Voriconazole: a new triazole antifungal agent

OBJECTIVE: To review the pharmacology, in vitro susceptibility, pharmacokinetics, clinical efficacy, and adverse effects of voriconazole, a triazole antifungal agent. DATA SOURCES: A MEDLINE search, restricted to English language, was conducted from 1990 to June 2002. Supplementary sources included program abstracts from the Interscience Conference on Antimicrobial Agents and Chemotherapy and the Infectious Diseases Society of America from 1996 to 2001 and manufacturer information available through the Food and Drug Administration's Web site. DATA EXTRACTION: All published and unpublished trials and abstracts citing voriconazole were selected. DATA SYNTHESIS: Voriconazole has shown in vitro activity against many yeasts and a variety of mold and dermatophyte isolates. Voriconazole can be administered either orally or parenterally. It exhibits good oral bioavailability, wide tissue distribution including distribution into the central nervous system, and hepatic metabolism. Drug interactions occur through inhibition of the CYP2C9, CYP2C19, and CYP3A4 isoenzymes, resulting in alterations in kinetic parameters of either voriconazole or the interacting agent. Efficacy has been illustrated in open, noncomparative studies of aspergillosis in immunocompromised patients. Human case reports describe successful treatment of rare fungal pathogens. The most commonly reported adverse events include visual disturbances and elevations in liver function tests. CONCLUSIONS: Voriconazole is at least as effective as amphotericin B in the treatment of acute invasive aspergillosis in immunocompromised patients. It has similar efficacy as fluconazole in treatment of esophageal candidiasis. Voriconazole did not achieve statistical non-inferiority to liposomal amphotericin B for empirical therapy in patients with neutropenia and persistent fever, diminishing enthusiasm for use in this indication until additional trials are completed. Based on case reports and in vitro efficacy, voriconazole may prove to be a clinically useful agent in the treatment of other fungal disease.     

In vitro antifungal activity of luliconazole (NND-502), a novel imidazole antifungal agent

The in vitro activity of luliconazole (NND-502), a novel imidazole antifungal agent, against dermatophytes and several other groups of medically important fungi including the rare causative agents of dermatomycoses, was studied. The luliconazole susceptibility tests were performed with a total of 58 fungal strains of 23 species of fungi grouped into dermatophytes, dematiaceous fungi, hyaline hyphomycetes, yeastlike fungi, and zygomycetes using a broth microdilution method with RPMI 1640 medium. The minimum inhibitory concentration (MIC) values for luliconazole were compared with those of three reference drugs, lanoconazole (LCZ), bifonazole (BFZ), and terbinafine (TBF), all of which have been popular for the topical treatment of dermatophytosis, cutaneous candidiasis, and other superficial fungal infections in Japan. Luliconazole inhibited growth of all filamentous fungi except zygomycetes at low concentrations (MIC, 0.004–0.125µg/ml), with dermatophytes being most susceptible (MIC, 0.004–0.008µg/ml). The susceptibility of these filamentous fungi to luliconazole was almost equal to that to LCZ, and surpassed TBF and BFZ, although to a lesser extent; yeastlike fungi were also susceptible to luliconazole (MIC, 0.125–4µg/ml). Again the antiyeastlike fungi activity of luliconazole was at the same level as LCZ and was greater than that of BFZ and TBF. In contrast to BFZ and TBF, however, luliconazole and LCZ were virtually inactive against zygomycetes.     

抗真菌新药--卡泊芬净

随着免疫缺陷患者的增多以及新的操作技术的开展，深部真菌感染的发病率逐年增加。据报道，深部真菌感染列美国医院感染第4位。是侵袭性真菌感染病死率上升的重要原因。卡泊芬净(caspofungin)是一类全新的抗真菌药——棘白菌素(echinocandins)的第1个上市品种(商品名Cancidas，Merk公司)。本品对包括曲霉和念珠菌属在内的真菌均有良好的抗菌作用，已有的临床资料显示本品用于     

Anidulafungin: review of a new echinocandin antifungal agent

Anidulafungin (Vicuron Pharmaceuticals) is a new echinocandin antifungal with potent activity against Aspergillus and Candida spp. Anidulafungin is a noncompetitive inhibitor of (1,3)-beta-D-glucan synthase within fungal cells. The drug is rapidly distributed and steady-state concentrations are achieved after the first dose, when a loading dose of twice the daily maintenance dose is given on day 1. Drug biotransformation occurs via chemical degradation, with no hepatic metabolism or renal elimination. A favorable pharmacokinetic profile and lack of significant drug interactions suggest that patients can receive anidulafungin without dosage adjustments. These characteristics, in addition to comparable efficacy to fluconazole (Diflucan, Pfizer Ltd) in the treatment of esophageal candidiasis, support further investigation of its use in the treatment of systemic fungal infections caused by Candida and Aspergillus spp.     

