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Patz-Sobczak C, Young J, Bunton D, Kuklinski C, Estabrook M. A novel approach to reducing hepatotoxicity related to fungal prophylaxis in pediatric lung transplant recipients. Pediatr Transplant 2024; 28:e14740. [PMID: 38616325 DOI: 10.1111/petr.14740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 02/25/2024] [Accepted: 02/28/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Pediatric lung transplant patients are at risk for developing invasive fungal infections post-transplant. No consensus exists on optimal antifungal regimens and voriconazole, a common first-line agent, has been shown to cause hepatotoxicity. We describe a single-center experience utilizing a novel antifungal regimen of intravenous micafungin and nebulized amphotericin B immediately post-transplant with conversion to an azole at the time of hospital discharge and compare it to a historical cohort of patients who received voriconazole monotherapy throughout their immediate post-operative course. METHODS This is a retrospective review of patients in the age 0-18 who received a lung transplant from June 2016-May 2021. Data points collected included: demographic data, transplant date and discharge date, Aspergillus colonization, type of lung transplant, hospitalization and level of care information, induction and antifungal medication regimen; AST, ALT, GGT, bilirubin, and direct bilirubin at various timepoints; and respiratory and blood culture results. The two patient groups were compared by assessment of changes in LFTs and culture results. RESULTS Forty-two patients were included in the analysis, with 24 patients receiving micafungin and nebulized amphotericin and 18 patients receiving voriconazole. All patients in both groups experienced a post-operative elevation in at least one transaminase or bilirubin. More patients in the micafungin/amphotericin group had resolution of all abnormal LFTs by 1 month post-transplant (p = .036). Additionally, patients in the micafungin/amphotericin group experienced faster normalization of their LFTs compared with the voriconazole group (p < .001). Ten patients in the micafungin/amphotericin group and five patients in the voriconazole group were found to have fungal growth on culture post-transplant, but this difference was not found to be statistically significant (p = .507). CONCLUSIONS An antifungal regimen of micafungin and nebulized amphotericin B liposomal may be useful at decreasing the duration of elevated liver enzymes in pediatric patients in the immediate post-lung transplant period when compared with voriconazole monotherapy. Larger prospective studies looking at antifungal regimens in pediatric patients post-lung transplant are warranted.
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Affiliation(s)
| | - Jennifer Young
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Dawn Bunton
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Cadence Kuklinski
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
- Division of Allergy and Pulmonary Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michele Estabrook
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
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Padaraju A, Dwivedi F, Kumar G. Microemulsions, nanoemulsions and emulgels as carriers for antifungal antibiotics. Ther Deliv 2023; 14:721-740. [PMID: 38014430 DOI: 10.4155/tde-2023-0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
According to estimates, up to 25% of the world's population has fungal skin diseases, making them the most prevalent infectious disease. Several chemical classes of antifungal drugs are available to treat fungal infections. However, the major challenges of conventional formulations of antifungal drugs include poor pharmacokinetic profiles like solubility, low permeability, side effects and decreased efficacy. Novel drug delivery is a promising approach for overcoming pharmacokinetic limitations and increasing the effectiveness of antibiotics. In this review, we have shed light on microemulsions, nanoemulsions, and emulgels as novel drug delivery approaches for the topical delivery of antifungal antibiotics. We believe these formulations have potential translational value and could be developed for treating fungal infections in humans.
