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White O, Kennedy E, Huckabee JB, Rogers E, LeBlanc TW, Dillon M, Li Z, Hanna D. Isavuconazonium or posaconazole for antifungal prophylaxis in patients with acute myeloid leukemia. J Oncol Pharm Pract 2024; 30:527-534. [PMID: 37186784 DOI: 10.1177/10781552231175825] [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: 05/17/2023]
Abstract
BACKGROUND Invasive fungal infection (IFI) prophylaxis is recommended in patients with acute myeloid leukemia (AML) during induction chemotherapy. Posaconazole (POSA) is the recommended agent of choice; however, this medication can be associated with QTc prolongation, hepatotoxicity, and drug-drug interactions. Furthermore, there is conflicting evidence for the role of isavuconazole (ISAV) in this setting as an alternative to POSA. OBJECTIVE The primary objective of this study was to evaluate the use of ISAV prophylaxis for primary IFI prevention in patients with AML undergoing induction. Additionally, the study investigated the use of ISAV trough concentration monitoring and compared these results to the efficacy of POSA therapeutic drug monitoring (TDM). Other secondary objectives included assessing the rates of toxicities associated with either prophylactic agent. This study analyzed the impact these toxicities had on patient outcomes by examining the need to hold or discontinue therapy. The final endpoint considered the efficacy associated with multiple dosing strategies employed at the study institution. Specifically, this included the use of loading doses or foregoing these when initiating prophylaxis. METHODS This was a retrospective, single-center, cohort study. Patients included in this study were adults with AML admitted to Duke University Hospital between June 30, 2016 and June 30, 2021, who received induction chemotherapy and primary IFI prophylaxis for at least 7 days. Exclusion criteria included patients who received concomitant antifungal agents and patients who received antifungal agents as secondary prophylaxis. RESULTS 241 patients met inclusion criteria with 12 (4.98%) participants in the ISAV group and 229 (95.02%) participants in the POSA group. The IFI incidence in the POSA group was 14.5%, while the ISAV group did not have any occurrences of IFI. No significant difference was found in the rate of IFI occurrence between the two treatment groups (p = 0.3805). Furthermore, it was demonstrated that the use of a loading dose when initiating prophylaxis could impact rates of IFI for this patient population. CONCLUSION Due to no difference in incidence, patient specific factors such as concomitant medications and baseline QTc should influence the choice between prophylactic agent.
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Affiliation(s)
- Olivia White
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
| | - Erin Kennedy
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
| | - Jordan B Huckabee
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
| | - Elizabeth Rogers
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
| | - Thomas W LeBlanc
- Department of Hematologic Malignancies, Duke University Hospital, Durham, North Carolina, USA
| | - Mairead Dillon
- Department of Biostatistics and Bioinformatics, Duke University Hospital, Durham, North Carolina, USA
| | - Zhiguo Li
- Department of Biostatistics and Bioinformatics, Duke University Hospital, Durham, North Carolina, USA
| | - Desirae Hanna
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
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Hawkins BK, Walker SD, Shorman MA. Missed Opportunities for Antifungal Stewardship during the COVID-19 Era. Antibiotics (Basel) 2023; 12:1352. [PMID: 37760649 PMCID: PMC10526074 DOI: 10.3390/antibiotics12091352] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 07/04/2023] [Revised: 07/28/2023] [Accepted: 08/10/2023] [Indexed: 09/29/2023] Open
Abstract
Significant increases in antibacterial use were observed during the COVID-19 pandemic. However, subsequent analyses found this increase in antibiotic use to be excessive in comparison with the relatively low rates of bacterial coinfection. Although patients who are critically ill with COVID-19 may be at an increased risk for pulmonary aspergillosis, antifungal use in these populations remained underreported, particularly in later phases of the pandemic. This single-center, population-level cohort analysis compares the monthly use rates of mold-active antifungal drugs in the medical intensive care unit during April 2019-March 2020 (baseline) with those during April 2020-November 2022. The antifungal drugs included in the analysis were liposomal amphotericin B, anidulafungin, isavuconazonium, posaconazole, and voriconazole. We found that during 2020-2022, the usage of antifungal drugs was not significantly different from baseline for all included agents except isavuconazonium, which was used significantly more (p = 0.009). There were no changes in diagnostic modalities between the two time periods. The reported prevalence of and mortality from COVID-19-associated pulmonary aspergillosis (CAPA) may have resulted in higher rates of prescribing antifungal drugs for critically ill patients with COVID-19. Antimicrobial stewardship programs should develop and apply tools to facilitate more effective and appropriate antifungal use.