Anidulafungin: review of a new echinocandin antifungal agent

Anidulafungin (Vicuron Pharmaceuticals) is a new echinocandin antifungal with potent activity against Aspergillus and Candida spp. Anidulafungin is a noncompetitive inhibitor of (1,3)-β-d-glucan synthase within fungal cells. The drug is rapidly distributed and steady-state concentrations are achieved after the first dose, when a loading dose of twice the daily maintenance dose is given on day 1. Drug biotransformation occurs via chemical degradation, with no hepatic metabolism or renal elimination. A favorable pharmacokinetic profile and lack of significant drug interactions suggest that patients can receive anidulafungin without dosage adjustments. These characteristics, in addition to comparable efficacy to fluconazole (Diflucan^®, Pfizer Ltd) in the treatment of esophageal candidiasis, support further investigation of its use in the treatment of systemic fungal infections caused by Candida and Aspergillus spp.     

Therapeutic efficacy of lanoconazole, a new imidazole antimycotic agent, for experimental cutaneous candidiasis in guinea pigs.

The therapeutic efficacy of 1% cream and 1% solution of lanoconazole, a new imidazole antimycotic agent, in the model of cutaneous candidiasis in prednisolone-treated guinea pigs was evaluated in comparison with that of comparable formulations of bifonazole. Each preparation was topically applied once a day for 3 consecutive days, starting on the fifth day postinfection, and quantitative culture study wsa conducted on the ninth day postinfection. Both formulations of lanoconazole were much more highly effective in terms of eradication of fungi than the bifonazole formulations.     

In vitro activity of naftifine, a new antifungal agent.

Naftifine exhibits an interesting in vitro spectrum of activity against dermatophytes (38 strains; minimal inhibitory concentration [MIC] range 0.1 to 0.2 microgram/ml), aspergilli (6 strains; MIC range, 0.8 to 12.5 microgram/ml), Sporothrix schenckii (2 strains; MICs, 0.8 and 1.5 microgram/ml), and yeasts of the genus Candida (77 strains; MIC range, 1.5 to greater than 100 microgram/ml). Its degree of efficacy is unaffected by the organism density in the test medium, and it is primarily fungicidal against dermatophytes as well as yeasts. Its in vitro efficacy is pH dependent and rises with increasing pH values.     

In vitro activity of ME1401, a new antifungal agent.

The in vitro antifungal activity of ME1401, a potential topical antifungal agent, was compared with that of haloprogin, clotrimazole, miconazole, tolnaftate, and ciclopirox olamine by using an agar dilution procedure. ME1401 showed a broad antifungal spectrum and inhibited all of the 428 strains of 52 species of pathogenic yeasts and filamentous fungi tested at concentrations ranging from 0.01 to 12.5 micrograms/ml. In general, the activity of ME1401 was comparable or superior to that of clotrimazole and was greater than that of haloprogin and the other reference drugs under the conditions used. Only tolnaftate was superior to ME1401 in its activity against clinical isolates of Trichophyton rubrum. ME1401 showed no cross-resistance with any of the reference drugs and exhibited potent fungicidal activity.     

An overview of the pharmacology, efficacy, safety and cost-effectiveness of lansoprazole

Lansoprazole is a proton pump inhibitor that reduces gastric acid secretion in a dose-dependent manner via inhibition of H+/K+-adenosine triphosphatase in gastric parietal cells. It also exhibits antibacterial activity against Helicobacter pylori in vitro. During almost 10 years of clinical use, lansoprazole has proved effective and well tolerated in a wide range of acid-related disorders, including gastro-oesophageal reflux disease (GORD), duodenal ulcers, gastric ulcers, non-steroidal anti-inflammatory drug-related ulcers, as well as non-ulcer dyspepsia and acid hypersecretion. It is also used, in combination with antibiotics, for H. pylori eradication. In the above indications, lansoprazole has generally proved to be superior to the histamine H2-receptor antagonists, and is at least as effective as the other currently available proton pump inhibitors. This review aims to evaluate the pharmacology, efficacy, safety and cost-effectiveness of lansoprazole in acid-related disorders, with particular emphasis on its use in GORD and H. pylori eradication regimens.     

The pharmacology of flazalone: a new class of anti-inflammatory agent.

The anti-inflammatory activity of flazalone, a unique chemical drug, is described. In acute irritant anti-inflammatory tests, flazalone exhibited a wide spectrum of activity. The compound was active in affecting the course of paw swelling in adjuvant arthritis when given daily either at the outset of the polyarthritis or after induction. The most unusual aspect of this compound is its ability to inhibit graft rejection in goldfish and rabbits. The pattern of anti-inflammatory activity does not allow one to classify this drug in the usual groups.     

Bioassay for SF 86-327, a new antifungal agent.

