Voriconazole and posaconazole therapeutic drug monitoring: a retrospective study

Background

Therapeutic drug monitoring (TDM) aims to minimize the clinical impact of posaconazole and voriconazole pharmacokinetic variability. However, its benefits on clinical outcomes are still being defined. Additionally, TDM data are limited for posaconazole IV and delayed-release tablet formulations among specific patient populations, including critically ill. The aim of this study was to determine the percentage of therapeutic posaconazole and voriconazole drug levels across all formulations in a real-world clinical setting and elucidate factors affecting attainment of target concentrations.

Methods

This study was a retrospective cohort study conducted at the University of Colorado Hospital between September 2006 and June 2015 that evaluated patients who received posaconazole or voriconazole TDM as part of routine care.

Results

Voriconazole (n = 250) and posaconazole (n = 100) levels were analyzed from 151 patients. Of these, 54% of voriconazole and 69% of posaconazole levels were therapeutic. For posaconazole, 14/38 (37%), 28/29 (97%) and 27/33 (82%) levels were therapeutic for the oral suspension, IV, and delayed-release tablet, respectively. Intravenous and delayed-release tablet posaconazole were 20 fold (p < 0.01) and sevenfold (p = 0.002) more likely than the oral suspension to achieve a therapeutic level. Subsequent levels were more likely to be therapeutic after dose adjustments (OR 3.31; 95% CI 1.3–8.6; p = 0.02), regardless of timing of initial non-therapeutic level. In a multivariable logistic regression analysis, no characteristics were independently predictive of therapeutic voriconazole levels and only absence of H2RA/PPI use was independently predictive of therapeutic posaconazole levels. There was no correlation between survival and therapeutic drug levels for either voriconazole (p = 0.67) or posaconazole (p = 0.50).

Conclusions

A high percentage of drug levels did not achieve TDM targets for voriconazole and posaconazole oral suspension, supporting the need for routine TDM for those formulations. The utility of TDM for the IV and delayed-release tablet formulations of posaconazole is less apparent.

     

East Coast fever: quantitative studies of Theileria parva in cattle

A series of experiments is described in which infective material obtained by grinding adult Rhipicephalus appendiculatus ticks containing mature Theileria parva parasites was titrated in East Coast fever-susceptible cattle. The reactions of the cattle to the various inocula, and the rate of multiplication of macroschizonts in their lymph nodes, were studied. In the final experiment, conclusive evidence was produced to support the observations of previous workers that the prepatent period, time to onset of febrile response, and time to death of the animals was dose-dependent, whereas the production of intraerythrocytic piroplasms was totally time-dependent. Furthermore, the effective rate of multiplication of macroschizonts was shown for the first time to be dose-dependent. It was not possible to detect macroschizonts before the fifth day after inoculation, and an occult phase of the parasite's life cycle, between the infective particle and the uninuclear macroschizont, is postulated. The discrepancies between the results of the present work and those of previous workers are discussed.     

Expression of HSV-1 glycoproteins in tunicamycin-treated monkey kidney cells

The role of glycosylation in transport and expression of HSV-1 glycoproteins on the surface of HSV-1-infected African green monkey kidney cells was investigated by using tunicamycin (TM). A concentration of 0.05 microgram/ml of TM inhibited the replication of HSV-1 by greater than 99%. Immunoblot analysis of TM-treated and virus-infected cells indicated that 0.05 microgram/ml of TM blocked the addition of N-linked oligosaccharides into glycoproteins B, C and D. An immunofluorescence assay of TM-treated (0.05 and 0.1 microgram/ml) and virus-infected cells demonstrated the presence of nonglycosylated gC, gD and a reduced amount of gB on the surface of infected cells. The results suggest that the addition of N-linked oligosaccharides on the studied HSV-1 glycoproteins was not necessary for their transport and expression on the virus-infected cell surface.     

Thermodynamic analysis of intracellular ice recrystallization in mouse oocytes

In a recent article published in Cryobiology, Seki and Mazur [9] performed kinetic analysis to investigate the physicochemical mechanism of the intracellular ice formation in mouse oocytes subjected to rapid cooling. Based on their results, the authors calculated the activation energy for the ice recrystallization process to be 27.5 kcal/mol. In this letter, we report our analysis of the result in terms of the transition-state theory to show that the process is unfavorable in terms of enthalpy but favorable in terms of entropy accompanying molecular expansions. This report is expected to evoke interests in applying thermodynamics to the investigation of the intracellular ice formation.