Amphotericin B fever in rabbits

The slow intravenous infusion of amphotericin B (amB) induced a moderate, partially dose-dependent fever in male adult rabbits, whereas the iv bolus injection of the drug was less pyrogenic and only at higher doses. Higher, more sustained fevers occured with doses of 2.5 and 5.0 mg of amB. The threshold pyrogenic dose of amB in the rabbits tested approached 0.16 mg per Kg (ΔT greater than 0.4°C). Endotoxin-tolerant rabbits had a lower increase in rectal temperature when challenged with amB. No fever occured in mice treated with amB.     

Conformational analysis of Amphotericin B

Within a theoretical approach to the problem of antifungal action of Amphotericin B (AmB), a conformational analysis of the neutral and zwitterionic form of this antibiotic in vacuo was performed by the MM2P and AM1 methods. The analysis was carried out with regard to the mutual orientation of the macrolidic and glycosidic fragments of the molecule, which is defined by the phi and psi steric angles. This orientation defines the overall shape of the molecule and is postulated to be important for the antifungal action of the drug. As a result of the MM2P calculations, phi, psi steric energy and population maps were prepared. Several conformers were found on these maps but only two of them (one each for the zwitterionic and the neutral forms of the antibiotic) were previously observed experimentally for isolated molecules. Our other calculated conformers were not observed experimentally but we propose that they may also appear in the AmB channel structure. The results of our conformational analysis were compared with experimental NMR data (nuclear Overhauser effects between selected hydrogen atoms) obtained previously. New structural information obtained for AmB in the present work will be useful for building a molecular model of AmB-target interactions as well as for designing new derivatives of AmB.     

Amphotericin B channel conductance inactivation

Effects induced in bilayer lipid membranes by amphotericin B and its alkyl derivatives was analysed. Inactivation of the antibiotic-dependent multichannel membrane conductance was discovered. Kinetics of membrane conductivity was shown to depend on the antibiotic concentration in the membrane. At concentrations between 10(-8) and 10(-7) M, the resulting conductance appeared to the transient. We suggest that the phenomenon of biphasic kinetics of membrane conductance is the result of a consecutive transformation of polyene channels in the membrane: half-pores are assembled on either side of membrane-nonconducting 1; two half-pores combine to build up a conducting channels-conducting 2, and the conducting channels are disassemled to monomers and nonconducting self-associated forms inside the membrane-disassembled state (nonconducting 3). To explain the transient characteristics of the induced conductance, it is proposed that the antibiotic, present in the solution under self-associated form, binds the membrane and forms pores, then dissociates in the bilayer in a non-active monomeric form. The existence of definite monomers and nonconducting self-associated forms of amphotericin B molecules inside the membrane was estimated from the dependence of kinetic conductance of lipid membranes of amphotericin B and its alkyl derivatives, when the antibiotics are washed out from aqueous medium. Equilibrium between different antibiotic assemblies inside the membrane was demonstrated by the kinetics of conductance decrease following washing the antibiotic. Using circular dichroism measurements, we observed that amphotericin B alkyl derivatives were in self-associated form being susceptible to form pores across cholesterol-containing membranes. The phenomenon of biophasic kinetics was observed only in the cholesterol-containing membrane. The substitution of membrane cholesterol for ergosterol provides monotonic kinetics of membrane conductance at any antibiotic concentration.     

Amphotericin B Serum Concentrations During Therapy

Therapeutic outcome of patients being treated for systemic mycoses with amphotericin B is possibly related to the serum concentrations of this drug that are produced in these patients. Because current data are conflicting, the magnitude of these concentrations was restudied by using a bioassay which gave precise and accurate results. The highest of 155 serum concentrations was 2.01 mug/ml. Mean concentrations were 1.21, 0.62, and 0.32 mug/ml, at 1, 18, and 42 hr, respectively, after intravenous infusion of amphotericin B. This drug was detected in serum 7 weeks after completion of treatment, but it could not be detected 13 weeks after treatment. Drug levels did not appreciably decrease in serum stored for 8 to 9 months at - 10 C. Unequal serum content in assay tubes and measurement of assay turbidity by visual inspection may explain previously reported amphotericin B levels of 3.0 to 12.5 mug/ml.     