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Affiliation(s)
- Brandon K. Hawkins
- College of Pharmacy, University of Tennessee Health Science Center, Knoxville, TN 37920, USA
| | - Samantha D. Walker
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, TN 37920, USA
| | - Mahmoud A. Shorman
- Division of Infectious Diseases, University of Tennessee Medical Center, Knoxville, TN 37920, USA
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Heidari A, Sharma R, Shakir Q, Shah M, Clement J, Donnelley MA, Reynolds T, Trigg K, Jolliff J, Kuran R, Johnson R, Thompson GR. Isavuconazole in the Treatment of Chronic Forms of Coccidioidomycosis. Clin Infect Dis 2023; 76:2196-2199. [PMID: 36905151 PMCID: PMC10893960 DOI: 10.1093/cid/ciad146] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/16/2023] [Accepted: 03/09/2023] [Indexed: 03/12/2023] Open
Abstract
Coccidioidomycosis is a fungal infection with a range of clinical manifestations. Currently used antifungal agents exhibit variable efficacy and toxicity profiles that necessitate evaluation of additional therapeutic options. Improvement was observed in the majority of patients treated with isavuconazole, with clinical failures observed only in those with coccidioidal meningitis.
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Affiliation(s)
- Arash Heidari
- Department of Medicine, Division of Infectious Diseases, Kern Medical Center–University of California–Los Angeles, Bakersfield, California, USA
- Valley Fever Institute, Bakersfield, California, USA
- Department of Medicine, David Geffen School of Medicine, University of California–Los Angeles, Los Angeles, California, USA
| | - Rupam Sharma
- Valley Fever Institute, Bakersfield, California, USA
- Department of Medicine, David Geffen School of Medicine, University of California–Los Angeles, Los Angeles, California, USA
| | - Qusai Shakir
- Valley Fever Institute, Bakersfield, California, USA
| | - Madiha Shah
- Department of Pharmacy, University of California–Davis Medical Center, Sacramento, California, USA
| | - Josh Clement
- Department of Pharmacy, University of California–Davis Medical Center, Sacramento, California, USA
| | - Monica A Donnelley
- Department of Pharmacy, University of California–Davis Medical Center, Sacramento, California, USA
| | - Trina Reynolds
- Department of Internal Medicine, Division of Infectious Diseases, University of California–Davis Medical Center, Sacramento, California, USA
| | - Kate Trigg
- Department of Internal Medicine, Division of Infectious Diseases, University of California–Davis Medical Center, Sacramento, California, USA
| | - Jeff Jolliff
- Department of Medicine, Division of Infectious Diseases, Kern Medical Center–University of California–Los Angeles, Bakersfield, California, USA
- Valley Fever Institute, Bakersfield, California, USA
| | - Rasha Kuran
- Department of Medicine, Division of Infectious Diseases, Kern Medical Center–University of California–Los Angeles, Bakersfield, California, USA
- Valley Fever Institute, Bakersfield, California, USA
- Department of Medicine, David Geffen School of Medicine, University of California–Los Angeles, Los Angeles, California, USA
| | - Royce Johnson
- Department of Medicine, Division of Infectious Diseases, Kern Medical Center–University of California–Los Angeles, Bakersfield, California, USA
- Valley Fever Institute, Bakersfield, California, USA
- Department of Medicine, David Geffen School of Medicine, University of California–Los Angeles, Los Angeles, California, USA
| | - George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases, University of California–Davis Medical Center, Sacramento, California, USA
- Department of Medical Microbiology and Immunology, University of California–Davis, Davis, California, USA
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Muacevic A, Adler JR, Denmeade T, Luther V, Palavecino E, Beardsley J. Treatment of Candida nivariensis Blood Stream Infection With Oral Isavuconazole. Cureus 2022; 14:e32137. [PMID: 36601144 PMCID: PMC9805793 DOI: 10.7759/cureus.32137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2022] [Indexed: 12/05/2022] Open
Abstract
Candida nivariensis is a rarely isolated yeast that is now considered a species within the Candida glabrata complex. Anti-fungal susceptibilities and treatments of Candida nivariensis are often assessed on a case-by-case basis. In this case, a 70-year-old male with a complex medical history presented to a large academic medical center in the United States for vascular surgery. After surgery, the patient's white blood cell count increased prompting an infectious workup. The patient was found to have a Candida nivariensis bloodstream infection of unknown origin. Given the patient's clinical stability and QTc prolongation, he was treated with a 14-day course of oral isavuconazole. The patient experienced resolution of symptoms and clearance of subsequent blood cultures. At the time of writing this case report (11 months later), he has had no relapse of his fungal infection. Based on a search of the medical literature, this appears to be the first published case of Candida nivariensis fungemia successfully treated with oral isavuconazole.