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Affiliation(s)
- Annapurna Padaraju
- Department of Natural Products, Chemical Sciences, National Institute of Pharmaceutical Education & Research-Hyderabad, Hyderabad, Balanagar, 500037, India
| | - Falguni Dwivedi
- Department of Natural Products, Chemical Sciences, National Institute of Pharmaceutical Education & Research-Hyderabad, Hyderabad, Balanagar, 500037, India
| | - Gautam Kumar
- Department of Natural Products, Chemical Sciences, National Institute of Pharmaceutical Education & Research-Hyderabad, Hyderabad, Balanagar, 500037, India
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Ierano C, Percival M, Poole S, Mackie K, Rashidzada Z, Corallo C, Mcmahon JH, Morrissey CO, Duncan A. Echinocandin use in an Australian tertiary hospital: implications for antifungal stewardship. Pharmacy Practice and Res 2023. [DOI: 10.1002/jppr.1859] [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: 03/29/2023]
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Zhou ZX, Yin XD, Zhang Y, Shao QH, Mao XY, Hu WJ, Shen YL, Zhao B, Li ZL. Antifungal Drugs and Drug-Induced Liver Injury: A Real-World Study Leveraging the FDA Adverse Event Reporting System Database. Front Pharmacol 2022; 13:891336. [PMID: 35571077 PMCID: PMC9098189 DOI: 10.3389/fphar.2022.891336] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/28/2022] [Indexed: 12/02/2022] Open
Abstract
Aims: We aimed to estimate the risk of drug-induced liver injury (DILI) from various antifungal treatments with azoles and echinocandins causing in real-world practice. Methods: We performed disproportionality and Bayesian analyses based on data from the first quarter in 2004 to the third quarter in 2021 in the Food and Drug Administration Adverse Event Reporting System to characterize the signal differences of antifungal drugs-related DILI. We also compared the onset time and mortality differences of different antifungal agents. Results: A total of 2943 antifungal drugs-related DILI were identified. Affected patients tended to be aged >45 years (51.38%), with more males than females (49.03% vs. 38.09%). Antifungal drug-induced liver injury is most commonly reported with voriconazole (32.45%), fluconazole (19.37%), and itraconazole (14.51%). Almost all antifungal drugs were shown to be associated with DILI under disproportionality and Bayesian analyses. The intraclass analysis of correlation between different antifungal agents and DILI showed the following ranking: caspofungin (ROR = 6.12; 95%CI: 5.36–6.98) > anidulafungin (5.15; 3.69–7.18) > itraconazole (5.06; 4.58–5.60) > voriconazole (4.58; 4.29–4.90) > micafungin (4.53; 3.89–5.27) > posaconazole (3.99; 3.47–4.59) > fluconazole (3.19; 2.93–3.47) > ketoconazole (2.28; 1.96–2.64). The onset time of DILI was significantly different among different antifungal drugs (p < 0.0001), and anidulafungin result in the highest mortality rate (50.00%), while ketoconazole has the lowest mortality rate (9.60%). Conclusion: Based on the Food and Drug Administration Adverse Event Reporting System database, antifungal drugs are significantly associated with DILI, and itraconazole and voriconazole had the greatest risk of liver injury. Due to indication bias, more clinical studies are needed to confirm the safety of echinocandins.
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Affiliation(s)
- Zhi-Xuan Zhou
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xue-Dong Yin
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Zhang
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- Department of Pharmacy, Nanyang Central Hospital, Affiliated Hospital of Zhengzhou University, Nanyang, China
| | - Qi-Hui Shao
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin-Yu Mao
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wen-Juan Hu
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yun-Lin Shen
- Department of Neonatology, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Yun-Lin Shen, ; Bin Zhao, ; Zhi-Ling Li,
| | - Bin Zhao
- Pharmacy Department, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Yun-Lin Shen, ; Bin Zhao, ; Zhi-Ling Li,
| | - Zhi-Ling Li
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Yun-Lin Shen, ; Bin Zhao, ; Zhi-Ling Li,
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Asai Y, Yamamoto T, Sato Y. Risk assessment of micafungin-induced liver injury using spontaneous reporting system data and electronic medical records. J Infect Chemother 2022; 28:690-695. [PMID: 35148944 DOI: 10.1016/j.jiac.2022.01.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 02/08/2023]
Abstract
INTRODUCTION There is limited information regarding antifungal-induced liver injuries, which have high mortality rates. Therefore, we used the Japanese Adverse Drug Event Report (JADER) database for signal detection associated with antifungal-induced liver injuries and medical records for risk assessment. METHODS Reports of antifungal-induced liver injuries from JADER data were analyzed to calculate the reporting odds ratio (ROR) and 95% confidence interval (CI). A medical record-based study involving 109 adult patients treated with micafungin shows liver injury as the primary outcome in patients treated with micafungin. The albumin-bilirubin (ALBI) score was calculated based on albumin and total bilirubin levels. We selected five explanatory factors for multivariable logistic regression: alanine aminotransferase ≥20 IU/L, alkaline phosphatase ≥372 IU/L, aspartate aminotransferase ≥25 IU/L, ALBI score ≥ -1.290, and age ≥65 years. RESULTS Signal detection for micafungin was observed in both, hepatocellular and cholestatic injuries, as per data from JADER. Univariate analyses performed on medical records suggest that alanine aminotransferase (p = 0.008), aspartate aminotransferase (p = 0.036), alkaline phosphatase (p = 0.045), and ALBI score (p = 0.028) may be factors associated with micafungin-induced liver injury. Based on multivariable logistic regression, the adjusted odds ratio for micafungin-induced liver injury in patients with ALBI score ≥ -1.290 was 2.78 (95% CI: 1.014-7.605, p = 0.047), suggesting that low hepatic functional reserve could be a risk factor for micafungin-induced liver injury. CONCLUSIONS Careful monitoring of liver function may be necessary for micafungin administration in patients with low hepatic functional reserve.