Amphotericin B: side effects and toxicity

Amphotericin B (AmB) is a crucial agent in the management of serious systemic fungal infections. In spite of its proven track record, its well-known side effects and toxicity will sometimes require discontinuation of therapy despite a life-threatening systemic fungal infection. The mechanism of action of AmB is based on the binding of the AmB molecule to the fungal cell membrane ergosterol, producing an aggregate that creates a transmembrane channel, allowing the cytoplasmic contents to leak out, leading to cell death. Most of the efforts at improving AmB have been focused on the preparation of AmB with a lipid conjugate.AmB administration is limited by infusion-related toxicity, an effect postulated to result from proinflammatory cytokine production. The principal acute toxicity of AmB deoxycholate includes nausea, vomiting, rigors, fever, hypertension or hypotension, and hypoxia.Its principal chronic adverse effect is nephrotoxicity. AmB probably produces renal injury by a variety of mechanisms. Risk factors for AmB nephrotoxicity include male gender, higher average daily dose of AmB (≥35 mg/day), diuretic use, body weight ≥90 kg, concomitant use of nephrotoxic drugs, and abnormal baseline renal function. Clinical manifestations of AmB nephrotoxicity include renal insufficiency, hypokalemia, hypomagnesemia, metabolic academia, and polyuria due to nephrogenic diabetes insipidus. Human studies show convincingly that sodium loading in excess of the usual dietary intake notably reduces the incidence and severity of AmB-induced nephrotoxicity.     

Complexes of Amphotericin B and Cholesteryl Sulfate

Abstract

To improve the clinical utility of amphotericin B, we have developed a novel formulation of amphotericin B, Amphocil® (also known as Amphotericin B Colloidal Dispersion, or ABCD). Amphocil is a uniform disc-shaped complex of amphotericin B and sodium cholesteryl sulfate in a molar ratio of 1:1. The complex has a mean hydrodynamic diameter of approximately 115 nm and is thermodynamically stable. In an extensive series of pharmacodynamic, pharmacokinetic and toxicology studies, Amphocil was found to be less toxic than conventional amphotericin B (Fungizone®), providing a four- to five-fold improvement in safety, while remaining effective in treating a variety of fungal infections. Plasma pharmacokinetics and tissue disposition of amphotericin B differ in several respects after administration of Amphocil and conventional amphotericin B, due to a rapid uptake of Amphocil by liver. Animals receiving Amphocil demonstrated reduced peak levels in plasma, prolonged residence time and lowered levels of amphotericin B in most tissues including the kidney, the major target organ for toxicity, compared with animals receiving conventional amphotericin B.

In healthy male subjects receiving a single dose of Amphocil, ranging from 0.25-1.5 mg/kg, mild to moderate dose-dependent acute side effects typically seen with conventional amphotericin B were observed but there was no sign of renal or hepatic toxicities. In two dose-escalating studies, multiple daily doses of Amphocil up to 4.5 mg/kg were well tolerated in patients who had previously failed to tolerate or respond to conventional amphotericin B. In addition, complete clearance of fungal infection was observed with the Amphocil therapy. Thus, Amphocil is a safe and effective agent for treating systemic mycoses. Toleration and efficacy of higher doses of Amphocil in patients with life-threatening mycoses is currently being evaluated.     