A bioassay with Trichophyton mentagrophytes is described for SF 86-327, an allylamine antifungal agent. SF 86-327 serum concentrations were measured by bioassay in 117 serum sampler from five patients receiving 500 mg/day. The peak, trough, and area under the concentration-time curve were determined after the first dose and at steady state. Drug accumulation occurred with prolonged therapy.     

In vivo efficacy of SM-8668 (Sch 39304), a new oral triazole antifungal agent.

SM-8668 (Sch 39304) is a new oral antifungal agent which we evaluated in comparison with fluconazole in various fungal infection models. The prophylactic effect of SM-8668 was excellent against systemic candidiasis, aspergillosis, and cryptococcosis in mice. The 50% effective dose for SM-8668 was assessed at 10 days after infection and was 0.18, 3.7, and 5.9 mg/kg (body weight), respectively, for the above-mentioned fungal diseases. Fluconazole was about four times less effective than SM-8668 against systemic candidiasis and was only slightly effective at doses of 80 and 25 mg/kg against systemic aspergilosis and cryptococcosis, respectively. SM-8668 was also about four to eight times more active than fluconazole against vaginal candidiasis in rats and against dermatophytic infection in guinea pigs. In addition, topical SM-8668 was as effective as topical miconazole or tioconazole against skin mycosis in guinea pigs. After oral administration, SM-8668 showed a maximum concentration in serum similar to that of fluconazole in both mice and rats, but the elimination half-life and area under the serum concentration-time curve for SM-8668 were twice those for fluconazole.     

Clinical update on the pharmacology,efficacy and safety of transdermal buprenorphine

Buprenorphine was not used widely in clinical practice over many years, mainly due to analgesic potency and clinical safety concerns based on misinterpreted animal data. Contrary to previous concerns, however, no analgesic ceiling effect and no antagonism of combined pure μ‐opioid receptor agonists is seen within the therapeutic dose range. In recent studies, buprenorphine could be effectively and safely combined with full μ‐agonists, and switching between buprenorphine and another opioid provided comparable pain relief based on equianalgesic doses. Moreover, buprenorphine exerts an antihyperalgesic effect, which is due—at least in part—to antagonistic activity at κ‐opioid receptors. Buprenorphine pharmacokinetics are not altered by advanced age or renal dysfunction. In addition, the risk of respiratory depression is lower than with other opioids including morphine, hydromorphone, methadone and fentanyl. Unlike morphine and fentanyl, there is no immunosuppressive activity with buprenorphine at therapeutic analgesic doses. Transdermal buprenorphine has significantly improved the clinical use of the drug, providing continuous buprenorphine release for up to 96h. In clinical trials, patients receiving transdermal buprenorphine experienced significantly greater pain relief, better sleep, and a reduced need for rescue therapy, compared to placebo. Large‐scale post‐marketing studies have confirmed the effectiveness of transdermal buprenorphine in treating moderate‐to‐severe cancer and non‐cancer pain including neuropathic syndromes. Finally, the comparably low incidence of CNS adverse events and constipation, and the possibility of use in severe renal dysfunction without a need for dose adjustment make buprenorphine well suited for chronic pain management in at‐risk patients, such as diabetics, elderly or renally impaired individuals including those requiring haemodialysis.     

In vitro activity, efficacy, and pharmacology of moxalactam, a new beta-lactam antibiotic.

Moxalactam, a potent new beta-lactam antibiotic with a relatively wide spectrum of activity against facultative and anaerobic gram-negative bacilli, was evaluated in vitro and in 28 patients with a variety of severe infections with moxalactam-susceptible organisms (minimum inhibitory concentration less than or equal to 31 microgram/ml). Although therapy was successful in most of these patients, caution is suggested because of the development of resistance on therapy in one patient, persistence of Bacteroides fragilis endocarditis in another, and for certain organisms, a significant inoculum effect on the minimum inhibitory concentration and minimum bactericidal concentration of moxalactam.     

Intravenous disopyramide: safety and efficacy of a new dosage regimen

The efficacy and safety of a new dosage regimen of intravenous disopyramide in ventricular arrhythmias were evaluated in 10 patients. Each had at least four premature ventricular contractions (PVCs)/min during a 30-min period before dosing. By the classification of Lown et al., grade III arrhythmia was present in four patients, grade IVA in three patients, and grade IVB in three patients. Disopyramide was injected intravenously as a bolus of 0.5 mg/kg over 5 min. Each patient received two to three additional boluses of same strength with 5-min intervals between each dosing during the first hour. Continuous intravenous infusion was started with the first bolus and continued at a rate of 1 mg/kg/hr for 3 hr and at 0.4 mg/kg/hr for 15 hr. All patients had continuous Holter monitoring throughout the 18-hr treatment period and for 30 to 60 min before treatment. In eight patients the grade of arrhythmia after drug decreased and the frequency of PVCs fell by 70% to 100% (greater than 85% in six patients and less than 85% in two patients), and the response persisted during the continuous infusion. In two patients PVC frequency increased. For the group as a whole, PVC frequency decreased on the average by 68.4%. Therapeutic serum levels (greater than 2 micrograms/ml) were reached after the first or second bolus and were maintained during the continuous infusion period. There were no side effects necessitating termination of disopyramide infusion. The dosage regimen of intravenous disopyramide evaluated was effective in 60% of patients with ventricular arrhythmia, induced no severe toxic effects, and rapidly achieved therapeutic serum levels that were maintained during continuous infusion.     

