edema due to itraconazole in the absence of a concomitant risk factor. Case presentation A 72-year-old Caucasian man was started on itraconazole following diagnosis of severe asthma with fungal sensitization. One month later he presented with severe bilateral ankle edema with an elevated serum itraconazole level. The itraconazole dose was reduced but his ankle edema persisted and he developed weakness of all four limbs. Itraconazole was completely stopped leading to improvement in his leg edema but he became bed bound due to weakness. He gradually improved with supportive care and neurorehabilitation. On review at six months, our patient was able to mobilize with the aid of two elbow crutches and power had returned to 5/5 in distal extremities and 4+/5 in proximal extremities. The diagnosis was established based on the classical presentation of drug-induced neuropathy and negative investigatory findings for any alternative diagnoses. Conclusion We report the case of a patient presenting with an unusual complication of severe neuropathy and peripheral edema due to itraconazole. Clinicians should be alert to this association when encountered with neuropathy and/or edema in an itraconazole therapy recipient.
Collapse
Affiliation(s)
- Rangaprasad L Karadi
- National Aspergillosis Centre, Education and Research Centre, University Hospital of South Manchester (Wythenshawe Hospital), Southmoor Road, Manchester M23 9LT, UK.
| | | | | | | | | |
Collapse
|
12
|
Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2010; 19:i-xii. [DOI: 10.1002/pds.1855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|