Amphotericin B synergy testing by the FCST

The flow cytofluorometric susceptibility test (FCST) was incorporated into two in vitro synergy assays of amphotericin B-drug combinations. The FCST checkerboard assay and the FCST concentration-effect assay were developed to detect subtle modulation of amphotericin B fungicidal effects onCandida albicans andCryptococcus neoformans. Amphotericin B × cyclosporine A was a synergistic fungicidal combination against bothC. albicans andC. neoformans. Amphotericin B×gentamicin and amphotericin B×ketoconazole were synergistic combinations againstC. neoformans. In all cases tested, the synergy was effective when 0.50–0.62 g amphotericin B/ml was used with>-0.50 g of the other drug/ml. The fungicidal effect of 1.00 g amphotericin B/ml overwhelmed the synergistic effects. A number of other drug combinations were additive, autonomous, or antagonistic.     

Optimizing efficacy of Amphotericin B through nanomodification

The polyene antibiotic Amphotericin B (AMB) is one of the first therapeutic agents to be marketed commercially as nanosized formulations in which the drug is associated with lipids as liposomes or complexes. In this way, its renal toxicity is reduced and its therapeutic index improved. This review summarizes the particular properties of AMB which justify this type of formulation and the early work leading up to their development. The clinical results obtained in the treatment of fungal infections are reviewed and their activity against leishmaniasis is also evoked. Some newer formulations of AMB, based on both lipids and polymers are described. In particular, their potential by the oral and pulmonary routes are discussed. Finally, the development of targeted systems to deliver the drug to specific cells and tissues is considered.     

Amphotericin B covalent dimers bearing a tartarate linkage

Amphotericin B (AmB, 1) is known to assemble together and form an ion channel across biomembranes, by which the drug presumably exerts its antimicrobial activity. To access the whole architecture of this channel assemblage, the understanding of binary interaction between AmB molecules is of prime importance because the dimeric interaction is the basis of the assemblage. In this context, we have recently reported covalently conjugated AmB dimers such as 2 and 3 with a long linker, which show prominent hemolytic potency and ion-channel activity. To evaluate the effect of the length and hydrophilicity of linker parts on the activity, we prepared new dimers bearing tartarate linkages (4 and 5). Especially, 5 exhibited potent hemolytic activity (EC50, 0.03 microM) surpassing those of AmB, 2, and 3. Measurements of UV and CD spectra of 5 in liposomes indicated that AmB portions of 5 could adopt appropriate arrangements in molecular assemblage in spite of the short linkage, and also indicated that the assemblage formed by 5 appeared more stable than AmB. These short-tethered dimers are expected to be a promising tool to reveal the mechanism of dimeric interaction in the ion channel formed by AmB.     

Amphotericin B induces interdigitation of apolipoprotein stabilized nanodisk bilayers

Amphotericin B nanodisks (AMB-ND) are ternary complexes of AMB, phospholipid and apolipoprotein organized as discrete nanometer scale disk-shaped bilayers. In gel filtration chromatography experiments, empty ND lacking AMB elute as a single population of particles with a molecular weight in the range of 200 kDa. AMB-ND formulated at a 4:1 phospholipid:AMB weight ratio separated into two peaks. One peak eluted at the position of control ND lacking AMB while the second peak, containing all of the AMB present in the original sample, eluted in the void volume. When ND prepared with increased AMB were subjected to gel filtration chromatography an increased proportion of phospholipid and apolipoprotein was recovered in the void volume with AMB. Native gradient gel electrophoresis corroborated the gel filtration chromatography data and electron microscopy studies revealed an AMB concentration-dependent heterogeneity in ND particle size. Stability studies revealed that introduction of AMB into ND decreases the ability of apoA-I to resist denaturation. Atomic force microscopy experiments showed that AMB induces compression of ND bilayer thickness while infrared spectroscopy analysis revealed that the presence of AMB does not induce extreme lipid disorder or alter the mean angle of the molecular axis along fatty acyl chains of ND phospholipids. Taken together the results are consistent with AMB-induced bilayer interdigitation, a phenomenon that likely contributes to AMB-dependent pore formation in susceptible membranes.     