Successful treatment of Candida krusei infection with caspofungin acetate: a new antifungal agent

OBJECTIVE: Systemic fungal infections have high mortality, and therapy is often toxic. Caspofungin acetate, a new antifungal agent with minimal toxicity, may provide a better alternative to typical therapy for Candida krusei. DESIGN: Case report. SETTING: Multidisciplinary intensive care unit (ICU) of a community teaching hospital. PATIENT: A 22-yr-old male with acute lymphoblastic leukemia and Candida krusei fungemia failed therapy with fluconazole and amphotericin B. INTERVENTIONS: Caspofungin acetate given intravenously as a 70-mg loading dose, followed up by 50 mg daily along with standard ICU care. RESULTS: Survival without toxicity from therapy. CONCLUSION: Efficacy of caspofungin acetate in a patient with life-threatening Candida Krusei infection.     

Cellular pharmacology of 7(R)-O-methylnogarol: a new anticancer agent.

The cellular accumulation and disposition of 7(R)-O-methylnogarol (7-OMEN), a derivative of the anthracycline antibiotic, nogalamycin, were compared to those of daunorubicin. Although both drugs were avidly accumulated by cells, intracellular concentrations of 7-OMEN were 5 to 10 times those of daunorubicin. Lowered temperature (0 degrees C) reduced intracellular accumulation of both drugs, but 10 mM sodium azide reduced the accumulation of 7-OMEN only. Both drugs exited from cells placed in drug-free medium, a process that was reduced at 0 degrees C. Sodium azide, 10 mM, did not alter the efflux of daunorubicin from cells but hastened the efflux of 7-OMEN. Unlike whole cells, isolated nuclei accumulated more daunorubicin than 7-OMEN. This process was not reduced at 0 degrees C. Both drugs were lost from nuclei placed in drug free buffer with only slight reduction at 0 degrees C. Unlike daunorubicin which localized in cell nuclei, 7-OMEN localized in the cytoplasm with no detectable nuclear fluorescence. Both drugs produced nearly equivalent dose-dependent inhibition of [3H]thymidine incorporation by L1210 and P388 cells. P388/ADR cells proved resistant to both anthracyclines. [3H]uridine and [3H]valine incorporations were inhibited by daunorubicin but were not altered by 7-OMEN.     

Treatment of murine pulmonary blastomycosis with SCH 39304, a new triazole antifungal agent.

SCH 39304, a broad-spectrum azole derivative, was evaluated in an experimental mouse model of blastomycosis pneumonia. Five days after being inoculated with Blastomyces dermatitidis, infected mice were treated with either oral SCH 39304, fluconazole, or intraperitoneal amphotericin B. A dose response protective effect was observed with SCH 39304 at 5 to 100 mg/kg of body weight per day, with 5 mg of SCH 39304 per kg per day providing activity similar to that of 100 mg of fluconazole per kg per day. Colony counts of yeasts in the lungs of mice sacrificed while on therapy with SCH 39304 were consistently below those of controls, and several lungs were sterile. We conclude that SCH 39304 is effective in murine blastomycosis treatment and deserves to be evaluated in the treatment of human blastomycosis.     

Efficacy of FK463, a new lipopeptide antifungal agent, in mouse models of pulmonary aspergillosis

The efficacy of FK463, a novel water-soluble lipopeptide, was evaluated in mouse models of pulmonary aspergillosis and was compared with that of amphotericin B (AMPH-B). In the pulmonary aspergillosis models induced by intranasal inoculation, FK463 exhibited good efficacy, with 50% effective doses in the range of 0. 26 to 0.51 mg/kg of body weight; these values were comparable to those of AMPH-B. In an Aspergillus target organ assay with immunosuppressed mice, under conditions of constant plasma levels of FK463, using a subcutaneously implanted osmotic pressure pump, a significant reduction in viable fungal cells was observed at plasma FK463 levels of 0.55 to 0.80 microgram/ml or higher. We conclude that FK463 is highly effective in the treatment of pulmonary aspergillosis in this animal model. These results indicate that FK463 may be a potent parenterally administered antifungal agent for pulmonary aspergillosis.