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Okudo J, Civelli VF, Narang VK, Johnson RH, Khan N, Andruszko B, Heidari A. A Rare Case of Cryptococcus gattii Meningitis in Advanced HIV Disease, Sagittal Thrombosis, and Immune Reconstitution Syndrome, Resolved With Isavuconazonium. J Investig Med High Impact Case Rep 2021; 8:2324709620959880. [PMID: 32935587 PMCID: PMC7498974 DOI: 10.1177/2324709620959880] [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: 01/25/2023] Open
Abstract
Cryptococcus gattii is a species that has received more
recognition in the recent past as distinct from Cryptococcus neoformans.
C gattii is known to cause meningeal disease in both
immunocompetent and immunosuppressed hosts. Patients may be clinically
asymptomatic until immunosuppressive conditions occur such as corticosteroid
treatment or an HIV infection. HIV-associated cryptococcal infections are most
often due to C neoformans. C gattii is found in a minority.
Speciation and subtyping of Cryptococcus are not always
accomplished. In many parts of the world, there is no availability for
speciation of Cryptococcus. Travel history may provide a clue
to the most probable species. This case demonstrates a case of C
gattii meningitis with a multiplicity of complications. These
include advanced HIV disease secondary to nonadherence, immune reconstitution
inflammatory syndrome, and superior sagittal sinus thrombosis. The patient
represented diagnostic and therapeutic dilemmas over time. Headache was the
primary symptom in cryptococcal meningitis, immune reconstitution inflammatory
syndrome, and superior sagittal sinus thrombosis. All are discussed in detail as
potential etiologies for the primary disease. Isavuconazonium is a relatively
new broad-spectrum antifungal azole that was used as salvage therapy.
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Davis MR, Chang S, Gaynor P, McCreary EK, Allyn P. Isavuconazole for treatment of refractory coccidioidal meningitis with concomitant cerebrospinal fluid and plasma therapeutic drug monitoring. Med Mycol 2021; 59:939-942. [PMID: 34143187 DOI: 10.1093/mmy/myab035] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/07/2021] [Accepted: 06/16/2021] [Indexed: 01/08/2023] Open
Abstract
Coccidioidal meningitis (CM) is a life-threatening infection with limited treatment options. Small series have reported success with isavuconazole; however, limited data exist on cerebrospinal fluid (CSF) penetration. Paired plasma and CSF isavuconazole concentrations were measured. Eleven CSF levels were tested, (7 ventricular, 4 lumbar) in three CM patients. Ventricular CSF levels were undetectable despite detectable plasma levels. All lumbar CSF levels were detectable (mean 1.00 µg/mL). Three pairs of lumbar CSF/plasma concentrations taken within one hour of each other yielded a mean CSF/plasma ratio of 0.31. Isavuconazole was detectable in lumbar but not ventricular CSF in three patients treated for refractory CM.
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Affiliation(s)
- Matthew R Davis
- Department of Pharmacy, University of California Los Angeles Ronald Reagan Medical Center, Los Angeles, California
| | - Sandy Chang
- Division of Infectious Diseases, Department of Internal Medicine, University of California Ronald Reagan Los Angeles Medical Center, Los Angeles, California
| | - Pryce Gaynor
- Division of Infectious Diseases, Department of Internal Medicine, University of California Ronald Reagan Los Angeles Medical Center, Los Angeles, California
| | - Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, UPMC, Pittsburgh, PA, USA
| | - Paul Allyn
- Division of Infectious Diseases, Department of Internal Medicine, University of California Ronald Reagan Los Angeles Medical Center, Los Angeles, California
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Desai A, Yamazaki T, Dietz AJ, Kowalski D, Lademacher C, Pearlman H, Akhtar S, Townsend R. Pharmacokinetic and Pharmacodynamic Evaluation of the Drug-Drug Interaction Between Isavuconazole and Warfarin in Healthy Subjects. Clin Pharmacol Drug Dev 2016; 6:86-92. [PMID: 27278712 PMCID: PMC5298089 DOI: 10.1002/cpdd.283] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [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: 02/19/2016] [Revised: 05/18/2016] [Accepted: 06/03/2016] [Indexed: 12/11/2022]
Abstract
This phase 1 trial evaluated pharmacokinetic and pharmacodynamic interactions between the novel triazole antifungal agent isavuconazole and warfarin in healthy adults. Multiple doses of isavuconazole were administered as the oral prodrug, isavuconazonium sulfate (372 mg 3 times a day for 2 days loading dose, then 372 mg once daily thereafter; equivalent to isavuconazole 200 mg), in the presence and absence of single doses of oral warfarin sodium 20 mg. Coadministration with isavuconazole increased the mean area under the plasma concentration‐time curves from time 0 to infinity of S‐ and R‐warfarin by 11% and 20%, respectively, but decreased the mean maximum plasma concentrations of S‐ and R‐warfarin by 12% and 7%, respectively, relative to warfarin alone. Mean area under the international normalized ratio curve and maximum international normalized ratio were 4% lower in the presence vs absence of isavuconazole. Mean warfarin area under the prothrombin time curve and maximum prothrombin time were 3% lower in the presence vs absence of isavuconazole. There were no serious treatment‐emergent adverse events (TEAEs), and no subjects discontinued the study due to TEAEs. All TEAEs were mild in intensity. These findings indicate that coadministration with isavuconazole has no clinically relevant effects on warfarin pharmacokinetics or pharmacodynamics.