Amphotericin B induces interdigitation of apolipoprotein stabilized nanodisk bilayers

Amphotericin B nanodisks (AMB-ND) are ternary complexes of AMB, phospholipid and apolipoprotein organized as discrete nanometer scale disk-shaped bilayers. In gel filtration chromatography experiments, empty ND lacking AMB elute as a single population of particles with a molecular weight in the range of 200 kDa. AMB-ND formulated at a 4:1 phospholipid:AMB weight ratio separated into two peaks. One peak eluted at the position of control ND lacking AMB while the second peak, containing all of the AMB present in the original sample, eluted in the void volume. When ND prepared with increased AMB were subjected to gel filtration chromatography an increased proportion of phospholipid and apolipoprotein was recovered in the void volume with AMB. Native gradient gel electrophoresis corroborated the gel filtration chromatography data and electron microscopy studies revealed an AMB concentration-dependent heterogeneity in ND particle size. Stability studies revealed that introduction of AMB into ND decreases the ability of apoA-I to resist denaturation. Atomic force microscopy experiments showed that AMB induces compression of ND bilayer thickness while infrared spectroscopy analysis revealed that the presence of AMB does not induce extreme lipid disorder or alter the mean angle of the molecular axis along fatty acyl chains of ND phospholipids. Taken together the results are consistent with AMB-induced bilayer interdigitation, a phenomenon that likely contributes to AMB-dependent pore formation in susceptible membranes.     

Channels Formed by Amphotericin B Covalent Dimers Exhibit Rectification

Amphotericin B (AmB) is a widely used antifungal antibiotic with high specificity for fungi. We previously synthesized several covalently conjugated AmB dimers to clarify the AmB channel structure. Among these dimers, that with an aminoalkyl linker was found to exhibit potent hemolytic activity. We continue this work by investigating the channel activity of the dimer, finding that all channels comprised of AmB dimers show rectification. The direction of the dimer channel in the membrane depended on the electric potential at which the dimer channel was formed. On the other hand, only about half the monomer channels showed rectification. In addition, these channels were easily switched from a rectified to a nonrectified state following voltage stimulation, indicating instability. We propose a model to describe the AmB channel structure that explains why AmB dimer channels necessarily show rectification.     

Liposomal Amphotericin B as Monotherapy in Relapsed Coccidioidal Meningitis

Coccidioidal meningitis remains a difficult clinical problem, and despite life-long therapy with triazole antifungals, relapses of disease and medication intolerance occur necessitating salvage treatment. We report two patients with recurrent coccidioidal meningitis who improved following a 2-week course of liposomal amphotericin B monotherapy and discuss potential advantages of this treatment option.     

Therapeutic Activity of Liposomal Amphotericin B in Systemic Mycoses

Abstract

Several clinical trials are presently underway to study various liposomal formulations of antineoplastics and antimicrobial agents (1–3). Both liposomal amphotericin B (L-AmpB) and various liposome formulations have been used in the treatment of experimental systemic fungal infections (4–6) and leishmaniasis (7,8) in animals. In most reports, an enhanced therapeutic index was observed. A uniform reduction in the toxic effects usually attributed to AmpB was reported and, in some cases, an enhanced therapeutic efficacy was also attained. We recently reported on the use of L-AmpB in 46 patients with systemic fungal infections (9). of that number, 31 had leukemia, 2 had lymphoma, 11 had other diagnoses (5 had received intensive immunosuppressive therapy following a heart transplantation, 2 had multiple myeloma, and the rest had other malignancies); 2 patients had no underlying disease. Forty-one of these patients had been previously treated with conventional AmpB. the fungal diagnosis was candidiasis in 21 patients, aspergillosis in 19, agents of mucormycosis in 3, and other diagnoses in the rest.     

Conformational analysis of Amphotericin B I. Isolated molecule

Theoretical conformational analysis have been performed on an isolated Amphotericin B molecule as a first step toward theoretical investigations of molecular association. Analysis of the conformational space of this cyclic molecule have been performed using a constrained energy minimization procedure in order to keep the molecule closed in the right way. Results show that Amphotericin B can be seen as a rigid molecule and that a unique energetically stable conformer can be found for this molecule under different physico-chemical conditions.