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Affiliation(s)
- Yuki Asai
- Pharmacy, National Hospital Organization Mie Chuo Medical Center; 2158-5 Hisaimyojincho, Tsu, Mie, 514-1101 Japan.
| | - Takanori Yamamoto
- Pharmacy, National Hospital Organization Mie Chuo Medical Center; 2158-5 Hisaimyojincho, Tsu, Mie, 514-1101 Japan
| | - Yoshiharu Sato
- Pharmacy, National Hospital Organization Mie Chuo Medical Center; 2158-5 Hisaimyojincho, Tsu, Mie, 514-1101 Japan
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Kim HY, Baldelli S, Märtson AG, Stocker S, Alffenaar JW, Cattaneo D, Marriott DJE. Therapeutic Drug Monitoring of the Echinocandin Antifungal Agents: Is There a Role in Clinical Practice? A Position Statement of the Anti-Infective Drugs Committee of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology. Ther Drug Monit 2022; 44:198-214. [PMID: 34654030 DOI: 10.1097/ftd.0000000000000931] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/01/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Reduced exposure to echinocandins has been reported in specific patient populations, such as critically ill patients; however, fixed dosing strategies are still used. The present review examines the accumulated evidence supporting echinocandin therapeutic drug monitoring (TDM) and summarizes available assays and sampling strategies. METHODS A literature search was conducted using PubMed in December 2020, with search terms such as echinocandins, anidulafungin, caspofungin, micafungin, or rezafungin with pharmacology, pharmacokinetics (PKs), pharmacodynamics (PDs), drug-drug interactions, TDM, resistance, drug susceptibility testing, toxicity, adverse drug reactions, bioanalysis, chromatography, and mass spectrometry. Data on PD/PD (PK/PD) outcome markers, drug resistance, PK variability, drug-drug interactions, assays, and TDM sampling strategies were summarized. RESULTS Echinocandins demonstrate drug exposure-efficacy relationships, and maximum concentration/minimal inhibitory concentration ratio (Cmax/MIC) and area under the concentration-time curve/MIC ratio (AUC/MIC) are proposed PK/PD markers for clinical response. The relationship between drug exposure and toxicity remains poorly clarified. TDM could be valuable in patients at risk of low drug exposure, such as those with critical illness and/or obesity. TDM of echinocandins may also be useful in patients with moderate liver impairment, drug-drug interactions, hypoalbuminemia, and those undergoing extracorporeal membrane oxygenation, as these conditions are associated with altered exposure to caspofungin and/or micafungin. Assays are available to measure anidulafungin, micafungin, and caspofungin concentrations. A limited-sampling strategy for anidulafungin has been reported. CONCLUSIONS Echinocandin TDM should be considered in patients at known risk of suboptimal drug exposure. However, for implementing TDM, clinical validation of PK/PD targets is needed.