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Affiliation(s)
- Amit Desai
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Takao Yamazaki
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | - Donna Kowalski
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | - Helene Pearlman
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Shahzad Akhtar
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Robert Townsend
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
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Yamazaki T, Desai A, Goldwater R, Han D, Howieson C, Akhtar S, Kowalski D, Lademacher C, Pearlman H, Rammelsberg D, Townsend R. Pharmacokinetic Effects of Isavuconazole Coadministration With the Cytochrome P450 Enzyme Substrates Bupropion, Repaglinide, Caffeine, Dextromethorphan, and Methadone in Healthy Subjects. Clin Pharmacol Drug Dev 2016; 6:54-65. [PMID: 27273149 PMCID: PMC5297975 DOI: 10.1002/cpdd.281] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [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] [Received: 02/19/2016] [Revised: 05/18/2016] [Accepted: 06/03/2016] [Indexed: 01/01/2023]
Abstract
This report describes phase 1 clinical trials performed to assess interactions of oral isavuconazole at the clinically targeted dose (200 mg, administered as isavuconazonium sulfate 372 mg, 3 times a day for 2 days; 200 mg once daily [QD] thereafter) with single oral doses of the cytochrome P450 (CYP) substrates: bupropion hydrochloride (CYP2B6; 100 mg; n = 24), repaglinide (CYP2C8/CYP3A4; 0.5 mg; n = 24), caffeine (CYP1A2; 200 mg; n = 24), dextromethorphan hydrobromide (CYP2D6/CYP3A4; 30 mg; n = 24), and methadone (CYP2B6/CYP2C19/CYP3A4; 10 mg; n = 23). Compared with each drug alone, coadministration with isavuconazole changed the area under the concentration‐time curves (AUC∞) and maximum concentrations (Cmax) as follows: bupropion, AUC∞ reduced 42%, Cmax reduced 31%; repaglinide, AUC∞ reduced 8%, Cmax reduced 14%; caffeine, AUC∞ increased 4%, Cmax reduced 1%; dextromethorphan, AUC∞ increased 18%, Cmax increased 17%; R‐methadone, AUC∞ reduced 10%, Cmax increased 3%; S‐methadone, AUC∞ reduced 35%, Cmax increased 1%. In all studies, there were no deaths, 1 serious adverse event (dextromethorphan study; perioral numbness, numbness of right arm and leg), and adverse events leading to study discontinuation were rare. Thus, isavuconazole is a mild inducer of CYP2B6 but does not appear to affect CYP1A2‐, CYP2C8‐, or CYP2D6‐mediated metabolism.
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Affiliation(s)
- Takao Yamazaki
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Amit Desai
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | | | - Corrie Howieson
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Shahzad Akhtar
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Donna Kowalski
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | - Helene Pearlman
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | - Robert Townsend
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
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Abstract
We have a limited arsenal with which to treat invasive fungal infections caused by Aspergillus and Mucorales. The morbidity and mortality for both pathogens remains high. A triazole antifungal, isavuconazole, was recently granted approval by the US Food and Drug Administration and the European Medicines Agency for the treatment of invasive aspergillosis and mucormycosis. A randomized double-blind comparison trial for the treatment of invasive aspergillosis found isavuconazole noninferior to voriconazole. A separate, open-label study evaluating the efficacy of isavuconazole in the treatment of mucormycosis found comparable response rates to amphotericin B and posaconazole treated historical controls. The prodrug isavuconazonium sulfate is commercially available in both an oral and intravenous formulation and is generally well tolerated. Isavuconazole’s broad spectrum of activity, limited side effect profile, and favorable pharmacokinetics will likely solidify its place in therapy.
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Affiliation(s)
- Monica A Donnelley
- Department of Inpatient Pharmacy, University of California - Davis, Sacramento, USA; Department of Clinical Sciences, Touro University College of Pharmacy, Vallejo, USA
| | - Elizabeth S Zhu
- Department of Inpatient Pharmacy, University of California - Davis, Sacramento, USA
| | - George R Thompson
- Department of Medicine, Division of Infectious Diseases, University of California - Davis, Davis, CA, USA
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