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Affiliation(s)
- Hannah Yejin Kim
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia
| | - Sara Baldelli
- Unit of Clinical Pharmacology, Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Anne-Grete Märtson
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Sophie Stocker
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- St Vincent's Clinical School, University of New South Wales, Kensington, NSW Australia; and
| | - Jan-Willem Alffenaar
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, Fatebenefratelli Sacco University Hospital, Milan, Italy
- Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Deborah J E Marriott
- St Vincent's Clinical School, University of New South Wales, Kensington, NSW Australia; and
- Department of Microbiology and Infectious Diseases, St. Vincent's Hospital, Darlinghurst, NSW, Australia
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Ng DQ, Dang E, Chen L, Nguyen MT, Nguyen MKN, Samman S, Nguyen TMT, Cadiz CL, Nguyen L, Chan A. Current and recommended practices for evaluating adverse drug events using electronic health records: A systematic review. J Am Coll Clin Pharm 2021. [DOI: 10.1002/jac5.1524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ding Quan Ng
- School of Pharmacy & Pharmaceutical Sciences University of California Irvine Irvine California USA
| | - Emily Dang
- School of Pharmacy & Pharmaceutical Sciences University of California Irvine Irvine California USA
| | - Lijie Chen
- School of Pharmacy & Pharmaceutical Sciences University of California Irvine Irvine California USA
| | - Mary Thuy Nguyen
- School of Pharmacy & Pharmaceutical Sciences University of California Irvine Irvine California USA
| | - Michael Ky Nguyen Nguyen
- School of Pharmacy & Pharmaceutical Sciences University of California Irvine Irvine California USA
| | - Sarah Samman
- School of Pharmacy & Pharmaceutical Sciences University of California Irvine Irvine California USA
| | - Tiffany Mai Thy Nguyen
- School of Pharmacy & Pharmaceutical Sciences University of California Irvine Irvine California USA
| | - Christine Luu Cadiz
- School of Pharmacy & Pharmaceutical Sciences University of California Irvine Irvine California USA
| | - Lee Nguyen
- School of Pharmacy & Pharmaceutical Sciences University of California Irvine Irvine California USA
| | - Alexandre Chan
- School of Pharmacy & Pharmaceutical Sciences University of California Irvine Irvine California USA
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Suh JW, Kim SB, Yoon YK, Sohn JW, Kim MJ, Kim JH. Anidulafungin Versus Micafungin in the Treatment of Candidemia in Adult Patients. Mycopathologia 2020; 185:653-664. [PMID: 32705415 PMCID: PMC7377311 DOI: 10.1007/s11046-020-00471-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Received: 01/26/2020] [Accepted: 06/29/2020] [Indexed: 11/24/2022]
Abstract
Background Echinocandins are recommended for the treatment of invasive candidiasis and candidemia. However, there are few studies comparing anidulafungin and micafungin in terms of efficacy and safety. The objective of this study was to evaluate the clinical efficacy and safety between anidulafungin and micafungin treatment for adult patients with candidemia. Methods This retrospective cohort study performed on adult candidemia patients diagnosed from January 2006 through December 2018 at a tertiary medical center. The study subjects included adult patients ≥ 19 years with candidemia who were only treated with anidulafungin or micafungin for ≥ 3 days. Clinical characteristics were collected and analyzed. Hepatotoxicity was assessed according to the Common Terminology Criteria for Adverse Events Version 5.0. Results A total of 98 patients with candidemia were treated with anidulafungin (n = 52, 53.1%) or micafungin (n = 46, 46.9%). There were no significant differences in age, sex, source of candidemia, and comorbidities between the anidulafungin and micafungin groups. Although there were more patients with abnormal baseline liver function test (LFT) in the anidulafungin group, the rate of clinical response (51.9% vs. 46.7%), mycological response (76.9% vs. 67.4%), and mortality (30-day mortality 26.9% vs. 21.7% and 90-day mortality 78.8% vs. 73.9%) was similar between the anidulafungin and micafungin groups. Also, there was no significant difference in terms of hepatotoxicity, even among the patients with abnormal baseline LFT between the two groups. Conclusions Our results suggest that clinical efficacy and safety may be similar between anidulafungin and micafungin treatment for adult patients with candidemia. Electronic supplementary material The online version of this article (10.1007/s11046-020-00471-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jin Woong Suh
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Sun Bean Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Jang Wook Sohn
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Min Ja Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Jong Hun Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea.
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